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Helicobacter pylori (H. pylori) infection is one of the most common in the world. More than 50% of the world’s population is infected and infection rates are especially high in countries with poor socio-economic conditions. H. pylori causes gastroduodenal and extra-gastroduodenal diseases including such metabolic disorders as obesity, diabetes mellitus and non-alcoholic fatty liver disease. Recent epidemiological and clinical studies showed that the long-term persistence of H. pylori infection is associated with the development and progression of atherosclerosis and consequently cardiovascular diseases. However, the correlation between these conditions is ambiguous and there is not enough evidence to confirm it. The lack of consensus might be related to differences in diagnostic methods used for H. pylori and the variety of its genotypes. Considering high prevalence of H. pylori infection as well as high incidence of metabolic and cardiovascular diseases, a verified correlation between these can be of great epidemiological, prophylactic and clinical significance.

Introduction: The impact of consensus, prescription choices and efficacy trends on clinical practice over time has not been studied in depth.Aims & Methods: International multicenter prospective non-intervention-al registry aimed to evaluate the decisions and outcomes of H. pyloriman-agement by European gastroenterologists. All infected adult patients were systematically registered at AEG-REDCap e-CRF from 2013 to December 2021. Variables included: previous eradication attempts, prescribed treatment, adverse events, and outcomes. Modified intention- to-treat (mITT) and time trend analyses were performed. Data were subject to quality review.Results: So far 49, 739 patients from 29 European countries have been in-cluded, and 35, 203 (71%) were first-line empirical prescriptions. Overall, the most common prescribed treatments in the 2013-21 period were triple therapies ; however, a shift in antibiotic regimens was identi-fied. Triple therapies decreased from over 50% of prescription in 2013/15 to less than 25% in 2020/21 ; likewise, non-bismuth concomitant therapy use decreased from 21% in 2013/14 to 13% in 2020/21, while three-in-one single- capsuleincreased from 0- 1% in 2014/2015 to 17% in 2020/21. An increase in the average duration of treatments from 9.8 days in 2013 to 13 days in 2021 was identified, as well as the daily high- dose of PPIs increasing from 16% in 2013 to 50% in 2021. Detailed description of most common treatments is shown in Table 1. Re-garding the effectiveness of each specific treatment, no trend was identi-fied (data now shown) ; however, there was a 10% overall improvement in first-line mITT overall effectiveness from 2013 to 2021. Conclusion: European gastroenterological practice is constantly adapting to the newest published evidence and recommendations (reducing the use of triple therapies and increasing both the duration of treatment and the dose of PPIs), with a subsequent progressive improvement in overall effectiveness.

Introduction: Management of Helicobacter pylori infection (H. pylori) re-quires co- treatment with proton pump inhibitors (PPIs) and the use of an- tibiotics to achieve successful eradicationAims & Methods: To evaluate the role of PPIs in the eradication of H. py-lori, based on the “European Registry onHelicobacter pylori Management” (Hp- EuReg).The Hp-EuReg is a multicentre, prospective, non-interventional, registry assessing decisions and outcomes of H. pylori management by European gastroenterologists in routine clinical practice. Countries recruiting more than 1, 000 patients were included. Effectiveness was assessed by modi- fied intention-to-treat (mITT). Data were quality reviewed.Results: Overall, 22, 078 patients from 5 countries were analysed. Optimal (»90%) first-line mITT effectiveness was achieved with the following treatments: 14-day clarithromycin- amoxicillin- bismuth quadruple therapy, and 14- day metronidazole-tetracycline-bismuth quadruple therapy, both inde-pendently of the PPI dose prescribed ; in all 10- or 14-day therapies with high-dose PPIs (except with standard 10-day triple therapy) ; in 10-day se-quential and 10- day quadruple clarithromycin-amoxicillin- bismuth, and 10-day quadruple metronidazole- tetracycline- bismuth with standard-dose PPIs. None of the 7-day therapies achieved optimal cure rates re-gardless of the PPI dose used. The PPI dose was significantly associated with the effectiveness of: 10- or 14- day standard triple and quadruple con-comitant therapies, and 10-day quadruple sequential and metronidazole-tetracycline-bismuth therapies. Table 1 details the mITT effectiveness by duration and PPI dose used.Conclusion: In first-lineH. pylori treatment, ≥90% effectiveness is obtained with standard-dose PPIs in 10-day sequential and 10- or 14-day bismuth quadruple therapies and with high-dose PPIs in all 10- or 14-day therapies except with standard 10-day triple therapy.

Introduction: Introduction: Randomized clinical trials and meta-analyses, primarily from Asian countries, have reported good effectiveness with high-dose dual therapy (HDDT, i.e., PPIs plus high amoxicillin doses) when prescribed for H. pylorifirst-line or rescue treatment. However, combining amoxicillin with PPIs in the 1990s in several European countries yielded suboptimal results. The objective was to analyse the effectiveness, com-pliance and safety of HDDTin the European real clinical practice.Aims & Methods: Methods: International, multicenter, prospective non- interventional Registry aimed at evaluating the decisions and outcomes of H. pylori management by European gastroenterologists. All infected adult cases treated with HDDT were registered at AEG- REDCap e-CRF up to June 2021. Patients receiving HDDT (amoxicillin 1, 000 mg three times a day plus a PPI), with or without bismuth, in any treatment line and for at least 10 days, were selected for inclusion.Results: Sixty patients received HDDT (98% compliance), 19 of them as first-line and 41 as rescue treatment (2nd–6th line). Overall HDDT effec- tiveness was 52% (per-protocol) and 51% (modified intention-to- treat, mITT). First-line and rescue treatment lines were similarly effective. Cure rates were lower when patients had previously received metronidazole (mITT 32% vs. 70%, p

Proton Pump Inhibitors (PPIs) and traditional antacids are the common standard set of therapy for the management of gastroesophageal reflux disease (GERD) symptoms. The aim of the current study was to evaluate efficacy and safety of a novel galactomannan-based liquid formulation in reducing typical GERD symptoms in patients not taking PPIs.This was a single-center, randomized, double-blind, placebo-controlled study. Sixty patients met the eligibility criteria and were treated either with the investigational product (RefluG™) or placebo, one sachet three times per day for 14 consecutive days. Symptom intensity/frequency and quality of life were assessed over the course of the study by Reflux Disease Questionnaire (RDQ) and GERD-Health related Quality of life (HRQL) Questionnaire, respectively. The primary endpoint was to determine the number of subjects with at least 30% symptoms reduction from baseline to day 14 compared to placebo.RefluG™ was statistically superior to placebo (p0.001) as 100% of subjects experienced at least 30% symptoms reduction at the end of the study while none achieved a 30% reduction in the placebo group. For all domains both after 7 and 14 days of treatment, significant improvement in HRQL was seen in the active group in comparison to placebo. Tolerability and safety were good and comparable between groups.The investigational product was safe and effective as mono-therapy in providing early resolution of troublesome GERD symptoms as well as for improving quality of life.

Background The use of biologics in Crohn’s disease (CD) entails an increasing cost on national health systems. The use of biosimilars of adalimumab in CD is based on the concept of extrapolation of the results obtained in rheumatoid arthritis and in psoriasis, while no study about the efficacy and safety on CD of the biosimilars approved in Europe have been published. The aim of our study was to analyse, for the first time in literature, the effectiveness and safety of ABP 501 in CD patients naïve to adalimumab and its retention rate in CD patients who switched from adalimumab originator. Methods We performed an observational study on patients prospectively followed at the gastroenterology clinic of the Turin University Hospital. Inclusion criteria are (a) CD diagnosed according to ECCO criteria; (b) age ≥16 years; (c) initiation of therapy with ABP 501. Exclusion criterian is follow-up duration of less than 3 months for adalimumab-naïve patients, less than 6 months for patients who switched to ABP 501. Primary outcomes were (a) for patients treated with ABP 501 as first adalimumab: clinical response rate at 12 weeks and (b) for patients who switched to ABP 501: drug retention at 24 weeks. Secondary outcomes were (a) clinical remission rate at week 12 (for patients treated with ABP 501 as first adalimumab); (b) HBI and CRP reduction at week 12 (for patients treated with ABP 501 as first adalimumab), no significant change in HBI and CRP values at week 24 (for patients who switched to ABP 501); (c) analysis of predictors; and (d) adverse events incidence. Results Eighty-seven patients were included, of which 25 were naïve to adalimumab originator and 62 were switched to ABP 501. In adalimumab-naïve patients, the clinical response at 3 months was 60% (15/25), clinical remission at 3 months was 56% (14/25). At 6 months, 95.2% (59/62) of the patients switched to ABP 501 were still in therapy, without a significant increment of clinical activity (Harvey–Bradshaw Index from 3.4, 95% CI = 2.4 – 4.4, to 3.8, 95% CI = 2.7 – 4.9, p = 0.23), and inflammatory biomarker (CRP from 4.2 mg/l, 95% CI = 2.5 mg/l – 5.9 mg/l, to 3.6 mg/l, 95% CI = 2.2 mg/l – 5 mg/l, p = 0.32). No unexpected adverse events occurred during the study period. Conclusion Our results support ABP 501 as an efficacious and well-tolerated drug, at least in the short-term, and its interchangeability with its originator in the treatment of CD.

Helicobacter pylori (H. pylori) infection is a large worldwide infection usually acquired during childhood, whose prevalence in pediatric population varies, with lower incidence rates in developed countries compared to developing countries (up to 10-15% and 70%, respectively). Diagnosis can be performed both with endoscopic-based methods and noninvasive diagnostic tests, such as urea breath test and fecal antigen. Current guidelines recommend endoscopic evaluation of the young patients, in order to determine the underlying cause of abdominal pain. Even in case of suspected functional pain, patient should not be investigated for infection, unless upper endoscopy is performed to rule out organic causes. Nowadays, in pediatric population, applications of noninvasive tests are limited to verifying eradication after therapy and to investigating the presence of infection in asymptomatic patients with first-degree relatives affected by gastric cancer. Since correlation between abdominal pain and H. pylori gastritis, in absence of peptic ulcer disease is still debated, "test and treat" strategy is not recommended in children. As for adults, treatment regimens are based on the combination of proton-pump inhibitor and two or more antibiotics, for 7-14 days, depending on resistance rates of geographic areas.

Functional dyspepsia, though benign, leads to deterioration of the quality of life and high costs for healthcare systems. The optimal therapy for functional dyspepsia is still to be defined because of its multifactorial pathogenesis. In an open multicentric study of patients with functional dyspepsia, we prospectively evaluated the benefit of treatment with a food supplement composed of sodium alginate, carbonate calcium, pineapple, papaya, ginger, α-galactosidase and fennel (Perdiges, Bioten Snc, Turin, Italy).Ninety-one consecutive patients were included, suffering from functional dyspepsia, who had been previously submitted to therapy to eradicate the infection from Helicobacter pylori (H. pylori) and were waiting to perform the Urea Breath Test (UBT). The primary goal was to establish the percentage of patients who continued to abstain from proton pump inhibitors (PPI) as they waited to carry out the UBT, differentiating between patients who were treated (N.=55) with Perdiges and those who were not (N.=36). Our secondary goal was to document the differences within the 2 groups in terms of symptoms perceived between the start and end of the observation period. The wellness reported, during or in absence of treatment with Perdiges, was evaluated by the use of the VAS scale (Visual Analogical Scale) completed before the start of the treatment and after 30 days.All the patients treated with Perdiges (55/55, 100%) and 31/36 (86.1%) patients who were not (P=0.008) continued to abstain from PPI in the period awaiting the UBT. The VAS scale of those who took Perdiges improved on average by 1.78 points versus a worsening of 0.08 points of those who did not take it (P0.0001). Furthermore, while among those who took Perdiges there was a statistically significant improvement (P0.0001) in the VAS scale, between the baseline and the end of treatment, a worsening of 0.08 points (P=0.78) was noticed among the patients who did not take it.Perdiges is significantly effective in the period following treatment to eradicate the infection from H. pylori in patients with functional dyspepsia. This allows to reduce the need to use antisecretive drugs. Further randomised studies, with wide ranging case histories, must assess its long-term efficacy.

Gastroenteropancreatic neuroendocrine tumors (GEP-NETs) are a group of neoplasms arising from the diffuse neuroendocrine system of the gastrointestinal (GI) tract. They often represent a diagnostic challenge because of their little dimensions, the deep localization into the retroperitoneum or in extramucosal sites, the possibility to be multilocated and the heterogeneous patterns of presentation. Endoscopic ultrasound (EUS) is a cost-effective technique that enables to look very definitely at a suspicious mass and at the surrounding area both within the GI wall and in the pancreas, allowing to precisely assess T and N stage. Under EUS-guidance it is possible to obtain tissue samples in order to reach a definitive diagnosis and to establish the tumor grade. In the therapeutic field, EUS is crucial to assess the safety and the feasibility of resective endoscopic techniques for the GI-wall NETs and it can guide local ablative techniques for pancreatic NETs. After treatment, EUS can be successfully useful to assess complete endoscopic resection and to follow-up resected or ablated patients. It is so evident that EUS has a role in the whole route of NETs management, from diagnosis, evaluation, grading and staging assessment, to therapy and consequent follow-up.

Endoscopic ultrasound (EUS) is a technique that combines the potential of endoscopy, which enables the visual examination of the mucosal surface of any gastrointestinal (GI) tract, with ultrasonography. Despite diagnostic and therapeutic advance, pancreatic cancer (PC), in particular ductal adenocarcinoma, remains the most deadly of all GI malignancies, with a 5-years survival rate less than 1.8%. Moreover its incidence appears to be increasing and most patients present with advanced cancer either locally or with metastatic spread. Thus, all efforts must be oriented towards the need of an early diagnosis and to reliably identify patients who really can benefit from major surgical interventions. To date the most accurate imaging techniques for PC diagnosis and staging remain contrast-enhanced computed tomography and EUS. While the former should be the first choice in patients with suspected PC, EUS has the highest accuracy in detecting small lesions, in assessing tumor size and lymph nodes involvement. The possibility to obtain samples from suspicious lesions or lymph nodes, by means of EUS-guided fine-needle aspiration, makes this procedure an ideal staging modality for PC. Since an accurate preoperative evaluation is essential to choose the correct management strategy, EUS role is crucial.

Helicobacter pylori (H. pylori) has been conclusively related to several gastroduodenal diseases. The possible role of the bacterium in the development of extragastric manifestations has been investigated in the past few years. To identify all publications on the association between H. pylori and respiratory diseases, a MEDLINE search of all studies published in English from 1965 to 2013 was conducted. All data are based on case-control studies. Controversial findings of H. pylori seroprevalence have been obtained in patients with bronchial asthma, lung cancer, pulmonary tuberculosis, sarcoidosis, cystic fibrosis, chronic bronchitis and bronchiectasis. At present, on epidemiological bases, there is no definite evidence of a causal relationship between H. pylori infection and respiratory diseases. There is a low consideration of confounding factors as poorer socioeconomic status and tobacco use. The activation of pro-inflammatory cytokines by H. pylori might be a possible pathogenetic mechanism. However, there are no convincing data about the influence of H. pylori on the inflammatory changes of the bronchoepithelium so far. Further studies are needed on the impact of H. pylori eradication, on the prevention, development and natural history of these disorders.

Chronic or acute pain related to skin ulcers or their management (medication, debridement) is a typical case of mixed pain, both neuropathic and nociceptive. It represents a disabling clinical condition that deteriorates the patient's quality of life. The pharmaceutical therapy must be based on both, intensity and the type of pain. Although NSAIDs, Non Steroidal Anti-Inflammatory Drugs are notoriously effective on nociceptive pain, do not give great results on neuropathic and mixed pain. Also the consumption of NSAIDs is affected by a series of side effects that may involve several organs. In case of neuropathic pain, the benefit deriving from the use of a single active principle is relative. This sets the rational grounds for the use of combined drugs. The paracetamol/tramadol combination represents an innovative solution in the treatment of both the neuropathic and nociceptive components of the pain, since both active principles have a different action mechanism, multiple targets and different pharmacokinetics. It is very interesting, from the clinical point of view, that tramadol is a pure antagonist, not selective, of µ, δ, and κ receptors and carries out and important inhibition action of serotonin and norepinephrine reuptake. This double mechanism, opioid and non-opioid, explains its analgesic efficacy also on neuropathic pain. Besides, since its opioid action is rather weak, it does not induce the severe side effects typical of traditional opioids. The benefit of such combination comes from their complementary pharmacokinetic profile, since the first has a quick action insurgence, while tramadol has a more prolonged effect. Therefore, this combination allows to obtain a quick and long lasting effect with a high tolerability profile also when treating skin ulcer pain.

Hepatitis C virus (HCV) is one of the major causes of chronic liver disease worldwide but its morbidity is also due to a variety of extra-hepatic manifestations including mixed cryoglubulinemia, non-Hodgkin lymphoma, diabetes, porphyria cutanea tarda and lichen planus. The aims of this study were to conduct a systematic review and a meta-analysis on the prevalence of HCV in lichen planus patients and on the prevalence of lichen planus in chronic HCV infection.Bibliographic searches were conducted in several electronic databases. Pooled data were analysed by calculating odds ratios, using a random effects model.Thirty-three studies comparing the seroprevalence of HCV in lichen planus patients and six reporting the prevalence of lichen planus in patients with HCV infection were included in the meta-analysis. The summary estimate showed that LP patients have significantly higher risk (odds ratio 4.85; 95% confidence interval 3.58-6.56) than controls of being HCV seropositive. A similar odds ratio of having lichen planus was found among HCV patients (4.47; 95% confidence interval 1.84-10.86). Sub-analyses indicated that variability of HCV/lichen planus association seemed only partially depending on geographic effect.

Conservative proctocolectomy with ileal pouch-anal anastomosis (IPAA) has become the intervention of choice for severe ulcerative colitis (UC) requiring surgery. Sporadically, the occurrence of carcinoma arising in or near the ileo-anal pouch after IPAA for UC has been reported. This issue is of utmost importance as an endoscopic follow-up is mandatory also after the operation. The present paper reports a case of cancer which developed four years after proctocolectomy with IPAA in a young man suffering from UC. Moreover, the authors provide update (PubMed research) by literature review on this issue.

Because of the multifactorial pathogenesis of functional dyspepsia, strategies alternative to antacid therapy are being sought for treating the disorder. This prospective study evaluated the benefit of treatment with a dietary integrator composed of sodium alginate, sodium bicarbonate, bromelin and essential oils.The study population included 53 consecutive patients (22 males, 31 females; mean age, 54+/-2.5 years) with functional dyspepsia and negative for Helicobacter pylori infection. The patients were categorized into four subgroups according to predominant symptom: ulcer-like dyspepsia, motility-like dyspepsia, reflux-like dyspepsia, and nonspecific dyspepsia. All received TUBES gastro (0.80 g oral tablets bid) for a minimum of 3 months (range, 3-11). Treatment efficacy was measured by means of a Visual Analogue Scale (VAS).Two patients were lost to follow-up; of the remaining 51 patients who completed the study, 35 (68%) showed an improvement in VAS score. The difference in scores between the initial and the final visit was -1.9+/-2.1 cm (range, -6 to +3), or 23.8+/-40.8% (range, -150% to 100%) compared to the scores at the baseline visit (P=0.0001).The study results indicate that in the short term TUBES gastro can significantly improve dyspeptic symptoms in dyspeptic patients negative for H. pylori infection through the synergistic action of its components: alginate buffers gastric acid; bicarbonate helps to eliminate gas and rebalance pH; essential oils regulate motility; and bromelin stimulates enzymatic activity.

Both hepatic parenchymal and biliary tract diseases are common in patients with human immunodeficiency virus (HIV). In this paper, the authors focus mainly on clinical aspects of acquired immunodeficiency syndrome (AIDS)-related cholangiopathy. Although the etiology is unclear, several opportunistic infections (cytomegalovirus, Cryptosporidium and others) are suspected to cause it. Endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic gold standard and it offers a therapeutic means to provide symptomatic relief in case of papillary stenosis. The most common ERCP pattern is diffuse sclerosing cholangitis in combination with papillary stenosis. Clinically, the presentation may be variable, although right upper quadrant pain and fever accompanied by an elevated serum alkaline phosphatase (ALP) level are the most common manifestations. Jaundice is unusual suggesting that complete ductal obstruction is rare. While ERCP results and the need of sphincterotomy do not influence the prognosis, antiretroviral therapy is a protective factor and, on the contrary, high ALP level is related to a less favorable outcome. Regarding the possible pathogenic mechanisms through which HIV infection could be involved in AIDS-related cholangiopathy, in vitro experiments have shown that concurrent active HIV replication and Cryptosporidium parvum infection synergistically increase cholangiocyte apoptosis and thus jointly contribute to AIDS-related cholangiopathies.

Third-level Day-Hospital Services of Gastro-Hepatology are likely to recruit patients with an increased disease severity. The burden of request for immunomodulation drugs is presently unclear.The charts of 1 012 consecutive patients who underwent day-hospital admission were reviewed. Among them, 975 were admitted for several reasons (percutaneous liver biopsies, abdominal fluid aspirations, infiltrations of hepatic nodules, gastrointestinal endoscopies with specific treatments). Data of the remaining 37 patients were elaborated.Of them, 31 (83%) suffered from ulcerative colitis (UC) or Crohn's disease (CD) (17 and 14, respectively) and 6 from autoimmune type 1 hepatitis (AIH). Of the 14 non-operated UC patients, 12 were taking azathioprine (AZA) and 2 infliximab (IFX). Among CD patients, the majority received AZA (N=6) or IFX (N=6). Of the AIH patients, 5 were treated with AZA and 2 had also cyclosporine. Overall, corticosteroids (32%) and IFX (21%) ranked first and second among the induction drugs, and AZA ranked first (62%) as maintenance option. Of the 4 CD patients under IFX treatment, 2 were switched to leukapheresis for incomplete response, the third one developed thrombotic complications, and the last one achieved disease remission after 12 months. Of the 2 cases of UC, one lost response soon and was colectomized, the other is maintaining moderately active disease, requiring scheduled injections every 8 weeks.Despite the caution imposed by the very small numbers, this analysis confirms that the potent available options are difficult to be correctly positioned in the therapeutic algorithm of inflammatory bowel disease.

Irritable bowel syndrome (IBS), as defined by Rome III diagnostic criteria, affects 10-20% of the general population, with women 20-40 years old accounting for the majority of patients. Although variable and intermittent, IBS symptoms may persist for many years. Repeated referrals for medical consultation and diagnostic studies generate huge healthcare costs. Since there is no evidence that IBS leads to more severe gastrointestinal disorders, in absence of alarm symptoms or signs, an invasive diagnostic algorithm is not indicated. Optimal treatment for IBS still needs to be defined. The clinical approach is based on treatment of the prevalent symptom. When pain predominates, antispasmodics are the first choice. In case of diarrhea, loperamide is useful for reducing bowel frequency. Soluble fiber represents the first option in subjects with IBS and constipation or mixed IBS. Dietary integrators composed of probiotics and serotonin precursors are a promising therapeutic option.

Sepsis of the biliary tract is a severe disease, due to its course and its significant association with relevant diseases, either benign or malignant, of the biliary tract, pancreas, hepatic hilus. In many cases it remains difficult to set the limit between medical therapy, percutaneous or endoscopic therapy and surgical treatment. Through a thorough review of the last 20 years' literature, we have studied this topic and classified cholangitis according to its etiology: Iithiasis, benign stenosis or Klatskin tumor as malignant diseases. The sequential approach, endoscopy-surgery, seems to provide the best results in lithiasic cholangitis. In patients with benign stenosis of the biliary tract, a percutaneous drainage is indicated as a first choice, meanwhile surgery is limited to unsuccessful bilioplasty and to segmental extrahepatic localization of sclerosing cholangitis. On the contrary, in Klatskin tumours preoperative percutaneous drainages are useful to obtain an accurate map, which is indispensable to perform an aggressive radical hepatic resection.

The availability of osteodensitometry has contributed significantly to increase the awareness of inflammatory bowel disease (IBD)-associated bone disease. Reported osteoporosis prevalence in patients with IBD range from 2% to 30%. The fractures risk varies between studies, influenced by demographic, clinical and genetic factors. The main pathogenetic factors involved are malabsorption, treatment with glucocorticoids, inflammation (increased cytokine production) and hypogonadism. A screening should be considered for all patients with small bowel Crohn's disease and especially for those with extensive disease, multiple resections, and malnutrition. Supplementation with both calcium and vitamin D is frequently the first step taken, but is insufficient to inhibit bone loss in many patients requiring use of glucocorticoids. Among available therapies, only biphosphonates are effective for treatment of glucocorticoid-induced osteoporosis.

An association between lichen planus (LP) and liver diseases has been reported. PubMed database has been used to extract information on hepatitis C virus (HCV) infection and LP. The results suggest that LP, mainly the oral type, is significantly associated with HCV infection in Southern Europe and Japan but not in Northern Europe. These differences may be related to genetic factors. Detection of HCV viral sequences and HCV-specific CD4+ and/or CD8+ T lymphocytes in oral samples of LP patients suggests that HCV might be involved in the development of oral lesions via an immunological pathway, characterized by an excessive production of Th1 cytokines following an uneffective antiviral immuno-response.

Clostridium difficile-associated disease (CDAD) ranges in severity from mild diarrhoea to fulminant colitis and death. Antimicrobial use is the primary risk factor for development of CDAD. C. difficile typically affects older or severely ill patients, hospitalized or residents in long-term-care facilities. We report a case of CDAD in a 77-year-old woman operated on for cholecystitis calculosa and treated with cephalosporins and aminoglycosides. Symptoms and signs of CDAD were watery diarrhoea, mucus stool, high fever and, weakness. Sigmoidoscopy was provided on the second day after hospitalization. It revealed diffuse pseudomembranes throughout the distal colon, confirming C. difficile infection. Antimicrobial agents administered at the admission were stopped and treatment with oral vancomycin, metronidazole and famotidine was initiated. Despite this the patient's status worsened and she died because of cardiogenic shock.

Endoscopic ultrasound (EUS) is a relatively new technology developed in the early 80's, but introduced into the clinical practice only in the late 80's. Nowadays there is an increase in demand for EUS examinations and services, because this technique is more and more recognized as an important and integral part in the diagnostic and staging algorithm of many gastrointestinal (GI) and nongastrointestinal pathologies. Even if today the EUS panorama enrich itself with a large number of different instruments, mechanical and electronic scopes, radial and linear ones, several types of miniprobes and specialty probes, for diagnostic purposes the dedicated radial scanning instruments remain the more adopted choice while miniprobes can have applications only in niche areas, like superficial GI cancers staging, small subepithelial lesions evaluation or intraductal ultrasound and some technological advances are needed to solve the potential drawbacks of this miniaturized probes. At last the EUS equipment borrowed most of the electronic sophistication from the mainstream ultrasonography, this made the choice of an EUS instrument even more difficult and challenging, but you must consider that there is no right or wrong equipment, there is only the right instrument for that specific clinical need or situation.

Gastrointestinal (GI) disorders represent the third cause of consultations by general practitioners among subjects older than 65 years in Western countries. Although GI diseases in the elderly do not show peculiar characteristics, they often may present a more severe course, due to comorbidities and intake of many drugs. Moreover, several illnesses, such as neoplasias, are more frequent in the elderly. This review focuses on the epidemiological, physiopathological, and clinical aspects of GI diseases in advanced age. Some relevant issues are considered. It is advisable to avoid empirical approaches in the elderly and to choose endoscopic examinations because of the possibility to detect conditions such as already complicated gastroesophageal reflux disease or peptic ulcers as well as to diagnose precociously neoplastic formations in esophagus, stomach or colon. The monitoring of chronic liver disease is very important, mainly to prevent or detect hepatocellular carcinoma early. Idiopathic (or autoimmune) chronic pancreatitis in the elderly is more frequent than other forms of pancreatic diseases, like alcoholic pancreatitis.

Gastroesophageal reflux disease (GERD) is known to cause erosive esophagitis, Barrett esophagus and has been linked to the development of adenocarcinoma of the esophagus. Currently, endoscopy is the main clinical tool for visualizing esophageal lesions, but the majority of GERD patients do not have endoscopic visible lesions and other methods are required. Ambulatory esophageal pH monitoring is the gold standard in diagnosing GERD, since it measures distal esophageal acid exposure and demonstrates the relationship between symptoms and acid reflux. The effectiveness of selective gastric acid suppressive therapy led to the introduction of short trials of proton pump inhibitors (PPIs) to diagnose GERD and they are often used as a first line diagnostic tool in clinical practice and, in particular, in the primary care setting, the current trend being that gastroenterologists are asked to evaluate mainly patients with persistent GERD symptoms while on PPI therapy. In these patients the question is whether the persistent symptoms are or not associated with reflux (acid or nonacid). Recently, either combined multichannel intraluminal impedance and pH monitoring or bilimetry allow to study the mechanisms underlying the persistent symptoms on acid suppressive therapy. Manometry is mandatory prior to any surgical approach and to verify motility disorders that could be associated to GERD.

The interest that surrounds the bacterium Helicobacter pylori (H. pylori) is due not only to its causal role in several gastroduodenal diseases, but also to its supposed involvement in the pathogenesis of extragastric manifestations. This review provides a literature update on the hypothetic correlation between H. pylori and headache. The authors examine three aspects of this potential association: epidemiology, intervention trials and pathogenesis. Regarding the first, apart in some subgroups, no difference in prevalence exists between patients and controls. Considering the intervention studies, it is documented that, at 6 and 12 months, bacterial eradication is associated to disappearance of symptoms in 23% and 28% of cases, and to a significant decrease of intensity, frequency and duration of acute attacks in the remaining patients. As to the pathogenetic aspect, if H. pylori has a role, it does not act through oxidative stress. In conclusion, the involvement of H. pylori infection in the pathogenesis of headache is unclear. Further investigations should focalize on particular subgroups of patients and, encouraged from data produced by intervention studies, evaluate the long-term benefit of eradication.

As optimal therapy for irritable bowel syndrome (IBS) remains elusive, current approach to therapy is based on symptomatic treatment. With this case-control experience we wanted to determine the beneficial effect in IBS patients of a dietary integrator (IBS Active), composed of L-tryptophan, inulin, angelica, vegetal charcoal, vitamin PP, group B vitamins (B1, B2, B6) and probiotics (Lactobacillus sporogenes, Lactobacillus acidophilus, Streptococcus thermophilus).The treatment group comprised 37 patients (11 men and 27 women; mean age, 44.3+/-5.1 years) given IBS Active (440 mg bid) over a mean period of 6 months (range, 5-8). The control group comprised 28 patients (6 men and 22 women; mean age, 48.6+/-3.7 years) who were instructed to continue their customary therapy for 6 months (range, 5-7). All subjects were assessed for the presence of abdominal pain and/or distension, constipation, diarrhea and alternating constipation and diarrhea.Compared with baseline values, the reduction in abdominal pain in the treatment group was 62% (P0.0001), 55% (P0.0001) in abdominal distension, 58% (P=0.05) in constipation, 33% (P=0.3) in diarrhea, and 62% (P=0.01) in alternation constipation and diarrhea. Compared with baseline values, no statistically significant reduction in symptoms was found in the control group. Post-treatment comparison between the two groups showed that the study product had reduced symptoms and that the difference was statistically significant for abdominal pain (P0.000001), abdominal distension (P=0.003) and constipation (P=0.03).The use of IBS Active led to a significant improvement in pain symptoms, abdominal distension and regulation of bowel movement in IBS patients. Further study is needed to evaluate the long-term benefit of the study product.

Mortality due to hepatocellular carcinoma (HCC) is still high, because of its development in liver with impaired function due to underlying cirrhosis, of its chemoresistance and of its high rate of recurrence. Liver transplantation is considered the most efficacious treatment for patients with HCC. However, the low availability of organs limits the offer of this option to all candidates. Furthermore, liver transplantation is not lacking in risk of tumour recurrence. Other curative options include surgical resection and ablation using percutaneous techniques. Such approaches give similar and satisfactory survival rates, providing that patient selection is optimal in terms of tumour size and liver function. Since even in the presence of a radical therapeutic result this cancer maintains a high tendency for local recurrence, it is very important to explore the adjuvant ways to increase the disease-free survival in patients surgically treated. Treatment with interferon a and intrahepatic injection of (131)-Iodine labelled lipiodol ((131)I-Lipiodol) are instead showing encouraging results. This review presents a concise update on this issue.

Duodenal ulcer is a chronic disease, punctuated by acute relapses. The pathogenic mechanism in 90-100% of cases is infection by Helicobacter pylori. Two major strains exist of this bacterium: I strain, which secretes a vacuolating cytotoxin (Vac-A), and another protein named cytotoxin-associated (Cag-A) and type II strain, unable to produce both proteins and unable to produce duodenal pathology. We sought to identify the natural history of relapsing duodenal ulcer after cure of the bacterial infection. In particular, we followed the outcome of patients who repeatedly had bled from their recurrent ulcer disease, after success in eliminating the microorganism from the stomach. None of 12 repeated bleeders had an ulcer recurrence after the cure of Helicobacter pylori infection. Only 3 (5%) of 60 frequent relapser had a new episode of duodenal ulcer during a follow-up reinfection by Helicobacter pylori. We demonstrated that the cure of bacterial infection is also the cure of duodenal ulcer recurrence, but for a few cases, in the latter, event one could hypothesize a defect in the production of growth factors (Epidermal Growth Factor, Fibroblast Growth Factor) or of cellular polyamines synthesis. It is important to improve the diagnosis of reinfection by implementing the urea breath test.

Today it is expected that the great majority of patients with duodenal ulcer (DU) respond to H. pylori eradication treatment without DU recurrence. The aim of the research is to identify patients who need a different therapeutic approach and the best management of their disease.We examined retrospectively the medical history of 474 patients (326 males, mean age 61 years), followed up in 5 years in the outpatients department of a third level GI Center. From our research, 5 subgroups of patients emerged: 1) 63.5% carrying H. pylori infection, with successful eradication treatment and without DU recurrence; 2) 4% failing 3 courses of H.pylori eradication treatment; 3) 11% with DU lacking evidence of H. pylori infection or relapsing after verified eradication; 4) 8% being treated with NSAIDs; 5) 13% with DU complicated by hemorrhage or perforation.23% of patients with DU need long-term therapy after H. pylori eradication treatment. Concerning this, the percentage of ulcerous recurrences in patients receiving anti-H2 therapy is 18.5%, but decreases considerably to 2% when PPI were used.Although representing the mainstay of DU therapy, H. pylori eradication treatment may not abolish all issue in DU management. Actually, of DU patients referred to a third level GI Center, 23% need a different therapeutic approach, which results from a thorough analysis of the medical history of the patient.