Objectives:H. pylori infection is prevalent in Pakistan, affecting nearly 81% of the population. Many high-quality clinical practice guidelines (CPGs) have been developed in high-income countries. Low- and middle-income countries (LMICs) face challenges in developing de novo CPGs. Modifying pre-existing guidelines through the GRADE-ADOLOPMENT process is a practical approach to addressing this issue. We aimed to create a contextually relevant and comprehensive CPG for H. pylori management in Pakistan. Methods:The selected source guidelines underwent a thorough literature review and evaluation aligned with the GRADE approach. Recommendations were categorized as "Adopt," "Adapt," or "Exclude" after assessment by expert gastroenterologists. Adopted recommendations were included as-is or with minor changes. Excluded recommendations were removed, while adapted recommendations underwent significant alterations through the GRADE-ADOLOPMENT process. The GRADEPro application and Evidence to Decision tables aided the consensus process. The final meeting resulted in unanimous agreement on the CPG. Results:The source guidelines included 33 recommendations: 29 were adopted, and three were excluded. One recommendation required adaptation: "non-endoscopic testing for H. pylori infection is an option for patients under 60 with uninvestigated dyspepsia and no alarm features." According to the adapted version, patients under the age of 50 years with uninvestigated dyspepsia should undergo non-endoscopic testing. Conclusions:The creation of this CPG will equip general physicians with effective management strategies. Our study presents a CPG for H. pylori infection treatment in Pakistan, recommending endoscopic testing for patients aged over 50 years. Further research is needed to investigate the efficacy of early screening for uninvestigated dyspepsia in Pakistan. Our approach can help improve patient care globally, especially in LMICs.
Objectives:Successful eradication of Helicobacter pylori is essential for improving patient outcomes and preventing gastric cancer; however, evidence regarding sex-specific differences in treatment success and adverse event profiles remain limited. This study investigated sex-based differences in eradication efficacy and treatment tolerability. Methods:We retrospectively reviewed patients who underwent diagnostic testing, received eradication therapy, and completed post-treatment confirmation testing between 2003 and 2024 at Seoul National University Bundang Hospital. First-line therapy consisted of 10-day sequential therapy, while second-line treatment included 14-day bismuth-based quadruple therapy or 14-day moxifloxacin-based triple therapy. Treatment success and adverse events were evaluated by sex and treatment regimen. Results:Females had lower eradication rates in the overall cohort. The intention-to-treat analysis showed significantly higher success rates in males compared to females in the total population (71.1% vs. 65.1%, p<0.001) and in sequential therapy (70.5% vs. 62.1%, p<0.001), although this pattern was not replicated in the per-protocol results. Adverse events were reported nearly twice as often in females, regardless of the regimen, which may partly explain the reduced rates of successful eradication and increased discontinuation. Conclusions:Sex-based differences influence H. pylori eradication outcomes, with females showing lower treatment success rates and substantially more adverse events. Higher therapy intolerance and dropout rates in females may partially account for reduced effectiveness of eradication therapy, highlighting the need for sex-specific strategies and improved supportive care.
Objectives Endoscopic submucosal dissection (ESD) has become a standard minimally invasive treatment for selected patients with early gastric cancer (EGC). This study presents the first nationwide survey of patients with EGC treated with ESD in 2023, conducted by the Korean College of Helicobacter and Upper Gastrointestinal Research. Methods Data were retrospectively collected from participating referral centers across Korea using a standardized case report form covering patient characteristics, tumor features, procedural details, histopathological findings, and clinical outcomes. Descriptive and comparative analyses were conducted to summarize nationwide ESD practice patterns and outcomes. Results Data from 5460 ESD cases from 5250 patients across 27 institutions were analyzed. The mean age was 67.4 years, with 74.1% males. Multiple synchronous lesions were identified in 3.7%. Most lesions were located in the lower third of the stomach (64.0%), and differentiated-type adenocarcinomas accounted for 87.8%. The en bloc and complete resection rates were 99.2% and 91.4%, respectively. Curative resection was achieved in 80.5%, whereas local non-curative resection (L-NCR) and surgical non-curative resection (S-NCR) were identified in 2.8% and 16.7%, respectively. Additional surgery was performed more frequently in patients with S-NCR than in those with L-NCR (59.3% vs. 24.7%). The bleeding and perforation rates were 3.6% and 0.9%, respectively, and were mostly managed conservatively or endoscopically. The median length of hospitalization was 4.0 days. Conclusions This first nationwide survey provides a comprehensive overview of the current practice of EGC treatment using ESD in Korea, demonstrating high technical success and safety, and establishing a baseline dataset for future longitudinal research.
Plexiform fibromyxoma (PF) is a very rare mesenchymal tumor that presents as a subepithelial lesion (SEL). Endoscopically, it is almost indistinguishable from other SELs, and it has been reported to cause hemorrhage. Herein, the case of a patient diagnosed with PF after surgical resection for symptoms of hemorrhage, following a period of surveillance for a diagnosed SEL, is reported, and a review of the disease is provided.
Objectives Tegoprazan is an alternative to proton pump inhibitors (PPIs). This study evaluated the occurrence of upper gastrointestinal (GI) and cardiovascular (CV) complications in patients with ischemic heart disease undergoing antiplatelet therapy after percutaneous coronary intervention (PCI) who were treated with tegoprazan or PPIs. Methods Data from 604 patients who received antiplatelet therapy with tegoprazan or PPIs for >6 months after PCI between March 2019 and November 2023 were retrospectively analyzed. The primary GI endpoints were symptomatic gastroduodenal ulcers and upper GI bleeding, while the primary CV endpoints comprised major adverse cardiac events (MACEs), nonfatal myocardial infarction (MI), target vessel revascularization, and death from CV-related causes. Results Among the 604 patients, 265 received tegoprazan and 339 received PPIs. During a mean follow-up of 17 months, seven patients experienced a GI event (0.4% with tegoprazan vs. 1.8% with PPIs; p=0.112) and 12 experienced MACEs (1.1% with tegoprazan vs. 2.7% with PPIs; p=0.183). Subgroup analysis indicated that target vessel revascularization occurred in six patients, with event rates of 0.8% (n=2) for tegoprazan and 1.2% (n=4) for PPIs (p=0.598). Tegoprazan was associated with similar rates of nonfatal MI (0.8% vs. 2.4%; p=0.125) and death from CV-related causes (0.4% vs. 0%; p=0.258) as PPIs. Conclusions There were no significant differences in GI- or CV-related complications between patients treated with tegoprazan and those treated with PPIs.
Although the incidence and complications of peptic ulcer disease have declined, Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use remain key risk factors. Advances in proton pump inhibitors and potassium-competitive acid blockers have improved treatment outcomes. However, increasing antibiotic resistance has reduced the efficacy of the standard therapies for H. pylori eradication, necessitating the development of new approaches such as novel antibiotic combinations and bismuth-based regimens. Future studies should emphasize tailored strategies to address resistance and the development of innovative anti-ulcer therapies to enhance eradication and prevention efforts.
Reflux esophagitis is a significant clinical manifestation of gastroesophageal reflux disease (GERD), and its prevalence is increasing because of lifestyle changes and increasing obesity. The diagnosis of GERD primarily emphasizes symptom-based approaches that focus on heartburn and acid regurgitation. GERD can be confirmed through proton pump inhibitor (PPI) therapy, endoscopy, and 24-hour impedance-pH monitoring. Of these methods, endoscopy plays a critical role in diagnosing reflux esophagitis. Recently, both PPIs and potassium-competitive acid blockers (P-CABs) have been recommended as first-line treatments, with P-CABs showing greater efficacy in severe cases or in patients unresponsive to PPIs. This review discusses the prevalence and risk factors of reflux esophagitis, presents the latest insights into its pathophysiology and diagnosis, and provides a comparative analysis of recent domestic and international guidelines.
A 75-year-old woman presented with hematemesis and a history of perihilar cholangiocarcinoma treated with left lobectomy, caudate lobectomy, and Roux-en-Y hepaticojejunostomy. Esophagogastroduodenoscopy revealed a 3×3-cm polypoid lesion accompanied by active bleeding. Biopsy revealed adenocarcinoma, favoring metastasis over primary gastric cancer, considering the patient’s medical history and previous endoscopic evaluations. Despite endoscopic hemostasis, anemia persisted, prompting laparoscopic wedge resection of the gastric mass. Here, we present a rare case of gastric metastasis from cholangiocarcinoma, underscoring the unusual presentation of upper gastrointestinal bleeding caused by a gastric tumor in a patient previously treated for cholangiocarcinoma.
Surgery is the definitive treatment for superficial esophageal cancer. However, the risks and complications associated with surgery often lead to further complications. Endoscopic resection is an effective treatment option for superficial esophageal cancer. However, if the cancer invades more than three-quarters of the esophageal lumen, the risk of complications is high from both the procedure and potentially troublesome post-endoscopic esophageal stricture. To mitigate these issues, neoadjuvant radiotherapy or chemoradiotherapy may be administered before endoscopic resection to reduce the size of esophageal cancer. This report presents a case of complete remission of superficial esophagus cancer achieved with radiotherapy alone.
Stevens–Johnson syndrome and toxic epidermal necrolysis (TEN) are rare, life-threatening adverse drug reactions. Here, we report a fatal case of TEN in an 80-year-old patient who developed diffuse bullous eruptions and multiorgan failure following first-line Helicobacter pylori eradication therapy with a proton pump inhibitor, amoxicillin, and clarithromycin. Initial symptoms appeared four days posttreatment. Despite intensive care, including corticosteroids and supportive treatment, the patient died of sepsis and progressive organ failure. This case highlights the need for early detection of severe cutaneous adverse reactions, particularly in elderly patients receiving H. pylori eradication therapy.
The surgical management of gastric cancer has evolved rapidly, with minimally invasive, function-preserving, and fluorescence-guided techniques increasingly adopted as standard practice. Laparoscopic and robotic gastrectomies have shown comparable long-term oncologic outcomes while providing improved perioperative recovery, and individualized reconstruction methods further enhance postoperative quality of life. Recent trials support the use of neoadjuvant chemotherapy for locally advanced disease, demonstrating improved recurrence-free survival. Postoperative management has shifted its focus from early complication prevention to long-term care, addressing nutritional deficiencies and functional syndromes such as anemia, osteoporosis, dumping syndrome, and gastrointestinal dysfunction. Close coordination between surgeons and multidisciplinary care teams is crucial to ensure the prompt management of postoperative complications, including bleeding, leakage, and abscess formation. The implementation of structured protocols for nutritional assessment, micronutrient supplementation, and comprehensive long-term surveillance is strongly advocated to optimize patient survival and preserve postoperative quality of life. This review summarizes the latest evidence and trends in surgical and postoperative care for gastric cancer, highlighting the importance of standardized, evidence-based protocols and individualized patient care strategies.
Multiple primary malignant neoplasms are defined as the occurrence of two or more distinct malignant neoplasms in a single patient. However, synchronous triple primary malignant neoplasms have rarely been reported. We present the case of a 54-year-old male patient who was referred to our outpatient clinic after abnormal findings were detected during upper gastrointestinal endoscopy screening at a local clinic. Comprehensive evaluation using endoscopy, computed tomography, and positron emission tomography led to the simultaneous diagnosis of early gastric, early esophageal, and sigmoid colon cancers. The patient underwent endoscopic submucosal dissection and simultaneous surgical resection of the other two neoplasms. The patient remained without evidence of recurrence or metastasis at the one-year follow-up.
With the increasing number of upper gastrointestinal (GI) surgeries, the anatomical changes resulting from these procedures have become diverse and complex, presenting significant challenges for endoscopic evaluation and intervention. This review systematically analyzes the representative anatomical alterations following upper GI surgeries, including esophageal, gastric, and bariatric surgeries, and proposes effective endoscopic approaches tailored to each surgical type. In esophageal surgery, strategies for evaluating structural changes, such as conduit reconstruction, anastomotic strictures, and delayed gastric emptying, are reviewed. Anatomical alterations associated with various reconstruction methods (Billroth I, Billroth II, Roux-en-Y, and double-tract reconstruction), including anastomotic strictures, bile reflux, and remnant gastric dilatation, are discussed, along with detailed approaches for endoscopic access and assessment. Additionally, we address the significant increase in bariatric surgeries (sleeve gastrectomy and Roux-en-Y gastric bypass) in South Korea and discuss the endoscopic management of related complications, such as marginal ulcers, strictures, and gastrogastric fistulae. Through this review, we emphasize that a thorough understanding of surgery-specific anatomical characteristics, meticulous pre- and post-operative reviews of medical records and imaging, and adherence to the recently highlighted “3C principles” (confirm anatomy, check perfusion, and control complications) are essential for enhancing the accuracy and safety of endoscopic diagnoses and interventions in patients with surgically altered anatomy.
Objectives This preliminary, randomized, double-blind, multi-center study evaluated the efficacy of alternate-day tegoprazan (50 mg) versus daily lansoprazole (15 mg) as for maintenance therapy in patients with non-erosive reflux disease (NERD). Methods Forty five participants were enrolled and treated for 8 weeks. The primary endpoint was the proportion of symptom-free days. The secondary endpoints were changes in Gastrointestinal Symptom Rating Scale (GSRS) and Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) scores. Results It showed no significant difference between groups in the proportion of symptom-free days between both groups (tegoprazan: 60.4%±6.3%; lansoprazole: 74.0%±6.5%). The GSRS and GERD-HRQL score improvements were also comparable between both groups. Both treatments were well tolerated, with no serious adverse events reported. Conclusions These findings suggest that alternate-day tegoprazan offers comparable efficacy and safety to daily lansoprazole therapy and may serve as a more flexible and patient-friendly maintenance option for NERD.
The over-the-scope clip (OTSC) system is increasingly used for the endoscopic hemostasis of bleeding non-variceal upper gastrointestinal lesions. OTSCs provide secure, full-thickness tissue compression. The Stop the Bleeding Trial (STING-1) was a German multicenter randomized controlled trial (RCT) that compared OTSC to standard treatment (through-the-scope clips and contact thermal devices) for refractory bleeding ulcers. The rate of further bleeding was significantly reduced with the use of OTSC (19 of 33 patients [57.6%] in the standard therapy group and 5 of 33 patients [15.2%] in the OTSC group). As a first-line endoscopic treatment, OTSCs have been compared with standard treatments in five RCTs, including the STING-2 trial. OTSCs are generally superior in controlling bleeding. Therefore, we recommend the use of OTSCs for lesions with a high risk of further bleeding. These include large ulcers (2 cm in size or larger) located at the duodenal bulb and the lesser curve of the stomach, and ulcers with vessels >2 mm in size. We have also used OTSCs for Dieulafoy’s lesions, often with thick submucosal arteries. An ongoing RCT is comparing the use of OTSCs with trans-arterial embolization (TAE) for refractory bleeding. TAE is considered the most definitive, but is associated with a 30% rate of further bleeding. The results of the RCT will help define the management algorithm for such cases.
Objectives Early diagnosis of upper gastrointestinal (UGI) amyloidosis and the establishment of appropriate treatment and follow-up strategies remains challenging. This study aimed to elucidate the endoscopic characteristics and clinical courses of patients with isolated UGI amyloidosis. Methods We retrospectively reviewed 11 patients diagnosed with isolated UGI amyloidosis at Chonnam National University Hospital and Chonnam National University Hwasun Hospital. None of the patients exhibited systemic involvement or multiple myeloma. Clinical data, including endoscopic features, presenting symptoms, and outcomes such as disease progression and mortality, were analyzed. Results The cohort included seven males (63.6%) and four females (36.4%), with a median age of 72 (37–82) years. Isolated gastric amyloidosis was identified in four patients, and five patients had disease confined to the duodenum. Two patients (18.2%) presented with gastric or duodenal involvement. Endoscopic findings were heterogeneous, with diffuse yellowish linear lesions being the most frequently observed in four patients (36.4%). Histopathological analysis revealed AA amyloidosis in three patients, whereas five patients exhibited only amorphous deposits without amyloid A, amyloid P, or light chains. Six patients (54.5%) were asymptomatic at diagnosis, whereas gastrointestinal bleeding was observed in two patients (18.2%). Only one patient (9.1%) experienced disease progression that necessitated systemic chemotherapy. The mean follow-up duration was 20 months, and the 3-year mortality rate was 9.1%. Conclusions Isolated UGI amyloidosis is a heterogeneous condition that can be easily misdiagnosed. Familiarity with the characteristic endoscopic features and natural disease course is essential for appropriate management.
With advances in gastric cancer treatment, survival outcomes following surgery have improved; however, recurrence remains a significant challenge. Postoperative follow-up is crucial for the early detection of recurrence, enabling timely intervention and improving long-term survival. In patients who undergo curative resection of gastric cancer, postoperative surveillance typically includes regular esophagogastroduodenoscopy, blood tests—including tumor marker assessments—and imaging studies such as computed tomography. However, there is limited evidence that such follow-up strategies contribute to improved long-term survival. Multiple international guidelines recommend postoperative follow-up schedules and strategies based on retrospective studies and expert opinions. The impact of Helicobacter pylori eradication on long-term outcomes after gastric cancer surgery remains a subject of ongoing debate. Secondary primary cancer following gastric cancer treatment is another issue during postoperative follow-up. Optimizing follow-ups using an individualized, evidence-based approach is crucial.
Remnant gastric cancer (RGC) can develop in patients who have undergone curative resection for gastric cancer and in those who have undergone gastrectomies for benign disorders such as peptic ulcer disease. Routine endoscopic surveillance is recommended for early detection of cancer at the anastomosis site or within the remnant stomach. However, endoscopy in postgastrectomy patients may be challenging because of the limited space of the remnant stomach, deformity at the anastomosis site, interference from retained food material, and inflammation associated with recurrent bile reflux. The interval and location of RGC occurrence may vary depending on the type of primary disease, the stage of the initial cancer, and the reconstruction method used. Elevated lesions are the most common finding in early stage RGC in the remnant stomach, whereas ulceroinfiltrative lesions are more frequently observed in advanced RGC at the anastomosis site. Therefore, meticulous examination of the gastric mucosa at both the anastomosis site and in the remnant stomach is crucial for the early detection and diagnosis of RGC in post-gastrectomy patients.
