BACKGROUND:Carcinomas of the stomach and esophagogastric junction (EGJ) are the fifth leading cause of cancer-related deaths worldwide. In Germany, gastric cancer ranks tenth in incidence across both sexes. The new German national guideline aims to provide the most relevant evidence-based recommendations on diagnosis and treatment of gastric and EGJ adenocarcinomas and has been comprehensively updated by an interdisciplinary panel of experts from national medical societies. SUMMARY:The updated S3 guideline reflects the latest advances in diagnostics, improved palliative therapies, and supportive care. The objectives are to improve the quality of individual and broad care and to ensure consistent, evidence-based treatment strategies. KEY MESSAGES:New recommendations introduce preventive strategies, including management of familial risk due to microsatellite instability (MSI) and H. pylori eradication. The biomarkers HER2, PD-L1, MSI, and Claudin 18.2 enable the use of targeted therapies that improve long-term outcomes in advanced disease. Combinations of chemotherapy with immunotherapy nivolumab, pembrolizumab, or tislelizumab significantly prolong survival compared with chemotherapy alone (e.g., nivolumab 14.4 vs. 11.1 months, HR 0.71; pembrolizumab 13.0 vs. 11.4 months, HR 0.75; tislelizumab 17.2 vs. 12.6 months, HR 0.74) with 5-year survival rates up to 16%. In patients with high Claudin 18.2 expression, zolbetuximab plus chemotherapy improved median survival to 16.4 vs. 13.4 months (HR 0.77). For patients in good general condition, subsequent lines of therapy including biomarker-driven approaches (trastuzumab deruxtecan, pembrolizumab) or third-line therapies (e.g., trifluridine tipiracil) and advanced molecular diagnostics are recommended after treatment failure.

Background and aims:Endoscopic assessment of the regular arrangement of collecting venules (RAC) is a simple and reliable tool for predicting the absence of Helicobacter pylori (H. pylori) infection in the stomach, particularly in Asian populations. While initial studies in Western countries have yielded similar findings, RAC assessment has not yet been widely adopted in these settings. This study aims to evaluate the diagnostic accuracy of RAC in determining H. pylori status in a non-Asian population. Methods:This prospective, multicenter study was conducted in 12 hospitals across non-Asian countries. Patients with no history of H. pylori infection or eradication were included, regardless of proton pump inhibitor (PPI) use. All participants underwent high-definition upper endoscopy without magnification or virtual chromoendoscopy. Endoscopists were trained using a 20-image test to identify the RAC pattern. H. pylori status was determined by histology and/or immunohistochemistry. Results:A total of 648 patients were included, with an H. pylori infection prevalence of 34.7%. The RAC+ pattern was observed in 31.5% of patients, with no significant differences between those receiving PPI treatment and those who were not (p = 0.55). Absence of pathological endoscopic findings was significantly associated with a RAC+ pattern (p = 0.01). The sensitivity and negative predictive value (NPV) of RAC+ for ruling out H. pylori infection were 0.97 (95% CI: 0.94-0.99), reaching 1.00 when discordant images were reviewed by a blinded expert endoscopist. No significant differences in sensitivity or NPV were found between PPI users and non-users, or between regions with high and low H. pylori prevalence. Conclusion:The presence of the RAC pattern along the minor gastric curvature, as assessed with white-light endoscopy, accurately identifies patients without H. pylori infection in non-Asian countries, regardless of PPI use.

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Strategies for population-based screening are thus far only implemented in high incidence countries such as South Korea or Japan with data showing a positive impact on gastric cancer mortality. Screening in most Western countries is deemed not cost-effective as these are mainly classified as low or intermediate risk regions. This is in part due to high costs for endoscopy as the diagnostic gold-standard. Blood testing for serum pepsinogens is implemented as a pre-screening tool in some Asian countries but can better highlight mucosal atrophy than the cancer itself. Endoscopic surveillance of patients with advanced preneoplastic conditions allows detection of early neoplastic lesions that can be treated endoscopically, resulting in better outcome, and is hence now also recommended by several European countries. However, there is no uniform approach, so screening and surveillance strategies need to take regional characteristics into account including gastric cancer incidence and cost for endoscopy among others.

Onco-gastroenterology is defined as a collaborative subspecialty of Gastroenterology that is dedicated to the unique needs of individuals with or at risk of cancer, with a focus on maintaining and managing their digestive and liver health throughout their clinical course.

Crohn’s disease often presents with fistulae, abnormal tunnels that connect the intestine to the skin or other organs. Despite their profound effect on morbidity, the molecular basis of fistula formation remains unclear, largely owing to the challenge of capturing intact fistula tracts and their inherent heterogeneity 1–3 . Here we construct a subcellular-resolution spatial atlas of 68 intestinal fistulae spanning diverse anatomical locations. We describe fistula-associated epithelial, immune and stromal cell states, revealing abnormal zonation of growth factors and morphogens linked to establishment of tunnelling anatomy. We identify fistula-associated stromal (FAS) fibroblasts, which are assembled in concentric layers: a proliferative, lumen-adjacent zone beneath neutrophil and macrophage-rich granulation tissue, an active lesion core of FAS cells and a quiescent, pro-fibrotic outer zone. We examine the architecture of the extracellular matrix in the fistula tract and demonstrate that FAS populations associate with distinct collagen structures, exhibiting properties ranging from proliferation, migration and extracellular matrix remodelling to dense collagen deposition and fibrosis. We define niches supporting epithelialization of fistula tunnels and a FAS-like population that is detected at the base of ulcers in non-penetrating Crohn’s disease. Our study demonstrates that common molecular pathways and cellular niches underpin fistulae across intestinal locations, revealing the cellular protagonists of fistula establishment and persistence. This resource will inform the development of model systems and interventions to mitigate aberrant fibroblast activity while preserving their regenerative properties in Crohn’s disease.

Background:The first international guideline for managing preneoplastic conditions of the stomach (MAPS I) was published in 2012, followed by an update (MAPS II) in 2019. As adherence to these guidelines remains uncertain, we evaluated adherence by comparing the management of preneoplastic gastric conditions before and after the introduction of MAPS I and II in selected European centers. Methods:Patient data were retrieved from nine endoscopy units in seven European countries during three periods: pre-MAPS I (2010/2011), post-MAPS I (2017/2018), and post-MAPS II (2022/2023). Screening and dyspepsia-related endoscopies were included. Data on endoscopies, histopathology, Helicobacter pylori treatment, and surveillance were collected using a standardized form. Adherence to nine MAPS recommendations was assessed, with improvement defined as a ≥10-percentage point increase in guideline-concordant management. Results:A total of 2426 patients were included. Over the years, most centers (57%) improved in seven of the nine recommendations. Virtual chromoendoscopy use improved in six centers, with four reporting its use in >50% of cases. All centers improved in performing biopsies from the antrum and corpus, five conducted random biopsies in nearly all patients, and four performed these plus a biopsy from the incisura in >90% of cases. Endoscopic scores for patient stratification were rarely used, although five centers improved in histological scoring or intestinal metaplasia subtyping. H. pylori treatment recommendations remained high (71%–100%), and endoscopic surveillance adherence improved in 4/7 centers. Conclusions:Adherence to MAPS guidelines improved in most centers; however, gaps in virtual chromoendoscopy, targeted biopsies, and endoscopic/histopathological scoring remain, potentially affecting surveillance recommendations. This underscores the need for a more tailored approach to enhance implementation.

BACKGROUND:Helicobacter pylori resistance to antibiotics commonly used in eradication regimens is increasing dramatically in many locations; new strategies are needed to manage this infectious disease. OBJECTIVE:This study's aim was to collect and update information on antibiotic resistance (AR) rates in H. pylori as well as current strategies for H. pylori management, including public health issues, from a global perspective. DESIGN:An international survey was conducted in 31 countries on 6 continents to address key issues concerning the management of H. pylori-related AR. Individual aspects included the prevalence of AR for specific antibiotics, antibiotic susceptibility testing (AST) in different healthcare systems, availability of drugs, reimbursement issues and strategies for H. pylori AR surveillance. RESULTS:Resistance to the most effective antibiotics used in H. pylori eradication regimens is increasing globally, with clarithromycin and levofloxacin resistance exceeding 15% in 24/31 and 18/31 countries, respectively. Amoxicillin remains an exception, with resistance rates under 2% in 14/31 countries; though African countries have reported amoxicillin resistance rates of over 90%. Bismuth-based treatment regimens are the most effective and are recommended as first-line treatment in several countries. However, more than 1 billion inhabitants worldwide have no access to bismuth-based regimens. PCR-based tests for AR are used in 16/26 countries but are reimbursed in only 4, while next generation sequencing-based tests are available, but not reimbursed, in 3 countries. In 22/26 countries only culture-based methods are available (reimbursed in 9/26 countries). AR surveillance programmes have only been established in 4/26 countries. Therefore, in most countries, empirical therapy with the most effective local regimen available locally is practiced. CONCLUSION:The dramatic global rise in H. pylori antibiotic resistance requires an urgent revision of current management strategies. Possible solutions include AST-based selection of effective treatment regimens, identification of novel combinations of existing drugs and exploration of novel drugs.

BACKGROUND:Survival rates after a diagnosis of cancer are improving. Poorly managed gastrointestinal (GI) side effects can interfere with delivery of curative cancer treatment. Long-term physical side effects of cancer therapy impinge on quality of life in up to 25% of those treated for cancer, and GI side effects are the most common and troublesome. AIM:To provide comprehensive, practical guidance on the management of acute and chronic luminal gastrointestinal symptoms arising during and after treatment for cancer METHODS: A multidisciplinary expert group including patients treated for cancer, divided into working parties to identify, and synthesise recommendations for the optimal assessment, diagnosis and appropriate interventions for luminal GI side effects of systemic and local cancer therapies. Recommendations were developed using the principles of the BMJ AGREE II reporting. RESULTS:103 recommendations were agreed. The importance of the patient perspective and what can be done to support patients are emphasised. Key physiological principles underlying the development of GI toxicity arising from cancer therapy are outlined. Individual symptoms or symptom clusters are poor at distinguishing the underlying cause(s), and investigations are required if empirical therapy does not lead rapidly to significant benefits. Patients frequently have multiple GI causes for symptoms; all need to be diagnosed and optimally treated to achieve resolution. Investigations and management approaches now known to be ineffective or of questionable benefit are highlighted. CONCLUSIONS:The physical, emotional and financial costs to individuals, their families and society from cancer therapy can be considerable. Identifying and signposting affected patients who require specialist services is the role of all clinicians. Progress in the treatment of cancer increasingly means that patients require expert, multidisciplinary supportive care providing effective and safe treatment at every stage of the cancer journey. Development of such expertise should be prioritised as should the education of health professionals and the public in what, when and how acute and chronic gastrointestinal symptoms and complications should be managed.

BACKGROUND & AIMS:Although Helicobacter pylori screen-and-treat has demonstrated effectiveness in preventing gastric cancer (GC), the impact on other diseases, such as peptic ulcer disease (PUD), dyspepsia, and gastric lymphomas, is often overlooked in guidelines and policy-analyses. This study quantifies the disease burden attributable to H pylori beyond GC. METHODS:A systematic literature search identified studies reporting the relative risk of developing PUD, dyspepsia, or gastric lymphomas due to H pylori to calculate the population attributable fraction (PAF) for each condition. The PAF represents the proportion of disease burden caused by H pylori. Preventable case numbers were calculated based on the risk reduction from eradication, both globally and specific for countries with varying H pylori prevalence. RESULTS:The proportions of PUD, dyspepsia, and gastric lymphoma attributable to H pylori (95% confidence interval) were 57% (44%-68%), 7% (2%-13%), and 33% (12%-53%), respectively, corresponding to 3.5 (2.7-4.2) million, 30 (7.1-52.2) million, and 12,000 (4200-19,100) cases potentially preventable through eradication, globally. Country-specific estimates varied with lowest PAFs (PUD, dyspepsia, gastric lymphomas) observed in the United States (35% [24%-47%], 3% [2%-13%], and 17% [5%-31%]) and highest in South Korea (63% [50%-73%], 9% [2%-15%], and 39% [14%-58%]). However, even in the United States, preventable case numbers remained substantial for PUD (134,000 [93,000-177,000]) and dyspepsia (860,000 [196,000-1.5 million]). CONCLUSIONS:Omitting PUD and dyspepsia as outcomes in studies on H pylori screen-and-treat may substantially underestimate benefits. Incorporating these diseases alongside GC into cost-effectiveness and policy analyses, therefore, may improve the evaluation of H pylori screen-and-treat programs. The actual benefit depends on the extent to which H pylori triggers an irreversible pathway to disease early in life.

ABSTRACT Microbiome analysis has become a crucial tool for basic and translational research due to its potential for translation into clinical practice. However, there is ongoing controversy regarding the comparability of different bioinformatic analysis platforms and a lack of recognized standards, which might have an impact on the translational potential of results. This study investigates how the performance of different microbiome analysis platforms impacts the final results of mucosal microbiome signatures. Across five independent research groups, we compared three distinct and frequently used microbiome analysis bioinformatic packages (DADA2, MOTHUR, and QIIME2) on the same subset of fastQ files. The source data set encompassed 16S rRNA gene raw sequencing data (V1–V2) from gastric biopsy samples of clinically well-defined gastric cancer (GC) patients ( n = 40; with and without Helicobacter pylori [ H. pylori ] infection) and controls ( n = 39, with and without H. pylori infection). Independent of the applied protocol, H. pylori status, microbial diversity and relative bacterial abundance were reproducible across all platforms, although differences in performance were detected. Furthermore, alignment of the filtered sequences to the old and new taxonomic databases (i.e., Ribosomal Database Project, Greengenes, and SILVA) had only a limited impact on the taxonomic assignment and thus on global analytical outcomes. Taken together, our results clearly demonstrate that different microbiome analysis approaches from independent expert groups generate comparable results when applied to the same data set. This is crucial for interpreting respective studies and underscores the broader applicability of microbiome analysis in clinical research, provided that robust pipelines are utilized and thoroughly documented to ensure reproducibility. IMPORTANCE Microbiome analysis is one of the most important tools for basic and translational research due to its potential for translation into clinical practice. However, there is an ongoing controversy about the comparability of different bioinformatic analysis platforms and a lack of recognized standards. In this study, we investigate how the performance of different microbiome analysis platforms affects the final results of mucosal microbiome signatures. Five independent research groups used three different and commonly used bioinformatics packages for microbiome analysis on the same data set and compared the results. This data set included microbiome sequencing data from gastric biopsy samples of GC patients. Regardless of the protocol used, Helicobacter pylori status, microbial diversity, and relative bacterial abundance were reproducible across all platforms. The results show that different microbiome analysis approaches provide comparable results. This is crucial for the interpretation of corresponding studies and underlines the broader applicability of microbiome analysis.

Aims Helicobacter pylori (HP) is the major cause of gastritis and gastritis-associated diseases. Endoscopic detection of a regular arrangement of collecting venules (RAC) pattern in the lesser gastric curvature correlates with negative HP status in Asian countries when using magnification endoscopes. The aim of the study was to evaluate the value of RAC as a diagnostic method of HP infection during non-magnification white-light endoscopy in Western countries.

Key word therapy - diagnostics - eradication - resistance - antibiotics

Abstract Background Crohn's disease (CD) frequently results in fistula development in approximately 40% of patients due to sustained, transmural inflammation within the bowel wall. Despite advanced treatments, recurrence of fistulae affects one third of patients. Understanding its pathogenesis is crucial for targeted treatments, yet remains poorly defined. This study employs spatial transcriptomic and single-cell RNA-sequencing (scRNA-seq) technologies to characterise human fistulating CD tissue pathology. Methods Unbiased FFPE spatial transcriptomics (10x Visium) were applied to surgically resected, full-thickness (FT) tissue from 20 CD-associated fistulae cases and 15 controls. Subsequently, selected cases underwent further analysis using custom 500-plex MERFISH subcellular resolution spatial transcriptomics (Vizgen MERSCOPE). Additionally, a reference single-cell cohort encompassing patients with fistulating, stricturing, and inflammatory CD phenotypes, along with healthy controls, was generated. Optimisation of scRNA-seq for resected FT ileal tissue enabled the isolation and profiling of epithelial, immune, and stromal populations (10x Chromium). Computational analysis facilitated the spatial localisation of single-cell clusters enriched in fistula CD tissue, identifying key parameters linked to fistula development. Results The scRNA-seq data revealed diverse CD-specific cellular states adopted by intestinal fibroblasts, with IL11+ fibroblasts prominently expressing CD82, COL7A1, MMP1, CHI3L1, suggestive of pro-fibrotic signalling and regenerative morphogen pathways. This coincided with the expansion of a CD-specific subpopulation of pericytes (CCL19/CCL21) involved in leucocyte migration. Spatial profiling of CD fistula tracts by Visium and MERSCOPE unveiled an enrichment of key epithelial developmental transcription factors (e.g., GRHL3) and localised the pro-fibrotic signature displaying increased IL11 and MMP expression, along with perturbed WNT signalling within the fistula stroma. Active proliferation (HOPX, MKI67) was observed at the base of fistula tracts and within the stroma. Transcriptomic characterisation depicted a gradual loss in stem cell signature (LGR5, ASCL2, SMOC2) and supporting telocytes (POSTN) toward the leading edge of the fistula, signifying abnormal epithelium loss. Conclusion This pioneering study integrates multi-modal spatial transcriptomics and single-cell profiling to unveil the intricate cellular and molecular landscape in FT, fistulating CD pathology. Spatial analyses elucidate specific mechanisms involved in epithelial loss, stromal remodelling, and perturbed WNT signalling pathways within fistulating tissue, outlining a course of disrupted regenerative processes in fistulating CD.

ObjectiveDuring the last decade, the management of gastric intestinal metaplasia (GIM) has been addressed by several distinct international evidence-based guidelines. In this review, we aimed to synthesise these guidelines and provide clinicians with a global perspective of the current recommendations for managing patients with GIM, as well as highlight evidence gaps that need to be addressed with future research.DesignWe conducted a systematic review of the literature for guidelines and consensus statements published between January 2010 and February 2023 that address the diagnosis and management of GIM.ResultsFrom 426 manuscripts identified, 16 guidelines were assessed. There was consistency across guidelines regarding the purpose of endoscopic surveillance of GIM, which is to identify prevalent neoplastic lesions and stage gastric preneoplastic conditions. The guidelines also agreed that only patients with high-risk GIM phenotypes (eg, corpus-extended GIM, OLGIM stages III/IV, incomplete GIM subtype), persistent refractoryHelicobacter pyloriinfection or first-degree family history of gastric cancer should undergo regular-interval endoscopic surveillance. In contrast, low-risk phenotypes, which comprise most patients with GIM, do not require surveillance. Not all guidelines are aligned on histological staging systems. If surveillance is indicated, most guidelines recommend a 3-year interval, but there is some variability. All guidelines recommendH. pylorieradication as the only non-endoscopic intervention for gastric cancer prevention, while some offer additional recommendations regarding lifestyle modifications. While most guidelines allude to the importance of high-quality endoscopy for endoscopic surveillance, few detail important metrics apart from stating that a systematic gastric biopsy protocol should be followed. Notably, most guidelines comment on the role of endoscopy for gastric cancer screening and detection of gastric precancerous conditions, but with high heterogeneity, limited guidance regarding implementation, and lack of robust evidence.ConclusionDespite heterogeneous populations and practices, international guidelines are generally aligned on the importance of GIM as a precancerous condition and the need for a risk-stratified approach to endoscopic surveillance, as well asH. pylorieradication when present. There is room for harmonisation of guidelines regarding (1) which populations merit index endoscopic screening for gastric cancer and GIM detection/staging; (2) objective metrics for high-quality endoscopy; (3) consensus on the need for histological staging and (4) non-endoscopic interventions for gastric cancer prevention apart fromH. pylorieradication alone. Robust studies, ideally in the form of randomised trials, are needed to bridge the ample evidence gaps that exist.

We read with interest the excellent and comprehensive British Society of Gastroenterology guidelines on the management of functional dyspepsia. While this guideline covers a very important topic in gastroenterology and provides valuable recommendations for clinical practice, we would like to take the opportunity to comment on one recommendation that is not in line with other international standards. The authors recommend that ‘successful eradication of Helicobacter pylori after ‘test and treat’ should only be confirmed in patients with an increased risk of gastric cancer’ and refer in the accompanying text to the fourth edition of the European Maastricht consensus guidelines on this topic. While this topic was not discussed in detail in version IV of Maastricht, a clear recommendation on this matter was made in its predecessor (version III): ‘H. pylori eradication should be confirmed at least 4 weeks after treatment’. This refers to all patients who have been treated and this point was reiterated in the recently published current version (VI) which states that testing after treatment should be ‘routinely performed in all patients’. H. pylori infection is an infectious disease which has the potential to cause severe complications including peptic ulceration and gastric cancer. As there are no reliable biomarkers which can predict the consequences of H. pylori gastritis in an individual patient, it is important that treatment success is confirmed. Furthermore, significant problems have arisen over the last two decades as a result of increasing resistance rates to the antibiotics that are usually prescribed for first line eradication, including clarithromycin, metronidazole and levofloxacin. 7 This has led to a substantial increase in firstline treatment failure. Although local monitoring of the efficacy of eradication therapy and of antibiotic resistance rates is recommended, this has not been routinely performed in the UK for many years and national resistance data are not available. 7 Therefore, we do not currently know the efficacy of firstline eradication therapy in the UK, but most gastroenterologists are nowadays encountering treatment failure frequently. Unlike most other areas of the world, the current standard eradication treatment in the UK remains clarithromycinbased triple therapy for 7 days, with the recommendation by Public Health England that treatment success should be assessed based on symptom response. This approach, however, has two key problems. H. pylori eradication treatment may lead to transient symptom reduction because of the acid suppressant component in eradication regimens or even a placebo effect. Second, recrudescent infection may lead to serious conditions such as gastric cancer. Without a formal diagnostic test to confirm eradication, some patients might be inappropriately considered as ‘cured’, and still be at risk of developing future complications. Equally important, some patients with upper GI symptoms that are not primarily caused by H. pylori infection might be considered as treatment failures even when eradication has been achieved and might be prescribed several further rounds of empiric treatment. This could lead to further generation of resistant bacteria which is a tremendous concern in the modern era of antibiotic stewardship. The guidelines also recommend testing of success of eradication treatment only in patients who are at increased risk for gastric cancer (without further details about how such increased risk is defined). The stratification of individuals according to their individual gastric cancer risk only applies to the setting of primary screening in areas with a low incidence of gastric cancer. As risk in this situation is a continuum, the recommendation is impractical to implement and for the reasons listed above, we instead advocate testing for eradication success in all patients. The modalities used to check eradication success are noninvasive and inexpensive. Thus, we strongly advocate that successful H. pylori eradication is confirmed using a dedicated test in all patients who have been treated for this infection. This does not depend on the initial indication for testing and includes those patients who have been investigated for (functional) dyspepsia.