Gastric cancer, Helicobacter pylori infection and other risk factors

Gastric cancer incidence is declining. However, it is too early to consider this neoplastic disease as rare and the worldwide mortality rate still remains high. Several risk factors have been identif ied for non-cardia gastric cancer and primary prevention is feasible since most of the risk factors can be removed. Helicobacter pylori eradication treatment reduces but does not abolish gastric cancer risk. Indeed, gastric cancer is a multifactorial disease and removing one factor does not therefore prevent all cases. Endoscopic surveillance is still needed, especially in subjects at higher risk. The def inition of high-risk patients will be the future challenge as well as identifying the best surveillance strategy for such patients.

Diagnosis and management of gastric antral vascular ectasia

Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding, responsible of about 4% of non-variceal upper GI haemorrhage. The diagnosis is mainly based on endoscopic pattern and, for uncertain cases, on histology. GAVE is characterized by a pathognomonic endoscopic pattern, mainly represented by red spots either organized in stripes radially departing from pylorus, defined as watermelon stomach, or arranged in a diffused-way, the so called honeycomb stomach. The histological pattern, although not pathognomonic, is characterized by four alterations:vascular ectasia of mucosal capillaries, focal thrombosis, spindle cell proliferation and fibrohyalinosis, which consist of homogeneous substance around the ectatic capillaries of the lamina propria. The main differential diagnosis is with Portal Hypertensive Gastropathy, that can frequently co-exists, since about 30% of patients with GAVE co-present a liver cirrhosis. Autoimmune disorders, mainly represented by Reynaud's phenomenon and sclerodactyly, are co-present in about 60% of patients with GAVE; other autoimmune and connective tissue disorders are occasionally reported such as Sjogren's syndrome, systemic lupus erythematosus, primary biliary cirrhosis and systemic sclerosis. In the remaining cases, GAVE syndrome has been described in patients with chronic renal failure, bone marrow transplantation and cardiac diseases. The pathogenesis of GAVE is still obscure and many hypotheses have been proposed such as mechanical stress, humoural and autoimmune factors and hemodynamic alterations. In the last two decades, many therapeutic options have been proposed including surgical, endoscopic and medical choices. Medical therapy has not clearly shown satisfactory results and surgery should only be considered for refractory severe cases, since this approach has significant mortality and morbidity risks, especially in the setting of portal hypertension and liver cirrhosis. Endoscopic therapy, particularly treatment with Argon Plasma Coagulation, has shown to be as effective and also safer than surgery, and should be considered the first-line treatment for patients with GAVE-related bleeding.

Prevention of pelvic radiation disease

Pelvic cancers are among the most frequently diagnosed cancers worldwide. Treatment of patients requires a multidisciplinary approach that frequently includes radiotherapy. Gastrointestinal(GI) radiation-induced toxicity is a major complication and the transient or long-term problems, ranging from mild to very severe, arising in non-cancerous tissues resulting from radiation treatment to a tumor of pelvic origin, are actually called as pelvic radiation disease. The incidence of pelvic radiation disease changes according to the radiation technique, the length of follow up, the assessmentmethod, the type and stage of cancer and several other variables. Notably, even with the most recent radiation techniques, i.e., intensity-modulated radiotherapy, the incidence of radiation-induced GI side effects is overall reduced but still not negligible. In addition, radiation-induced GI side effects can develop even after several decades; therefore, the improvement of patient life expectancy will unavoidably increase the risk of developing radiation-induced complications. Once developed, the management of pelvic radiation disease may be challenging. Therefore, the prevention of radiation-induced toxicity represents a reasonable way to avoid a dramatic drop of the quality of life of these patients. In the current manuscript we provide an updated and practical review on the best available evidences in the field of the prevention of pelvic radiation disease.

Current status of peroral cholangioscopy in biliary tract diseases

Peroral cholangioscopy(POC) is an important tool for the management of a selected group of biliary diseases. Because of its direct visualization, POC allows targeted diagnostic and therapeutic procedures. POC can be performed using a dedicated cholangioscope that is advanced through the accessory channel of a duodenoscope or via the insertion of a small-diameter endoscope directly into the bile duct. POC was first described in the 1970 s, but the use of earlier generation devices was substantially limited by the cumbersome equipment setup and high repair costs. For nearly ten years, several technical improvements, including the single-operator system, high-quality images, the development of dedicated accessories and the increased size of the working channel, have led to increased diagnostic accuracy, thus assisting in the differentiation of benign and malignant intraductal lesions, targeting biopsies and the precise delineation of intraductal tumor spread before surgery. Furthermore, lithotripsy of difficult bile duct stones, ablative therapies for biliary malignancies and direct biliary drainage can be performed under POC control. Recent developments of new types of conventional POCs allow feasible, safe and effective procedures at reasonable costs. In the current review, we provide an updated overview of POC, focusing our attention on the main current clinical applications and on areas for future research.

Pelvic radiation disease:Updates on treatment options

Pelvic cancers are among the most frequently diagnosed neoplasms and radiotherapy represents one of the main treatment options. The irradiation field usually encompasses healthy intestinal tissue,especially of distal large bowel,thus inducing gastrointestinal(GI) radiation-induced toxicity. Indeed,up to half of radiationtreated patients say that their quality of life is affected by GI symptoms(e.g.,rectal bleeding,diarrhoea). The constellation of GI symptoms- from transient to longterm,from mild to very severe- experienced by patients who underwent radiation treatment for a pelvic tumor have been comprised in the definition of pelvic radiation disease(PRD). A correct and evidence-based therapeutic approach of patients experiencing GI radiation-induced toxicity is mandatory. Therapeutic non-surgical strategies for PRD can be summarized in two broad categories,i.e.,medical and endoscopic. Of note,most of the studies have investigated the management of radiation-induced rectal bleeding. Patients with clinically significant bleeding(i.e.,causing chronic anemia) should firstly be considered for medical management(i.e.,sucralfate enemas,metronidazole and hyperbaric oxygen); in case of failure,endoscopic treatment should be implemented. This latter should be considered the first choice in case of acute,transfusion requiring,bleeding. More well-performed,high quality studies should be performed,especially the role of medical treatments should be better investigated as well as the comparative studies between endoscopic and hyperbaric oxygen treatments.

Gastric metastasis from ovarian adenocarcinoma presenting as a subepithelial tumor and diagnosed by endoscopic ultrasound-guided tissue acquisition

We describe an uncommon case of a patient with a metastatic adenocarcinoma of ovarian origin presented as a gastric subepithelial tumor(SET) and that was diagnosed by endoscopic ultrasound fine-needle biopsy(EUS-FNB). Malignant gastric lesions are rarely metastatic and the primary tumor is mainly breast, lung, esophageal cancer or cutaneous melanoma. Gastric metastasis from ovarian cancer is unusual, presenting synchronously with the primary tumor but also several years later than the initial diagnosis. From an endoscopic point of view, gastric metastasis does not present specific features. They may mimic both a primary gastric tumor or, less frequently, an SET.This case demonstrates the importance of EUS-FNB in distinguishing SETs and how this may alter treatment and prognosis.

Effect of Endocuff use on colonoscopy outcomes: A systematic review and meta-analysis

BACKGROUND Endocuff-a plastic device with flexible projections-mounted on the distal tip of the colonoscope, promises improved colonic mucosa inspection.AIM To elucidate the effect of Endocuff on adenoma detection rate(ADR), advanced ADR(AADR) and mean number of adenomas per colonoscopy(MAC).METHODS Literature searches identified randomized-controlled trials evaluating Endocuffassisted colonoscopy(EAC) vs conventional colonoscopy(CC) in terms of ADR,AADR and MAC. The effect size on study outcomes was calculated using fixed or random effect model, as appropriate, and it is shown as relative risk(RR) [95%confidence interval(CI)] and mean difference(MD)(95%CI). The rate of device removal in EAC arms was also calculated.RESULTS We identified nine studies enrolling 6038 patients. All studies included mixed population(screening, surveillance and diagnostic examinations). Seven and two studies evaluated the first and the second-generation device, respectively. EAC was associated with increased ADR compared to CC [RR(95%CI): 1.18(1.05-1.32); Ι~2 = 71%]; EAC benefits more endoscopists with ADR ≤ 35% compared to those with ADR > 35% [RR(95%CI): 1.37(1.08-1.74); Ι~2 = 49% vs 1.10(0.99-1.24); Ι~2= 71%]. In terms of AADR and MAC, no difference was detected between EAC and CC [RR(95%CI): 1.03(0.85-1.25); Ι~2 = 15% and MD(95%CI): 0.30(-0.17-0.78);Ι~2 = 99%]. Subgroup analysis did not show any difference between the two device generations regarding all three endpoints. In EAC arms, the device had to be removed in 3%(95%CI: 2%-5%) of the cases mainly due to tortuous sigmoid or presence of diverticula along it.CONCLUSION EAC increases ADR compared to CC, especially for endoscopists with lower ADR. On the other hand, no significant effect on AADR and MAC was detected.

Colonoscopy-related colonic ischemia

Colonoscopy is a risk factor for colon ischemia.The colon is susceptible to ischemia due to its minor blood flow compared to other abdominal organs;the etiology of colon ischemia after colonoscopy is multifactorial.The causative mechanisms include splanchnic circulation impairment,bowel preparation,drugs used for sedation,bowel wall ischemia due to insufflation/barotrauma,and introduction of the endoscope.Gastroenterologists must be aware of this condition and its risk factors for risk minimization,early diagnosis,and proper treatment.

Management of gastro-esophageal reflux disease:Practice-oriented answers to clinical questions

Gastro-esophageal reflux disease(GERD)is a condition which is frequently faced by primary care physicians and gastroenterologists.Improving management of GERD is crucial to maximise both patient care and resource utilization.In fact,the management of patients with GERD is complex and poses several questions to the clinician who faces them in clinical practice.For instance,many aspects should be considered,including the appropriateness of indication to endoscopy,the quality of the endoscopic examination,the use and interpretation of ambulatory reflux testing,and the choice and management of anti-reflux treatments,i.e.,protonpump inhibitors and surgery.Aim of the present review was to provide a comprehensive update on the clinical management of patients with GERD,through a literature review on the diagnosis and management of patients with GER symptoms.In details,we provide practice-oriented concise answers to clinical questions,with the aim of optimising patient management and healthcare resource use.