AIM: To validate an optimized 13C-urea breath test (13C-UBT) protocol for the diagnosis of H pylori infection that is cost-efficient and maintains excellent diagnostic accuracy. METHODS: 70 healthy volunteers were tes...AIM: To validate an optimized 13C-urea breath test (13C-UBT) protocol for the diagnosis of H pylori infection that is cost-efficient and maintains excellent diagnostic accuracy. METHODS: 70 healthy volunteers were tested with two simplified 13C-UBT protocols,with test meal (Protocol 2) and without test meal (Protocol 1). Breath samples were collected at 10,20 and 30 min after ingestion of 50 mg 13C-urea dissolved in 10 mL of water,taken as a single swallow,followed by 200 mL of water (pH 6.0) and a circular motion around the waistline to homogenize the urea solution. Performance of both protocols was analyzed at various cut-off values. Results were validated against the European protocol. RESULTS: According to the reference protocol,65.7% individuals were positive for H pylori infection and 34.3% were negative. There were no significant differences in the ability of both protocols to correctly identify positive and negative H pylori individuals. However,only Protocol 1 with no test meal achieved accuracy,sensitivity,specificity,positive and negative predictive values of 100%. The highest values achieved by Protocol 2 were 98.57%,97.83%,100%,100% and 100%,respectively. CONCLUSION: A 10 min,50 mg 13C-UBT with no test meal using a cut-off value of 2-2.5 is a highly accurate test for the diagnosis of H pylori infection at a reduced cost.展开更多
AIM: To compare the accuracy of capsule 13C-urea breath test (UBT) with conventional invasive methods for the diagnosis of Helicobacter pylori infection.METHODS: One hundred patients received CLO test,histological exa...AIM: To compare the accuracy of capsule 13C-urea breath test (UBT) with conventional invasive methods for the diagnosis of Helicobacter pylori infection.METHODS: One hundred patients received CLO test,histological examination, culture and 100- or 50-mg capsule UBT for the diagnosis of Hpyloriinfection. Hpylori infection was defined as those with positive culture or positive results from both histology and CLO test.RESULTS: Both the sensitivity and specificity of the 100-mg capsule UBT (n = 50) were 100%. The sensitivity and specificity of the 50-mg capsule UBT (n = 50) were 96.4and 100%, respectively. Taken together, the accuracy of capsule UBT (n=100) was higher than that of CLO test,histology and culture (100% vs 92%, 91% and 89%,respectively; P= 0.035, 0.018 and 0.005, respectively). Our data showed that the optimal timing of sampling for 100-and 50-mg capsule UBT was 15-30 and 6-15 min, respectively.CONCLUSION: Capsule UBT has a higher accuracy compared with biopsy-based tests. It is an ideal method for the diagnosis of Hpyloriinfection.展开更多
AIM:To compare the costs and effectiveness of no screening and no eradication therapy, the population- based Helicobacter pylori (H pylori) serology screening with eradication therapy and 13C-Urea breath test (UBT) wi...AIM:To compare the costs and effectiveness of no screening and no eradication therapy, the population- based Helicobacter pylori (H pylori) serology screening with eradication therapy and 13C-Urea breath test (UBT) with eradication therapy. METHODS:A Markov model simulation was carried out in all 237 900 Chinese males with age between 35 and 44 from the perspective of the public healthcare provider in Singapore. The main outcome measures were the costs, number of gastric cancer cases prevented, life years saved, and quality-adjusted life years (QALYs) gained from screening age to death. The uncertainty surrounding the cost-effectiveness ratio was addressed by one-way sensitivity analyses. RESULTS:Compared to no screening, the incremental cost-effectiveness ratio (ICER) was $16 166 per life year saved or $13 571 per QALY gained for the serology screening, and $38 792 per life year saved and $32 525 per QALY gained for the UBT. The ICER was $477 079 per life year saved or $390 337 per QALY gained for the UBT compared to the serology screening. The cost- effectiveness of serology screening over the UBT was robust to most parameters in the model. CONCLUSION:The population-based serologyscreening for H pylori was more cost-effective than the UBT in prevention of gastric cancer in Singapore Chinese males.展开更多
AIM: To investigate whether posture affects the accuracy of 13C-urea breath test(13C-UBT) for Helicobacter pylori(H. pylori) detection in partial gastrectomy patients. METHODS: We studied 156 consecutive residual stom...AIM: To investigate whether posture affects the accuracy of 13C-urea breath test(13C-UBT) for Helicobacter pylori(H. pylori) detection in partial gastrectomy patients. METHODS: We studied 156 consecutive residual stomach patients, including 76 with H. pylori infection(infection group) and 80 without H. pylori infection(control group). H. pylori infection was confirmed if both the rapid urease test and histology were positive during gastroscopy. The two groups were divided into four subgroups according to patients' posture during the 13C-UBT: subgroup A, sitting position; subgroup B, supine position; subgroup C, right lateral recumbent position; and subgroup D, left lateral recumbent position. Each subject underwent the following modified 13C-UBT: 75 mg of 13C-urea(powder) in 100 m L of citric acid solution was administered, and a mouth wash was performed immediately; breath samples were then collected at baseline and at 5-min intervals up to 30 min while the position was maintained. Seven breathsamples were collected for each subject. The cutoff value was 2.0‰.RESULTS: The mean delta over baseline(DOB) values in the subgroups of the infection group were similar at 5 min(P > 0.05) and significantly higher than those in the corresponding control subgroups at all time points(P < 0.01). In the infection group, the mean DOB values in subgroup A were higher than those in other subgroups within 10 min and peaked at the 10-min point(12.4‰± 2.4‰). The values in subgroups B and C both reached their peaks at 15 min(B, 13.9‰± 1.5‰; C, 12.2‰± 1.7‰) and then decreased gradually until the 30-min point. In subgroup D, the value peaked at 20 min(14.7‰± 1.7‰). Significant differences were found between the values in subgroups D and B at both 25 min(t = 2.093, P = 0.043) and 30 min(t = 2.141, P = 0.039). At 30 min, the value in subgroup D was also significantly different from those in subgroups A and C(D vs C: t = 6.325, P = 0.000; D vs A: t = 5.912, P = 0.000). The mean DOB values of subjects with Billroth Ⅰ anastomosis were higher than those of subjects with Billroth Ⅱ anastomosis irrespectively of the detection time and posture(P > 0.05).CONCLUSION: Utilization of the left lateral recumbent position during the procedure and when collecting the last breath sample may improve the diagnostic accuracy of the 13C-UBT in partial gastrectomy patients.展开更多
AIM: To evaluate the role of the 13C-methacetin breath test(13C-MBT) in the assessment of acute liver injury in a rat model.METHODS: Acute liver injury in rats was induced by a single intraperitoneal injection of D-ga...AIM: To evaluate the role of the 13C-methacetin breath test(13C-MBT) in the assessment of acute liver injury in a rat model.METHODS: Acute liver injury in rats was induced by a single intraperitoneal injection of D-galactosamine(D-GalN). Forty-eight male Sprague-Dawley rats were randomly assigned to a control group(n = 8) and five model groups(each n = 8), and acute liver injury was assessed at different time points(6, 12, 24, 48 and 72 h) after D-GalN injection. The 13C-MBT, biochemical tests, 15-min retention rate of indocyanine green(ICGR15), and liver biopsy were performed and compared between the control and model groups. Correlations between parameters of the 13C-MBT(Tmax, MVmax, CUM120 and DOBmax), biochemical tests, ICGR15 and liver necrosis score were also analyzed using Spearman'scorrelation analysis.RESULTS: Tmax, MVmax, CUM120 and DOBmax, as well as most of the traditional methods, correlated with the liver necrosis score(r = 0.493, P < 0.05; r =-0.731, P < 0.01; r =-0.618, P < 0.01; r =-0.592, P < 0.01, respectively). MVmax, CUM120 and DOBmax rapidly decreased and were lower than those in the controls as early as 6 h after D-GalN injection(3.84 ± 0.84 vs 5.06 ± 0.78, P < 0.01; 3.35 ± 0.72 vs 4.21 ± 1.44, P < 0.05; 52.3 ± 20.58 vs 75.1 ± 9.57, P < 0.05, respectively) and reached the lowest point 24 h after D-GalN injection. MVmax, CUM120 and DOBmax returned to normal levels 72 h after D-GalN injection and preceded most of the traditional methods, including liver biopsy.CONCLUSION: The 13C-MBT is a sensitive tool for the timely detection of acute liver injury and early prediction of recovery in a rat model. Further clinical studies are warranted to validate its role in patients with acute liver injury.展开更多
Many gastrointestinal complaints and motility disorders are described in patients suffering from different eating disorders. These have a negative impact on refeeding. This report evaluated–on admission-gastric empty...Many gastrointestinal complaints and motility disorders are described in patients suffering from different eating disorders. These have a negative impact on refeeding. This report evaluated–on admission-gastric emptying of a standardized solid meal with 13C octanoic acid breath test in anorexic adolescents. The results were compared with age and gender matched controls. Gastric emptying data were related to a subjective symptom score. 21 Anorexic girls and 3 boys (mean age: 15.6 y ± 1.3 y), body mass index (mean 15.6 kg/m2 ± 1.6 kg/m2), weight loss (mean: 22.2% ± 10.7%) were studied. T? of the gastric emptying time exceeded the P95 in 14/24 (58%) patients, classified as having delayed gastric emptying (DGE). One patient (4%) had a T? exceeding P75 and was classified as slow (SGE), whereas 9/24 (38%) patients had normal gastric emptying (NGE). In comparison to NGE, subjects with DGE had significantly higher symptom scores (p = 0.01) and more weight loss. The DGE and SGE patients lost 25.29% and 21.38% of weight respectively, whereas a weight loss of 17.64% was found in anorexics with NGE. In conclusion, gastric emptying is delayed in patients with anorexia. This is associated with more significant gastrointestinal symptoms and higher weight loss.展开更多
Introduction: Delayed gastric emptying (DGE) often occurs in patients with gastroesophageal reflux (GER) due to neurological impairment (NI). 13C has been used as an alternative tool for measuring the gastric emptying...Introduction: Delayed gastric emptying (DGE) often occurs in patients with gastroesophageal reflux (GER) due to neurological impairment (NI). 13C has been used as an alternative tool for measuring the gastric emptying rates. The aim of this study was to predict gastric emptying in children with GER using 13C-acetate breath test (ABT) by 24-hour pH monitoring. Methods: Nineteen patients were divided into 2 groups: a DGE group with NI (14 patients), and normal-emptying group without NI (5 patients). The liquid test meal consisted of RacolTM (5 ml/kg) mixed with 13C-acetate (50 mg for infants, 100 mg for children, and 150 mg for adolescents). 13CO2 was measured using a gas chromatograph-isotope ratio mass spectrometer. The results are expressed as the % of 13C expired per hour and cumulative 13C excretion over a 3-hour periods including the parameters of half excretion and lag time. Results: The mean half excretion time was 1.762 hour in the DGE group and 1.095 hour in the normal-emptying group (P = 0.0196). The mean lag time was 0.971 hour in the DGE group and 0.666 hour in the normal-emptying group (P = 0.0196). Therefore, DGE was significantly more prevalent in the DGE compared to the normal-emptying group. The percentage of the time when the pH was less than 4 on 24-hour esophageal pH monitoring was 21.6% ± 9.2% in the DGE group and 28.5% ± 11.6% in the normal-emptying group (P = 0.4634). Conclusion: The percentage of time when the pH is less than 4 on 24-hour pH monitoring cannot predict DGE measured by the 13C-ABT in GER.展开更多
AIM: Helicobacter pylori ( H pylofi) resistance after failed eradication has a major impact on the outcome of a further treatment regimen. The aim of this study was to assess the validity of a non-invasive strategy us...AIM: Helicobacter pylori ( H pylofi) resistance after failed eradication has a major impact on the outcome of a further treatment regimen. The aim of this study was to assess the validity of a non-invasive strategy using the 13C-urea breath test (UBT) and the gastric string test in identifying post-treatment resistance of Hpylori.METHODS: The UBT was routinely performed 4 to 6 wk after H pylorieradication therapy. Forty-two patients (24 females, 18 males, mean age 48 years) with a positive UBT were included in the study. A gastric string test using a capsule containing a 90 cm-long nylon fiber was performed.Before the capsule was swallowed, the free end of the string was taped to the cheek. After one hour in the stomach, the string was withdrawn. The distal 20 cm of the string was inoculated onto an agar plate and processed under microaerophilic conditions. Following the string test, upper gastrointestinal endoscopy was performed to obtain gastric biopsies for conventional culture.RESULTS: H pyloriwas successfully cultured from the gastric string in 34 patients (81%), but not in 5 patients due to contamination with oropharyngeal flora. Hpyloriwas cultured from the gastric biopsies obtained at endoscopy in 39 patients (93%).CONCLUSION: The UBT followed by the gastric string test in the case of treatment failure is a valid diagnostic strategy with the aim of determining the post-therapeutic antibiotic resistance of Hpyloriwith little inconvenience to the patient.Upper GI-endoscopy can be avoided in several cases by applying consequently this diagnostic package.展开更多
文摘AIM: To validate an optimized 13C-urea breath test (13C-UBT) protocol for the diagnosis of H pylori infection that is cost-efficient and maintains excellent diagnostic accuracy. METHODS: 70 healthy volunteers were tested with two simplified 13C-UBT protocols,with test meal (Protocol 2) and without test meal (Protocol 1). Breath samples were collected at 10,20 and 30 min after ingestion of 50 mg 13C-urea dissolved in 10 mL of water,taken as a single swallow,followed by 200 mL of water (pH 6.0) and a circular motion around the waistline to homogenize the urea solution. Performance of both protocols was analyzed at various cut-off values. Results were validated against the European protocol. RESULTS: According to the reference protocol,65.7% individuals were positive for H pylori infection and 34.3% were negative. There were no significant differences in the ability of both protocols to correctly identify positive and negative H pylori individuals. However,only Protocol 1 with no test meal achieved accuracy,sensitivity,specificity,positive and negative predictive values of 100%. The highest values achieved by Protocol 2 were 98.57%,97.83%,100%,100% and 100%,respectively. CONCLUSION: A 10 min,50 mg 13C-UBT with no test meal using a cut-off value of 2-2.5 is a highly accurate test for the diagnosis of H pylori infection at a reduced cost.
基金Supported by Grant From the National Science Council, Taiwan NSC 90-2314-B-075B-008
文摘AIM: To compare the accuracy of capsule 13C-urea breath test (UBT) with conventional invasive methods for the diagnosis of Helicobacter pylori infection.METHODS: One hundred patients received CLO test,histological examination, culture and 100- or 50-mg capsule UBT for the diagnosis of Hpyloriinfection. Hpylori infection was defined as those with positive culture or positive results from both histology and CLO test.RESULTS: Both the sensitivity and specificity of the 100-mg capsule UBT (n = 50) were 100%. The sensitivity and specificity of the 50-mg capsule UBT (n = 50) were 96.4and 100%, respectively. Taken together, the accuracy of capsule UBT (n=100) was higher than that of CLO test,histology and culture (100% vs 92%, 91% and 89%,respectively; P= 0.035, 0.018 and 0.005, respectively). Our data showed that the optimal timing of sampling for 100-and 50-mg capsule UBT was 15-30 and 6-15 min, respectively.CONCLUSION: Capsule UBT has a higher accuracy compared with biopsy-based tests. It is an ideal method for the diagnosis of Hpyloriinfection.
文摘AIM:To compare the costs and effectiveness of no screening and no eradication therapy, the population- based Helicobacter pylori (H pylori) serology screening with eradication therapy and 13C-Urea breath test (UBT) with eradication therapy. METHODS:A Markov model simulation was carried out in all 237 900 Chinese males with age between 35 and 44 from the perspective of the public healthcare provider in Singapore. The main outcome measures were the costs, number of gastric cancer cases prevented, life years saved, and quality-adjusted life years (QALYs) gained from screening age to death. The uncertainty surrounding the cost-effectiveness ratio was addressed by one-way sensitivity analyses. RESULTS:Compared to no screening, the incremental cost-effectiveness ratio (ICER) was $16 166 per life year saved or $13 571 per QALY gained for the serology screening, and $38 792 per life year saved and $32 525 per QALY gained for the UBT. The ICER was $477 079 per life year saved or $390 337 per QALY gained for the UBT compared to the serology screening. The cost- effectiveness of serology screening over the UBT was robust to most parameters in the model. CONCLUSION:The population-based serologyscreening for H pylori was more cost-effective than the UBT in prevention of gastric cancer in Singapore Chinese males.
基金Supported by The Guidance Project of Science and Technology Commission of Shanghai MunicipalityNo.134119a1700+5 种基金the Appropriate Project of Shanghai Municipal Health BureauNo.2013SY049Shanghai Key Laboratory of Clinical Geriatric MedicineNo.13DZ2260700the Scientific Research Projects of Shanghai Municipal Health BureauNo.20134377
文摘AIM: To investigate whether posture affects the accuracy of 13C-urea breath test(13C-UBT) for Helicobacter pylori(H. pylori) detection in partial gastrectomy patients. METHODS: We studied 156 consecutive residual stomach patients, including 76 with H. pylori infection(infection group) and 80 without H. pylori infection(control group). H. pylori infection was confirmed if both the rapid urease test and histology were positive during gastroscopy. The two groups were divided into four subgroups according to patients' posture during the 13C-UBT: subgroup A, sitting position; subgroup B, supine position; subgroup C, right lateral recumbent position; and subgroup D, left lateral recumbent position. Each subject underwent the following modified 13C-UBT: 75 mg of 13C-urea(powder) in 100 m L of citric acid solution was administered, and a mouth wash was performed immediately; breath samples were then collected at baseline and at 5-min intervals up to 30 min while the position was maintained. Seven breathsamples were collected for each subject. The cutoff value was 2.0‰.RESULTS: The mean delta over baseline(DOB) values in the subgroups of the infection group were similar at 5 min(P > 0.05) and significantly higher than those in the corresponding control subgroups at all time points(P < 0.01). In the infection group, the mean DOB values in subgroup A were higher than those in other subgroups within 10 min and peaked at the 10-min point(12.4‰± 2.4‰). The values in subgroups B and C both reached their peaks at 15 min(B, 13.9‰± 1.5‰; C, 12.2‰± 1.7‰) and then decreased gradually until the 30-min point. In subgroup D, the value peaked at 20 min(14.7‰± 1.7‰). Significant differences were found between the values in subgroups D and B at both 25 min(t = 2.093, P = 0.043) and 30 min(t = 2.141, P = 0.039). At 30 min, the value in subgroup D was also significantly different from those in subgroups A and C(D vs C: t = 6.325, P = 0.000; D vs A: t = 5.912, P = 0.000). The mean DOB values of subjects with Billroth Ⅰ anastomosis were higher than those of subjects with Billroth Ⅱ anastomosis irrespectively of the detection time and posture(P > 0.05).CONCLUSION: Utilization of the left lateral recumbent position during the procedure and when collecting the last breath sample may improve the diagnostic accuracy of the 13C-UBT in partial gastrectomy patients.
基金Supported by Beijing Health System Advanced Health Technology Talent Cultivation Plan,No.2011-2-08
文摘AIM: To evaluate the role of the 13C-methacetin breath test(13C-MBT) in the assessment of acute liver injury in a rat model.METHODS: Acute liver injury in rats was induced by a single intraperitoneal injection of D-galactosamine(D-GalN). Forty-eight male Sprague-Dawley rats were randomly assigned to a control group(n = 8) and five model groups(each n = 8), and acute liver injury was assessed at different time points(6, 12, 24, 48 and 72 h) after D-GalN injection. The 13C-MBT, biochemical tests, 15-min retention rate of indocyanine green(ICGR15), and liver biopsy were performed and compared between the control and model groups. Correlations between parameters of the 13C-MBT(Tmax, MVmax, CUM120 and DOBmax), biochemical tests, ICGR15 and liver necrosis score were also analyzed using Spearman'scorrelation analysis.RESULTS: Tmax, MVmax, CUM120 and DOBmax, as well as most of the traditional methods, correlated with the liver necrosis score(r = 0.493, P < 0.05; r =-0.731, P < 0.01; r =-0.618, P < 0.01; r =-0.592, P < 0.01, respectively). MVmax, CUM120 and DOBmax rapidly decreased and were lower than those in the controls as early as 6 h after D-GalN injection(3.84 ± 0.84 vs 5.06 ± 0.78, P < 0.01; 3.35 ± 0.72 vs 4.21 ± 1.44, P < 0.05; 52.3 ± 20.58 vs 75.1 ± 9.57, P < 0.05, respectively) and reached the lowest point 24 h after D-GalN injection. MVmax, CUM120 and DOBmax returned to normal levels 72 h after D-GalN injection and preceded most of the traditional methods, including liver biopsy.CONCLUSION: The 13C-MBT is a sensitive tool for the timely detection of acute liver injury and early prediction of recovery in a rat model. Further clinical studies are warranted to validate its role in patients with acute liver injury.
文摘Many gastrointestinal complaints and motility disorders are described in patients suffering from different eating disorders. These have a negative impact on refeeding. This report evaluated–on admission-gastric emptying of a standardized solid meal with 13C octanoic acid breath test in anorexic adolescents. The results were compared with age and gender matched controls. Gastric emptying data were related to a subjective symptom score. 21 Anorexic girls and 3 boys (mean age: 15.6 y ± 1.3 y), body mass index (mean 15.6 kg/m2 ± 1.6 kg/m2), weight loss (mean: 22.2% ± 10.7%) were studied. T? of the gastric emptying time exceeded the P95 in 14/24 (58%) patients, classified as having delayed gastric emptying (DGE). One patient (4%) had a T? exceeding P75 and was classified as slow (SGE), whereas 9/24 (38%) patients had normal gastric emptying (NGE). In comparison to NGE, subjects with DGE had significantly higher symptom scores (p = 0.01) and more weight loss. The DGE and SGE patients lost 25.29% and 21.38% of weight respectively, whereas a weight loss of 17.64% was found in anorexics with NGE. In conclusion, gastric emptying is delayed in patients with anorexia. This is associated with more significant gastrointestinal symptoms and higher weight loss.
文摘Introduction: Delayed gastric emptying (DGE) often occurs in patients with gastroesophageal reflux (GER) due to neurological impairment (NI). 13C has been used as an alternative tool for measuring the gastric emptying rates. The aim of this study was to predict gastric emptying in children with GER using 13C-acetate breath test (ABT) by 24-hour pH monitoring. Methods: Nineteen patients were divided into 2 groups: a DGE group with NI (14 patients), and normal-emptying group without NI (5 patients). The liquid test meal consisted of RacolTM (5 ml/kg) mixed with 13C-acetate (50 mg for infants, 100 mg for children, and 150 mg for adolescents). 13CO2 was measured using a gas chromatograph-isotope ratio mass spectrometer. The results are expressed as the % of 13C expired per hour and cumulative 13C excretion over a 3-hour periods including the parameters of half excretion and lag time. Results: The mean half excretion time was 1.762 hour in the DGE group and 1.095 hour in the normal-emptying group (P = 0.0196). The mean lag time was 0.971 hour in the DGE group and 0.666 hour in the normal-emptying group (P = 0.0196). Therefore, DGE was significantly more prevalent in the DGE compared to the normal-emptying group. The percentage of the time when the pH was less than 4 on 24-hour esophageal pH monitoring was 21.6% ± 9.2% in the DGE group and 28.5% ± 11.6% in the normal-emptying group (P = 0.4634). Conclusion: The percentage of time when the pH is less than 4 on 24-hour pH monitoring cannot predict DGE measured by the 13C-ABT in GER.
文摘AIM: Helicobacter pylori ( H pylofi) resistance after failed eradication has a major impact on the outcome of a further treatment regimen. The aim of this study was to assess the validity of a non-invasive strategy using the 13C-urea breath test (UBT) and the gastric string test in identifying post-treatment resistance of Hpylori.METHODS: The UBT was routinely performed 4 to 6 wk after H pylorieradication therapy. Forty-two patients (24 females, 18 males, mean age 48 years) with a positive UBT were included in the study. A gastric string test using a capsule containing a 90 cm-long nylon fiber was performed.Before the capsule was swallowed, the free end of the string was taped to the cheek. After one hour in the stomach, the string was withdrawn. The distal 20 cm of the string was inoculated onto an agar plate and processed under microaerophilic conditions. Following the string test, upper gastrointestinal endoscopy was performed to obtain gastric biopsies for conventional culture.RESULTS: H pyloriwas successfully cultured from the gastric string in 34 patients (81%), but not in 5 patients due to contamination with oropharyngeal flora. Hpyloriwas cultured from the gastric biopsies obtained at endoscopy in 39 patients (93%).CONCLUSION: The UBT followed by the gastric string test in the case of treatment failure is a valid diagnostic strategy with the aim of determining the post-therapeutic antibiotic resistance of Hpyloriwith little inconvenience to the patient.Upper GI-endoscopy can be avoided in several cases by applying consequently this diagnostic package.