Gut and Liver最新文献

Background/aims: Triple therapy with vonoprazan, a potassium-competitive acid blocker, has shown an acceptable eradication rate. The aim of this study was to evaluate the efficacy and safety of tegoprazan-based triple therapy compared with those of vonoprazan-based triple therapy for Helicobacter pylori eradication.

Methods: This randomized, double-blind, active-controlled, multicenter pilot study included treatment-naive adults with H. pylori infection. Participants were randomized 1:1:1 to receive tegoprazan 50 mg (TAC 1), tegoprazan 100 mg (TAC 2), or vonoprazan 20 mg (VAC) with amoxicillin 1,000 mg plus clarithromycin 500 mg twice daily for 10 days. The primary outcome was the eradication rate.

Results: Of the 102 enrolled participants, 97 completed the study. The eradication rates in the full analysis set were 60.61% (95% confidence interval [CI], 43.93% to 77.28%), 78.79% (95% CI, 64.84% to 92.74%), and 84.85% (95% CI, 72.62% to 97.08%) in TAC 1, TAC 2, and VAC, respectively. The eradication rates in the per-protocol set were 66.67% (95% CI, 49.80% to 83.54%), 86.67% (95% CI, 74.50% to 98.83%), and 87.50% (95% CI, 76.04% to 98.96%) in TAC 1, TAC 2, and VAC, respectively. In the full analysis set, the eradication rate differences were -6.06% (95% CI, -24.61% to 12.49%) between TAC 2 and VAC and -24.24% (95% CI, -44.92% to -3.56%) between TAC 1 and VAC. In the per-protocol set, the eradication rate differences were -0.83% (95% CI, -19.97% to 17.37%) between TAC 2 and VAC and -20.83% (95% CI, -41.23% to -0.44%) between TAC 1 and VAC. All therapies were well tolerated with no notable safety differences.

Conclusions: After 10 days, tegoprazan 100 mg showed eradication rates comparable to those of vonoprazan 20 mg, while 50 mg may be insufficient. These findings support future research to optimize tegoprazan dosing in clinical practice (ClinicalTrials.gov; NCT04128917).

Background/aims: Physicians are challenged with balancing benefits and risks of performing colonoscopies in older adults. We identified adverse event risk factors in this population and developed a predictive risk score for colonoscopy-related adverse events.

Methods: From August 2017 to August 2022, 8,154 patients aged ≥60 years who underwent screening or diagnostic colonoscopies were enrolled at Gangnam Severance Hospital. The primary outcome was 30-day adverse events, defined as emergency room visits or unplanned hospitalizations post-colonoscopy. The frailty index calculated via laboratory findings (FI-LAB) was derived from blood test results and vital signs. A risk score was developed and categorized to predict colonoscopy-related adverse events. Data from 9,154 colonoscopies from September 2022 to December 2023 at two tertiary referral hospitals were used for internal and external validation.

Results: The mean age was 67.9 years (range, 60 to 94 years). The 30-day adverse event rate was 1.4%. Adverse events were independently associated with the use of aspirin (adjusted odds ratio [aOR], 2.24), P2Y12 inhibitors (aOR, 1.79), and anticoagulants (aOR, 2.47) and with moderate (aOR, 4.54) and high (aOR, 11.40) FI-LABs. The incidence of adverse events in the low-, moderate-, and high-risk groups were 0.3%, 2.2%, and 10.7%, respectively (p<0.001). The area under the receiver operating characteristic curve for the risk scores were 0.821, 0.856, and 0.757 for the derivation, internal, and external cohorts, respectively.

Conclusions: Colonoscopy-related adverse events in older adults were linked to frailty and medication use and were not dependent on age. This novel risk score supports personalized decision-making when performing colonoscopies in older adults.

The Lyon Consensus 2.0, published in 2023, provides an updated diagnostic framework for gastroesophageal reflux disease (GERD), emphasizing objective physiological testing and introducing the concept of "actionable GERD" to guide individualized therapy. This review evaluates the clinical applicability of this framework in Asia, where normative values require regional adaptation. Given limited access to physiological testing in primary care, an endoscopy-based strategy may be considered due to its greater availability, helping overcome diagnostic barriers. Key updates include recognizing Los Angeles grade B esophagitis as conclusive GERD evidence, adoption of prolonged wireless pH monitoring, and revised thresholds for pH-impedance studies, including mean nocturnal baseline impedance. High-resolution manometry and impedance remain important for evaluating refractory symptoms and regurgitation-predominant presentations. Challenges in Asian contexts include the limited predictive performance of Western-derived tools, such as the Lyon score, and the need for lower acid exposure thresholds. The Milan score, a novel manometry-based index, provides an assessment of anti-reflux barrier integrity and may guide selection of candidates for endoscopic anti-reflux therapies. The COuGH RefluX score, based on symptoms and risk factors, estimates GERD probability in patients with laryngeal complaints. Incorporating psychophysiological assessments, such as esophageal hypervigilance and symptom-related anxiety, can further enhance diagnostic precision and improve outcomes. Successful implementation of Lyon Consensus 2.0 in Asia will depend on contextual adaptation of diagnostic criteria and integration of accessible clinical and psychological tools.

Management of common bile duct (CBD) stones has evolved substantially with the advent of endoscopic techniques and dedicated high-end devices. Endoscopic retrograde cholangiopancreatography (ERCP) has become a widespread essential technique for managing CBD stones, with high success rates in standard cases. However, for patients with large stones, stones in an impacted state, and stones in anatomically challenging regions, advanced strategies using various dedicated devices may be needed. Although mechanical lithotripsy and endoscopic papillary large balloon dilation are effective techniques for managing giant stones, temporary biliary stenting with interval stone extraction, commonly referred to as two-stage ERCP, is a valuable approach, particularly in patients with sepsis or significant comorbidities. Digital single-operator cholangioscopy (DSOC) combined with electrohydraulic or laser lithotripsy has significantly transformed the endoscopic treatment strategy for managing difficult-to-extract stones by enabling direct visualization of stones and real-time targeted fragmentation. In very difficult situations where conventional ERCP is unsuccessful, percutaneous transhepatic cholangioscopy may be an effective solution, with DSOC enhancing both efficacy and safety. Advances in endoscopic technology, including integrated laser systems and next-generation retrieval devices, are expected to further improve procedural outcomes. Artificial intelligence is also gaining traction, with potential applications in diagnostic imaging interpretation, intraprocedural decision support, and prediction of stone recurrence. In conclusion, optimal management of CBD stones requires a patient specific, resource-sensitive approach. The integration of cutting-edge technologies and data-driven strategies is expected to improve the precision, efficiency, and overall quality of endoscopic CBD stone management.

Background/aims: Current guidelines recommend biannual ultrasound for hepatocellular carcinoma (HCC) surveillance in chronic hepatitis B (CHB) patients. However, computed tomography (CT) or magnetic resonance imaging (MRI) may be used when ultrasound is inadequate. The clinical impact of these alternative modalities remains unclear.

Methods: CHB patients undergoing regular HCC surveillance were classified into two groups: ultrasound-only and alternative surveillance (CT/MRI). Patients were stratified into high- and low-risk groups using the Risk Estimation for HCC in CHB (REACH-B) score. Outcomes included 10-year overall survival (OS), HCC tumor size, Barcelona Clinic Liver Cancer (BCLC) stage at diagnosis, and OS after HCC diagnosis. Propensity score matching was applied to balance baseline characteristics.

Results: A total of 2,024 patients were included after propensity score matching to ensure balanced baseline characteristics, with 1,012 patients in each group. OS was similar (ultrasound-only 96.0% vs alternative 96.8%; p=0.379). HCC occurred in 66 patients in each group. Alternative surveillance detected smaller HCC tumors (1.6 cm vs 2.1 cm; p<0.001) and more BCLC stage 0 cases (alternative 71.2% vs ultrasound-only 42.4%; p=0.003). The OS after HCC diagnosis was higher with alternative surveillance (83.0% vs 67.0%; p=0.025). In high-risk patients (n=970), alternative surveillance increased the OS (97.3% vs 93.6%; p=0.029) and the OS after HCC diagnosis (83.0% vs 60.6%; p=0.010). No significant differences were observed in low-risk patients.

Conclusions: CT/MRI-based alternative surveillance led to earlier HCC detection and improved post-diagnosis survival, particularly in high-risk CHB patients, supporting its potential role as an alternative to ultrasound in selected populations.

Background/aims: Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality, particularly in Korea. We analyzed trends in the epidemiology, tumor characteristics, treatment modalities, and outcomes of HCC over the past 15 years, using a large-scale hospital-based registry.

Methods: We examined Asan Medical Center HCC registry data on 21,699 treatment-naïve patients with HCC diagnosed between 2009 and 2023. Patients were categorized into four periods based on their year of diagnosis: period 1 (2009-2011), period 2 (2012-2015), period 3 (2016-2019), and period 4 (2020-2023). HCC staging followed the Barcelona Clinic Liver Cancer (BCLC) system.

Results: The prevalence of hepatitis B virus declined continuously from 74.9% to 61.2%, with an increase in nonviral etiologies. The median age at diagnosis increased from 56 years in period 1 to 62 years in period 4, with increased comorbidities such as diabetes and hypertension. Early-stage HCC detection improved, with more patients diagnosed at BCLC stage 0 or A. The use of systemic therapy, particularly atezolizumab-bevacizumab treatment, increased from 2020, especially among patients with BCLC stage C. The 5-year survival rate improved significantly from 44.0% in period 1 to 65.2% in period 3, with overall survival rates increasing across all stages except BCLC stage D. Patients with hepatitis B virus-related HCC experienced the best outcomes. Recurrence rates after curative treatment gradually decreased over time.

Conclusions: Over the past 15 years, significant advancements in the early detection and treatment of HCC in Korea have led to improved survival outcomes. These findings underscore the need for ongoing clinical strategy evolution to address the changing landscape of HCC.

Background/aims: To compare the efficacy and safety of fexuprazan and lansoprazole for preventing peptic ulcers (PUs) induced by nonsteroidal anti-inflammatory drugs (NSAIDs).

Methods: This multicenter, double-blind, randomized, active-controlled study was conducted across 32 hospitals in South Korea. Patients with musculoskeletal disease requiring long-term treatment with celecoxib, naproxen, or meloxicam were randomized to receive either fexuprazan 20 mg/day (n=212) or lansoprazole 15 mg/day (n=211) for 24 weeks. The primary endpoint was the occurrence of PUs, which were confirmed via esophagogastroduodenoscopy (EGD), with a non-inferiority margin of 8.3%. Only ulcers that developed during the treatment period were examined in the analysis. The occurrence of gastroduodenal bleeding was also monitored via EGD, and symptoms were assessed by using the Patient Assessment of Upper Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM). Adverse events were recorded during the study.

Results: The incidence rate of EGD-confirmed PUs at week 24 was 1.16% in the fexuprazan group and 2.76% in the lansoprazole group, with a between-group difference of -1.64% (95% confidence interval, -4.52% to 1.25%), demonstrating non-inferiority. No patients presented with gastroduodenal bleeding. No significant between-group differences were found in the PAGI-SYM scores (leastsquare mean difference in the total score at week 24, -0.42; 95% confidence interval, -2.48 to 1.64; p=0.69). There were low rates of adverse drug reactions in the fexuprazan and lansoprazole groups (8.57% vs 4.78%, respectively p=0.12).

Conclusions: Given its non-inferiority to lansoprazole and similar safety profile, fexuprazan is a promising alternative for the prevention of NSAID-induced PUs (ClinicalTrials.gov identifier NCT04784910).

Background/aims: Ampullary adenomas are precancerous lesions requiring accurate diagnosis and timely intervention to prevent malignant transformation. Endoscopic papillectomy (EP) has emerged as a less invasive alternative to surgery; however, technical variations in practice remain. This study evaluated contemporary real-world approaches to the diagnosis, treatment, and surveillance of ampullary adenomas among pancreatobiliary endoscopists.

Methods: A nationwide cross-sectional survey was conducted among pancreatobiliary endoscopists certified by the Korean Pancreatobiliary Association between January 19 and March 2, 2025. A 29-item questionnaire assessed diagnostic methods, procedural techniques, and follow-up strategies. Of 231 invitations sent, 85 responses (36.8%) were analyzed. Respondents were stratified by EP experience: ≤10 years (n=40) and >10 years (n=45).

Results: Diagnostic and procedural strategies were largely comparable across the two experience groups. No significant differences were observed in the histologic reassessment, endoscopic ultrasound test, or cross-sectional images. Single pigtail plastic stents were the most preferred type for prophylactic pancreatic stenting, with a significantly higher preference among endoscopists with ≤10 years of experience compared to those with >10 years (92.5% vs 66.7%, p=0.008). For post-procedural bleeding management, fully covered self-expandable metal stents were more frequently used by endoscopists with ≤10 years of experience (47.5% vs 11.1%, p=0.001). Surveillance intervals, follow-up modalities, and timing of stent removal showed substantial heterogeneity, with no standardized patterns.

Conclusions: Although general clinical practices appear standardized, significant variability remains in specific procedural and post-procedural approaches. These findings highlight the need for refined guidelines to support a more consistent and comprehensive approach to EP.