Conor Costigan

Background The rate of gastric cancer(GC) has reduced globally in all ages in recent years, but some data has started to emerge of a reversal in those >50 years, particularly in wealthier countries. H. pylori(HP) infection is associated with 89% of GC diagnoses, and its eradication is associated with a clear risk-reduction. The approach to diagnosis varies globally, however recently IARC haas reccommended screening in all populations. Summary A test-and-treat approach towards symptomatic young people is advocated among European populations, and has been shown to improve dyspepsia and reduce costs. Its impact on GC rates are less clear. Studies in high-incidence countries have demonstrated cost-effective, real-world reductions in GC rates with population-based HP screening(screen-and-treat). Abundant modelling data in these countries show economic benefits to nearly all screening programs, however, data in European populations, at lower risk, is lacking. Modelled data suggests it may be feasible, but currently no guidelines recommend a specific approach. Prospective European studies are underway to assess the feasibility of various screening methods. We discuss the evidence behind both approaches and the use of both endoscopy(Test-scope-and-treat) and biomarkers as adjuncts to population-based screening to maximise gastric cancer reduction from any future European screening programme. Key Messages Prospective data from H. pylori high-incidence countries have shown a clear cost-effective reduction in gastric cancer diagnoses after introduction of population-screening. Modelled data from H. pylori low-incidence countries shows population-based screening may be cost effective, but real-world feasibility data is lacking.

Resistance surveillance programmes are essential for choosing the most appropriate eradication therapy for the stomach pathogen Helicobacter pylori. This study aimed to determine H. pylori antimicrobial resistance rates in Ireland. H. pylori was cultured from patients attending four gastroenterology clinics from 2018 to 2023. Antimicrobial susceptibility testing (AST) was performed using Etests for metronidazole, clarithromycin, levofloxacin, amoxicillin, tetracycline and rifampicin and resistance classified using EUCAST guidelines. Resistance rates were compared between H. pylori treatment-naïve and previously treated patients (primary and secondary resistance, respectively). Samples from 138 culture-positive patients (mean age 49.4 ± 15.7 years, 47.1% female) were analysed. A total of 28.7% of isolates from treatment-naïve patients were susceptible to all antimicrobials tested. Primary resistance rates to metronidazole, clarithromycin, levofloxacin, amoxicillin, tetracycline and rifampicin were 44.3%, 36.5%, 18.3%, 14.6%, 9.6% and 9.6%, respectively. Primary dual resistance to clarithromycin and metronidazole was 22.6% and primary multidrug resistance was 13.0%. Secondary resistance rates were significantly higher than primary resistance rates for clarithromycin, metronidazole, dual resistance to clarithromycin and either amoxicillin, metronidazole or levofloxacin, and multidrug resistance. Female sex and older age were associated with increased risk of resistance. H. pylori resistance rates were high in our cohort. Clarithromycin-based triple therapy should no longer be used in Ireland in the absence of pre-treatment AST. Resistance to amoxicillin, tetracycline and rifampicin should be monitored closely.

Background and study aims Diagnostic yields of small bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE) are known to be similar. SBCE is normally recommended as the initial diagnostic test, with DAE reserved for therapeutic indications. As most DAE procedures are not pan-enteric, a completion capsule may be of benefit to identify residual or overlooked disease. Our aim was to assess the clinical utility of completion SBCE performed following DAE. Patients and methods A retrospective analysis of completion capsules post double balloon enteroscopy (DBE) from a single referral center was performed. Cases were identified by cross-referencing endoscopy and capsule databases. A completion capsule was defined as a capsule endoscopy requested on the enteroscopy report and performed after DAE without a new clinical indication. Main outcome measures included diagnostic yield of completion SBCE and impact on management. Results Of 350 DBE patients, 70 (21%) underwent a completion SBCE, 27 of the 70 (39%) on the same day as DBE. In all, 39 of the 70 (56%) had undergone SBCE before DBE. Both completion rate (91%; 64/70) and diagnostic yield (43%; 30/70) surpassed the European Society of Gastrointestinal Endoscopy standards. A positive completion capsule resulted in a change in management in 80% of patients (24/30). Conclusions Completion SBCE is feasible and effective, detecting and localizing clinically significant disease in over one-third of cases, while also reducing the need for further investigations in those with negative studies.

Device-assisted enteroscopy (DAE) plays a critical role in evaluation and treatment of small bowel disorders, with double-balloon enteroscopy (DBE) being the most widely used technique. Sedation strategies for enteroscopy remain a topic of debate, with conscious sedation (CS) and general anesthesia (GA) both being utilized. Our aim was to assess patient-reported experience measures (PREMs) for DAE, comparing CS and GA to determine their impact on patient satisfaction, procedure success, and pain perception. PREMs were prospectively collected from 118 unselected patients referred to a single center for DAE between July 2022 and March 2025. PREMs, procedure details, and sedation techniques were analyzed. Overall patient satisfaction was good with 100% being satisfied or very satisfied. A significantly higher proportion in the GA group reporting being "very satisfied, (92.3% GA vs 71.0% CS, P = 0.004). Despite experiencing greater discomfort, albeit within acceptable parameters (median 0, average 1.9) the CS group still reported high overall satisfaction. Technical success was achieved in 98.3% of cases and there was no statistical difference in technical outcomes between the groups. Although GA provides optimal conditions for enteroscopy, in our experience, CS remains an effective and acceptable option for patients, maintaining accessibility to the procedure. Our study supports use of PREMs in enteroscopy as a quality assurance measure and underscores the need for individualized sedation strategies to optimize patient care.

Device-assisted enteroscopy (DAE) has seen a rapid increase in demand in recent years. European Society of Gastrointestinal Endoscopy (ESGE) DAE key performance indicators (KPIs) have been published as well as some national datasets. Data suggest variation in practice and service provision impacts outcomes. The aim of this study was to review DAE services in Ireland according to ESGE KPIs and wider outcomes. DAE data from records at Tallaght and Connolly Hospital from January 2015 to May 2024 were retrospectively collated. Overall, 941 studies were included. 798 (85%) were index procedures and 548 (58%) were on men with a mean age of 61. Double-balloon enteroscopy was used in 864 (92%), 745 (79%) were anterograde (ADBE), and 196 (21%) were retrograde (RDBE). Mean depths of insertion were 201 cm ± 101 cm for ADBE and 101 cm ± 67 cm for RDBE. Of the procedures, 868 (92%) used conscious sedation; median doses of midazolam and fentanyl were 5 mg and 75 µg, respectively, with a mean comfort score (Modified Gloucester Scale) of 1.45 ± 0.67. Overall yield was 63%. Therapeutic intervention was performed in 385 (41%), 98% successfully, whereas 91% of detected lesions were tattooed. Significant adverse events occurred in < 1%. ESGE major KPIs by intention to treat (result/target) were: approved indication (94%/95%), depth-of-insertion tattoo (64%/80%), lesion detection (59%/50%-70%), lesion marking (91%/95%), complications (3.3%/< 5%), and adequate comfort (98%/> 90%). All minor KPIs were met. KPIs were consistent between both high-volume Irish-centers and were comparable to the three high-volume UK centers published in the recent DEEP-UK study, all of which performed better than lower-volume UK centers. Conscious sedation was used predominantly in our cohort with acceptable outcomes. DAE requirement is increasing. Our study suggests that a high-volume model ensures compliance with international KPIs. These data also suggest that conscious sedation is a viable option for the majority of DAEs without reducing effectiveness, while maintaining comfort.

Background/Objectives: Healthcare accounts for approximately 4.4% of global carbon emissions. Gastroenterology is a particularly heavy producer, with professional organisations outlining targets to move towards carbon neutrality. Missed hospital appointments, associated with poor medical outcomes, also represent physical and economic waste to the sector. COVID-19 expedited the shift toward virtual clinics, but tele-diagnostics have not expanded similarly. We aimed to assess the feasibility of a virtual C13 urea breath test clinic for H. pylori in Ireland. Methods: C13 urea breath test kits were provided to patients in the community, who were subsequently invited to book an online video appointment with a GI lab technician to assist them in performing the test at home. Completed tests were returned to the hospital via local GP, by post, or a specified hospital drop-off point, and analysed using our standard protocol. Results: 423 virtual appointments were reviewed. 135 (32%) were male, and the mean age was 42 years. The test positivity rate was 22%, similar to a matched in-person testing cohort (21%). In all, there were no non-attenders, and two cancellations. Virtual patients were more likely to attend their appointments (OR = 153.9, p = 0.0004) than in-person patients. Virtual UBT appointments saved 9943.5 Km of road journeys, equivalent to 254 person-hours of travel time and 1.24 metric tonnes of CO₂. Additionally, 300 (71%) patients returned a feedback questionnaire, of which 276 (92%) rated the overall home breath test experience as ‘good’ or ‘excellent’. Conclusions: Home testing for H. pylori is effective, acceptable, and reduces both reliance on invasive procedures such as endoscopy and carbon emissions.

Introduction: The RHEMITT score (RS) has showed an excellent accuracy to predict rebleeding after video capsule endoscopy (VCE), in patients with small bowel bleeding (SBB). However, RS was developed and subsequently validated in a heterogeneous population of patients with overt and occult SBB. As the bleeding presentation is a recognized independent predictor for rebleeding, the aim of this study was to assess the RS utility in a homogeneous cohort of patients admitted with only overt SBB. Methods: Retrospective, single centre study, including patients admitted with overt SBB. RS was calculated and the rebleeding rates compared. The follow-up was 12 months. Univariate analysis used simple logistic regression, chi-squared test, or Mann-Whitney as needed. To test the performance of the score, ROC analysis was performed selecting the optimal cut-off point maximized by the Youden index. A rebleeding-free survival was also assessed. Results: Seventy-nine patients were included, 62% showed relevant findings on VCE. In total, 27.8% rebled, of which 63.3% rebled within the first 6 months. The rate of rebleeding in low-risk RS category was 10.5%, in the intermediate-risk 30.2% and in the high-risk 57.1%. Urea (p = 0.008), relevant findings on VCE (p = 0.021), and high-risk RS category (p = 0.048) were predictive factors for rebleeding. The area under the curve for RS was 0.665 (95% confidence interval 0.773–0.526). The Kaplan-Meier plots were not statistically different according to the RS categories (log-rank p = 0.113). Conclusion: High-risk RS performed well in predicting rebleeding in this cohort of patients with overt SBB. However, in low and intermediate RS categories further research is warranted.

Background: There has been a reduction in successful H. pylori eradication rates recently, which is largely attributed to increasing antibiotic resistance. In areas of high dual clarithromycin and metronidazole resistance such as ours, Maastricht VI/Florence guidelines recommend bismuth quadruple therapy (BQT) as first line of therapy; however, the availability of bismuth was poor in Ireland until recently. Similarly, tetracycline, a component of BQT, is restricted locally, with doxycycline (D) being approved and reimbursed for most indications. Aims: To assess the efficacy of BQT-D therapy for H. pylori eradication in an Irish cohort. Methods: All patients testing positive for H. pylori in three Irish referral centres by urea breath test, stool antigen, or histology were treated prospectively with BQT-D (bismuth subcitrate 120 mg QDS, metronidazole 400 mg TDS, doxycycline 100 mg BD and esomeprazole 40 mg BD) for 14 days. Eradication was evaluated with a urea breath test (UBT) >4 weeks after therapy cessation or by stool antigen testing, as available. Outcomes were recorded and analysed according to demographics and H. pylori treatment history of the patients. Results: 217 patients completed post-eradication testing. Of which, 124 (57%) were female, with a mean age 52 years. 180 patients (83%) were treatment-naïve. A total of 165/180 (92%) of the treatment-naïve patients had successful eradication. There was no association between eradication and gender or age in this cohort (p = 0.3091, p = 0.962 respectively). A total of 29 patients received this therapy as second-line therapy, of which 22 (76%) had successful eradication. Eight patients received the regimen as rescue therapy, with seven (88%) having successful eradication. No serious adverse events were reported. Eleven individuals (6.5%) commented on the complicated nature of the regimen, with 11 tablets being taken at five intervals daily. Conclusions: BQT-D as first-line therapy for H. pylori infection is highly effective in a high dual-resistance population, achieving >90% eradication. BQT-D as a second-line treatment performed less well. Our data support BQT-D as a first-line treatment.

Background: Local audits of Helicobacter pylori (H. pylori) prescriptions and outcomes are necessary to assess guideline awareness among clinicians and treatment effectiveness. Aims: The aims were to investigate first-line prescriptions and effectiveness over a 10-year period in Ireland and evaluate the influence of the 2017 Irish consensus guidelines on these trends. Methods: Data were collected at e-CRF AEG-REDCap from the European Registry on H. pylori management (Hp-EuReg) and quality reviewed from 2013 to 2022. All treatment-naïve cases were assessed for effectiveness by modified intention-to-treat (mITT) analysis. Multivariate analysis was also performed. Results: Data from 1000 patients (mean age 50 ± 15 years; 54% female) were analyzed. Clarithromycin (C) and amoxicillin (A) triple therapy represented 88% of treatments, followed by sequential C, A, and metronidazole (M) therapy (4.3%) and triple C + M (2.7%). Bismuth quadruple therapy was prescribed in 1.7% of cases. Treatment durations of 14, 10, and 7 days accounted for 87%, 4.5%, and 8.5% of prescriptions, respectively. High-, standard-, and low-dose proton pump inhibitors (PPIs; 80 mg, 40 mg, and 20 mg omeprazole equivalent b.i.d.) were used in 86%, 0.9%, and 13% of cases, respectively. The overall eradication rate was 80%, while it was 81% for triple C + A. Good compliance and high-dose PPI were associated with higher overall mITT eradication rates (OR 4.5 and OR 1.9, respectively) and triple C + A eradication rates (OR 4.2 and OR 1.9, respectively). Overall eradication rates increased from 74% pre-2017 to 82% (p < 0.05) by the end of 2022. Similarly, the triple C + A eradication rates increased from 76% to 83% (p < 0.05). Conclusions: While first-line treatment effectiveness improved in clinical practice over time, cure rates remain below 90%. Alternative first-line strategies are required in Ireland.