Real-world practice of Helicobacter pylori management: A survey among physicians in Southeast Asia

BACKGROUND

Multidrug-resistant Helicobacter pylori strains are emerging in Southeast Asia. This study evaluates the region's real-world practice in H. pylori management.

MATERIALS AND METHODS

Physicians who managed H. pylori eradication in daily practice across 10 Southeast Asian countries were invited to participate in an online questionnaire, which included questions about the local availability of antimicrobial susceptibility tests (ASTs) and their preferred eradication regimens in real-world practice. An empiric regimen was considered inappropriate if it did not follow the local guidelines/consensus, particularly if it contained antibiotics with a high reported resistance rate or was recommended not to be empirically used worldwide.

RESULTS

There were 564 valid responses, including 314 (55.7%) from gastroenterologists (GIs) and 250 (44.3%) from non-GI physicians. ASTs were unavailable in 41.7%. In countries with low and intermediate clarithromycin resistance, the most common first-line regimen was PAC (proton pump inhibitor [PPI], amoxicillin, clarithromycin) (72.7% and 73.2%, respectively). Regarding second-line therapy, the most common regimen was bismuth-based quadruple therapy, PBMT (PPI, bismuth, metronidazole, tetracycline) (50.0% and 59.8%, respectively), if other regimens were used as first-line treatment. Concomitant therapy (PPI, amoxicillin, clarithromycin, metronidazole) (30.5% and 25.9%, respectively) and PAL (PPI, amoxicillin, levofloxacin) (22.7% and 27.7%, respectively) were favored if PBMT had been used as first-line treatment. In countries with high clarithromycin resistance, the most common first-line regimen was PBMT, but the utilization rate was only 57.7%. Alarmingly, PAC was prescribed in 27.8% of patients, ranking as the second most common regimen, and its prescription rate was higher in non-GI physicians than GI physicians (40.1% vs. 16.2%, p < 0.001).

CONCLUSIONS

Choosing inappropriate regimens containing antibiotics with high resistance rates is not uncommon in Southeast Asia, especially among non-GI physicians. In countries with high clarithromycin resistance, the PBMT regimen is underutilized.

Association of mental health conditions and functional gastrointestinal disorders among Vietnamese new-entry medical students

BACKGROUND

Functional gastrointestinal disorders (FGIDs), also known as disorders of gut-brain interaction, occur not only in the elderly but also in young adults. This study aimed to evaluate the association between mental health conditions and FGIDs among Vietnamese new-entry medical students.

METHODS

This cross-sectional study was conducted in February 2022 among new-entry medical students in Ho Chi Minh City, Vietnam. A printed questionnaire was distributed to all students on the day of freshmen health screening. Their urine samples were collected to screen for Helicobacter pylori infection using rapid urinary test. FGIDs were diagnosed using ROME IV criteria. Gastroesophageal reflux disease (GERD) was defined as the presence of typical reflux symptoms at least twice a week. Mental health conditions, including generalized anxiety disorder (GAD) and major depressive disorder (MDD), were identified using Generalized Anxiety Disorder Assessment-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scales, respectively.

RESULTS

Among 400 new-entry medical students who participated in the study, the overall prevalence of FGIDs was 10.3% (functional dyspepsia 6.5%, irritable bowel disease 5.5%). The overlap syndrome (OS) of GERD-FGIDs or different FGIDs was present in 3.0% of participants. The prevalences of GAD and MDD were 6.8% and 10.2%, respectively. The urinary test was positive in 180 (45.0%) participants. In the multivariable logistic regression analysis, MDD was significantly associated with not only the risk of FGIDs (OR = 5.599, 95%CI: 2.173-14.430, p<0.001) but also the risk of OS (OR = 10.076, 95CI%: 2.243-45.266, p = 0.003).

CONCLUSIONS

MDD is associated with FGIDs and OS among new-entry medical students.

Utility of narrow-band imaging with or without dual focus magnification in neoplastic prediction of small colorectal polyps: a Vietnamese experience

BACKGROUND/AIMS

Accurate neoplastic prediction can significantly decrease costs associated with pathology and unnecessary colorectal polypectomies. Narrow band imaging (NBI) and dual-focus (DF) mode are promising emerging optical technologies for recognizing neoplastic features of colorectal polyps digitally. This study aimed to clarify the clinical usefulness of NBI with and without DF assistance in the neoplastic prediction of small colorectal polyps (<10 mm).

METHODS

This cross-sectional study included 530 small colorectal polyps from 343 consecutive patients who underwent colonoscopy at the University Medical Center from September 2020 to May 2021. Each polyp was endoscopically diagnosed in three successive steps using white-light endoscopy (WLE), NBI, and NBI-DF and retrieved for histopathological assessment. The diagnostic accuracy of each modality was evaluated with reference to histopathology.

RESULTS

There were 295 neoplastic polyps and 235 non-neoplastic polyps. The overall accuracies of WLE, WLE+NBI, and WLE+NBI+NBI-DF in the neoplastic prediction of colorectal polyps were 70.8%, 87.4%, and 90.8%, respectively (p<0.001). The accuracy of WLE+NBI+NBI-DF was significantly higher than that of WLE+NBI in the polyp size ≤5 mm subgroup (87.3% vs. 90.1%, p<0.001).

CONCLUSION

NBI improved the real-time neoplastic prediction of small colorectal polyps. The DF mode was especially useful in polyps ≤5 mm in size.

Prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding among COVID-19 inpatients

OBJECTIVE

Since there has been little evidence regarding acute gastrointestinal bleeding (AGIB) among Asian populations with COVID-19, this study aimed to evaluate the prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding (AGIB) among COVID-19 patients hospitalized during the delta pandemic in Vietnam.

METHODS

The medical records of COVID-19 patients hospitalized in a tertiary hospital in Vietnam from July to October 2021 were retrospectively collected. Data regarding age, sex, comorbidities, COVID-19 severity, onset time of AGIB, therapeutic interventions for AGIB, and mortality outcome were analyzed.

RESULTS

Of 1567 COVID-19 inpatients, 56 (3.6%) had AGIB. In multivariable analysis, the independent risk factors for AGIB in COVID-19 inpatients included age (OR = 1.03, 95% CI: 1.01-1.04, p = 0.003), male sex (OR = 1.86, 95% CI: 1.06-3.26, p = 0.03), chronic liver disease (OR = 6.21, 95% CI: 2.97-13.00, p < 0.001), and chronic kidney disease (OR = 2.17, 95% CI: 1.01-4.65, p = 0.047). Among 34 patients with AGIB undergoing endoscopy, upper AGIB was determined in 24 (70.6%) patients. Peptic ulcer disease and hemorrhagic erosive gastritis were the most common causes, accounting for 64.7% (22/34) of cases. The therapeutic interventions for AGIB included blood transfusion (76.8%, 43/56), endoscopic hemostasis (23.5%, 8/34), and surgery (1.8%, 1/56). The mortality rate in the AGIB group was significantly higher than that in the non-AGIB group (46.4% vs. 27.7%, OR = 2.26, 95% CI: 1.32-3.87, p = 0.002). However, the majority (76.9%) of deaths in COVID-19 patients presenting with AGIB were not bleeding-related.

CONCLUSIONS

Age, male sex, chronic liver disease, and chronic kidney disease are risk factors for AGIB among COVID-19 inpatients. Peptic ulcer disease is the most common cause. COVID-19 inpatients with AGIB have a higher risk of mortality, but a large percentage of deaths are not bleeding-related.

Helicobacter pylori World Gastroenterology Organization Global Guideline

Helicobacter pylori remains a major health problem worldwide, causing considerable morbidity and mortality due to peptic ulcer disease and gastric cancer. The burden of disease falls disproportionally on less well-resourced populations. As with most infectious diseases, the largest impact on reducing this burden comes from improvement in socioeconomic status, which interrupts transmission. This has been observed in many regions of the world, but the prevalence of infection remains high in many regions where improvements in living standards are slow to occur. Meanwhile, the optimal clinical management and treatment pathways remain unsettled and are evolving with changing antimicrobial resistance patterns. Despite decades of research and clinical practice, major challenges remain. The quest for the most effective, safe, and simple therapy remains the major issue for clinicians. The search for an effective vaccine appears to be elusive still. Clinical guidelines do not infrequently proffer discordant advice. A major challenge for guidelines is for relevance across a variety of populations with a varying spectrum of disease, antimicrobial resistance rates, and vastly different resources. As local factors are central to determining the impact and management strategies for H. pylori infection, it is important that pathways are based on the best available local knowledge rather than solely extrapolating from guidelines formulated in other regions, which may be less applicable. To this end, this revision of the World Gastroenterology Organisation (WGO) H. pylori guideline uses a "Cascades" approach that seeks to summarize the principles of management and offer advice for pragmatic, relevant and achievable diagnostic and treatment pathways based on established key treatment principles and using local knowledge and available resources to guide regional practice.

Vietnam Association of Gastroenterology (VNAGE) consensus on the management of Helicobacter pylori infection

Helicobacter pylori (H. pylori) infection is prevalent and has a rapidly increasing antibiotic resistance rate in Vietnam. Reinfection is quite common, and gastric carcinoma remains one of the most common malignancies, which is not uncommon to develop after successful eradication. The purpose of this consensus is to provide updated recommendations on the management of H. pylori infection in the country. The consensus panel consisted of 32 experts from 14 major universities and institutions in Vietnam who were invited to review the evidence and develop the statements using the Delphi method. The process followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The consensus level was defined as ≥80% for agreement on the proposed statements. Due to the limited availability of high-quality local evidence, this consensus was also based on high-quality evidence from international studies, especially those conducted in other populations in the Asia-Pacific region. The panel finally reached a consensus on 27 statements after two voting rounds, which consisted of four sections (1) indications for testing and selection of diagnostic tests (2), treatment regimens, (3) post-treatment confirmation of H. pylori status, and (4) reinfection prevention methods and follow-up after eradication. Important issues that require further evidence include studies on third-line regimens, strategies to prevent H. pylori reinfection, and post-eradication follow-up for precancerous gastric lesions. We hope this consensus will help guide the current clinical practice in Vietnam and promote multicenter studies in the country and international collaborations.

Efficacy of international web-based educational intervention in the detection of high-risk flat and depressed colorectal lesions higher (CATCH project) with a video: Randomized trial

OBJECTIVES

Three subcategories of high-risk flat and depressed lesions (FDLs), laterally spreading tumors non-granular type (LST-NG), depressed lesions, and large sessile serrated lesions (SSLs), are highly attributable to post-colonoscopy colorectal cancer (CRC). Efficient and organized educational programs on detecting high-risk FDLs are lacking. We aimed to explore whether a web-based educational intervention with training on FIND clues (fold deformation, intensive stool/mucus attachment, no vessel visibility, and demarcated reddish area) may improve the ability to detect high-risk FDLs.

METHODS

This was an international web-based randomized control trial that enrolled non-expert endoscopists in 13 Asian countries. The participants were randomized into either education or non-education group. All participants took the pre-test and post-test to read 60 endoscopic images (40 high-risk FDLs, five polypoid, 15 no lesions) and answered whether there was a lesion. Only the education group received a self-education program (video and training questions and answers) between the tests. The primary outcome was a detection rate of high-risk FDLs.

RESULTS

In total, 284 participants were randomized. After excluding non-responders, the final data analyses were based on 139 participants in the education group and 130 in the non-education group. The detection rate of high-risk FDLs in the education group significantly improved by 14.7% (66.6-81.3%) compared with -0.8% (70.8-70.0%) in the non-education group. Similarly, the detection rate of LST-NG, depressed lesions, and large SSLs significantly increased only in the education group by 12.7%, 12.0%, and 21.6%, respectively.

CONCLUSION

Short self-education focusing on detecting high-risk FDLs was effective for Asian non-expert endoscopists. (UMIN000042348).

Ischemic Colitis Presented as Pseudomembranous Colitis: An Untypical Case from Vietnam

Ischemic colitis (IC) is an underreported chronic disease characterized by the hypoperfusion of the bowel mucosa. The diagnosis and treatment may be challenging because its clinical course resembles other colitis or even colorectal malignancies. This paper reports an untypical case to underline the diversity of IC manifestation. A 68-year-old man with several comorbidities was admitted because of abdominal pain with a 6-month duration and a mass in the left lower quadrant. Colonoscopy revealed erosive pseudomembranous colitis narrowed colon segments with ulcerated mucosa mimicking colorectal cancer and inflammatory bowel disease. The stool cultures and Clostridium difficile toxin tests were negative. After the failure of conservative therapy, the Hartmann procedure with temporary ileostomy was performed uneventfully. The histological results of the surgical specimens revealed IC with focal pseudomembranous areas.

Performance of chromoendoscopy and narrow-band imaging in the diagnosis of gastric intestinal metaplasia

BACKGROUND/AIMS

Chromoendoscopy and narrow-band imaging (NBI) have been reported to aid in the diagnosis of gastric intestinal metaplasia (GIM). This study aimed to assess the diagnostic validity of chromoendoscopy combined with NBI in the diagnosis of GIM in Vietnamese.

METHODS

A cross-sectional study was carried out on patients with dyspeptic symptoms who underwent esophagogastroduodenoscopy (EGD) at the University Medical Center at Ho Chi Minh City. We compared the detection rates of GIM in the group of patients examined with white-light endoscopy (WLE) alone and those examined with WLE in combination with chromoendoscopy and NBI.

RESULTS

A total of 374 patients have been recruited. The additional GIM detection rate after chromoendoscopy combined with NBI was 8.6% (95% confidence interval [CI]: 4.3 - 12.8), p < .005. The rate of GIM within the group of patients biopsied under the guidance of chromoendoscopy combined with NBI was statistically significantly higher than in the group with WLE alone with a distinct rate of 14.4% (95% CI: 6.3 - 2.6), p = .001.

CONCLUSIONS

Chromoendoscopy combined with NBI helped to detect the GIM lesions missed by WLE and was a more reliable endoscopic method for the diagnosis of GIM.

Overlap of Gastroesophageal Reflux Disease and Functional Dyspepsia and Yield of Esophagogastroduodenoscopy in Patients Clinically Fulfilling the Rome IV Criteria for Functional Dyspepsia

Aim

To assess (1) the overlap rate of gastroesophageal reflux disease (GERD) and functional dyspepsia (FD) and (2) the yield of esophagogastroduodenoscopy in patients clinically presenting with FD.

Materials and Methods

Outpatients aged ≥18 years with typical reflux symptoms ≥2 times a week or clinically fulfilling the Rome IV criteria for FD were recruited and underwent esophagogastroduodenoscopy. GERD was classified into non-erosive reflux disease (NERD) and erosive reflux disease (ERD), and FD was classified into epigastric pain syndrome and postprandial distress syndrome. The endoscopic findings that could explain patients’ symptoms were considered clinically significant endoscopic findings. After esophagogastroduodenoscopy, patients were categorized into three groups: GERD-only, FD-only, and GERD-FD overlap.

Results

There were 439 patients with a mean age of 42.3 ± 11.6 years. Ninety-one (20.7%) patients had clinically significant endoscopic findings: 73 (16.6%) reflux esophagitis, 6 (1.4%) Barrett’s esophagus and 14 (3.2%) gastroduodenal ulcers. After excluding gastroduodenal ulcers, the numbers of patients with GERD-only, FD-only, and GERD-FD overlap were 69 (16.2%), 138 (32.5%), and 218 (51.3%), respectively. Postprandial distress syndrome was more prevalent in GERD-FD overlap than in FD-only (72.9 vs. 44.2%, p < 0.001). The rates of gastroduodenal ulcers in patients clinically fulfilling the criteria for FD with and without reflux symptoms were 0.6 and 4.7%, respectively (p = 0.027).

Conclusion

The GERD-FD overlap was more common than each disorder alone, of which postprandial distress syndrome was significantly prominent. Organic dyspepsia was uncommon in patients clinically fulfilling the Rome IV criteria for FD.

Emergence of amoxicillin resistance and identification of novel mutations of the pbp1A gene in Helicobacter pylori in Vietnam

Background

Amoxicillin-resistant Helicobacter pylori (H. pylori) strains seem to have increased over time in Vietnam. This threatens the effectiveness of H. pylori eradication therapies with this antibiotic. This study aimed to investigate the prevalence of primary resistance of H. pylori to amoxicillin and to assess its association with pbp1A point mutations in Vietnamese patients.

Materials and methods

Naive patients who presented with dyspepsia undergoing upper gastrointestinal endoscopy were recruited. Rapid urease tests and PCR assays were used to diagnose H. pylori infection. Amoxicillin susceptibility was examined by E-tests. Molecular detection of the mutant pbp1A gene conferring amoxicillin resistance was carried out by real-time PCR followed by direct sequencing of the PCR products. Phylogenetic analyses were performed using the Tamura-Nei genetic distance model and the neighbor-joining tree building method.

Results

There were 308 patients (46.1% men and 53.9% women, p = 0.190) with H. pylori infection. The mean age of the patients was 40.5 ± 11.4 years, ranging from 18 to 74 years old. The E-test was used to determine the susceptibility to amoxicillin (minimum inhibitory concentration (MIC) ≤ 0.125 μg/ml) in 101 isolates, among which the rate of primarily resistant strains to amoxicillin was 25.7%. Then, 270 sequences of pbp1A gene fragments were analysed. There were 77 amino acid substitution positions investigated, spanning amino acids 310–596, with the proportion varying from 0.4 to 100%. Seven amino acid changes were significantly different between amoxicillin-sensitive (Amox^S) and amoxicillin-resistant (Amox^R) samples, including Phe₃₆₆ to Leu (p <  0.001), Ser₄₁₄ to Arg (p <  0.001), Glu/Asn_464–465 (p = 0.009), Val₄₆₉ to Met (p = 0.021), Phe₄₇₃ to Val (p <  0.001), Asp₄₇₉ to Glu (p = 0.044), and Ser/Ala/Gly_595–596 (p = 0.001). Phylogenetic analyses suggested that other molecular mechanisms might contribute to amoxicillin resistance in H. pylori in addition to the alterations in PBP1A.

Conclusions

We reported the emergence of amoxicillin-resistant Helicobacter pylori strains in Vietnam and new mutations statistically associated with this antimicrobial resistance. Additional studies are necessary to identify the mechanisms contributing to this resistance in Vietnam.

Diagnostic Accuracy of H. pylori Status by Conventional Endoscopy: Time-Trend Change After Eradication and Impact of Endoscopic Image Quality

Aim

To assess the time trend of diagnostic accuracy of pre- and post-eradication H. pylori status and interobserver agreement of gastric atrophy grading.

Methods

A series 100 of conventional endoscopic image sets taken from subjects undergoing gastric cancer screening at a polyclinic were evaluated by 5 experienced assessors. Each assessor independently examined endoscopic findings according to the Kyoto classification and then determined the H. pylori status (never, current, or past infected). Gastric atrophy was assessed according to the Kimura-Takemoto classification and classified into 3 grades (none/mild, moderate, or severe). The image series that ≥3 assessors considered to have good quality were arbitrarily defined as high-quality image (HQI) series, and the rest were defined as low-quality image (LQI) series.

Results

The overall diagnostic accuracy of H. pylori status was 83.0%. It was lowest in subjects with current infection (54%), gradually increased at 1 year (79%, P < 0.001) and 3 years (94.0%, P = 0.002), but then did not significantly change at 5 years (91.0%, P = 0.420) after eradication. The rate of LQI series was 28%. The overall diagnostic accuracy of H. pylori status dropped from 88.9% to 67.9% (P < 0.001), and the mean kappa value on gastric atrophy grading dropped from 0.730 to 0.580 (P = 0.002) in the HQI and LQI series, respectively.

Conclusions

Diagnostic accuracy of H. pylori status increased over time after eradication. LQI series badly affected the diagnostic accuracy of H. pylori status and the level of agreement when grading gastric atrophy.

A Long Duration of Reflux Symptoms is the Predominant Risk Factor for Depression in Vietnamese Patients with Gastroesophageal Reflux Disease

PURPOSE

Depression is more prevalent in patients with gastroesophageal reflux disease (GERD) than in controls. The disorder can worsen the quality of life of GERD patients and is also associated with poor treatment response. However, there are limited data on its prevalence and risk factors in GERD patients in Southeast Asia. We aimed to assess the prevalence and severity of depression and its associated factors in Vietnamese patients with GERD.

PATIENTS AND METHODS

A cross-sectional study was conducted on GERD patients. GERD was defined as troublesome typical reflux symptoms at least twice a week or having endoscopic erosive reflux disease. The revised Beck's Depression Inventory (BDI-IA), which has been locally validated, was used to evaluate depression (BDI-IA < 10: none, 10-18: mild to moderate, 19-29: moderate to severe, and ≥ 30: severe depression). Multiple logistic regression analysis was used to identify independent factors associated with depression.

RESULTS

A total of 194 patients were recruited. The mean age was 44.1 ± 12.0 years, and the male-to-female ratio was 1:1.2. The depression rate was 47.9% (mild to moderate: 30.9%, moderate to severe: 16.0%, and severe: 1.0%). In multivariate analysis, sex and duration of reflux symptoms were the only two risk factors for depression. Compared to males, females were more likely to suffer from depression: odds ratio (OR) = 3.941 (95% confidence interval [CI], 1.386-11.205), p = 0.010. Compared to patients with a duration of reflux symptoms < 1 year, those with a duration of 1-10 years and > 10 years were more likely to suffer from depression with a dose‒response: OR = 3.520 (95% CI, 1.057-11.717), p = 0.040; and OR = 5.605 (1.046-30.019), p = 0.044, respectively.

CONCLUSION

Depression was prevalent, and a long duration of reflux symptoms was its predominant risk factor in Vietnamese patients with GERD.

Age Cutoff and Yield of Prompt Esophagogastroduodenoscopy to Detect Malignancy in Vietnamese with Upper Gastrointestinal Symptoms: An Endoscopic Database Review of 472,744 Patients from 2014 to 2019

BACKGROUND AND AIMS

Age cutoff is an important factor in deciding whether esophagogastroduodenoscopy (EGD) is necessary for patients presenting with upper gastrointestinal symptoms. However, the cutoff value is significantly different across populations. We aimed to determine the age cutoff for EGD that assures a low rate of missing upper gastrointestinal malignancy (UGIM) and to assess the yield of prompt EGD in Vietnamese patients presenting with upper gastrointestinal symptoms.

METHODS

All EGDs performed in outpatients during a 6-year period (2014-2019) at a tertiary hospital that provided an open-access endoscopy service were retrospectively reviewed. Repeat or surveillance EGDs were excluded. Different age cutoffs were evaluated in terms of their prediction of the absence of UGIM. The yield of endoscopy to detect one malignancy (YoE) was also calculated.

RESULTS

Of 472,744 outpatients presenting with upper gastrointestinal symptoms, there were 2198 (0.4%) patients with UGIM. The median age and male-to-female ratio of patients with UGIMs were 57.9 ± 12.5 years and 2.5 : 1, respectively. The YoEs in patients <40, 40-60, and >60 years of age were <1, 1-10, and >10 per 1000 EGDs, respectively. The age cutoffs of 30 years in females and 35 years in males could detect 98.2% (95% CI: 97.7%-98.8%) of UGIM cases with a YoE of about 1 per 1000 EGDs.

CONCLUSIONS

The age cutoff for EGD in Vietnamese should be lower than that recommended by current international guidelines. The strategy of prompt EGD showed a low YoE, and its cost-effectiveness requires further investigation.

Screening and surveillance for gastric cancer: Does family history play an important role in shaping our strategy?

Family history is an important risk factor of gastric cancer. No guidelines have been developed that target gastric cancer with a family history; only hereditary familial gastric cancer is targeted. We review the available evidence regarding the familial aggregation mechanisms of gastric cancer and a strategy of screening and surveillance for gastric cancer in individuals with a positive family history of the disease. As there is a synergic effect of Helicobacter pylori infection and family history on the increased risk of gastric cancer, Helicobacter pylori eradication should be considered in all infected individuals with a family history of gastric cancer. Currently, there is weak evidence indicating that suitable timing to initiate eradication therapy is at the age of 20, when precancerous lesions, including significant gastric atrophy and intestinal metaplasia, have not been established. Reasonable timing to initiate screening for gastric cancer in individuals with a family history of gastric cancer is 10 years prior to the age of onset of gastric cancer in affected relatives. A 2-year surveillance interval, instead of the 3-year interval recommended in the present guidelines, may be better to detect early gastric cancer in those individuals who have already developed precancerous gastric lesions.

Prevalence, clinical characteristics, and management of irritable bowel syndrome in Vietnam: A scoping review

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders worldwide. Its prevalence varies significantly from country to country, largely due to heterogeneity in the available data. Recent studies show that the prevalence of IBS in Asia is on the rise. However, there are very limited data regarding its prevalence in the Vietnamese population. This review aims to offer an overview of the prevalence and clinical characteristics of IBS in the Vietnamese population; and to discuss the current management of IBS in Vietnam-taking into account the available medical resources and the local spectrum of lower gastrointestinal disorders that may mimic IBS.

Consensus statements and recommendations on the management of mild-to-moderate gastroesophageal reflux disease in the Southeast Asian region

This paper reports the proceedings from the first consensus meeting on the management of mild-to-moderate gastroesophageal reflux disease (GERD) in the Southeast Asian (SEA) region. Seventeen statements were drawn up by a steering committee that focused on epidemiology, mechanism of action, diagnostic investigations, and treatment. Voting on the recommendations used the Delphi method with two rounds of voting among the 10 panel members. The consensus panel agreed that GERD is mostly a mild disease in the SEA region with predominantly non-erosive reflux disease (NERD). Complicated GERD and Barrett's esophagus are infrequently seen. The panel recommended endoscopy in patients with alarm or refractory symptoms but cautioned that the incidence of gastric cancer is higher in SEA. pH and impedance measurements were not recommended for routine assessment. The acid pocket is recognized as an important pathogenic factor in GERD. Lifestyle measures such as weight reduction, avoidance of smoking, reduction of alcohol intake, and elevation of the head of the bed were recommended but strict avoidance of specific foods or drinks was not. Alginates was recommended as the first-line treatment for patients with mild-to-moderate GERD while recognizing that proton-pump inhibitors (PPIs) remained the mainstay of treatment of GERD. The use of alginates was also recommended as adjunctive therapy when GERD symptoms were only partially responsive to PPIs.

Missed Giant Lower Esophageal Leiomyoma in a Young Female Presenting with Refractory Gastroesophageal Reflux Disease

Esophageal leiomyoma is a rare disease commonly reported in middle-aged patients with a male predominance. Many patients are asymptomatic, and a few may present with symptoms such as dysphagia and chest pain. However, heartburn is only reported in patients with accompanying hiatal hernia. We hereby report a giant lower esophageal leiomyoma with concomitant hiatal hernia in a young Vietnamese female, who presented with refractory gastroesophageal reflux symptoms. The diagnosis was challenging as the tumor grew outward. As a consequence, the patient did not experience dysphagia and the tumor was hardly detected under endoscopy. The hiatal hernia in this patient was probably related to the presence of the leiomyoma. It is important to look carefully for submucosal tumor at the lower esophagus and cardia under endoscopy in patients with similar manifestations.

Multinational survey on the preferred approach to management of Barrett’s esophagus in the Asia-Pacific region

BACKGROUND

Major societies provide differing guidance on management of Barrett’s esophagus (BE), making standardization challenging.

AIM

To evaluate the preferred diagnosis and management practices of BE among Asian endoscopists.

METHODS

Endoscopists from across Asia were invited to participate in an online questionnaire comprising eleven questions regarding diagnosis, surveillance and management of BE.

RESULTS

Five hundred sixty-nine of 1016 (56.0%) respondents completed the survey, with most respondents from Japan (n = 310, 54.5%) and China (n = 129, 22.7%). Overall, the preferred endoscopic landmark of the esophagogastric junction was squamo-columnar junction (42.0%). Distal palisade vessels was preferred in Japan (59.0% vs 10.0%, P < 0.001) while outside Japan, squamo-columnar junction was preferred (59.5% vs 27.4%, P < 0.001). Only 16.3% of respondents used Prague C and M criteria all the time. It was never used by 46.1% of Japanese, whereas 84.2% outside Japan, endoscopists used it to varying extents (P < 0.001). Most Asian endoscopists (70.8%) would survey long-segment BE without dysplasia every two years. Adherence to Seattle protocol was poor with only 6.3% always performing it. 73.2% of Japanese never did it, compared to 19.3% outside Japan (P < 0.001). The most preferred (74.0%) treatment of non-dysplastic BE was proton pump inhibitor only when the patient was symptomatic or had esophagitis. For BE with low-grade dysplasia, 6-monthly surveillance was preferred in 61.9% within Japan vs 47.9% outside Japan (P < 0.001).

CONCLUSION

Diagnosis and management of BE varied within Asia, with stark contrast between Japan and outside Japan. Most Asian endoscopists chose squamo-columnar junction to be the landmark for esophagogastric junction, which is incorrect. Most also did not consistently use Prague criteria, and Seattle protocol. Lack of standardization, education and research are possible reasons.

Short Meal-to-Bed Time Is a Predominant Risk Factor of Gastroesophageal Reflux Disease in Pregnancy

BACKGROUND

Short meal-to-bed time (MTBT) has been reported to relate to gastroesophageal reflux disease (GERD), but evidence is lacking in pregnant women. We aimed to assess the characteristics of GERD and the association between MTBT and GERD during pregnancy.

PATIENTS AND METHODS

A cross-sectional study was carried out on 400 pregnant women aged 18 years and older visiting the antenatal clinic of Gia-Dinh People's Hospital, Vietnam. GERD was defined as having troublesome heartburn and/or regurgitation at least once a week. Reflux-related insomnia was defined as having difficulties in initiating or maintaining sleep through the night. MTBT was defined as "short" if it was ≤2 hours in more than two thirds of days in a week.

RESULTS

There were 154 (38.5%) patients with GERD and 20 (13.0%) patients with reflux-related insomnia. In multivariate analysis, there were 3 factors significantly associated with GERD: third trimester [odds ratio (OR)=1.66; 95% confidence interval (CI): 1.03-2.69], previous history of typical reflux symptoms (OR=9.05; 95% CI: 5.29-15.50), and short MTBT (OR=12.73; 95% CI: 2.92-55.45). The frequency of reflux symptoms progressively increased across subgroups of patients with no short MTBT, either daytime or nighttime short MTBT, and with both daytime and nighttime short MTBT. Nighttime MTBT was also a significant risk factor for reflux-related insomnia (OR=4.60; 95% CI: 1.64-12.92).

CONCLUSIONS

We reported for the first time that short MTBT was a predominant risk factor of GERD in pregnancy. This dieting habit was significantly associated with reflux symptom frequency and reflux-related insomnia.

Clinical characteristics and risk factors of gastroesophageal reflux disease in Vietnamese patients with upper gastrointestinal symptoms undergoing esophagogastroduodenoscopy

Background and Aim

The risk factors associated with the increase in prevalence of gastroesophageal reflux disease (GERD) are not consistent across countries and there have been few studies in Asia in the past 10 years. This study was conducted to assess the features and risk factors of GERD in Vietnamese patients.

Methods

A cross-sectional study was conducted on 1947 out-patients ≥18 years of age who were presented with upper gastrointestinal symptoms and underwent esophagogastroduodenoscopy. Reflux esophagitis was graded according to the Los Angeles classification. Endoscopically suspected Barrett's esophagus (BE) was recorded according to the Prague C and M criteria and biopsy was taken for histologic examination.

Results

There were 511 (26.2%) patients with GERD, 242 (47.4%) with nonerosive reflux disease, and 269 (52.6%) with reflux esophagitis and/or BE. Epigastric pain, regurgitation, and heartburn were the chief complaints in 36.8%, 27.0%, and 9.2% of patients, respectively. Most of the patients with mucosal injury had reflux esophagitis in mild grade and BE in the form of C0M ≤2 (99.6%, 231/232 and 97.8%, 46/47, respectively). In multivariate analysis, hiatal hernia, male gender, waist-to-hip ratio (independent from general obesity), and smoking were risk factors for GERD while Helicobacter pylori infection was negatively associated with GERD.

Conclusions

The majority of GERD patients had none or mild mucosal injury. Typical reflux symptoms, however, may not be the chief complaints. Central obesity would be more important than general obesity as a risk factor, while H. pylori infection was a "protective" factor for GERD in Vietnamese patients.

Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese

BACKGROUND/AIMS

The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese.

METHODS

Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis.

RESULTS

There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 10³/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively).

CONCLUSIONS

The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese.

Knowledge, Attitude, and Practice Survey of Gastroparesis in Asia by Asian Neurogastroenterology and Motility Association

Background/Aims

Gastroparesis is identified as a subject that is understudied in Asia. The scientific committee of the Asian Neurogastroenterology and Motility Association performed a Knowledge, Attitude, and Practices survey on gastroparesis among doctors in Asia.

Methods

The questionnaire was created and developed through a literature review of current gastroparesis works of literature by the scientific committee of Asian Neurogastroenterology and Motility Association.

Results

A total of 490 doctors from across Asia (including Bangladesh, China, Hong Kong, Indonesia, Japan, Malaysia, Myanmar, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam) participated in the survey. Gastroparesis is a significant gastrointestinal condition. However, a substantial proportion of respondents was unable to give the correct definition and accurate diagnostic test. The main reason for lack of interest in diagnosing gastroparesis was "the lack of reliable diagnostic tests" (46.8%) or "a lack of effective treatment" (41.5%). Only 41.7% of respondents had access to gastric emptying scintigraphy. Most doctors had never diagnosed gastroparesis at all (25.2%) or diagnosed fewer than 5 patients a year (52.1%).

Conclusions

Gastroparesis can be challenging to diagnose due to the lack of instrument, standardized method, and paucity of research data on normative value, risk factors, and treatment studies in Asian patients. Future strategies should concentrate on how to disseminate the latest knowledge of gastroparesis in Asia. In particular, there is an urgent need to estimate the magnitude of the problems in high risk and idiopathic patients as well as a standardized diagnostic procedure in Asia.

An External Validation Study of the Oakland and Glasgow-Blatchford Scores for Predicting Adverse Outcomes of Acute Lower Gastrointestinal Bleeding in an Asian Population

Aims

This study is aimed at (1) validating the performance of Oakland and Glasgow-Blatchford (GBS) scores and (2) comparing these scores with the SALGIB score in predicting adverse outcomes of acute lower gastrointestinal bleeding (ALGIB) in a Vietnamese population.

Methods

A multicenter cohort study was conducted on ALGIB patients admitted to seven hospitals across Vietnam. The adverse outcomes of ALGIB consisted of blood transfusion; endoscopic, radiologic, or surgical interventions; severe bleeding; and in-hospital death. The Oakland and GBS scores were calculated, and their performance was compared with that of SALGIB, a locally developed prediction score for adverse outcomes of ALGIB in Vietnamese, based on the data at admission. The accuracy of these scores was measured using the area under the receiver operating characteristic curve (AUC) and compared by the chi-squared test.

Results

There were 414 patients with a median age of 60 (48-71). The rates of blood transfusion, hemostatic intervention, severe bleeding, and in-hospital death were 26.8%, 15.2%, 16.4, and 1.4%, respectively. The SALGIB score had comparable performance with the Oakland score (AUC: 0.81 and 0.81, respectively; p = 0.631) and outperformed the GBS score (AUC: 0.81 and 0.76, respectively; p = 0.002) for predicting the presence of any adverse outcomes of ALGIB. All of the three scores had acceptable and comparable performance for in-hospital death but poor performance for hemostatic intervention. The Oakland score had the best performance for predicting severe bleeding.

Conclusions

The Oakland and SALGIB scores had excellent and comparable performance and outperformed the GBS score for predicting adverse outcomes of ALGIB in Vietnamese.

Prevalence, clinical characteristics, and risk factors of Barrett esophagus in Vietnamese patients with upper gastrointestinal symptoms

The current barrier for investigation of Barrett esophagus (BE) in Asia is diagnostic standardization, which is a challenge to identify its true risk factors. This study aimed to investigate the prevalence, clinical characteristics and risk factors of BE in Vietnamese patients with upper gastrointestinal symptoms.A cross-sectional study was conducted on consecutive outpatients who underwent upper gastrointestinal endoscopy. Endoscopically suspected esophageal metaplasia (ESEM) which was clearly visible at least 1 cm above the gastroesophageal junction at endoscopy was taken biopsy. At least 1 biopsy per 2 cm in tongues of ESEM and 4 biopsies per 2 cm of circumferential ESEM were taken. The diagnostic criterion for BE was replacement of the normal squamous epithelial lining by columnar epithelium confirmed by histology.A total of 1947 patients were recruited. Forty-seven out of 58 patients with ESEM were histologically confirmed BE. The prevalences of BE and hiatal hernia (HH) were 2.4% (95% confidence interval [CI], 1.7-3.1%) and 2.3% (95% CI, 1.6-2.9%), respectively. Heartburn and/or regurgitation presented in only 61.7% (95% CI, 46.4-75.5%) of patients with BE. In multivariate analysis, the only 2 factors significantly associated with BE were HH (OR 7.53; 95% CI, 3.13-18.11; P < .001) and typical reflux symptom (OR 2.07; 95% CI, 1.12-3.83; P = .020).BE is not uncommon in Vietnamese patients with upper gastrointestinal symptoms. In addition, typical reflux symptoms and HH are the risk factors for BE in Vietnamese.

Improving Efficacy of Endoscopic Diagnosis of Early Gastric Cancer: Gaps to Overcome from the Real-World Practice in Vietnam

Objective

To identify factors associated with increased proportion of early gastric cancer to total detected gastric cancer among patients undergoing diagnostic esophagogastroduodenoscopy.

Methods

A nationwide survey was conducted across 6 central-type and 6 municipal-type Vietnamese hospitals. A questionnaire regarding annual esophagogastroduodenoscopy volume, esophagogastroduodenoscopy preparation, the use of image-enhanced endoscopy, and number of gastric cancer diagnosed in 2018 was sent to each hospital.

Results

The total proportion of early gastric cancer was 4.0% (115/2857). Routine preparation with simethicone and the use of image-enhanced endoscopy were associated with higher proportion of early gastric cancer (OR 1.9, 95% CI: 1.1-3.2, p = 0.016; OR 2.7, 95% CI: 1.8-4.0, p < 0.001, respectively). Esophagogastroduodenoscopies performed at central-type hospitals were associated with higher proportion of early gastric cancer (OR 1.9, 95% CI: 1.1-3.2, p = 0.017). Esophagogastroduodenoscopies performed at hospitals with an annual volume of 30.000-60.000 were associated with higher proportion of early gastric cancer than those performed at hospitals with an annual volume of 10.000-<30.000 (OR 2.7, 95% CI: 1.6-4.8, p < 0.001) and with a volume of >60.000-100.000 (OR 2.7, 95% CI: 1.7-4.2, p < 0.001). Only four (33.3%) hospitals reported all endoscopic types of early gastric cancer.

Conclusions

The detection of early gastric cancer is still challenging even for endoscopists working in regions with relatively high prevalence. The real-world evidence showed that endoscopic detection of early gastric cancer could potentially improve with simple adjustments of esophagogastroduodenoscopy protocols.

Use of endoscopic assessment of gastric atrophy for gastric cancer risk stratification to reduce the need for gastric mapping

Background/Aims: Stratification for gastric cancer risk typically involves histologic grading of gastric biopsies. This study aimed to compare endoscopic assessment of gastric atrophy and histologic gastric mapping for gastric cancer risk stratification in a region with relatively high risk of gastric cancer.Methods: Endoscopic and histologic gastric cancer risk stratification were compared in Vietnamese patients with functional dyspepsia. Endoscopic gastric atrophy was graded according to the Kimura-Takemoto classification. High-risk histologic lesions were defined as gastric dysplasia, Operative Link on Gastritis Assessment (OLGA) gastritis stage III/IV, intestinal metaplasia in both the antrum and the corpus or incomplete intestinal subtype at any site. Two experienced pathologists, blinded to endoscopic information, jointly examined all specimens and reached a consensus. The presence of high-risk histologic lesions was compared among patients with different endoscopic grades of gastric atrophy.Results: There were 280 subjects (mean age, 46.1 ± 10 years, and male, 50%). The numbers of patients with moderate/severe grade of endoscopic gastric atrophy and high-risk histologic lesions were 126 (45.0%) and 46 (16.4%), respectively. The sensitivity, specificity, positive and negative likelihood ratios of moderate/severe endoscopic atrophic grade for detecting high-risk histologic lesions were 93% (95% CI 86%-100%), 65% (95% CI 58%-71%), 2.64 (95% CI 2.18 - 3.18) and 0.10 (95% CI 0.03 - 0.30), respectively.Conclusions: Gastric cancer risk assessment using endoscopic or histologic methods provided similar results such that the absence or a mild grade of endoscopic gastric atrophy would preclude the need for histologic mapping.

Assessment of Endoscopic Gastric Atrophy according to the Kimura-Takemoto Classification and Its Potential Application in Daily Practice

The assessment of endoscopic gastric atrophy (EGA) according to the Kimura-Takemoto classification has been reported to correlate well with histological assessment. Although agreement among beginner endoscopists was less than that among experienced endoscopists, it has been shown that agreement level could markedly improve and remained stable after proper training. Several cohort studies have consistently shown that the severity of EGA at baseline is significantly associated with the presence of advanced precancerous gastric lesions and gastric cancer, as well as the development of gastric cancer in future. Patients with moderate-to-severe EGA still have high risk of gastric cancer even after successful Helicobacter pylori eradication and should be candidates for gastric cancer surveillance. The assessment of EGA, therefore, could be used as a preliminary tool to identify individuals at high risk for gastric cancer. In this paper, we review the agreement on mucosal atrophy assessment between the Kimura-Takemoto classification and histology as well as the potential application of this endoscopic classification to identify precancerous gastric lesions and gastric cancer in daily practice.

Identifying high-risk individuals for gastric cancer surveillance from western and eastern perspectives: Lessons to learn and possibility to develop an integrated approach for daily practice

Current evidence shows that individuals with gastric dysplasia, severe and extensive gastric atrophy, extensive gastric intestinal metaplasia and the incomplete subtype of intestinal metaplasia are at high risk for gastric cancer (GC) development. There are several approaches to identifying these subjects, including noninvasive methods, esophagogastroduodenoscopy and histology. The main approach in Western countries is histology-based while that in Eastern countries with a high prevalence of GC is endoscopy-based. Regarding asymptomatic individuals, the key issues in selecting applicable approaches are the ability to reduce GC mortality and the cost-effectiveness of the approach. At present, population-based screening programs have only been applied in a few Asian countries with a high risk of GC. Pre-endoscopic risk assessment based on demographic and clinical features, such as ethnicity, age, gender, smoking and Helicobacter pylori status, is helpful for identifying subjects with high pre-test probability for a possibly cost-effective approach, especially in intermediate- and low-risk countries. Regarding symptomatic patients with indications for esophagogastroduodenoscopy, the importance of opportunistic screening should be emphasized. The combination of endoscopic and histological approaches should always be considered as endoscopy provides a real-time assessment of the patient’s risk level. In addition, imaging enhanced endoscopy (IEE) has been shown to facilitate targeted biopsies resulting in better correlation between endoscopic and histological findings. Currently, the use of IEE is recommended for endoscopic examinations, and the Operative Link for Gastric Intestinal Metaplasia or Operative Link on Gastritis Assessment grading systems are recommended for histological examinations whenever available. However, resource limitations are an important barrier in many regions worldwide. Thus, for an approach to be applicable in real-life practice, it should be not only evidence-based but also resource-sensitive. In this review, we discuss the current understanding and approaches to identifying high-risk individuals from western and eastern perspectives, as well as the possibility of an integrated, resource-sensitive approach.

Magnifying Endoscopy with Narrow Band Imaging in Estimating the Invasion Depth of Superficial Esophageal Squamous Cell Carcinomas

BACKGROUND/AIM

The aim of this study was to compare the accuracy of magnifying endoscopy with narrow band imaging for the diagnosis of depth of invasion by Japan Esophageal Society (JES) classification and inter- and intraobserver agreement of JES intrapapillary capillary loop (IPCL) classification.

METHODS

It was a retrospective observational study that has analyzed 136 patients with esophageal malignant neoplasia with magnifying endoscopy narrow band imaging to compare JES's IPCL classification to the histopathologic findings and to evaluate the inter- and intraobserver agreement.

RESULTS

Histopathologic examinations revealed 34 (25.7%) intraepithelial neoplasias, 70 (51.5%) squamous cell carcinomas (SCCs) in the epithelium or with invasion into the lamina propria mucosa, 21 (15.4%) SCCs with invasion into the muscularis mucosa or mild invasion into the submucosa, and 11 (8.1%) SCCs with moderate or deep invasion into the submucosa. IPCL types B1, B2, and B3 also showed high accuracies of 80.8, 83.1, and 94.1%, respectively. The kappa values for inter- and intraobserver agreements of the IPCL classifications were moderate to almost perfect.

CONCLUSIONS

In the present study, the JES's IPCL classification has good accuracy to predict the depth of SCC invasion and moderate to almost perfect intra- and interobserver agreements.

Helicobacter pylori Infection and Related Gastrointestinal Diseases in Southeast Asian Countries: An Expert Opinion Survey

Background:

Helicobacter pylori (H. pylori) infection is currently considered as an infectious disease irrespective of symptoms and stage of disease. This study aimed to survey the impact of H. pylori infection and the current management approaches in Southeast Asian countries.

Materials and methods:

This is a survey among 26 experts from 9 Southeast Asian countries (Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam), who attended a meeting to develop the ASEAN consensus on H. pylori management in November 2015.

Results:

The prevalence of H. pylori varied significantly from 20% to 69% among countries, highest in Myanmar and lowest in Malaysia. The rate of H. pylori infection in patients with gastritis, peptic ulcer disease and gastric cancer (GC) also varied significantly, not only among countries but also among regions within the same country. The most common method for H. pylori diagnosis before treatment was rapid urease test, followed by urea breath test. In multi-ethnic countries, some ethnic groups including Chinese, Batak and Minahasanese were considered as having higher risk of GC. There have been no national screening programs for GC in all countries, and a majority of patients with GC were diagnosed in advanced stages with very poor 5-year survival.

Conclusions:

The prevalence of H. pylori infection and its infection rates in related gastrointestinal diseases were significantly different among Southeast Asian countries. The prognosis of patients with GC in the region was very poor. The result of this survey is a platform for future international and regional research collaboration.

The Endoscopic and Clinicopathological Characteristics of Early-onset Gastric Cancer in Vietnamese Patients

Aim: To assess the endoscopic and clinicopathological features of early-onset gastric cancer (EOGC) in Vietnamese, a population with intermediate risk of gastric cancer. Patients and methods: Consecutive patients diagnosed with gastric adenocarcinoma were prospectively recruited. The demographic, clinical data in each patient were collected. The location and macroscopic type of all gastric lesions suspected to be malignant were reported according to the Japanese classification. The histologic tumor type of gastric cancer (GC) was classified according to the Lauren classification. Helicobacter pylori (H. pylori) infection were diagnosed by rapid urease test and urinary H. pylori antibody test. The infection was diagnosed when at least one of the two tests was positive. Results: The rate of EOGC (i.e. ≤ 40 years of age) was 16.3% (23/141). The median age of patients with EOGC was 35 (range 28 – 40) years and the male-to-female was 1:1.09. Compared to the older group (i.e. ≥ 50 years of age), the rates of positive family history, H. pylori infection and alarm features in the EOGC group were not significantly different (0.0% vs. 5.4%, p = 0.581; 73.9% vs. 66.3%, p = 0.620; and 60.8% vs. 79.3%, p = 0.100; respectively). The EOGC group had significantly higher rate of tumor extending to entire stomach (21.7% vs. 3.4%, p = 0.003); but the rate of diffuse-type GC between the two groups were not significantly different (87.0% vs. 71.7%, p = 0.181). Conclusions: Vietnamese patients with EOGC had higher rate of tumor extending to entire stomach compared to the older group. But the family history of GC, H. pylori infection and the pathological characteristics were not significantly different between the two groups. Environmental factors which play important roles in the development of EOGC in Vietnam should be investigated in future study.

Prevalence and Pattern of Antibiotic Resistant Strains of Helicobacter Pylori Infection in ASEAN

Objective: Antibiotic resistance has significantly impact on eradication rates for H. pylori infection and remains important cause of treatment failure worldwide including ASEAN countries. The aim of this study was to survey the prevalence and antibiotic resistant pattern of H. pylori infection in ASEAN. Methods: This study was a survey among 26 experts from 9 ASEAN countries including Thailand, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore and Vietnam whom attended a meeting to develop the ASEAN consensus on H. pylori management in Bangkok in November 2015. A questionnaire was sent to each member of the consensus meeting. The detail of the questionnaire included information about prevalence of H. pylori infection, facilities to perform H. pylori culture, molecular testing for antibiotic resistance and antibiotic resistance rate in their countries. Results: H. pylori infection remain common in ASEAN ranging from 20% in Malaysia, 21-54% in Thailand and 69% in Myanmar. Most of ASEAN countries can perform H. pylori cultures and antibiotic susceptibility tests except Laos and Cambodia. In ASEAN countries, metronidazole resistant H pylori is quite common whereas amoxicillin resistance remain rare. Clarithromycin resistance results in a significant decrease in H. pylori eradication rate with clarithromycin-containing regimens. The prevalence of clarithromycin resistance varies in ASEAN countries being high in Vietnam (30%) and Cambodia (43%), moderate to high in Singapore (17%) and low in Malaysia (6.8%), Philippine (2%) and Myanmar (0%). In Thailand, clarithromycin resistance tends to higher in large cities (14%) than in rural areas (~3.7%). Conclusion: ASEAN countries should develop a standard protocol for regular susceptibility testing of H. pylori so that clinicians would be better able to choose reliably effective empiric therapies. The wide range of antibiotic resistance in ASEAN countries suggests that the preferred first line regimen should be depend on the local antibiotic resistance other than single recommendation.

The Distribution of Incomplete Gastric Intestinal Metaplasia (GIM) Subtype among Biopsy Sites according to the Updated Sydney System and Its Association with GIM Extension. Gastroenterol Res Pract. 2018;2018:4938730. [PMID: 29853861 PMCID: PMC5964434 DOI: 10.1155/2018/4938730]

Background

Current guidelines recommend that extensive gastric intestinal metaplasia (GIM) be considered as a high-risk marker for the development of gastric cancer (GC). But there is emerging evidence that the incomplete GIM subtype is also a high-risk marker.

Aims

To evaluate the performance of biopsy sites according to the updated Sydney system on detecting the incomplete GIM subtype and to assess its association with GIM extension.

Patients and methods

A cross-sectional study was conducted on 280 Vietnamese patients with nonulcer dyspepsia. Biopsy specimens were taken from gastric sites according to the updated Sydney system, and sections were routinely stained with Giemsa and hematoxylin and eosin. Biopsy specimens with intestinalization were further evaluated for GIM subtypes with alcian blue 2.5 and periodic acid Schiff stainings. Two experienced pathologists jointly examined all the specimens and reached consensus.

Results

The rates of patients with GIM and the incomplete GIM subtype were 81 (28.9%) and 24 (8.4%), respectively. There was no GIM in specimens taken from the greater curvature of corpus. The proportions of the incomplete GIM subtype detected at the incisura angularis, lesser curvature of corpus, lesser curvature of antrum, and greater curvature of antrum were 34.3% (12/35), 34.5% (10/29), 40.5% (17/42), and 31.6 (6/19), respectively, which were not significantly different (p = 0.89). The presence of an incomplete GIM subtype was associated with multifocal GIM (i.e., ≥3 out of 5 biopsy sites with GIM) (OR = 4.02, CI 95%, 1.33–12.16, p = 0.022) and extensive GIM (i.e., GIM in specimens from both of corpus and antrum) (OR = 2.89, CI 95% 1.04–8.02, p = 0.045).

Conclusions

The proportions of an incomplete GIM subtype were not significantly different among gastric biopsy sites with intestinalization. The association between an incomplete GIM subtype and GIM extension, therefore, may be due to an sum accumulation effect.

Abnormal Gastroesophageal Flap Valve Is Associated With High Gastresophageal Reflux Disease Questionnaire Score and the Severity of Gastroesophageal Reflux Disease in Vietnamese Patients With Upper Gastrointestinal Symptoms

Background/Aims

There have been no studies investigating the distribution of abnormal gastroesophageal flap valve (GEFV) among patients with dyspepsia, non-erosive reflux disease (NERD), and reflux esophagitis (RE) in the same set of patients. The aims of this study are to investigate (1) the association between GEFV and gastroesophageal reflux disease questionnaire (GERDQ) score, and (2) the distribution of abnormal GEFV in Vietnamese patients presenting with upper gastrointestinal symptoms.

Methods

Three hundred and thirty-one patients recruited in this prospective cross-sectional study were classified into 3 groups: reflux esophagitis (RE), non-erosive reflux disease (NERD) (GERDQ score ≥ 8, no endoscopic mucosal injury), and dyspepsia (GERDQ score < 8, no endoscopic mucosal injury). The GEFV was graded endoscopically according to the Hill classification. GEFV grades I and II were regarded as normal, while grades III and IV were regarded as abnormal GEFV.

Results

There were 215 (65.0%) patients with dyspepsia, 55 (16.6%) patients with NERD, and 61 (18.4%) patients with RE. Abnormal GEFV was an independent risk factor for GERD (OR, 2.93; CI 95%, 1.76–4.88) and RE (OR, 3.41; CI 95%, 1.78–6.53). The mean GERDQ score of patients with abnormal GEFV was significantly higher than that of patients with normal GEFV (5.7 ± 2.4 vs 4.9 ± 2.7, P = 0.011). The prevalence of abnormal GEFV gradually increased in patients with dyspepsia (27.4%), NERD (43.6%), grade A RE (56.8%), and grades B/C RE (80.0%) (P < 0.001).

Conclusions

Abnormal GEFV was significantly associated with high GERDQ score. Its prevalence gradually increased in patients with dyspepsia, NERD, and RE, respectively.

Helicobacter pylori management in ASEAN: The Bangkok consensus report

Helicobacter pylori (H. pylori) infection remains to be the major cause of important upper gastrointestinal diseases such as chronic gastritis, peptic ulcer, gastric adenocarcinoma, and mucosa-associated lymphoid tissue lymphoma. H. pylori management in ASEAN: the Bangkok consensus report gathered key opinion leaders for the region to review and evaluate clinical aspects of H. pylori infection and to develop consensus statements, rationales, and grades of recommendation for the management of H. pylori infection in clinical practice in ASEAN countries. This ASEAN Consensus consisted of 34 international experts from 10 ASEAN countries, Japan, Taiwan, and the United States. The meeting mainly focused on four issues: (i) epidemiology and disease association; (ii) diagnostic tests; (iii) management; and (iv) follow-up after eradication. The final results of each workshop were presented for consensus voting by all participants. Statements, rationale, and recommendations were developed from the available current evidence to help clinicians in the diagnosis and treatment of H. pylori and its clinical diseases.

Asia-Pacific Colorectal Screening score: A useful tool to stratify risk for colorectal advanced neoplasms in Vietnamese patients with irritable bowel syndrome

BACKGROUND AND AIM

The Asia-Pacific Colorectal Screening (APCS) score has been validated in several populations but not yet in patients with irritable bowel syndrome (IBS). The aim of this study was to assess the performance of APCS score in stratifying risk of colorectal advanced neoplasms (CAN) in Vietnamese IBS patients.

METHODS

Consecutive patients who fulfilled IBS diagnosis criteria according to the Rome III were prospectively enrolled and underwent colonoscopy. APCS score for each patient was calculated by summing the points attributed by risk factors. Three tiers of risk were defined: 0-1 "average risk" (AR); 2-3 "moderate risk" (MR); and 4-7 "high risk" (HR). Logistic regression analysis was performed to assess the relative risk of CAN in HR group and MR group compared with AR group.

RESULTS

There were 404 patients with excellent bowel preparation and complete colonoscopy. The mean age was 48.8 ± 11.2 years and male : female ratio was 1.2:1. Twenty-eight patients (6.9%) were diagnosed with CAN: 19 (4.7%) advanced adenoma and 9 (2.2%) invasive colorectal cancer. Patients in the MR and HR tiers had 5.6-fold (95% confidence interval 1.2 to 24.7, P = 0.012) and 12.1-fold (95% confidence interval 2.6 to 56.2, P < 0.001) increased rates of CAN compared with those in the AR tier, respectively. Three out of 9 patients with invasive colorectal cancer had no alarm features but had high sum APCS score (2 in MR tier and 1 in HR tier).

CONCLUSION

The APCS score is useful to identify IBS patients with high risk of CAN for colonoscopy priority.

The Performance of a Modified Glasgow Blatchford Score in Predicting Clinical Interventions in Patients with Acute Nonvariceal Upper Gastrointestinal Bleeding: A Vietnamese Prospective Multicenter Cohort Study

BACKGROUND/AIMS

To compare the performance of a modified Glasgow Blatchford score (mGBS) to the Glasgow Blatchford score (GBS) and the pre-endoscopic Rockall score (RS) in predicting clinical interventions in Vietnamese patients with acute nonvariceal upper gastrointestinal bleeding (ANVUGIB).

METHODS

A prospective multicenter cohort study was conducted in five tertiary hospitals from May 2013 to February 2014. The mGBS, GBS, and pre-endoscopic RS scores were prospectively calculated for all patients. The accuracy of mGBS was compared with that of GBS and preendoscopic RS using area under the receiver operating characteristic curve (AUC). Clinical interventions were defined as blood transfusions, endoscopic or radiological intervention, or surgery.

RESULTS

There were 395 patients including 128 (32.4%) needing endoscopic treatment, 117 (29.6%) requiring blood transfusion and two (0.5%) needing surgery. In predicting the need for clinical intervention, the mGBS (AUC, 0.707) performed as well as the GBS (AUC, 0.708; p=0.87) and outperformed the pre-endoscopic RS (AUC, 0.594; p<0.001). However, none of these scores effectively excluded the need for endoscopic intervention at a threshold of 0.

CONCLUSIONS

mGBS performed as well as GBS and better than pre-endoscopic RS for predicting clinical interventions in Vietnamese patients with ANVUGIB. (Gut Liver 2016;10375- 381).

Early Diagnosis of Helicobacter pylori Infection in Vietnamese Patients with Acute Peptic Ulcer Bleeding: A Prospective Study

Aims. To investigate H. pylori infection rate and evaluate a combined set of tests for H. pylori diagnosis in Vietnamese patients with acute peptic ulcer bleeding (PUD). Methods. Consecutive patients with acute PUB were enrolled prospectively. Rapid urease test (RUT) with 3 biopsies was carried out randomly. Patients without RUT or with negative RUT received urea breath test (UBT) and serological and urinary H. pylori antibody tests. H. pylori was considered positive if RUT or any noninvasive test was positive. Patients were divided into group A (RUT plus noninvasive tests) and group B (only noninvasive tests). Results. The overall H. pylori infection rate was 94.2% (161/171). Groups A and B had no differences in demographic characteristics, bleeding severity, endoscopic findings, and proton pump inhibitor use. H. pylori-positive rate in group A was significantly higher than that in group B (98.2% versus 86.7%, p = 0.004). The positive rate of RUT was similar at each biopsy site but significantly increased if RUT results from 2 or 3 sites were combined (p < 0.05). Conclusions. H. pylori infection rate in Vietnamese patients with acute PUB is high. RUT is an excellent test if at least 2 biopsies are taken.

Interobserver and intraobserver agreement for gastric mucosa atrophy

BACKGROUND

The grade of gastric mucosa atrophy caused by Helicobacter pylori (H. pylori) infection is closely associated with the risk of gastric cancer, especially of the intestinal type. Interobserver and intraobserver agreement for endoscopic gastric mucosa atrophy in subjects with H. pylori-uninfected, currently infected and past infected was investigated.

METHODS

Endoscopic images of 91 patients, 34 images per patient, were assessed. The assessors were 4 endoscopist groups: Japanese and Vietnamese experienced (≥7, ≤ 15 year experience with endoscopy) and Japanese and Vietnamese beginner (≤ 3 year experience) groups. Each group comprised 3 endoscopists. The grades of atrophy were classified as 3: none to mild (C-0 and C-1), moderate (C-2 and C-3), and severe (O-1, O-2, and O-3) using the Kimura-Takemoto Classification. After a period of 2 weeks, images of all patients were reevaluated by the investigators. Interobserver and intraobserver agreement was calculated by kappa statistics.

RESULTS

The kappa values for the interobserver agreement in the groups of Japanese and Vietnamese experienced, and Japanese and Vietnamese beginner were 0.474, 0.408, 0.291, and 0.373, respectively. The kappa value of intraobsever agreement in the Japanese and Vietnamese experienced endoscoists ranged from 0.585 to 0.871. On the other hand, the value in the beginner endoscopists ranged wider than that in experienced endoscopists, from 0.264 to 0.866.

CONCLUSIONS

Our results indicated that, although intraobserver agreement for gastric mucosa atrophy was good to excellent, interobserver agreement was moderate in experienced endoscopists. This suggests that better guidelines and firm criteria may be needed to properly diagnose and grade gastric atrophy.

Differences in K-ras and mitochondrial DNA mutations and microsatellite instability between colorectal cancers of Vietnamese and Japanese patients

Background

The incidence of early-onset (under 50 years of age) colorectal cancer (CRC) in the Vietnamese has been reported to be quite higher than that in the Japanese. To clarify the differences in genetic alterations between Vietnamese and Japanese CRCs, we investigated mutations in K-ras and mitochondrial DNA (mtDNA) and high-frequency microsatellite instability (MSI-H) in the CRCs of Vietnamese and Japanese patients.

Methods

We enrolled 60 Vietnamese and 233 Japanese patients with invasive CRCs. DNA was extracted from formalin-fixed, paraffin-embedded tissue sections. K-ras mutations were examined with PCR-single-strand conformation polymorphism analysis. mtDNA mutations and MSI-H were examined with microsatellite analysis using D310 and BAT-26, respectively.

Results

K-ras mutations were examined in 60 Vietnamese and 45 Japanese CRCs. The frequency of the mutations in the Vietnamese CRCs was significantly higher than that in the Japanese CRCs (8 of 24 [33%] vs 5 of 45 [11%], p =0.048). MSI-H was examined in 60 Vietnamese and 130 Japanese CRCs. The frequency of MSI-H in the Vietnamese CRCs was also significantly higher than that in the Japanese CRCs (6 of 27 [22%] vs 10 of 130 [8%], p =0.030). mtDNA mutations were examined in 60 Vietnamese and 138 Japanese CRCs. The frequency of mtDNA mutations in the Vietnamese CRCs was significantly higher than that in the Japanese CRCs (19 of 44 [43%] vs 11 of 133 [9%], p <0.001). There were no significant differences in clinicopathologic characteristics, such as age, sex, tumour location, and depth, in terms of tumours with/without each genetic alteration in the CRCs of the Vietnamese and Japanese patients.

Conclusions

These results indicate that the developmental pathways of CRCs in the Vietnamese may differ from those of CRCs in the Japanese.

Value of a new stick-type rapid urine test for the diagnosis of Helicobacter pylori infection in the Vietnamese population

AIM: To assess the value of a new test for the diagnosis of Helicobacter pylori (H. pylori) infection, Rapirun^®H. pylori Antibody Stick (Rapirun^® Stick), in a Vietnamese population.

METHODS: Eligible patients without previous history of H. pylori eradication were recruited. Rapid urease test (RUT) and histologic examination were used to diagnose the H. pylori infection. Patients were considered H. pylori positive when the RUT results were positive and/or the bacteria were detected histologically. Rapirun^® Stick tests were performed using urine samples, and the results were compared with the other 2 methods.

RESULTS: We enrolled 200 patients with a mean age of 36 (range, 18-76) years. There were 116 females and 84 males. Of the 200 patients, 111 (55.5%) were diagnosed as being H. pylori positive. The sensitivity, specificity, and accuracy of the Stick test were 84.7%, 89.9%, and 87.0%, respectively. There were 17 (8.5%) false-negative patients and 9 (4.5%) false-positive patients.

CONCLUSION: The Rapirun^® Stick test has high sensitivity, specificity, and accuracy for the diagnosis of H. pylori infection in the Vietnamese population. The test can be clinically applied in Vietnamese populations.

Relationship between endoscopic and histologic gastric atrophy and intestinal metaplasia

BACKGROUND

The severity of endoscopic gastric atrophy (EGA), high-stage Operative Link on Gastritis Assessment (OLGA) gastritis (i.e., stage III or IV), and extensive intestinal metaplasia (IM) with incomplete subtype have been separately reported as high-risk factors of gastric cancer (GC). The aim of this study was to evaluate the associations between these endoscopic and pathologic characteristics.

MATERIALS AND METHODS

A cross-sectional study was conducted on 280 patients with functional dyspepsia at the University Medical Center at Ho Chi Minh City, Vietnam. Biopsies were taken according to the updated Sydney System. EGA was assessed according to the Kimura-Takemoto classification, and gastritis stage was assessed according to the OLGA system.

RESULTS

All of patients with high-stage OLGA gastritis (i.e., stage III or IV) clustered in the subgroup of patients with moderate-to-severe EGA: 13/126 (10.3%) in patients with moderate-to-severe EGA versus 0/154 (0%) in patients with none-to-mild EGA (p < .001). Moderate-to-severe EGA was also significantly associated with extensive IM (p < .001, OR = 28.1 (CI 95% 6.4-173.3)) and incomplete IM subtype (p < .001, OR = 36.7 (CI 95% 5.1-742.1). Extensive IM was also associated with incomplete IM subtype (p = .01).

CONCLUSIONS

High-stage OLGA gastritis, extensive IM with incomplete subtype clustered in patients with moderate-to-severe EGA. Assessing the severity of EGA could potentially help to identify patients who should be taken systemic biopsy for evaluating GC risk.