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Administration of sedation by non-anesthesiologists during gastrointestinal endoscopy remains highly controversial in Greece. The aim of this set of 16 position statements prepared by experts in the field on behalf of the Hellenic Society of Gastroenterology is to aid gastroenterologists in their everyday clinical practice and provide evidence for the best use of drugs for the sedation of patients who undergo an endoscopy. The statements address issues such as the level of sedation required, the best drugs used, their mode of action, their side-effects and possible ways to counter their action, and were adopted if at least 80% of all participants agreed upon them., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Background: Gastric intestinal metaplasia (GIM) can be missed by random gastric biopsies taken during white light endoscopy. Narrow band imaging (NBI) may potentially improve the detection of GIM. However, pooled estimates from prospective studies are lacking and the diagnostic accuracy of NBI in detecting GIM needs to be more precisely defined. The aim of this systematic review and meta-analysis was to study the diagnostic performance of NBI in detecting GIM., Methods: PubMed/Medline and EMBASE were screened for studies examining GIM in relation to NBI. Data from each study were extracted and calculations of pooled sensitivity, specificity, likelihood ratios, diagnostic odds ratios (DORs), and areas under the curve (AUCs) were performed. Fixed or random effects models, were used as appropriate, depending on the presence of significant heterogeneity., Results: We included 11 eligible studies in the meta-analysis, comprising 1672 patients. NBI showed a pooled sensitivity of 80% (95% confidence interval [CI] 69-87), specificity of 93% (95%CI 85-97), DOR 48 (95%CI 20-121), and AUC of 0.93 (95%CI 0.91-0.95) in detecting GIM., Conclusions: This meta-analysis showed that NBI is a reliable endoscopic means of detecting GIM. NBI with magnification performed better than NBI without magnification. However, better designed prospective studies are needed to precisely determine the diagnostic role of NBI, especially in high-risk populations where early detection of GIM can impact gastric cancer prevention and survival., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Background: Helicobacter pylori ( H. pylori) is the most common chronic bacterial infection. Its management has to rely on local effectiveness, given the geographical variability of bacterial antibiotic resistance. We evaluated treatment effectiveness in naïve patients in Greece, as part of the European Registry on the management of H. pylori (Hp-EuReg)., Methods: Patients were registered in the AEG-REDCap Electronic Case Report Form from 2013-2020. All cases with a first-line treatment were included. Modified intention-to-treat (mITT) analysis was used., Results: A total of 547 patients from 5 medical institutions were treated with the following regimens: concomitant with proton pump inhibitors (PPIs), clarithromycin, amoxicillin and metronidazole (concomitant-C+A+M) (38%); hybrid with PPI, clarithromycin, amoxicillin and metronidazole (hybrid-C+A+M) (20%); sequential with PPI, clarithromycin, amoxicillin and tinidazole (sequential-C+A+T) (12%); sequential with PPI, clarithromycin, amoxicillin and metronidazole (sequential-C+A+M) (12%); concomitant with PPI, clarithromycin, amoxicillin and tinidazole (concomitant-C+A+T) (8%); triple with PPI, clarithromycin and amoxicillin (triple-C+A) (7%); and other (3%). Overall compliance was 99%. Triple-C+A, sequential-C+A+T, sequential-C+A+M and concomitant-C+A+T were used from 2013-2015. The respective mITT cure rates (95% confidence interval) were 92% (78-98), 87% (76-94), 67% (54-78) and 91% (79-98). Since 2015, patients were also treated with concomitant-C+A+M and hybrid-C+A+M regimens, with respective mITT cure rates of 90% (85-94) and 88% (80.5-94). Adverse events were reported by 31% of the patients, dysgeusia being the most frequent (15%)., Conclusions: "Optimized" H. pylori therapies should achieve cure rates over 90%. In Greece, at present, only non-bismuth quadruple concomitant regimens achieve this target and can be recommended as first-line treatment., Competing Interests: Conflicts of interest: Dr. Megraud received research support from Aptalis Pharma, bioMerieux and Mobidiag and is a consultant for Phathom Pharmaceuticals. Dr. Gisbert has served as speaker, consultant, and advisory member for, or has received research funding from Mayoly, Allergan, Diasorin, Phathom and Gebro Pharma. Dr Nyssen has received research funding from Mayoly and Allergan, (Copyright: © Hellenic Society of Gastroenterology.)

Background: There is evidence demonstrating the beneficial effects of 5-hydroxytryptamine 3 receptor antagonists (5-HT 3 ) for the treatment of non-constipated irritable bowel syndrome (NC-IBS). We aimed to determine the comparative effectiveness of 5-HT 3 antagonists in NC-IBS, as evidenced by the results of a network meta-analysis (NWM) of published relevant randomized controlled trials (RCTs)., Methods: We searched the PubMed/Medline, EMBASE, and Cochrane Library databases for relevant RCTs through September 2020 and data from each selected RCT were extracted. A Bayesian NWM was then performed to investigate the efficacy of 5-HT 3 antagonists and to explore the effectiveness rank order in treating NC-IBS patients., Results: Twenty-one eligible RCTs were identified and entered into this NWM. They included a total of 10,421 NC-IBS patients, randomized to alosetron, cilansetron, ondansetron, ramosetron, placebo, and mebeverine. The cumulative ranking probability for each intervention at the end of treatment period, was evaluated by means of surfaces under cumulative ranking (SUCRA) values. These results showed that alosetron had the best performance for global symptom improvement (SUCRA 0.82), cilansetron showed the best performance (SUCRA 0.90) for abdominal pain/discomfort improvement, while ondansetron (SUCRA 0.98) was by far the best choice concerning bowel habits/consistency improvement. The control regimens (mebeverine and placebo) represented the least efficacious interventions., Conclusions: This NWM showed that 5-HT 3 receptor antagonists performed better in comparison to control drugs. Consequently, this class of drugs may play an important role in improving the debilitating symptoms in NC-IBS patients, in particular those with diarrhea., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Competing Interests: Conflict of Interest: None

Background: Patients with COVID-19 usually manifest fever and respiratory symptoms. However, some patients also experience gastrointestinal (GI) symptoms such as diarrhea, vomiting and abdominal pain. In addition, SARS-CoV-2 RNA has been detected in feces of infected patients. Currently there is huge evolving research interest in this potentially lethal disease. We systematically reviewed and meta-analyzed the evidence suggesting involvement of the digestive system in COVID-19., Methods: PubMed, Medline and Embase databases were searched up to 10 April 2020, using suitable keywords. Individual and pooled prevalence rates with 95% confidence intervals (CI) were calculated using the fixed- or random-effects model as appropriate. Heterogeneity between studies was calculated employing the Cochran Q test and I 2 values, whereas the possibility of publication bias was examined by constructing funnel plots. Additionally, subgroup and sensitivity analyses were performed., Results: In adult COVID-19 patients, the prevalence rates (95%CI) for all GI symptoms, and separately for diarrhea, nausea/vomiting, and abdominal discomfort/pain were 9.8% (6.4-14.7), 10.4% (95%CI 7.7-13.9), 7.7% (95%CI 4.8-12.1), and 6.9% (95%CI 3.9-11.9) respectively. The prevalence rates for children were 9.6% (95%CI 6.3-14.3) for all symptoms, 9.6% (95%CI 6.3-14.3) for diarrhea, and 6.8% (95% CI 4.2-11) for nausea/vomiting. In 30.3% (95%CI 10.5-61.6) of the patients SARS-CoV-2 RNA was detected in feces., Conclusions: A percentage of patients with COVID-19 will manifest symptoms from the digestive system. The GI tract may be a target organ and potential transmission route of SARS-CoV-2, with important implications for disease management and transmission., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Competing Interests: Conflict of Interest: None

The Hellenic Society of Gastroenterology recently organized the "Hellenic consensus on Helicobacter pylori ( H. pylori ) infection". The aim of this publication is to report the guidelines in order to aid the national gastroenterology community in the management of H. pylori infection. Forty-one delegates from all Greek regions, including gastroenterologists, pathologists, clinical microbiologists, epidemiologists and basic scientists, were invited to this meeting. The participants were allocated to 1 of the 4 main topics of the meeting: i.e., H. pylori diagnosis and association with diseases; H. pylori and gastric cancer; H. pylori and extragastric associated disorders; and H. pylori treatment. The results of each subgroup were submitted to a final consensus vote that included all participants. Relevant data based on international and Greek publications were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. The cutoff level of 70% was considered as acceptance for the final statement. It is hoped that the recommendations and conclusions of this report will guide Greek doctors in their daily practice concerning the management of H. pylori infection., Competing Interests: Conflict of Interest: None, (Copyright: © Hellenic Society of Gastroenterology.)

Background: Increasing evidence has suggested that Helicobacter pylori ( H. pylori ) eradication might prevent the development of gastric cancer (GC). This systematic review and meta-analysis aimed to better explore the role of H. pylori eradication in preventing GC, with particular reference to patients with precancerous lesions at baseline histology., Methods: Searches for human studies were performed through October 2016 and risk ratios (RRs), were obtained. Heterogeneity between studies was estimated using the Cochran Q test and I 2 values, whereas the possibility of publication bias was estimated with funnel plots. Additionally, we performed subgroup and sensitivity analyses., Results: In 26 studies suitable for meta-analysis (10 randomized controlled trials and 16 cohort studies) 52,363 subjects were included. The risk of GC among patients in whom H. pylori was successfully eradicated was significantly lower than that among controls: pooled RRs [95% CI] 0.56 [0.48-0.66], Z= -7.27, P=0.00001. This finding applied separately for randomized controlled trials (0.65 [0.51-0.84], Z= -3.33, P=0.0009) and for cohort studies (0.51 [0.42-0.62], Z= -6.63, P=0.00001). Concerning H. pylori eradication in patients with precancerous lesions, subgroup analyses showed that patients with non-atrophic or atrophic gastritis benefited from H. pylori eradication for the risk of GC development, whereas those with intestinal metaplasia or dysplasia did not., Conclusion: H. pylori eradication is associated with a significantly lower risk of GC; this finding has significant implications for the prevention of this cancer. The benefit is maximized when H. pylori eradication is applied at early stages of the infection., Competing Interests: Conflict of Interest: None

Background: Recent meta-analyses have studied population differences concerning interleukin ( IL )- 1 gene polymorphisms in gastric carcinogenesis. In addition to the IL - 1 gene cluster, candidate genes include those encoding the pro-inflammatory cytokine tumor necrosis factor (TNF)-α. The aim of the study was to systematically review the role of TNF-α-238 and TNF-α-308 gene polymorphisms (genotypes G/G, G/A, A/A) in gastric carcinogenesis by meta-analyzing all relevant studies to look for any differences concerning TNF-α gene polymorphisms in gastric carcinogenesis., Methods: Extensive English language medical literature searches for human studies were performed up to the end of May 2013, using suitable keywords. Pooled estimates [odds ratio (OR) with 95% confidence intervals (CI)] were obtained using the random-effects model. Heterogeneity between studies was evaluated with the Cochran Q test whereas the likelihood of publication bias was assessed by constructing funnel plots. Their symmetry was estimated by the adjusted rank correlation test., Results: In seventeen studies, from various countries, the TNF-α-308 and TNF-α-238 frequencies of genotypes G/G, G/A, A/A were examined in gastric cancer patients and controls. For TNF-α-308 frequency overall, the pooled ORs with 95%CI for genotype G/G, A/A and G/A were 0.837 (0.712-0.982), 1.430 (1.064-1.923) and 1.145 (0.973-1.348) with respective P values 0.029, 0.018 and 0.104. Subgroup analyses showed significant results for genotype G/G only in Asians [OR=0.774 (0.610-0.983), P=0.036]., Conclusion: In this meta-analysis there was an overall statistically significant increased cancer risk associated with TNF-α-308 G/G and A/A genotypes. Subgroup analyses showed significant results for genotype G/G in Asians, whereas no such significant results were found for Caucasians and Hispanics.

Background: Helicobacter pylori (H. pylori) , infects gastric mucosa causing gastritis. Treatment failure is mainly due to certain genetic changes in the peptidyltransferase loop of 23S rRNA of the microorganism. The aim of the study was to evaluate genetic changes in gastric biopsies of H. pylori (+) patients that lead to clarithromycin resistance and to correlate them with histology data., Methods: A total of 150 H. pylori (+) gastric biopsies were studied, taken before and after eradication therapy from 75 dyspeptic patients divided in 2 groups: group A consisted of 25 H. pylori (+) triple-therapy resistant patients and group B consisted of 50 H. pylori (+) successfully treated patients. Histological classification of the H. pylori (+) gastritis was done according to the Sydney criteria. Genetic material was analyzed with the ClariRes™ RT-PCR bi-probe based assay for the determination of point mutations in the 23S rRNA gene and with a Quantitative-RT-PCR (Q-RT-PCR) method for the quantitation of H. pylori., Results: We showed that in 18/ 25 group A patients certain point mutations of 23S rRNA at sites A2142C, A2142G and A2143G had occurred. Nine of these 18 mutated cases (50%) were characterized as mixed infections. Mixed infections in 2/50 patients of group B were also observed. Using Q-RT-PCR, we found that gastric mucosal density of H. pylori correlates well with bacterial colonization. There was a statistically significant association (P<0.005) between the presence of the detected H. pylori genetic alterations and inflammation, activity and H. pylori density as histologically determined., Conclusion: Certain point mutations in H. pylori genome that affect susceptibility to clarithromycin correlate with histological features of gastritis.