Helicobacter pylori infection exhibits a wide disease spectrum ranging from asymptomatic gastritis, peptic ulcer disease, to gastric cancer. H. pylori can induce dysbiosis of gastric microbiota in the pathway of carcinogenesis and successful eradication can restore gastric homeostasis. Diagnostic testing and treatment for H. pylori infection is recommended in patients with active or past history of peptic ulcer, chronic dyspepsia, chronic non‐steroidal anti‐inflammatory drugs (NSAID) or aspirin use, precancerous gastric lesions, gastric cancer, mucosa‐associated lymphoid tissue (MALT) lymphoma, family history of gastric cancer, family history of peptic ulcers, household family member having active H. pylori infection, iron deficiency anemia, idiopathic thrombocytopenic purpura, or vitamin B12 deficiency. Recommended first‐line regimens for H. pylori eradication are classified according to clarithromycin resistance. In areas of high clarithromycin resistance (≥15%), we recommend 14‐day concomitant therapy or 14‐day bismuth quadruple therapy (BQT) as first‐line regimen. In areas of low clarithromycin resistance (<15%), we recommend 14‐day triple therapy or 14‐day BQT as first‐line treatment. Second‐line regimens are 14‐day levofloxacin triple therapy or 14‐day BQT if BQT is not previously used. For patients with multiple treatment failure, antimicrobial susceptibility testing (AST) should be performed. If AST is not available, we recommend using antibiotics not previously used or for which resistance is unlikely, such as amoxicillin, tetracycline, bismuth, or furazolidone. High‐dose potent proton pump inhibitor or vonoprazan is recommended to achieve adequate acid suppression. Probiotics can be used as an adjuvant treatment to reduce the side effects of antibiotics and enhance eradication rate.

Background: Helicobacter pylori (H. pylori) infection is important risk factors for chronic gastritis, peptic ulcer andgastric cancer. Bismuth-containing quadruple therapy has recently been the first-line regimen recommended in manyEuropean countries but has limited efficacy in ASEAN especially Thailand. This study was aim to evaluate efficacy ofhigh dose PPI Bismuth-containing quadruple therapy with probiotics supplement for H. pylori eradication. Methods:In this double-blind randomized placebo-controlled study, H. pylori infected patients were randomized to receive 7-or14-day high dose PPI- bismuth-containing quadruple therapy with or without probiotics supplement. Probiotic was37.5 mg Lactobacillus reuteri (Biogaia®) in tablet twice daily. CYP2C19 genotyping and antibiotic susceptibility testswere also done. H. pylori eradication was defined as a negative 13C-urea breath test at least 4 weeks after treatment.Results: 100 subjects were enrolled (72 females, 28 males, mean age=54 years). Antibiotic resistance was 15.6% forclarithromycin, 34.1% for metronidazole. CYP2C19 genotyping was performed in both group and revealed 13%, 50% and37% for poor, intermediate and rapid metabolizers, respectively. Overall eradication rates of 7-day and 14-day regimenswith probiotic were 68% and 96%; P value=0.027. The eradication rate for all patients with poor and rapid metabolizerswere 100% with 14-day regimen. 14-day regimen with probiotics can provide 100% eradication with clarithromycinresistance, metronidazole resistance or dual clarithromycin and metronidazole resistance group. Furthermore, theincidence of nausea and vomiting, abdominal discomfort, and bitter taste were significantly lower in patients withprobiotics group compared with placebo (6%vs.26%, P=0.002,OR=0.126,95% CI=0.03-0.53; 4%vs.18.0%, P=0.017,OR= 0.155,95% CI=0.03-0.81 and 4%vs.26%, P= 0.001,OR= 0.08, 95%CI= 0.016-0.41, respectively). Conclusions:The 14-day high dose PPI- bismuth-containing quadruple therapy with probiotic can provide an excellent cure rate forH. pylori infection as first line treatment irrespective of CYP2C19 and antibiotic resistance pattern. Adding probioticalso significantly reduced treatment-related adverse events and improve the patients’ compliance.

Epidemiology and Survival of Hepatocellular Carcinoma in the Central Region of Thailand Hepatocellular carcinoma;cirrhosis;chronic hepatitis B;Central Thailand; Background: Hepatocellular carcinoma (HCC) is one of the most common cancers in men and the third most common cancer in woman in Thailand. This retrospective study was designed to assess the prevalence, clinical manifestations, treatment outcomes and prognosis of HCC in the central region of Thailand. Materials and Methods: The authors retrospectively reviewed all HCC patients aged more than 15 years old in Thammasat university hospital (TUH) during the period from January 2007 to December 2012. Clinical information, biochemical tests and radiologic findings were collected from review of medical records. Results: There were 308 patients with HCC, which accounted for the prevalence of 5.19% of all cancers diagnosed in TUH during the study period. Of these, 125 (40.5%) had complete information retrievable from their medical records and met the inclusion criteria, 99 (79.2%) were males. The mean age was 57.4 years. A quarter of HCC patients in this study presented without any symptom before diagnosis. The common clinical presentations in the remaining patients were hepatomegaly 64/125 (51.2%), abdominal pain 56/125 (44.8%) and ascites 16/125 (20.8%). Cirrhosis was seen in almost all patients (92.8%). The most common causes of HCC in this study were chronic hepatitis B (49.6%) and C (19.2%). Based on Barcelona Clinic Liver Cancer staging, 75.4% presented at intermediate or late stage. Patients receiving curative therapy with either surgical treatment or radiofrequency ablation had significantly longer survival time after the HCC diagnosis than the palliative therapy group (11.0 months vs 4.0 months, p value= 0.004). The mean survival time after the HCC diagnosis was 10.5 months. Conclusions: The common causes of HCC in central region of Thailand were chronic hepatitis B and C. Surgical therapy or RFA seemed to provide better outcomes than other treatments but only in patients with early stage lesions. Most of the patients in this study presented with advanced diseases and had grave prognosis. Appropriate screening patients at risk for HCC might be an appropriate way to achieve early diagnosis and improve the treatment outcome.

Improved Eradication Rate of Standard Triple Therapy by Adding Bismuth and Probiotic Supplement for Helicobacter pylori Treatment in Thailand Bismuth;triple therapy;Helicobacter pylori;probiotic;Thailand; Background: Helicobacter pylori (H. pylori) remains an important cause of gastric cancer and peptic ulcer disease worldwide. Treatment of H. pylori infection is one of the effective ways to prevent gastric cancer. However, standard triple therapy for H. pylori eradication is no longer effective in many countries, including Thailand. This study was designed to evaluate the efficacy of adding bismuth and probiotic to standard triple therapy for H. pylori eradication. Materials and Methods: In this prospective single center study, H. pylori infected gastritis patients were randomized to receive 7- or 14-day standard triple therapy plus bismuth with probiotic or placebo. Treatment regimen consisted of 30 mg lansoprazole twice daily, 1 g amoxicillin twice daily, 1 g clarithromycin MR once daily and 1,048mg bismuth subsalicylate twice daily. Probiotic bacteria composed of Bifidobacterium lactis, Lactobacillus acidophilus and Lactobacillus paracasei. Placebo was conventional drinking yogurt without probiotic. CYP2C19 genotyping and antibiotic susceptibility tests were also done. H pylori eradication was defined as a negative $^{13}C$-urea breath test at least 2 weeks after completion of treatment. Results: One hundred subjects were enrolled (25 each to 7- and 14-day regimens with probiotic or placebo). Antibiotic susceptibility tests showed 36.7% metronidazole and 1.1% clarithromycin resistance. CYP2C19 genotyping revealed 40.8%, 49% and 10.2% were rapid, intermediate and poor metabolizers, respectively. The eradication rates of 7- or 14 regimens with probiotics were 100%. Regarding adverse events, the incidence of bitter taste was significantly lower in the 7- day regimen with the probiotic group compared with 7- day regimen with placebo (40% vs. 64%; p=0.04). Conclusions: The 7-day standard triple therapy plus bismuth and probiotic can provide an excellent cure rate of H. pylori (100%) in areas with low clarithromycin resistance such as Thailand, regardless of CYP2C19 genotype. Adding a probiotic also reduced treatment-related adverse events.

Hepatocellular carcinoma (HCC) is the most frequent type of malignant liver tumor in Thailand. The high incidence rate of HCC reflects from chronic HBV infection in this endemic area. Some patients are asymptomatic at presentation whereas many of them presented at advanced stage of HCC with limited treatment options and grave outcome. The Barcelona Clinic Liver Cancer (BCLC) staging system and management allocation for HCC is widely accepted and used in many international guidelines including Thailand. Curative treatment is expected in early stage of HCC while palliative treatment, combination treatment and best supportive care are offered to advanced stage of HCC. The most effective strategy to prevent the development of HCC is prevention of HBV vertical transmission and treatment HBV or HCV infection. The purpose of this article is to update information of HCC in Thailand including epidemiology, diagnosis, clinical manifestation, and treatment.