The Practice of Gastrointestinal Motility Laboratory During COVID-19 Pandemic: Position Statements of the Asian Neurogastroenterology and Motility Association (ANMA-GML-COVID-19 Position Statements)

During the Coronavirus Disease 2019 (COVID-19) pandemic, practices of gastrointestinal procedures within the digestive tract require special precautions due to the risk of contraction of severe acute respiratoy syndrome coronavirus-2 (SARS-CoV-2) infection. Many procedures in the gastrointestinal motility laboratory may be considered moderate to high-risk for viral transmission. Healthcare staff working in gastrointestinal motility laboratories are frequently exposed to splashes, air droplets, mucus, or saliva during the procedures. Moreover, some are aerosol-generating and thus have a high risk of viral transmission. There are multiple guidelines on the practices of gastrointestinal endoscopy during this pandemic. However, such guidelines are still lacking and urgently needed for the practice of gastrointestinal motility laboratories. Hence, the Asian Neurogastroenterology and Motility Association had organized a group of gastrointestinal motility experts and infectious disease specialists to produce a position statement paper based-on current available evidence and consensus opinion with aims to provide a clear guidance on the practices of gastrointestinal motility laboratories during the COVID-19 pandemic. This guideline covers a wide range of topics on gastrointestinal motility activities from scheduling a motility test, the precautions at different steps of the procedure to disinfection for the safety and well-being of the patients and the healthcare workers. These practices may vary in different countries depending on the stages of the pandemic, local or institutional policy, and the availability of healthcare resources. This guideline is useful when the transmission rate of SARS-CoV-2 is high. It may change rapidly depending on the situation of the epidemic and when new evidence becomes available.

AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients.

METHODS

Prospectively collected data from the AARC database were analyzed.

RESULTS

Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores.

CONCLUSION

Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Skin and soft tissue infections in cirrhotics: a prospective analysis of clinical presentation and factors affecting outcome

Skin and soft tissue infections (SSTI) are an important cause of morbidity and mortality in patients with cirrhosis. This prospective study aimed to analyze the clinical profile and factors affecting outcome of SSTIs in cirrhotics. All cirrhotics hospitalized between September 2007 and August 2010 were included. Frequency, site, extent, and type of SSTI were noted. Of 1,395 cirrhotics, 19.4 % (n = 271) had bacterial infections, out of which 32.8 % (89/271) had SSTI. Alcohol was the predominant etiological factor for cirrhosis; 95.2 % belonged to Child class B/C, and 67 % gave history of barefoot walking. The most common site of SSTI was the lower limbs (87.1 %), cellulitis was the most common type (61.2 %), and gram-negative bacilli (GNB) is the most common organism (86.7 %). Mortality rate was 23.5 %. Serum creatinine and model for end-stage liver disease (MELD) score were independent predictors of mortality. SSTIs in cirrhotics were common and mostly involved the lower limbs. Cellulitis was the most common type, and GNB was the most common organism. Serum creatinine and MELD score were independent predictors of mortality.

Muscle strength and physical performance, rather than muscle mass, correlate with mortality in end-stage liver disease

OBJECTIVES

Sarcopenia is characterized by the loss of skeletal muscle mass, strength and performance. The study aimed to provide cut off values of various Sarcopenia parameters [computerized tomography skeletal muscle index (SMI), handgrip strength (HGS), gait velocity and chair stand] to predict mortality in end-stage liver disease (ESLD).

METHODS

The inclusion criteria were age 18-75 years, model for end-stage liver disease > 15. All patients with advanced heart, lung, kidney diseases, active malignancy were excluded from the study. Sarcopenia indices were compared between survivors and non-survivors to find cut off value for prediction of mortality in ESLD patients.

RESULTS

One hundred sixty-one subjects suffering from ESLD were enrolled. The cutoff value of the SMI to identify high risk of mortality in sarcopenia patients is ≤21.2 cm2/m2, area under the curve (AUC) 0.537 [95% confidence interval (CI) 0.456-0.616]. The cutoff value of the hand grip strength to identify high-risk mortality is ≤25.3 kilogram-force, AUC 0.682 (95% CI 0.604-0.753). The cutoff value of the gait velocity for the same is as ≤0.84 m/s, AUC 0.551 (95% CI 0.459-0.641). The cutoff value of the chair stand is ≥20.9 seconds, AUC 0.956 (95% CI 0.910-0.983). In the multivariate analysis, HGS, gait velocity and chair stand correlated with mortality.

CONCLUSION

The current study is a comprehensive Asian study that gives the cut off values of Sarcopenia: muscle mass, strength and performance which identify high risk of mortality in ESLD patients. Muscle strength and performance correlated with mortality.

Treatment of chronic hepatitis C genotype 3 with Sofosbuvir-based therpy: a real-life study

BACKGROUND AND AIMS

Recently, Sofosbuvir was launched in India at affordable cost. We conducted a real-life study to determine the efficacy and safety of Sofosbuvir plus Ribavirin, with and without peginterferon-alfa 2a, in patients with chronic hepatitis C (CHC) genotype 3, the commonest genotype in South Asia.

METHODS

This study included data of CHC patients from 11 sites in northern India between March 2015 and December 2015 (n = 1203). Patients with CHC genotype 3 (n = 931), who were treated with either Sofosbuvir 400 mg plus weight-based Ribavirin, daily ×24 weeks (n = 432) (dual therapy), or Peginterferon-α2a 180 mcg weekly, Sofosbuvir 400 mg plus weight-based Ribavirin, daily ×12 weeks (n = 499) (triple therapy) were included for analysis. Primary outcome was the proportion of patients achieving sustained viral response at 12 weeks post-therapy.

RESULTS

The overall SVR rates were 91 and 92% in the dual and triple therapy arms, respectively. The SVR rates in treatment experienced were 67 and 74% versus 93 and 96% in naïve patients, on the dual and triple therapy arms, respectively. The SVR rates of cirrhotics were 73 and 75% on the dual and triple treatment arms, respectively. The SVR rates were low in the experienced cirrhotic patients: 44% (dual therapy) and 58% (triple therapy). Common adverse events were fatigue, headache, and myalgia.

CONCLUSION

Both dual and triple therapy regimes resulted in SVR rates of >95% in CHC genotype 3 who were naive non-cirrhotics. However, the SVR rates were low in treatment-experienced cirrhotics.

Clinical and anorectal manometry profile of patients with functional constipation and constipation-predominant irritable bowel syndrome

BACKGROUND

Functional constipation (FC) and constipation-predominant irritable bowel syndrome (IBS-C) have significant healthcare impact. Clinical and investigative data of patients with these disorders in Indian population is scarce. We aimed to compare the clinical and anorectal manometric profile of patients with FC and IBS-C.

METHODS

Consecutive patients with chronic constipation undergoing anorectal manometry (ARM) and balloon expulsion test (BET) were enrolled. Thirty healthy volunteers served as controls (HC). Functional defecatory disorder (FDD) was diagnosed according to ROME IV criteria if both ARM and BET were abnormal.

RESULTS

Of the 231 patients enrolled (median age 47 years, 87.8% males), FC and IBS-C were diagnosed in 132 (57.1%) and 99 (42.9%) patients, respectively. Significant clinical differences between FC and IBS-C patients included older age, lower stool frequency/week, higher frequency of straining, and greater frequency  of incomplete evacuation (p < 0.001). ARM revealed abnormal defecatory pattern in 55.3% (n = 73) FC patients and 47.5% (n = 47) IBS-C patients. Of them, 54.7% (40/73) of FC patients had inadequate defecatory propulsion while 89.4% (42/47) of the IBS-C patients had dyssynergic defecation (p < 0.001). Abnormal BET was seen in 67.4% of FC patients and 43.4% of IBS-C patients. Thus, FDD was diagnosed in 55.3% and 46.5% of FC and IBS-C patients, respectively. Rectal hyposensitivity was present in 60.6% of FC patients compared with 2% of IBS-C patients (p < 0.001).

CONCLUSIONS

There were significant differences in clinical and manometric profile of FC and IBS-C patients. Compared with IBS-C patients, FC patients were older, had higher prevalence of FDD, less often had dyssynergic defecation, and had higher prevalence of rectal hyposensitivity.

HCC surveillance results in earlier HCC detection: results from an Indian cohort

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide, with an increased incidence in South Asia. In order to describe the effect of surveillance for HCC with biannual ultrasound and alpha-fetoprotein (AFP) on diagnosis and survival in an Indian population a retrospective cohort-control study was performed at two liver clinics in India. The medical records of 3,258 patients with cirrhosis who received surveillance for HCC were reviewed, and 100 patients who developed HCC identified. Sixty-four cirrhotic patients diagnosed with HCC during the same time period without a history of surveillance were included and survival, BCLC stage at diagnosis, and treatment were compared. Patients who underwent surveillance were more likely to be diagnosed with potentially curable or treatable BCLC Stage 0/A disease and Stage B/C disease respectively, than late Stage D disease (χ2 = 0.0007). Patients diagnosed at an earlier stage of HCC lived significantly longer after diagnosis than patients diagnosed at a later stage (Stage 0/A: 15.6 ± 14.2 months vs. Stage B/C: 9.43 ± 19.7 months vs. Stage D: 5.59 ± 11.9 months; p = 0.0006). While treatment for HCC improved overall survival, only 28% of eligible patients received treatment, explaining the lack of survival benefit noted in the surveillance group. Surveillance for HCC led to detection of HCC at earlier stages. The impact of surveillance on improved mortality could not be evaluated given the limited number of patients who received treatment. HCC surveillance has the potential to improve survival in South Asian patients with cirrhosis only if improvements in access to appropriate treatment are made.

A multicenter double-blind, placebo-controlled randomized trial to evaluate the safety and efficacy of bovine colostrum in the treatment of severe alcoholic hepatitis (SAH)

BACKGROUND

Severe alcoholic hepatitis (SAH) is associated with high mortality. Numerous studies and meta-analysis have reported that corticosteroids reduce the 28-day mortality in SAH, but not the 6-month mortality. Therefore, newer treatments for SAH need to be studied. A pilot study from our group had recently treated ten patients with SAH with bovine colostrum (BC) [20 g thrice in a day for 8 weeks] and prednisolone. This therapy improved the biological functions and 3-month mortality. However, as more and more data showed the failure of corticosteroids to improve the 3- and 6-month mortality, especially in patients with high mDF and MELD scores, we planned this trial to study the safety and efficacy of BC (without corticosteroids) in the treatment of SAH.

METHOD

This is a multicenter, parallel, double-blind, randomized (1:1) placebo-controlled trial, which will enroll 174 patients with SAH from 5 academic centers in the India. Patients will receive freeze-dried BC or placebo by random 1:1 allocation for 4 weeks. The primary outcome measure is survival at 3 months. The secondary outcome measures are survival at 1 month, change in mDF and MELD scores, change in endotoxin and cytokines (alpha TNF, IL6, and IL8) levels, number of episodes of sepsis [pneumonia, spontaneous bacterial peritonitis (SBP), cellulitis, urinary tract infection (UTI)] from baseline to 4 weeks.

DISCUSSION

This study will evaluate the safety and efficacy of bovine colostrum in improving the survival of patients with SAH.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02473341. Prospectively registered on June 16, 2015.

Treatment of chronic hepatitis C genotype 1 early responders with 36 week pegylated interferon and ribavirin therapy

INTRODUCTION

Standard treatment for patients with chronic hepatitis C genotype 1 (CHC G-1) infection includes pegylated interferon plus ribavirin (PEG-RBV) for 48 weeks. Shorter treatment regimen would be more acceptable due to lower cost and fewer side-effects. We aimed to compare the efficacy of 36 week PEG-RBV therapy with standard 48 week therapy in CHC G-1 patients who achieve complete early virological response (cEVR).

MATERIAL AND METHODS

Consecutive treatment-naïve patients with CHC G-1 were treated with pegylated interferon a2b (1.5 μg/kg/week) or α2a (180 μg/week) and weight based ribavirin. Patients who achieved cEVR at 12 weeks [undetectable HCV RNA irrespective of RVR (rapid virological response)] were randomized into- group A (48 weeks therapy) and group B (36 weeks therapy). Primary end-point was achievement of sustained virological response (SVR) at 24 weeks of follow up.

RESULTS

Out of the total 166 patients started on treatment, 112 (69.3%) achieved cEVR, and were randomized into group A (n = 59) and group B (n = 53). Fifty-five (93.2%) patients in group A and 50 (94.3%) in group B completed therapy. The overall SVR rate in group A was 79.6% (47/59) and group B was 84.9% (45/53) (p = 0.622). SVR rates in the two groups were comparable in all patient sub-groups according to factors like viral load (≤ or > 400,000 IU/mL), RVR (achieved/not achieved), age (≤ or > 40 years), body mass index (≤ or > 27) and cirrhosis (present/absent).

CONCLUSION

In CHC G-1 patients who achieve cEVR, 36 weeks PEG-RBV therapy is as effective as standard 48 weeks therapy, irrespective of other host or virological factors.

Impact of Diabetes, Drug-Induced Liver Injury, and Sepsis on Outcomes in Metabolic Dysfunction Associated Fatty Liver Disease-Related Acute-on-Chronic Liver Failure

INTRODUCTION

The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute-on-chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied.

METHODS

Patients with MAFLD-ACLF were recruited from the Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were randomly split into derivation (n = 258) and validation (n = 111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered.

RESULTS

The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27% and hypertension in 29%. The dominant precipitants included viral hepatitis (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts.

DISCUSSION

Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

Celiac disease and intussusception - a rare but important association

Most of the cases of intussusception in children are labeled as idiopathic and not usually investigated. Only rare cases of chronic or recurrent intussusception receive greater attention and further investigations. Celiac disease appears to be associated with modestly increased risk of intussusception, although most of these cases remain asymptomatic. Debate still continues as to whether all patients of intussusception should be screened for celiac disease. We present case of a 7 years old child who presented with recurrent intussusception, underwent laparotomy initially and was later diagnosed to have celiac disease.

Quality of life in Indian patients with functional dyspepsia: Translation and validation of the Hindi version of Short-Form Nepean Dyspepsia Index

BACKGROUND/PURPOSE

Patients with functional dyspepsia (FD) have poor health-related quality of life (HRQOL), but Indian data are  lacking. Also, there is non-availability of validated disease-specific questionnaire to assess HRQOL in Hindi-speaking patients with dyspepsia. We aimed to develop and validate a reliable translation of Short-Form Nepean Dyspepsia Index (SF-NDI) in Hindi, and assess the impact of FD on HRQOL in Indian patients.

METHODS

Cross-cultural adaptation of English version of SF-NDI, translation to Hindi, and adaptation of Hindi version were performed using standard procedures. English and Hindi versions were assessed against Short Form-36 (SF-36), examining for internal consistency, test-retest reliability, and validity.

RESULTS

Total 211 FD patients (144 Hindi speaking, 67 English speaking) were enrolled (mean age 40.8 ± 11.7 years; male:female = 115:96). Median total SF-NDI scores for both languages were 38.75 and 40.0, respectively. Test-retest reliability intraclass correlation coefficients were 0.85 (Hindi) and 0.89 (English). Internal consistency evaluation revealed Cronbach's α coefficient of 0.79-0.86 (Hindi) and 0.78-0.89 (English). SF-NDI sub-scales showed moderate to good correlation with various domains of SF-36 (content validity). There was significant (p < 0.001) decline of HRQOL in patients with severe dyspepsia relative to those with mild dyspepsia (construct validity). On multivariate analysis, factors independently associated with HRQOL were duration of symptoms and dyspepsia severity.

CONCLUSION

Both English and Hindi versions of SF-NDI are reliable and valid for HRQOL assessment in Indian FD patients, and will be useful in future epidemiological and clinical studies. Indian FD patients have poor HRQOL, being worse in those with severe dyspepsia and longer duration of symptoms.

Emphysematous Gastritis with Air in Portal Venous System

Emphysematous gastritis is a rare but severe form of phlegmonous gastritis caused by gastric mucosal disruption and infection of stomach wall by gas-forming bacteria. Ingestion of corrosive substances is the most common predisposing factor, followed by alcohol abuse, abdominal surgery, diabetes and immunosuppression. Patients usually present with abdominal pain, vomiting, diarrhea, constipation and/or gastro-intestinal hemorrhage. Characteristic radiological findings include presence of gas in the gastric wall. Management of this condition includes broad-spectrum antibiotics and supportive therapy. Outcome of emphysematous gastritis is frequently fatal due to septic shock and multi-organ failure. We report a case of a 65 years old male who presented with fever and upper abdominal tenderness. He had history of uncontrolled diabetes and chronic alcohol intake. Radiological investigations revealed air within the gastric wall, portal vein, liver and spleen. Despite initial improvement with conservative management, patient succumbed due to sepsis and shock.

Noradrenaline is as Effective as Terlipressin in Hepatorenal Syndrome Type 1: A Prospective, Randomized Trial

OBJECTIVES

Hepatorenal syndrome (HRS) is a functional renal failure occurring in end stage liver disease, which is associated with poor prognosis. Terlipressin has been shown to be effective in treatment of HRS. More recently, it was suggested that noradrenaline, an alpha-adrenergic drug may be also effective in HRS. We aimed to compare the efficacy of noradrenaline versus terlipressin in treatment of HRS type 1.

METHODS

Consecutive patients with cirrhosis and HRS type 1 were enrolled and randomised into 2 groups- Group A received intravenous noradrenaline infusion (0.5-3 mg/h) and group B received intravenous terlipressin (0.5-2 mg/6h) for 2 weeks. Intravenous albumin (20 g/day) was given to both groups.

RESULTS

Out of 55 cirrhotics screened, 41 were randomised into group A (n=21) or group B (n=20). Baseline characteristics of the two groups were similar. HRS reversal was seen in 47.6%(10/21) patients in group A, and 45% (9/20) patients in group B (p=1.00). In both groups, there was a significant decrease in serum creatinine from baseline (group A- 3.1±1.4 mg/dl to 2.2±1.3 mg/dl, p=0.028; group B- 3.4±1.6 mg/dl to 2.3±1.3 mg/dl, p=0.035). Both the groups showed a significant increase in mean arterial pressure (group A- 77.3±8.6 mmHg to 103.4±8.3 mmHg, p=0.0001; group B- 76.8±11.6 mmHg to 100±9.4 mmHg, p=0.0001). Noradrenaline was associated with fewer adverse events and was significantly cheaper than terlipressin. Lower baseline MELD score was an independent predictor of response to treatment.

CONCLUSIONS

Noradrenaline is as effective and safe as terlipressin in the treatment of HRS type 1.

Noradrenaline is as Effective as Terlipressin in Hepatorenal Syndrome Type 1: A Prospective, Randomized Trial

OBJECTIVES

Hepatorenal syndrome (HRS) is a functional renal failure occurring in end stage liver disease, which is associated with poor prognosis. Terlipressin has been shown to be effective in treatment of HRS. More recently, it was suggested that noradrenaline, an alpha-adrenergic drug may be also effective in HRS. We aimed to compare the efficacy of noradrenaline versus terlipressin in treatment of HRS type 1.

METHODS

Consecutive patients with cirrhosis and HRS type 1 were enrolled and randomised into 2 groups- Group A received intravenous noradrenaline infusion (0.5-3 mg/h) and group B received intravenous terlipressin (0.5-2 mg/6h) for 2 weeks. Intravenous albumin (20 g/day) was given to both groups.

RESULTS

Out of 55 cirrhotics screened, 41 were randomised into group A (n=21) or group B (n=20). Baseline characteristics of the two groups were similar. HRS reversal was seen in 47.6%(10/21) patients in group A, and 45% (9/20) patients in group B (p=1.00). In both groups, there was a significant decrease in serum creatinine from baseline (group A- 3.1±1.4 mg/dl to 2.2±1.3 mg/dl, p=0.028; group B- 3.4±1.6 mg/dl to 2.3±1.3 mg/dl, p=0.035). Both the groups showed a significant increase in mean arterial pressure (group A- 77.3±8.6 mmHg to 103.4±8.3 mmHg, p=0.0001; group B- 76.8±11.6 mmHg to 100±9.4 mmHg, p=0.0001). Noradrenaline was associated with fewer adverse events and was significantly cheaper than terlipressin. Lower baseline MELD score was an independent predictor of response to treatment.

CONCLUSIONS

Noradrenaline is as effective and safe as terlipressin in the treatment of HRS type 1.

Overlap of 'disorders of gut-brain interaction' and their impact on quality of life and somatization in a tertiary care center- A cross-sectional study

BACKGROUND

Disorders of gut-brain interaction (DGBIs) constitute a global health challenge. Overlapping DGBIs amplify the clinical severity and have a profound impact on health-related quality of life (HRQoL) and somatization. Data on the prevalence and overlap of all individual DGBIs and their clinical ramifications remains limited. This study sought to elucidate these aspects within a northern Indian tertiary healthcare setting.

METHODS

This prospective cross-sectional study enrolled patients meeting Rome IV criteria for DGBIs and healthy controls (HC). Participants underwent elaborative assessments, including socio-demographic profiling, HRQoL evaluation (PROMIS Global-10) and somatization quantification (PHQ-12). Statistical analyses compared prevalence rates, overlap patterns and associated clinical outcomes between various groups.

RESULTS

Of the 2538 patients screened, 1044 (41.1%) with DGBIs (age 41.7 ± 12.6 years, 51.9% males) were enrolled; along with 1021 age and gender-matched HCs. Most common gastrointestinal region involved was gastroduodenal (49.9%), followed by bowel (39.7%) and esophageal (33.3%). Most common DGBIs were functional dyspepsia (FD; 44.4%), functional esophageal disorders (FEsD;32.4%), functional constipation (FC;18%), irritable bowel syndrome (IBS;16.1%). Overlapping DGBIs were present in 40.3% patients, with FD-FEsD (23.9%) and FD-FC(22.1%) and FD-IBS (52;12.4%) overlaps being the most common. Compared to HC, DGBI patients had significantly poorer HRQoL scores (19.1 ± 0.7 vs. 13.52 ± 3.39; p < 0.001) and significantly increased somatization scores (2.5 ± 1.7 vs. 18.5 ± 0.7; p < 0.001). Further, patients with overlapping DGBIs had significantly poorer HRQoL and significantly increased somatization scores compared to non-overlapping counterparts.

CONCLUSIONS

This study provides novel data on the clinical burden and the entire spectrum of overlapping and non-overlapping DGBIs, while studying their impact on HRQoL and somatization. DGBI patients had significantly poorer HRQoL and heightened somatization compared to HCs; with further detriments observed in those with overlapping DGBIs. These findings emphasize the need for an integrated multidisciplinary approach for the evaluation of possible overlaps and for assessment of HRQoL in all patients with DGBIs to improve clinical outcomes.

Indian consensus statements on irritable bowel syndrome in adults: A guideline by the Indian Neurogastroenterology and Motility Association and jointly supported by the Indian Society of Gastroenterology

The Indian Neurogastroenterology and Motility Association (INMA), earlier named the Indian Motility and Functional Diseases Association developed this evidence-based practice guidelines for the management of irritable bowel syndrome (IBS). A modified Delphi process was used to develop this consensus containing 28 statements, which were concerning diagnostic criteria, epidemiology, etiopathogenesis and comorbidities, investigations, lifestyle modifications and treatments. Owing to the Coronavirus disease-19 (COVID-19) pandemic, lockdowns and mobility restrictions, web-based meetings and electronic voting were the major tools used to develop this consensus. A statement was regarded as accepted when the sum of "completely accepted" and "accepted with minor reservation" voted responses were 80% or higher. Finally, the consensus was achieved on all 28 statements. The consensus team members are of the view that this work may find use in teaching, patient care, and research on IBS in India and other nations.

Critical analysis of the effects of proton pump inhibitors on inflammatory bowel disease: An updated review

This letter critically evaluates the effects of proton pump inhibitors (PPIs) on inflammatory bowel disease, particularly focusing on Crohn's disease (CD) and ulcerative colitis (UC), as discussed in Liang et al's recent review. While the review provides significant insights, it relies heavily on cross-sectional and observational studies, which limits the ability to draw causal inferences. The heterogeneous study populations and inconsistent definitions of long-term PPI use further complicate the findings. This letter also highlights the need for rigorous control of confounding factors and considers the potential publication bias in the existing literature. The implications of these issues are discussed in the context of both CD and UC, and future research directions are proposed to address these shortcomings.

Recurrent lung infection due to chronic peri-odontitis

Association between chronic lung disease and peri-odontal infection has recently been reported. The microbiology of peri-odontal infection and lung infection is almost similar. The most direct means by which the oral infection might influence lung disease is by aspiration of dental plaque bacteria into the lower respiratory tract. In this case report we are presenting a patient who suffered recurrent lung infection. Intra-oral examination revealed the presence of chronic peri-odontitis, which was not treated before. On providing treatment for lung infection in addition to that for peri-odontal infection, there was no recurrence of lung infection.