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Ulsh L, Halawi H, Triadafilopoulos G, Gurland B, Nguyen L, Garcia P, Sonu I, Fernandez-Becker N, Becker L, Sheth V, Neshatian L. Use of a footstool improves rectal balloon expulsion in some patients with defecatory disorders. Neurogastroenterol Motil 2024; 36:e14781. [PMID: 38488172 DOI: 10.1111/nmo.14781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 01/31/2024] [Accepted: 03/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Whether patients with defecatory disorders (DDs) with favorable response to a footstool have distinctive anorectal pressure characteristics is unknown. We aimed to identify the clinical phenotype and anorectal pressure profile of patients with DDs who benefit from a footstool. METHODS This is a retrospective review of patients with high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) from a tertiary referral center. BET was repeated with a 7-inch-high footstool in those who failed it after 120 s. Data were compared among groups with respect to BET results. KEY RESULTS Of the 667 patients with DDs, a total of 251 (38%) had failed BET. A footstool corrected BET in 41 (16%) of those with failed BET. Gender-specific differences were noted in anorectal pressures, among patients with and without normal BET, revealing gender-based nuances in pathophysiology of DDs. Comparing patients who passed BET with footstool with those who did not, the presence of optimal stool consistency, with reduced instances of loose stools and decreased reliance on laxatives were significant. Additionally, in women who benefited from a footstool, lower anal pressures at rest and simulated defecation were observed. Independent factors associated with a successful BET with a footstool in women included age <50, Bristol 3 or 4 stool consistency, lower anal resting pressure and higher rectoanal pressure gradient. CONCLUSION & INFERENCES Identification of distinctive clinical and anorectal phenotype of patients who benefited from a footstool could provide insight into the factors influencing the efficacy of footstool utilization and allow for an individualized treatment approach in patients with DDs.
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Affiliation(s)
- Lauren Ulsh
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Houssam Halawi
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Brooke Gurland
- Division of Colorectal Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Irene Sonu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nielsen Fernandez-Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Laren Becker
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Vipul Sheth
- Department of Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Leila Neshatian
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Camilleri M, Yang DY. Algorithms or biomarkers in patients with lower DGBI? Neurogastroenterol Motil 2024:e14856. [PMID: 38934414 DOI: 10.1111/nmo.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/16/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND Several organizations have proposed guidelines or clinical decision tools for the management of patients with disorders of gut-brain interactions (DGBI) affecting the lower digestive tract including irritable bowel syndrome and chronic idiopathic constipation. Such algorithms are based on sequential therapeutic trials and modifying the treatment strategy based on efficacy and adverse events. PURPOSE The aims of this review are to evaluate the evidence for efficacy of second- and third-line pharmacotherapies and to assess the evidence for the alternative option to manage subgroups of patients with symptoms suggestive of lower DGBI based on diagnostic tests or documented dysfunctions. The preeminent tests to identify such subgroups that present with symptoms that overlap with lower DGBI are detailed: digital rectal examination as well as anorectal manometry and balloon expulsion for evacuation disorders, detailed measurements of colonic transit, and diagnosis of bile acid diarrhea or carbohydrate malabsorption based on biochemical measurements. The review also addresses the cost implications of screening to exclude alternative diagnoses and the costs of therapy associated with the therapeutic options following an algorithmic approach to treatment from the perspective of society, insurer, or patient. Finally, the costs of the diagnostic tests to identify actionable biomarkers and the evidence of efficacy of individualized therapy based on formal diagnosis or documentation of abnormal functions are detailed in the review.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, Minnesota, USA
| | - David Yi Yang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Rochester, Minnesota, USA
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3
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Vakili O, Adibi Sedeh P, Pourfarzam M. Metabolic biomarkers in irritable bowel syndrome diagnosis. Clin Chim Acta 2024; 560:119753. [PMID: 38821336 DOI: 10.1016/j.cca.2024.119753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 05/24/2024] [Accepted: 05/27/2024] [Indexed: 06/02/2024]
Abstract
Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder characterized by altered bowel habits and abdominal discomfort during defecation. It significantly impacts life quality and work productivity for those affected. Global data suggests a slightly higher prevalence in females than in males. Today, unambiguous diagnosis of IBS remains challenging due to the absence of a specific biochemical, histopathological, or radiological test. Current diagnosis relies heavily on thorough symptom evaluation. Efforts by the Rome committees have established standardized diagnostic criteria (Rome I-IV), improving consistency and clinical applicability. Recent studies in this framework, seem to have successfully employed metabolomics techniques to identify distinct metabolite profiles in breath and stool samples of IBS patients, differentiating them from healthy controls and those with other functional GI disorders, such as inflammatory bowel disease (IBD). Building on this success, researchers are investigating the presence of similar metabolites in easily accessible biofluids such as urine, potentially offering a less invasive diagnostic approach. Accordingly, this review focuses on key metabolites specifically detected in IBS patients' biological specimens, with a focus on urinary metabolites, using various methods, particularly mass spectrometry (MS)-based techniques, including gas chromatography-MS (GC-MS), liquid chromatography-tandem MS (LC-MS/MS), and capillary electrophoresis-MS (CE-MS) metabolomics assays. These findings may make provision for a new set of non-invasive biomarkers for IBS diagnosis and management.
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Affiliation(s)
- Omid Vakili
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Peyman Adibi Sedeh
- Gastroenterology and Hepatology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Morteza Pourfarzam
- Department of Clinical Biochemistry, School of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran.
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Wang XJ. Diagnosing Dyssynergic Defecation with the Digital Rectal Exam: The New Digital Revolution? Dig Dis Sci 2024; 69:660-661. [PMID: 38170339 DOI: 10.1007/s10620-023-08234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, 200 1 Ave SW, Rochester, MN, 55901, USA.
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Camilleri M. Abnormal gastrointestinal motility is a major factor in explaining symptoms and a potential therapeutic target in patients with disorders of gut-brain interaction. Gut 2023; 72:2372-2380. [PMID: 37666657 PMCID: PMC10841318 DOI: 10.1136/gutjnl-2023-330542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023]
Abstract
The objective of this article is to review the evidence of abnormal gastrointestinal (GI) tract motor functions in the context of disorders of gut-brain interaction (DGBI). These include abnormalities of oesophageal motility, gastric emptying, gastric accommodation, colonic transit, colonic motility, colonic volume and rectal evacuation. For each section regarding GI motor dysfunction, the article describes the preferred methods and the documented motor dysfunctions in DGBI based on those methods. The predominantly non-invasive measurements of gut motility as well as therapeutic interventions directed to abnormalities of motility suggest that such measurements are to be considered in patients with DGBI not responding to first-line approaches to behavioural or empirical dietary or pharmacological treatment.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Camilleri M, BouSaba J. Potential Value of Biomarker-Based Approaches for Evaluation and Management of Costly Functional Gastrointestinal Diseases. Clin Gastroenterol Hepatol 2023; 21:2462-2472. [PMID: 37164114 PMCID: PMC10524924 DOI: 10.1016/j.cgh.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/18/2023] [Accepted: 04/24/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota.
| | - Joelle BouSaba
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, Minnesota
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Camilleri M, Boeckxstaens G. Irritable bowel syndrome: treatment based on pathophysiology and biomarkers. Gut 2023; 72:590-599. [PMID: 36307180 PMCID: PMC9990119 DOI: 10.1136/gutjnl-2022-328515] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To appraise the evidence that pathophysiological mechanisms and individualised treatment directed at those mechanisms provide an alternative approach to the treatment of patients with irritable bowel syndrome (IBS). DESIGN A PubMED-based literature review of mechanisms and treatment of IBS was conducted independently by the two authors, and any differences of perspective or interpretation of the literature were resolved following discussion. RESULTS The availability of several noninvasive clinical tests can appraise the mechanisms responsible for symptom generation in IBS, including rectal evacuation disorders, abnormal transit, visceral hypersensitivity or hypervigilance, bile acid diarrhoea, sugar intolerances, barrier dysfunction, the microbiome, immune activation and chemicals released by the latter mechanism. The basic molecular mechanisms contributing to these pathophysiologies are increasingly recognised, offering opportunities to intervene with medications directed specifically to food components, receptors and potentially the microbiome. Although the evidence supporting interventions for each mechanism is not at the same level of proof, the current state-of-the-art provides the opportunity to advance the practice from treatment based on symptoms to individualisation of treatment guided by pathophysiology and clinically identified biomarkers. CONCLUSION These advances augur well for the implementation of evidence-based individualised treatment for patients with IBS based on actionable biomarkers or psychological disturbances.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy Boeckxstaens
- Center of Intestinal Neuroimmune Interaction, Division of Gastroenterology, Translational Research Center for GI Disorders (TARGID), Leuven University, Leuven, Belgium
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Bharucha AE, Basilisco G, Malcolm A, Lee TH, Hoy MB, Scott SM, Rao SSC. Review of the indications, methods, and clinical utility of anorectal manometry and the rectal balloon expulsion test. Neurogastroenterol Motil 2022; 34:e14335. [PMID: 35220645 PMCID: PMC9418387 DOI: 10.1111/nmo.14335] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/24/2022] [Accepted: 02/01/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anorectal manometry (ARM) comprehensively assesses anorectal sensorimotor functions. PURPOSE This review examines the indications, techniques, interpretation, strengths, and weaknesses of high-resolution ARM (HR-ARM), 3-dimensional high-resolution anorectal manometry (3D-HR-ARM), and portable ARM, and other assessments (i.e., rectal sensation and rectal balloon expulsion test) that are performed alongside manometry. It is based on a literature search of articles related to ARM in adults. HR-ARM and 3D-HR-ARM are useful for diagnosing defecatory disorders (DD), to identify anorectal sensorimotor dysfunction and guide management in patients with fecal incontinence (FI), constipation, megacolon, and megarectum; and to screen for anorectal structural (e.g., rectal intussusception) abnormalities. The rectal balloon expulsion test is a useful, low-cost, radiation-free, outpatient assessment tool for impaired evacuation that is performed and interpreted in conjunction with ARM. The anorectal function tests should be interpreted with reference to age- and sex-matched normal values, clinical features, and results of other tests. A larger database of technique-specific normal values and newer paradigms of analyzing anorectal pressure profiles will increase the precision and diagnostic utility of HR-ARM for identifying abnormal mechanisms of defecation and continence.
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Affiliation(s)
- Adil E Bharucha
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Guido Basilisco
- UO Gastroenterologia, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Allison Malcolm
- Department of Gastroenterology, Royal North Shore Hospital and University of Sydney, Sydney, NSW, Australia
| | - Tae Hee Lee
- Digestive Disease Center, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Matthew B Hoy
- Mayo Medical Library, Mayo Clinic, Rochester, Minnesota, USA
| | - S Mark Scott
- National Bowel Research Centre, Queen Mary University of London, London, UK
| | - Satish S C Rao
- Department of Gastroenterology, Augusta University, Augusta, Georgia, USA
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White BA, Linder BJ, Szarka LA, Prichard DO. Urinary Symptoms and Bladder Voiding Dysfunction Are Common in Young Men with Defecatory Disorders: A Retrospective Evaluation. Dig Dis Sci 2022; 67:3036-3044. [PMID: 34292471 DOI: 10.1007/s10620-021-07167-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/07/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Lower urinary tract symptoms (LUTS) are frequently reported by constipated patients. Prospective studies investigating the association between defecatory disorders (DDs) and voiding dysfunction, predominantly in women, have reported conflicting results. This study investigated (1) the prevalence of LUTS in young men with DDs and (2) the association between objectively documented DDs and voiding dysfunction in constipated young men with LUTS. METHODS We reviewed the medical records, including validated questionnaires, of men aged 18-40 with confirmed DDs treated with pelvic floor physical therapy (PT) at our institution from May 2018 to November 2020. In a separate group of constipated young men with LUTS who underwent high-resolution anorectal manometry (HRM), rectal balloon expulsion test (BET), and uroflowmetry, we explored the relationship between DDs and voiding dysfunction. RESULTS A total of 72 men were evaluated in the study. Among 43 men receiving PT for a proven DD, 82% reported ≥ 1 LUTS, most commonly frequent urination. Over half of these men experienced a reduction in LUTS severity after bowel-directed pelvic floor PT. Among 29 constipated men with LUTS who had undergone HRM/BET and uroflowmetry, 28% had concurrent defecatory and voiding dysfunction, 10% had DD alone, 14% had only voiding dysfunction, and 48% had neither. The presence of DD was associated with significantly increased odds of concurrent voiding dysfunction (odds ratio 9.3 [95% CI 1.7-52.7]). CONCLUSIONS Most young men with DDs experience LUTS, which may respond to bowel-directed physical therapy. Patients with DD and urinary symptoms have increased odds of voiding dysfunction.
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Affiliation(s)
- Bradley A White
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Brian J Linder
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Lawrence A Szarka
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - David O Prichard
- Department of Internal Medicine (Dr. White), Department of Urology (Dr. Linder), and Division of Gastroenterology and Hepatology (Drs. Szarka and Prichard), Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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10
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Sannaa W, BouSaba J, Magnus Y, Vijayvargiya P, Camilleri M. Rectal Evacuation Disorders in Patients Presenting With Chronic Functional Diarrhea. GASTRO HEP ADVANCES 2022; 1:549-552. [PMID: 39132060 PMCID: PMC11307801 DOI: 10.1016/j.gastha.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/07/2022] [Indexed: 08/13/2024]
Affiliation(s)
| | | | - Y. Magnus
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - P. Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - M. Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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11
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Volumetric Rectal Perception Testing: Is It Clinically Relevant? Results From a Large Patient Cohort. Am J Gastroenterol 2021; 116:2419-2429. [PMID: 34608885 DOI: 10.14309/ajg.0000000000001526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Rectal perception testing is a recommended component of anorectal physiology testing. Although recent consensus (London) guidelines suggested criteria for categorizing hyporectal and hyper-rectal sensitivity, these were based on scant evidence. Moreover, data regarding diagnostic capabilities and clinical utility of rectal perception testing are lacking. The aims of this study were to determine the association between rectal perception testing and both clinical and physiological variables to enhance the analysis and interpretation of real-life test results. METHODS Prospectively documented data from 1,618 (92% female) patients referred for anorectal physiology testing were analyzed for 3 rectal perception thresholds (first, urge, and maximal tolerated). Normal values derived from healthy female subjects were used to categorize each threshold into hyposensitive and hypersensitive to examine the clinical relevance of this categorization. RESULTS There was poor to moderate agreement between the 3 thresholds. Older age, male sex, and constipation were associated with higher perception thresholds, whereas irritable bowel syndrome, fecal incontinence, connective tissue disease, and pelvic radiation were associated with lower perception thresholds to some, but not all, thresholds (P < 0.01 on multivariate analysis for all). The clinical utility and limitations of categorizing thresholds into "hypersensitivity" and "hyposensitivity" were determined. DISCUSSION Commonly practiced rectal perception testing is correlated with several disease states and thus has clinical relevance. However, most disease states were correlated with 2 or even only 1 abnormal threshold, and agreement between thresholds was limited. This may suggest each threshold measures different pathophysiological pathways. We suggest all 3 thresholds be measured and reported separately in routine clinical testing.
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Abstract
IMPORTANCE The prevalence of irritable bowel syndrome (IBS) in the United States is between 7% and 16%, most common in women and young people, with annual direct costs estimated at more than $1 billion dollars in the United States. Traditionally, the diagnosis of IBS has been based on the positive identification of symptoms that correlate with several different syndromes associated with disorders such as IBS diarrhea, IBS constipation, functional diarrhea, functional constipation, chronic functional abdominal pain, or bloating. Several peripheral and central mechanisms initiate gastrointestinal motor and sensory dysfunctions leading to IBS symptoms. Those dysfunctions may require evaluation in patients whose symptoms do not respond to first-line treatments. OBSERVATIONS Validation studies of consensus symptom-based criteria have identified deficiencies that favor a simpler identification of the predominant symptoms of abdominal pain, bowel dysfunction, and bloating and exclusion of alarm symptoms such as unintentional weight loss, rectal bleeding, or recent change in bowel function. Symptom-based diagnosis of IBS is enhanced with additional history for symptoms of somatoform and psychological disorders and alarm symptoms, physical examination including digital rectal examination, and screening tests to exclude organic disease (by measuring hemoglobin and C-reactive protein concentrations). The initial treatment plan should include patient education, reassurance, and first-line treatments such as fiber and osmotic laxatives for constipation, opioids for diarrhea, antispasmodics for pain and for management of associated psychological disorders. For patients who do not respond to those IBS treatments, testing for specific functional disorders may be required in a minority of patients with IBS. These disorders include rectal evacuation disorder, abnormal colonic transit, and bile acid diarrhea. Their identification is followed by individualized treatment, such as pelvic floor retraining for rectal evacuation disorders, sequestrants for bile acid diarrhea, and secretory agents for constipation, although there is only limited evidence that this individualized management approach is effective. CONCLUSIONS AND RELEVANCE Advances in the identification of specific dysfunctions as causes of individual symptoms in the "IBS spectrum" leads to the potential to enhance the diagnosis and management of symptoms for the majority of patients for whom first-line therapies of IBS and management of comorbid psychological disorders are insufficient.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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13
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Abstract
Chronic constipation is one of the five most common symptoms seen by gastroenterologist. In the absence of alarm symptoms, a confident symptom-based diagnosis can often be made using the Rome criteria. Three different subtypes have been identified to date: normal transit constipation, defaecatory disorders and slow transit constipation. Differentiation between these subtypes can be made through functional testing using tests such as anorectal manometry with balloon expulsion and a radio-opaque marker test. In general, patients are initially advised to increase their fluid and fibre intake. When these general lifestyle recommendations do not improve patients' symptoms, a step-wise and add-on treatment approach should be applied. This review summarises the diagnostic criteria to differentiate functional constipation from other causes of chronic constipation. In addition, current drug treatment options, including discussion of new therapeutic targets are discussed. Further, practical treatment approaches (choice and dosing), include discussion of combination/augmentation, treatment failure (adherence/expectations), and relapse prevention are mentioned. Finally, treatment and management of pain and bloating aspects are included.
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Affiliation(s)
- Jasper Pannemans
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium
| | - Imke Masuy
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium
| | - Jan Tack
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Herestraat 49, Box 701, 3000, Leuven, Belgium.
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Fomenko OY, Morozov SV, Scott S, Knowles H, Morozov DA, Shelygin YA, Maev IV, Nikityuk DB, Shkoda AS, Kashnikov VN, Bordin DS, Isakov VA, Biryukov OM, Belousova SV, Pimenova ES, Rumiantsev AS, Fedorov ED, Gvozdev MY, Trukhmanov AS, Storonova OA, Indeykina LH, Biryukova MG, Andreev DN, Kucheryavyy YA, Achkasov SI. [Recommendations for the Protocol of functional examination of the anorectal zone and disorders classification: the International Anorectal Physiology Working Group consensus and Russian real-world practice]. TERAPEVT ARKH 2020; 92:105-119. [PMID: 33720582 DOI: 10.26442/00403660.2020.12.200472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/07/2021] [Indexed: 02/07/2023]
Abstract
This manuscript summarizes consensus reached by the International Anorectal Physiology Working Group (IAPWG) for the performance, terminology used, and interpretation of anorectal function testing including anorectal manometry (focused on high-resolution manometry), the rectal sensory test, and the balloon expulsion test. Based on these measurements, a classification system for disorders of anorectal function is proposed. Aim to provide information about methods of diagnosis and new classification of functional anorectal disorders to a wide range of specialists general practitioners, therapists, gastroenterologists, coloproctologists all who face the manifestations of these diseases in everyday practice and determine the diagnostic and therapeutic algorithm. Current paper provides agreed statements of IAPWG Consensus and comments (in italics) of Russian experts on real-world practice, mainly on methodology of examination. These comments in no way intended to detract from the provisions agreed by the international group of experts. We hope that these comments will help to improve the quality of examination based on the systematization of local experience with the use of the methods discussed and the results obtained. Key recommendations: the International Anorectal Physiology Working Group protocol for the performance of anorectal function testing recommends a standardized sequence of maneuvers to test rectoanal reflexes, anal tone and contractility, rectoanal coordination, and rectal sensation. Major findings not seen in healthy controls defined by the classification are as follows: rectoanal areflexia, anal hypotension and hypocontractility, rectal hyposensitivity, and hypersensitivity. Minor and inconclusive findings that can be present in health and require additional information prior to diagnosis include anal hypertension and dyssynergia.
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Affiliation(s)
- O Y Fomenko
- Ryzhikh National Medical Research Centre for Coloproctology
| | - S V Morozov
- Federal Research Center of Nutrition and Biotechnology
| | - S Scott
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - H Knowles
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London
| | - D A Morozov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - Y A Shelygin
- Ryzhikh National Medical Research Centre for Coloproctology
| | - I V Maev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - D B Nikityuk
- Federal Research Center of Nutrition and Biotechnology
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - V N Kashnikov
- Ryzhikh National Medical Research Centre for Coloproctology
| | - D S Bordin
- Yevdokimov Moscow State University of Medicine and Dentistry
- Loginov Moscow Clinical Research Center
- Tver State Medical University
| | - V A Isakov
- Federal Research Center of Nutrition and Biotechnology
| | - O M Biryukov
- Ryzhikh National Medical Research Centre for Coloproctology
| | - S V Belousova
- Ryzhikh National Medical Research Centre for Coloproctology
| | - E S Pimenova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - E D Fedorov
- Pirogov Russian National Research Medical University
| | - M Y Gvozdev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - A S Trukhmanov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O A Storonova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - L H Indeykina
- Loginov Moscow Clinical Research Center
- Research Institute of Health Care Organization and Medical Management
| | - M G Biryukova
- Federal Research Center of Nutrition and Biotechnology
| | - D N Andreev
- Yevdokimov Moscow State University of Medicine and Dentistry
| | - Y A Kucheryavyy
- Yevdokimov Moscow State University of Medicine and Dentistry
- Ilyinsky Hospital
| | - S I Achkasov
- Ryzhikh National Medical Research Centre for Coloproctology
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15
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Caetano AC, Costa D, Gonçalves R, Correia-Pinto J, Rolanda C. Does sequential balloon expulsion test improve the screening of defecation disorders? BMC Gastroenterol 2020; 20:338. [PMID: 33054847 PMCID: PMC7559767 DOI: 10.1186/s12876-020-01490-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/07/2020] [Indexed: 12/30/2022] Open
Abstract
Background A defecation disorder (DD) is a difficulty in evacuation documented by physiological exams. However, this physiological evaluation can be cumbersome, inaccessible and costly. Three “low-cost” tools to evaluate DD—a clinical DD score, the balloon expulsion test (BET) and a digital rectal examination (DRE) score were evaluated as separate or combined tests for DD screening. Methods This prospective study occurred between January 2015 and March 2019 in the Gastroenterology Department of a tertiary hospital. Besides the gold standard physiological tests, constipated patients answered the clinical DD score and were evaluated by DRE and BET [standard and variable volume (VV)]. Results From 98 constipated patients, 35 (38.9%) were diagnosed with DD according to Rome IV criteria, mainly female (n = 30, 86%) with a median age of 60 years old. The clinical DD score revealed an AUC of 0.417 (SE = 0.07, p = 0.191). The DRE score displayed an AUC of 0.56 (SE = 0.063, p = 0.301). The standard BET displayed a sensitivity of 86%, specificity of 58%, positive predictive value (PPV) of 57% and negative predictive value (NPV) of 86%. The sequential VVBET followed by standard BET improved the BET performance regarding the evaluation of DD, with a sensitivity of 86%, specificity of 67%, PPV of 63% and NPV of 87%. The sequential BET had an OR 8.942, p > 0.001, CI 3.18–25.14, revealing to be the most significant predictor for DD screening. Conclusion The sequential BET is a low cost, well-performing DD screening tool, appropriate to the Primary Care Setting.
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Affiliation(s)
- A C Caetano
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal. .,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. .,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal.
| | - D Costa
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - R Gonçalves
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal
| | - J Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
| | - C Rolanda
- Department of Gastroenterology, Hospital of Braga, Sete Fontes - São Victor, 4710-243, Braga, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's-PT, Government Associate Laboratory, 4710-057, Braga, Guimarães, Portugal
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16
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Brandler J, Camilleri M. Pretest and Post-test Probabilities of Diagnoses of Rectal Evacuation Disorders Based on Symptoms, Rectal Exam, and Basic Tests: a Systematic Review. Clin Gastroenterol Hepatol 2020; 18:2479-2490. [PMID: 31811949 PMCID: PMC7269802 DOI: 10.1016/j.cgh.2019.11.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/15/2019] [Accepted: 11/24/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over the utility of symptoms, examination, and tests for diagnosis of rectal evacuation disorders (REDs) or slow-transit constipation (STC). We aimed to ascertain the pooled prevalence, sensitivity, specificity, and likelihood ratios for clinical parameters to determine pretest and post-test probabilities of diagnoses of RED and STC without RED. METHODS We searched the MEDLINE and PUBMED databases since 1999 for studies that used binary data to calculate sensitivity, specificity, and likelihood ratios to determine the diagnostic utility of history, symptoms, and tests for RED and STC. RED and STC were defined based on confirmation by at least 1 objective anorectal test or colonic transit test. Controls had normal test results based on the specific protocol in each study. RESULTS We reviewed 100 articles; 63 studies of RED and 61 studies of STC met the inclusion criteria. Among 3364 patients with chronic constipation, objective tests demonstrated RED alone, 27.2%; normal transit constipation alone, 37.2%; STC alone, 19.0%; and RED with STC, 16.6%. To diagnose RED, discriminant features were urinary symptoms (specificity, 100%; likelihood ratio, above 10; 58 patients), less than 2 findings of dyssynergia in a digital rectal exam (sensitivity, 83.2%; negative likelihood ratio, 0.2; 462 patients) and rectoanal pressure gradient below -40 mm Hg with high anal pressure during straining (specificity, 100%; likelihood ratio, above 10; 101 patients). The features most strongly associated with STC alone were call to stool (specificity, 91.5%; likelihood ratio, 10.5; 75 patients) and absence of abdominal distension, fullness, or bloating (sensitivity, 92.9%; negative likelihood ratio, 0.1; 93 patients). CONCLUSIONS In a systematic review, we found specific symptoms, lack of dyssynergia in a digital rectal exam, and findings on anorectal manometry to be highly informative and critical in evaluation of RED and STC.
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Affiliation(s)
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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17
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Camilleri M, Chedid V. Actionable biomarkers: the key to resolving disorders of gastrointestinal function. Gut 2020; 69:1730-1737. [PMID: 32269066 DOI: 10.1136/gutjnl-2019-320325] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/12/2020] [Accepted: 02/15/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor Chedid
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
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18
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Abstract
Patients are often referred for treatment of refractory constipation that may result from uncontrolled underlying disease or ineffective treatment. This article reviews clinical testing in patients with refractory constipation, differentiating subtypes of primary chronic idiopathic constipation, and common pitfalls in assessment of refractory chronic constipation. The constipation may also be refractory because of significant associated diseases affecting the colon and resulting in slow transit constipation. The choice of therapy is best guided by the subtype. Management of refractory constipation requires correct diagnosis and individualized treatment, which may rarely include conservative surgery (loop ileostomy).
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Charlton Building, Room 8-110, Rochester, MN 55905, USA.
| | - Justin Brandler
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Charlton Building, Room 8-110, Rochester, MN 55905, USA
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19
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Liu A, Chedid V, Wang XJ, Vijayvargiya P, Camilleri M. Clinical presentation and characteristics of pelvic floor myofascial pain in patients presenting with constipation. Neurogastroenterol Motil 2020; 32:e13845. [PMID: 32281205 DOI: 10.1111/nmo.13845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/02/2020] [Accepted: 03/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with pelvic floor myofascial pain (PFMP) have puborectalis tenderness on digital rectal examination (DRE). Little is known about its significance to anorectal function in patients presenting with constipation. AIM To characterize demographics, clinical characteristics, findings on anorectal manometry (ARM), diagnosis of rectal evacuation disorder (RED), colonic transit [normal (NTC) or slow (STC)], and imaging in constipated patients with PFMP and compare these features to constipation without PFMP. METHODS We performed an electronic medical records review of patients with constipation evaluated by a single gastroenterologist between January 2008 and February 2019. Patients with PFMP were compared to controls with constipation but without PFMP (1:2 ratio). KEY RESULTS A total of 98 PFMP cases and 196 controls were identified. Constipated patients with PFMP were more likely to have RED [OR 7.59 (3.82-15.09), P < .01]; controls were more likely to have either NTC [OR 4.25 (1.45-12.42), P < .01] or STC [OR 3.57 (1.45-8.78), P < .01]. RED in patients with PFMP is supported by comparison to controls: On DRE, they had increased resting tone [OR 2.25 (1.33-3.83), P < .01] and paradoxical contraction of the puborectalis upon simulated evacuation [OR 3.41 (1.94-6.00), P < .01]; on ARM, they had higher maximum resting pressure (102.9 mmHg vs 90.7 mmHg, P < .01) and lower rectoanal pressure gradient (-39.4 mmHg vs -24.7 mmHg, P < .01). CONCLUSIONS/INFERENCES In constipated patients, PFMP is highly associated with RED. Its presence provides a valuable clue regarding the etiology of a patient's constipation; it should be assessed in all patients with constipation and should also be an additional target for management.
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Affiliation(s)
- Andy Liu
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Victor Chedid
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Xiao J Wang
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Priya Vijayvargiya
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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20
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Camilleri M. Sex as a biological variable in irritable bowel syndrome. Neurogastroenterol Motil 2020; 32:e13802. [PMID: 31943595 PMCID: PMC7319890 DOI: 10.1111/nmo.13802] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/23/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The pathophysiology and mechanisms of irritable bowel syndrome (IBS) involve both central and peripheral mechanisms that result in altered perception, as well as changes in bowel functions. These dysfunctions are associated with motor, sensory, immune, barrier, and intraluminal perturbations, including the microbiota, and their products and endogenous molecules with bioactive properties. There is evidence that these mechanisms are altered in both females and males. However, there is also increasing evidence that sex is a biological variable that impacts a number of aspects of the mechanisms, epidemiology, and manifestations of IBS. PURPOSE The objective of this article is to review the evidence of the differences among genders of the following factors in IBS: the brain-gut axis and sex hormones, epidemiology, diagnostic criteria and prognosis, pain perception, colonic transit, abdominal distension, overlap with urogynecological conditions, psychologic issues, anorexia, fibromyalgia, serotonin, and responsiveness to treatment of IBS. It is important to consider the variations attributable to sex in order to enhance the management of patients with IBS and the research of mechanisms involved in IBS.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Mayo Clinic Rochester Minnesota
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21
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Vriesman MH, Koppen IJN, Camilleri M, Di Lorenzo C, Benninga MA. Management of functional constipation in children and adults. Nat Rev Gastroenterol Hepatol 2020; 17:21-39. [PMID: 31690829 DOI: 10.1038/s41575-019-0222-y] [Citation(s) in RCA: 200] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Abstract
Functional constipation is common in children and adults worldwide. Functional constipation shows similarities in children and adults, but important differences also exist regarding epidemiology, symptomatology, pathophysiology, diagnostic workup and therapeutic management. In children, the approach focuses on the behavioural nature of the disorder and the initial therapeutic steps involve toilet training and laxatives. In adults, management focuses on excluding an underlying cause and differentiating between different subtypes of functional constipation - normal transit, slow transit or an evacuation disorder - which has important therapeutic consequences. Treatment of adult functional constipation involves lifestyle interventions, pelvic floor interventions (in the presence of a rectal evacuation disorder) and pharmacological therapy. When conventional treatments fail, children and adults are considered to have intractable functional constipation, a troublesome and distressing condition. Intractable constipation is managed with a stepwise approach and in rare cases requires surgical interventions such as antegrade continence enemas in children or colectomy procedures for adults. New drugs, including prokinetic and prosecretory agents, and surgical strategies, such as sacral nerve stimulation, have the potential to improve the management of children and adults with intractable functional constipation.
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Affiliation(s)
- Mana H Vriesman
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
| | - Ilan J N Koppen
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Michael Camilleri
- C.E.N.T.E.R. Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Carlo Di Lorenzo
- Division of Gastroenterology, Hepatology and Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
| | - Marc A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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22
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Camilleri M. What's in the pipeline for lower functional gastrointestinal disorders in the next 5 years? Am J Physiol Gastrointest Liver Physiol 2019; 317:G640-G650. [PMID: 31460793 PMCID: PMC6879894 DOI: 10.1152/ajpgi.00205.2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/13/2019] [Accepted: 08/21/2019] [Indexed: 01/31/2023]
Abstract
The overall objectives of this review are to summarize actionable biomarkers for organic etiology of lower functional gastrointestinal disorders (FGIDs) that lead to individualized treatment for their FGIDs and to assess the pipeline for novel approaches to the management of constipation, diarrhea, and chronic abdominal pain in lower FGIDs. The new approaches to therapy include ion exchangers/transporters for functional constipation (sodium-glucose cotransporter 1, Na+/H+ exchanger 3, and solute carrier family 26 member 3 inhibitors), bile acid modulators for constipation such as ileal bile acid transporter inhibitors and fibroblast growth factor 19 analog for functional constipation, and bile acid sequestrants or farnesoid X receptor agonists for functional diarrhea. Treatment for chronic abdominal pain remains an unmet need in patients with lower FGIDs, and promising novel approaches include delayed-release linaclotide, nonclassical opioid visceral analgesics, and selective cannabinoid receptor agonists. The role of probiotics, fecal microbial transplantation, and possible future microbiome therapies is discussed.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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23
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Mazor Y, Kellow JE, Malcolm A. Reply to letter: Anorectal physiology in health: A randomized trial to determine the optimum catheter for the balloon expulsion test. Neurogastroenterol Motil 2019; 31:e13590. [PMID: 31183911 DOI: 10.1111/nmo.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Yoav Mazor
- Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia.,Northern Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - John E Kellow
- Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia.,Northern Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Allison Malcolm
- Royal North Shore Hospital School, Saint Leonards, New South Wales, Australia.,Northern Medical School, University of Sydney, Sydney, New South Wales, Australia
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24
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Wang XJ, Camilleri M. Personalized medicine in functional gastrointestinal disorders: Understanding pathogenesis to increase diagnostic and treatment efficacy. World J Gastroenterol 2019; 25:1185-1196. [PMID: 30886502 PMCID: PMC6421234 DOI: 10.3748/wjg.v25.i10.1185] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/04/2019] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
There is overwhelming evidence that functional gastrointestinal disorders (FGIDs) are associated with specific mechanisms that constitute important targets for personalized treatment. There are specific mechanisms in patients presenting with functional upper gastrointestinal symptoms (UGI Sx). Among patients with UGI Sx, approximately equal proportions (25%) of patients have delayed gastric emptying (GE), reduced gastric accommodation (GA), both impaired GE and GA, or neither, presumably due to increased gastric or duodenal sensitivity. Treatments targeted to the underlying pathophysiology utilize prokinetics, gastric relaxants, or central neuromodulators. Similarly, specific mechanisms in patients presenting with functional lower gastrointestinal symptoms, especially with diarrhea or constipation, are recognized, including at least 30% of patients with functional constipation pelvic floor dyssynergia and 5% has colonic inertia (with neural or interstitial cells of Cajal loss in myenteric plexus); 25% of patients with diarrhea-predominant irritable bowel syndrome (IBSD) has evidence of bile acid diarrhea; and, depending on ethnicity, a varying proportion of patients has disaccharidase deficiency, and less often sucrose-isomaltase deficiency. Among patients with predominant pain or bloating, the role of fermentable oligosaccharides, disaccharides, monosaccharides and polyols should be considered. Personalization is applied through pharmacogenomics related to drug pharmacokinetics, specifically the role of CYP2D6, 2C19 and 3A4 in the use of drugs for treatment of patients with FGIDs. Single mutations or multiple genetic variants are relatively rare, with limited impact to date on the understanding or treatment of FGIDs. The role of mucosal gene expression in FGIDs, particularly in IBS-D, is the subject of ongoing research. In summary, the time for personalization of FGIDs, based on deep phenotyping, is here; pharmacogenomics is relevant in the use of central neuromodulators. There is still unclear impact of the role of genetics in the management of FGIDs.
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Affiliation(s)
- Xiao Jing Wang
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN 55905, United States
| | - Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research, Mayo Clinic, Rochester, MN 55905, United States
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