In vitro models to evaluate ingestible devices: Present status and current trends

Orally ingestible medical devices offer significant opportunity in the diagnosis and treatment of gastrointestinal conditions. Their development necessitates the use of models that simulate the gastrointestinal environment on both a macro and micro scale. An evolution in scientific technology has enabled a wide range of in vitro, ex vivo and in vivo models to be developed that replicate the gastrointestinal tract. This review describes the landscape of the existing range of in vitro tools that are available to characterize ingestible devices. Models are presented with details on their benefits and limitations with regards to the evaluation of ingestible devices and examples of their use in the evaluation of such devices is presented where available. The multitude of models available provides a suite of tools that can be used in the evaluation of ingestible devices that should be selected on the functionality of the device and the mechanism of its function.

Data-Enabled Digestive Medicine: A New Big Data Analytics Platform

This paper presents a big data analystics platform for clinical research and practice in the Gastroenterology Department of Xiangya Hospital at Central South University in China. This platform features a comprehensive and systematic support of big data in digestive medicine including geneneral health management, clinical gastroenterology practice, and related genomics research, which is proven to be helpful in real world clinical practices. A typical use case of integrated analysis based on electronic medical records and colonoscopy data was presented and discussed, the analaystic report on risk factors of colorectal diseases shows a reasonable recommendation about the age when people should start to screen the colorectal cancer, which could be very useful to individual and group health management for the general population in China.

Multiple rapid swallows and rapid drink challenge in patients with esophagogastric junction outflow obstruction on high-resolution manometry

BACKGROUND

Esophagogastric junction outflow obstruction (EGJOO) as defined by Chicago Classification of esophageal motility disorders (CCv3.0) encompasses a broad range of diagnoses, thus posing clinical challenges. Our aims were to evaluate multiple rapid swallow (MRS) and rapid drink challenge (RDC) during high-resolution manometry (HRM) to aid identifying clinically relevant EGJOO.

METHODS

Patients with a HRM diagnosis of EGJOO based on CCv3.0 that also completed MRS and RDC during HRM and barium esophagram were retrospectively identified. Radiographic EGJOO (RAD-EGJOO) was defined by either liquid barium retention or delayed passage of a barium tablet on barium esophagram. Thirty healthy asymptomatic controls that completed HRM were also included. MRS involved drinking 2 mL for 5 successive swallows. RDC involved rapid drinking of 200 mL liquid. Integrated relaxation pressure (IRP) and presence of panesophageal pressurization (PEP) during MRS and RDC were assessed.

KEY RESULTS

One hundred one patients, mean (SD) age 56 (16) years, were included; 32% had RAD-EGJOO, 68% did not. RAD-EGJOO patients more frequently had elevated (>12 mmHg) upright IRP (100%), MRS-IRP (56%), RDC-IRP (53%), and PEP during RDC (66%) than both controls [17%; 0%; 7%; 3%] and patients without RAD-EGJOO [83%; 35%; 39%; 41%] Having IRP >12 mmHg during both MRS and RDC was twice as likely to be associated with RAD-EGJOO (19%) than those without RAD-EGJOO (9%) among patients with upright IRP >12 mmHg.

CONCLUSIONS AND INFERENCES

Adjunctive HRM maneuvers MRS and RDC appear to help identify clinically significant EGJOO. While future outcome studies are needed, comprehensive multimodal evaluation helps clarify relevance of EGJOO on HRM.

Pediatric Solid Gastric Emptying Scintigraphy: Normative Value Guidelines and Nonstandard Meal Alternatives

INTRODUCTION

Adult standards for gastric emptying scintigraphy, including the type of meal and range of normative values for percent gastric emptying, are routinely used in pediatric practice, but to date have not been validated. The purpose of this study is to determine whether the use of adult criteria for gastric emptying scintigraphy is valid for children and whether alternative nonstandard meals can also be offered based on these criteria.

METHODS

This retrospective study analyzed patients (n = 1,151 total) who underwent solid-phase gastric emptying scintigraphy. Patients were stratified into normal and delayed gastric emptying cohorts based on adult criteria, i.e., with normal gastric emptying defined as ≤10% gastric retention at 4 hours. Patients were further stratified based on the type of meal, namely complete or partial adult standard meals or alternative cheese-based meals. Percent gastric retention values at 1, 2, 3, and 4 hours were compared.

RESULTS

The median (95% upper reference limit) percentage gastric retention values for the complete standard meal were 72% (93%) at 1 hour, 39% (65%) at 2 hours, 15% (33%) at 3 hours, and 6% (10 %) at 4 hours. By comparison, the values for cheese-based meals were 60% (87%) at 1 hour, 29% (61%) at 2 hours, 10% (30%) at 3 hours, and 5% (10%) at 4 hours. Consumption of at least 50% of the standard meal yielded similar retention percentages; 68% (89%) at 1 hour, 32% (57%) at 2 hours, 10% (29%) at 3 hours, and 5% (10%) at 4 hours. There were no significant age- or sex-specific differences using the adult criteria.

DISCUSSION

The adult normative standards for gastric emptying scintigraphy are applicable for use in the pediatric population. These same standards can be also be applied to nonstandard meal options, including cheese-based alternative meals and partial standard meals.

Assessing Anorectal Function in Constipation and Fecal Incontinence

Constipation and fecal incontinence are commonly encountered complaints in the gastrointestinal clinic. Assessment of anorectal function includes comprehensive history, rectal examination, and prospective stool diary or electronic App diary that accurately captures bowel symptoms, evaluation of severity, and quality of life of measure. Evaluation of a suspected patient with dyssynergic constipation includes anorectal manometry, balloon expulsion test, and defecography. Investigation of a suspected patient with fecal incontinence includes high-resolution anorectal manometry; anal ultrasound or MRI; and neurophysiology tests, such as translumbosacral anorectal magnetic stimulation or pudendal nerve latency. This article provides an approach to the assessment of anorectal function.

EndoFLIP in the Esophagus: Assessing Sphincter Function, Wall Stiffness, and Motility to Guide Treatment

The functional luminal imaging probe (FLIP) uses high-resolution planimetry to provide a three-dimensional image of the esophageal lumen by measuring diameter, volume, and pressure changes. Literature surrounding use of FLIP has demonstrated its clinical utility as a diagnostic tool and as a device to guide and measure response to therapy. FLIP can assess and guide treatments for esophageal disease states including gastroesophageal reflux disease, achalasia, and eosinophilic esophagitis. FLIP may become the initial test for patients with undifferentiated dysphagia at their index endoscopy. This article summarizes use of FLIP in assessing sphincter function, wall stiffness, and motility to guide treatments.

Les colites microscopiques

Microscopic colitis is frequently found as a cause of chronic watery diarrhea in women after menopause. The disease can be associated with a medication side effect in half of the patients (non-steroidal anti-inflammatory drugs or proton pump inhibitors for instance). Colonic biopsies are mandatory for the diagnosis of microscopic colitis and should be performed in several locations of the colon. Management of microscopic colitis is first based on avoiding iatrogenic factors and smoking together with symptomatic treatment of diarrhea (loperamide, cholestyramine). In case of failure or severe symptoms, budesonide is the key treatment. The aim of the treatment is to achieve clinical remission, defined as less than 3 liquid stools per day, to improve quality of life. After a first course of budesonide, recurrence of diarrhea is frequent and a maintenance therapy can be prescribed for several months. In case of intolerance or refractoriness, second-line therapy (immunosuppressants, biological therapy, surgery) should be discussed in multidisciplinary team meeting.

[Why is it important to detect atrophic gastritis and gastric intestinal metaplasia? What is the proper way to do it?]

Gastric intestinal metaplasia and atrophic gastritis are a known precancerous condition (PCC) of the stomach, meaning that patients with PCC are at risk for gastric cancer and so, diagnosis and risk categorization for these patients is relevant. The aim of this review is to provide an update regarding the problem, diagnosis, and management of PCCs with an emphasis on the role of appropriate endoscopic detection.

Delayed Gastric Emptying Associates With Diabetic Complications in Diabetic Patients With Symptoms of Gastroparesis

OBJECTIVES

Diabetic gastroparesis (Gp) occurs more often in type 1 diabetes mellitus (T1DM) than in type 2 diabetes mellitus (T2DM). Other diabetic end-organ complications include peripheral neuropathy, nephropathy, and retinopathy (together termed triopathy). This study determines the prevalence of diabetic complications (retinopathy, nephropathy, and peripheral neuropathy) in diabetic patients with symptoms of Gp, assessing the differences between T1DM and T2DM and delayed and normal gastric emptying (GE).

METHODS

Diabetic patients with symptoms of Gp underwent history and physical examination, GE scintigraphy, electrogastrography with water load, autonomic function testing, and questionnaires assessing symptoms and peripheral neuropathy.

RESULTS

One hundred thirty-three diabetic patients with symptoms of Gp were studied: 59 with T1DM and 74 with T2DM and 103 with delayed GE and 30 without delayed GE. The presence of retinopathy (37% vs 24%; P = 0.13), nephropathy (19% vs 11%; P = 0.22), and peripheral neuropathy (53% vs 39%; P = 0.16) was not significantly higher in T1DM than in T2DM; however, triopathies (all 3 complications together) were seen in 10% of T1DM and 3% of T2DM (P = 0.04). Diabetic patients with delayed GE had increased prevalence of retinopathy (36% vs 10%; P = 0.006) and number of diabetic complications (1.0 vs 0.5; P = 0.009); however, 39% of diabetic patients with delayed GE did not have any diabetic complications.

DISCUSSION

In diabetic patients with symptoms of Gp, delayed GE was associated with the presence of retinopathy and the total number of diabetic complications. Only 10% of patients with T1DM and 3% of those with T2DM had triopathy of complications, and 39% of diabetic patients with Gp did not have any diabetic complications. Thus, the presence of diabetic complications should raise awareness for Gp in either T1DM or T2DM; however, diabetic Gp frequently occurs without other diabetic complications.

How I Approach Dysphagia

PURPOSE OF REVIEW

This review presents an overview of the diagnostic approach to esophageal dysphagia and summarizes recent epidemiological trends and technical advancements.

RECENT FINDINGS

The evaluation of dysphagia begins with a detailed history followed by endoscopy to evaluate for any structural abnormalities including malignancy. This is especially true given the emergence of eosinophilic esophagitis (EoE) as a dominant cause of esophageal dysphagia. In fact, it is now standard practice to obtain esophageal biopsies during endoscopy performed to evaluate dysphagia, since EoE can present without the characteristic mucosal features of rings, furrows, and exudate. Achalasia is also more frequently encountered since the introduction of high-resolution manometry (HRM) and the Chicago Classification into clinical practice. The Chicago Classification provides a stepwise diagnostic algorithm for evaluating HRM studies and systematically diagnosing esophageal motility disorders. Lastly, the functional lumen imaging probe (FLIP) is a novel technology that has added insight into both achalasia and EoE. Measuring esophageal distensibility with FLIP has useful prognostic implications for both diseases, and FLIP can identify motility abnormalities in achalasics not detected with HRM. A careful history is key to the efficient evaluation of dysphagia, and endoscopy is usually the first diagnostic study to obtain. For patients with prominent reflux symptoms, an empiric trial with proton pump inhibitors is reasonable then because reflux disease is such a common cause of dysphagia. Thereafter, patients should undergo HRM to evaluate for a motility disorder, and FLIP can provide complementary data to guide management.

British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis

These guidelines on the management of primary sclerosing cholangitis (PSC) were commissioned by the British Society of Gastroenterology liver section. The guideline writing committee included medical representatives from hepatology and gastroenterology groups as well as patient representatives from PSC Support. The guidelines aim to support general physicians, gastroenterologists and surgeons in managing adults with PSC or those presenting with similar cholangiopathies which may mimic PSC, such as IgG4 sclerosing cholangitis. It also acts as a reference for patients with PSC to help them understand their own management. Quality of evidence is presented using the AGREE II format. Guidance is meant to be used as a reference rather than for rigid protocol-based care as we understand that management of patients often requires individual patient-centred considerations.

Diagnostic accuracy of intestinal ultrasound and magnetic resonance enterography for the detection of endoscopy-based disease activity in ileocolonic Crohn's disease

BACKGROUND

Crohn's disease (CD) is characterised by chronic gastrointestinal inflammation with relapsing-remitting behaviour and often requires endoscopic and/or radiologic assessment.

OBJECTIVE

The objective of this study was to compare the diagnostic accuracy of intestinal ultrasound (IUS) and magnetic resonance enterography (MRE) for the assessment of disease activity in CD using a simple endoscopic score for CD as a reference standard.

PATIENTS AND METHODS

A prospective observational study was carried out in 71 consecutive adult patients with known CD, attending our tertiary inflammatory bowel disease clinic, between November 2014 and July 2016. Ileocolonoscopy, IUS and MRE were performed within 1 month prospectively. The simple endoscopic score-CD 0-2 was accepted as remission.

RESULTS

The sensitivity of IUS and MRE for detecting endoscopic activity was found similar with regard to bowel wall thickening and mesenteric fibrofatty proliferation (P>0.05). The overall accuracy for detecting mural lesions was similar between IUS and MRE. When mural lesions were analysed, the sensitivity of MRE in detecting the loss of wall stratification and stenosis was significantly higher than IUS (P<0.001 for both). IUS showed higher specificity for bowel wall thickening, loss of wall stratification and stenosis (P=0.009, P<0.001 and P<0.001, respectively). Sensitivity and accuracy of IUS were higher in detecting ascites in active disease (P=0.002).

DISCUSSION

Our results showed that IUS and MRE were equally accurate in detecting endoscopic activity. IUS may be the preferred technique for the evaluation of disease activity and for the follow-up of CD.

(Can't Get No) Patient Satisfaction: The Predictive Power of Demographic, GI, and Psychological Factors in IBS Patients

GOALS

The goal of this study is to assess: (1) the relative contribution of patient factors to satisfaction ratings in irritable bowel syndrome (IBS) patients and (2) the relationship between patient satisfaction (PS) and the number of diagnostic tests patients underwent prior to receiving IBS diagnosis.

BACKGROUND

Although PS is regarded as an important indicator of quality of care, little is known about its determinants.

STUDY

A total of 448 Rome III-diagnosed patients (M age=41 y; 79% F), whose GI symptoms were at least moderate in severity completed patient-reported outcome measures as part of pretreatment evaluation of an NIH-funded clinical trial. PS was measured with the 11-point Hospital Consumer Assessment of Healthcare Providers and Systems global rating scale modified to assess for IBS treatments. A series of multiple regression analyses were conducted for demographic, IBS-specific, general physical health, and psychological predictors before running a final model of significant predictors from each domain.

RESULTS

The final regression model was significant, F6,419=6.34, P<0.001, R=0.08, with race, insurance, number of diagnostic tests, and lower neuroticism predicting PS. Medical tests were rendered nonsignificant when history of seeking care from a gastroenterologist was introduced into the equation.

CONCLUSIONS

Contrary to hypotheses, neither the IBS symptom severity nor quality of life impairment predicted PS. Patient factors such as a neurotic personality style and sociodemographic profile had a significant but modest impact on PS. Pattern of regression analyses suggests that patients may turn to their gastroenterologist for testing for reassurance, which may in the long-term fuel demand for more testing.

Nutrient drink test: Normative values in Indian children

BACKGROUND

Nutrient drink test (NDT) is a simple, non-invasive method to assess gastric function including accommodation. However, data on normal satiety drink volume (SDV) in children is scanty with no information about postprandial symptoms (PPS). Our aims were to establish normal values of NDT in healthy children and evaluate its correlation with age, gender, and anthropometry.

METHODS

Six- to 18-year-old healthy children underwent the NDT. The nutrient drink (0.94 kcal/mL) was given at a constant rate of 15 mL/min in 6-12-year-old subjects and at 30 mL/min in 13-18-year-old subjects till satiety score of 5 was reached. Postprandial symptoms (30 min) of fullness, nausea, bloating, and pain were scored using a visual analogue scale (0-100 mm) individually and as aggregate score.

RESULTS

Sixty-seven children (40 boys, age 12 [6-18 years]) were enrolled. Median SDV was 360 [180-960 mL], higher in 13-18-year-olds in comparison to 6-12-year-old children (360 [240-1002] vs. 300 [148-960] mL; p=0.005). SDV showed significant correlation with age, weight, and height. SDV was higher in boys than girls (450 [240-1074] vs. 330 [240-480] mL; p=0.02) in the older children (13-18 y), but it was similar in the younger children. Mild fullness (40 [0-80]) was the only PPS seen in 85% children and none had pain. PPS were not different between boys and girls or younger and older children.

CONCLUSION

The study provides normative data of SDV and PPS by NDT in 6-18-year-old children. SDV correlated with age and was higher in adolescent boys than girls.

Rapid diagnosis of gastrointestinal tract infections due to parasites, viruses, and bacteria

Rapid diagnostic techniques are valuable tools in the diagnosis of gastrointestinal infections, especially for the detection of some microorganisms and in certain groups of patients. While antigen detection techniques are widely used in Clinical Microbiology laboratories, for the diagnosis of viruses, some parasites and some bacteria, molecular techniques are routinely used only for some pathogens (such as Clostridium difficile). However, molecular techniques are constantly evolving, and they allow a rapid diagnosis for an increasing number of pathogens, with high sensitivity and specificity. In addition, they are also able to detect virulence factors or resistance mechanisms. Syndromic surveillance systems, which detect different pathogens simultaneously, are very promising because they enable the most frequent pathogens to be diagnosed in a few hours and they can be very useful in certain patients. For the diagnosis of Helicobacter pylori infection, molecular techniques are able to detect bacteria and its resistance to clarithromycin and levofloxacin, allowing the most appropriate treatment to be selected for each patient when bacterial culture is not possible.

Sensitivity and Specificity of Fenyö-Lindberg and Teicher Scores in the Diagnosis of Acute Appendicitis in Women

The aim of the study was to assess diagnostic accuracy (sensitivity and specificity) of Fenyö-Lindberg and Teicher scores for distinguishing patients that need immediate surgical treatment from the others, in a female population from an urban setting. The study prospectively included 130 female patients admitted to the emergency department with abdominal pain indicating acute appendicitis. The scores and parameters of validity were calculated and compared to definitive diagnosis. For Fenyö-Lindberg score of -17 or less, 84.5% sensitivity, 55.6% specificity, 87.9% positive predictive value (PPV) and 48.4% negative predictive value (NPV) were recorded. For cut-off value greater or equal to -2, there was 59.2% sensitivity, 77.8% specificity, 91% PPV and 33.3% NPV. The Receiver Operating Characteristic (ROC) curve analysis of Fenyö-Lindberg score showed that the best single cut-off value for discriminating acute appendicitis in the study population was -15. For Teicher score, values greater than -3 yielded 89.3% sensitivity and 22.2% specificity, 81.4% PPV and 35.3% NPV. In conclusion, Fenyö-Lindberg score could be used as an additional tool to exclude appendicitis and avoid unnecessary appendectomies. Teicher score may help in recognizing patients with appendicitis. None of the two scores can indicate or decline appendectomy in all cases. Scoring systems may be useful for pointing to important clinical signs and symptoms in specific subpopulations.

[Laryngeal and larynx-associated reflexes]

The laryngeal adductor reflex and the pharyngoglottal closure reflex protect the trachea and lower respiratory tract against the entrance of foreign material. The laryngeal expiration reflex and the cough reflex serve to propel foreign material, which has penetrated in the cranial direction. The inspiration reflex, the sniff reflex, and the swallowing reflex are further larynx-associated reflexes. In patients with dysphagia the laryngeal adductor reflex can be clinically tested with air pulses. The water swallow test serves to show the integrity of the cough reflex. The sniff reflex is useful to test the abduction function of the vocal folds. Future studies should address laryngeal reflexes more specifically, both for a better understanding of these life-supporting mechanisms and to improve diagnostic procedures in patients with impaired laryngeal function.

Clozapine-treated Patients Have Marked Gastrointestinal Hypomotility, the Probable Basis of Life-threatening Gastrointestinal Complications: A Cross Sectional Study

BACKGROUND

Gastrointestinal side effects are particularly common with clozapine and occur with other antipsychotics, ranging from mild constipation to fatal bowel obstruction and/or ischemia. While this adverse-effect spectrum has been attributed to 'gastrointestinal hypomotility', gastrointestinal transit times in antipsychotic-treated patients have not previously been measured, making this mechanism speculative.

METHODS

Using standardized radiopaque marker ('Metcalf') methods we established colonic transit times of antipsychotic-treated psychiatric inpatients and compared them with population normative values. We analyzed results by antipsychotic type, antipsychotic dose equivalent, anticholinergic load, duration of treatment, gender, ethnicity, and age.

OUTCOMES

For patients not prescribed clozapine, median colonic transit time was 23 h. For patients prescribed clozapine, median transit time was 104.5 h, over four times longer than those on other antipsychotics or normative values (p < 0.0001). Eighty percent of clozapine-treated patients had colonic hypomotility, compared with none of those prescribed other antipsychotics (olanzapine, risperidone, paliperidone aripiprazole, zuclopenthixol or haloperidol). In the clozapine group, right colon, left colon and rectosigmoid transit times were all markedly abnormal suggesting pan-colonic pathology. Hypomotility occurred irrespective of gender, age, ethnicity, or length of clozapine treatment. Transit times were positively correlated with clozapine plasma level (rho = 0.451, p = 0.045), but not with duration of treatment, total antipsychotic load or demographic factors.

INTERPRETATION

Clozapine, unlike the other antipsychotics examined, causes marked gastrointestinal hypomotility, as previously hypothesized. Pre-emptive laxative treatment is recommended when starting clozapine.

Disease monitoring in inflammatory bowel disease

The optimal method for monitoring quiescent disease in patients with Crohn’s disease (CD) and ulcerative colitis is yet to be determined. Endoscopic evaluation with ileocolonoscopy is the gold standard but is invasive, costly, and time-consuming. There are many commercially available biomarkers that may be used in clinical practice to evaluate disease status in patients with inflammatory bowel disease (IBD), but the most widely adopted biomarkers are C-reactive protein (CRP) and fecal calprotectin (FC). This review summarizes the evidence for utilizing CRP and FC for monitoring IBD during clinical remission and after surgical resection. Endoscopic correlation with CRP and FC is evaluated in each disease state. Advantages and drawbacks of each biomarker are discussed with special consideration of isolated ileal CD. Fecal immunochemical testing, traditionally used for colorectal cancer screening, is mentioned as a potential new alternative assay in the evaluation of IBD. Based on a mixture of information gleaned from biomarkers, clinical status, and endoscopic evaluation, the best treatment decisions can be made for the patient with IBD.

Cracking the Code: The Unexpected Challenge of Identifying Major Bile Duct Injuries

The reported rate of major bile duct injury (BDI) after cholecystectomy is 0.2 to 0.5 per cent. We evaluated the accuracy of coding major BDIs integrating both Current Procedural Terminology (CPT) and ICD-9 coding. A retrospective review was conducted for more than 3.5 million members of a large managed health-care organization from January 2007 to December 2013. A total of 56,194 cholecystectomies were captured over this 6-year period. Major BDIs were defined as unintended transection of a major bile duct, Bismuth-Strasberg classification E1-E5, and requiring biliary reconstruction within one year of cholecystectomy. Based on two published study methods (CPT 47760, 47765, 47780 and ICD-9 code 998.2), 173 possible BDIs were identified. Only 13 (7.5%) were confirmed to have a major BDI. The remaining 160 cases were minor complications or were unrelated to cholecystectomy. This reflects an overall BDI rate of 0.02 per cent, an order of magnitude less than commonly published rates. There is a lack of consistent methodology to identify major bile duct injuries. This calls into question the accuracy of published rates. We suspect that some major injuries were not captured. We recommend a universal clinical registry and specific ICD codes to accurately identify this serious complication.

Surgical options to treat constipation: A brief overview

Patients with intractable chronic constipation should be evaluated with physiological tests after structural disorders and extracolonic causes have been excluded. Conservative treatment options should be tried unstintingly. It should be pointed out that especially new drugs such as prucalopride and linaclotide seem to be a big step forward in treating patients with chronic constipation. If surgery is indicated, for many years subtotal colectomy with IRA was the treatment of choice, although segmental resections were also a good option for isolated megasigmoid, sigmoidocele or recurrent sigmoid volvulus. Nowadays, less invasive procedures like sacral nerve modulation (SNM) should be tried first. If unsuccessful, colectomy can still be considered. In general, patients with a gastrointestinal dysmotility syndrome (GID) should not be offered any surgical options because of their anticipated poor results. Moreover, patients with psychiatric disorders should be actively discouraged from resection, as they tend to have a poorer prognosis. Patients must be counseled that pain and/or bloating will likely persist even if surgery normalizes bowel frequency. Patients with associated problems may be better served by having a stoma without resection as both a therapeutic maneuver and a diagnostic trial. Colectomy is not an option for the treatment of pain and/or abdominal bloating. In most cases outlet obstruction can be treated successfully with a conservative approach. However, nowadays there are also a variety of surgical options on the market. Each technique has its special place in the armamentarium of a colorectal surgeon but its exact role is not defined yet.The aim of this article is to give a brief overview, how to diagnose and treat chronic constipation from the standpoint of a colorectal surgeon.Surgical treatment of chronic constipation is not routine and is performed only in exceptional cases. But one thing first: a "too long gut" (dolichocolon) per se is never an indication for surgery. The aim of this manuscript is to give a brief overview about possible mechanisms of constipation, diagnostic methods and tools and the various conservative and operative treatment options. Moreover, please always keep in mind that constipation may not only be a symptom, but even a distinct disease!

Colonic transit diagnostic test shows significant gastrointestinal hypomotility in clozapine-treated patients in comparison with subjects treated with other antipsychotics

BACKGROUND

Constipation occurs in 25-60% of the subjects during administration of the antipsychotic drug (AP) clozapine (CLZ).

METHODS

We used a colonic transit diagnostic test that quantifies in a single abdominal X-ray the number of silver O-ring markers out of 25 units ingested five days before. The quantity of markers is directly proportional to the degree of gastrointestinal hypomotility, and elimination of over 80% of the markers is considered normal. The test was applied to three groups of AP-treated subjects for at least three consecutive months: CLZ alone (n=45), CLZ+Other APs (n=28), and Other APs (n=64).

RESULTS

The number of remaining markers at day 5 (mean±S.D.) was significantly higher in the CLZ alone (10.8±10.6) and in the CLZ+Other APs (9.7±9.7) groups than in the Other AP group (4.5±6.7), Kruskal-Wallis test: p=0.004. No significant associations were found between the number of markers, age, AP dose and treatment duration. All subjects who passed <80% of markers - which approximately corresponds to the 60th percentile of marker elimination - showed a scattered marker distribution along the colon, thus suggesting colon inertia. In subjects with hypomotility, 38.5% of the CLZ group, 25% of the CLZ+Other APs group, and 25% of the Other APs group were negative for the Rome III clinical criteria of constipation, thus showing objective, not subjective, hypomotility.

CONCLUSIONS

This study objectively confirms significant gastrointestinal hypomotility associated with CLZ administration.

[Diagnosis and initial assessment of cirrhosis]

When it is compensated, cirrhosis is usually asymptomatic meaning that many people with the disease are unaware they have it. It is however essential to establish with certainty the cirrhosis diagnosis as the condition is responsible for a number of complications such as liver cancer (most frequently hepatocellular carcinoma), gastrointestinal bleeding or severe liver failure. Knowledge of the diagnosis ensures the prevention, screening and early treatment of these complications.

What tests should you use to assess small intestinal bacterial overgrowth in systemic sclerosis?

OBJECTIVES

Small intestinal bacterial overgrowth (SIBO) plays a major role in the pathogenesis of malabsorption in SSc patients and is a source of great morbidity and even mortality, in those patients. This manuscript reviews which tests are valid and should be used in SSc when evaluating SIBO.

METHODS

We performed systematic literature searches in PubMed, Embase and the Cochrane library from 1966 up to November 2014 for English language, published articles examining bacterial overgrowth in SSc (e.g. malabsorption tests, breath tests, xylose test, etc). Articles obtained from these searches were reviewed for additional references. The validity of the tests was evaluated according to the OMERACT principles of truth, discrimination and feasibility.

RESULTS

From a total of 65 titles, 22 articles were reviewed and 20 were ultimately extracted to examine the validity of tests for GI morphology, bacterial overgrowth and malabsorption in SSc. Only 1 test (hydrogen and methane breath tests) is fully validated. Four tests are partially validated, including jejunal cultures, xylose, lactulose tests, and 72 hours fecal fat test.

CONCLUSIONS

Only 1 of a total of 5 GI tests of bacterial overgrowth (see above) is fully validated in SSc. For clinical trials, fully validated tests are preferred, although some investigators use partially validated tests (4 tests). Further validation of GI tests in SSc is needed.

Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity

Cereal crops and cereal consumption have had a vital role in Mankind’s history. In the recent years gluten ingestion has been linked with a range of clinical disorders. Gluten-related disorders have gradually emerged as an epidemiologically relevant phenomenon with an estimated global prevalence around 5%. Celiac disease, wheat allergy and non-celiac gluten sensitivity represent different gluten-related disorders. Similar clinical manifestations can be observed in these disorders, yet there are peculiar pathogenetic pathways involved in their development. Celiac disease and wheat allergy have been extensively studied, while non-celiac gluten sensitivity is a relatively novel clinical entity, believed to be closely related to other gastrointestinal functional syndromes. The diagnosis of celiac disease and wheat allergy is based on a combination of findings from the patient’s clinical history and specific tests, including serology and duodenal biopsies in case of celiac disease, or laboratory and functional assays for wheat allergy. On the other hand, non-celiac gluten sensitivity is still mainly a diagnosis of exclusion, in the absence of clear-cut diagnostic criteria. A multimodal pragmatic approach combining findings from the clinical history, symptoms, serological and histological tests is required in order to reach an accurate diagnosis. A thorough knowledge of the differences and overlap in clinical presentation among gluten-related disorders, and between them and other gastrointestinal disorders, will help clinicians in the process of differential diagnosis.

Microscopic colitis

Microscopic colitis (MC) is the common denominator for lymphocytic and collagenous colitis (CC). It is now recognized as a relatively frequent cause of diarrhea that equals the prevalence of inflammatory bowel disease. Patients are typically middle-aged women, but disease may occur at every age. Patients with MC report watery, non-bloody diarrhea in the absence of endoscopic and radiologic abnormalities. Lymphocytic colitis is characterized by an increased number of intraepithelial lymphocytes, and CC by a thickened subepithelial collagen band, whereas in both an increased mononuclear infiltration of the lamina propria is found. The pathogenesis of MC is largely unknown, but may relate to autoimmunity, adverse reactions to drugs or (bacterial) toxins, and abnormal collagen metabolism in the case of CC. Budesonide is so far the only drug that has proven efficacy in randomized controlled trials both for the induction and maintenance of remission. Patients who are nonresponsive, dependent or who experience side effects on budesonide may benefit from thiopurine or anti-TNF treatment, but these options are still experimental. The long-term prognosis of MC is good; it does not appear to predispose to malignancies and can in some cases be self-limiting. Further research and randomized clinical trials are required to expand our understanding of the natural course and the pathogenesis of MC.

Application of ultrasound technology in the diagnosis and treatment of digestive tract diseases

Ultrasound is commonly used in clinical examination which is economic, non-invasive and convenient. Ultrasound can be used for the examination of solid organs and hollow organs. Due to the presence of air, routine ultrasound examination of the digestive tract is not very appropriate, Because of the development of endosonography and its related technology, diagnosis and treatment of gastrointestinal diseases have been improved which is valuable in clinic. This review focused on the application of ultrasound technology in the diagnosis and treatment of digestive tract diseases.

Differential diagnosis in inflammatory bowel disease colitis: State of the art and future perspectives

Distinction between Crohn’s disease of the colon-rectum and ulcerative colitis or inflammatory bowel disease (IBD) type unclassified can be of pivotal importance for a tailored clinical management, as each entity often involves specific therapeutic strategies and prognosis. Nonetheless, no gold standard is available and the uncertainty of diagnosis may frequently lead to misclassification or repeated examinations. Hence, we have performed a literature search to address the problem of differential diagnosis in IBD colitis, revised current and emerging diagnostic tools and refined disease classification strategies. Nowadays, the differential diagnosis is an untangled issue, and the proper diagnosis cannot be reached in up to 10% of patients presenting with IBD colitis. This topic is receiving emerging attention, as medical therapies, surgical approaches and leading prognostic outcomes require more and more disease-specific strategies in IBD patients. The optimization of standard diagnostic approaches based on clinical features, biomarkers, radiology, endoscopy and histopathology appears to provide only marginal benefits. Conversely, emerging diagnostic techniques in the field of gastrointestinal endoscopy, molecular pathology, genetics, epigenetics, metabolomics and proteomics have already shown promising results. Novel advanced endoscopic imaging techniques and biomarkers can shed new light for the differential diagnosis of IBD, better reflecting diverse disease behaviors based on specific pathogenic pathways.

Serum markers in the clinical management of celiac disease

The advent of highly reliable noninvasive celiac diagnostic tests has transformed the field of celiac disease, from diagnosis, to evaluation of epidemiology, to clinical and translational research. Serologic tests in their modern forms are highly sensitive and specific for diagnosis, allowing for consideration of avoidance of diagnostic intestinal biopsy in some settings. On the other hand, as predictors of intestinal damage and for use in monitoring disease activity, currently available noninvasive tests have been disappointing. Serologic tests, while a measure of disease activity, do not correlate well with histology or symptomatology, and it is unclear if they predict long-term risk. Additionally, while the many clinically available tests have improved accessibility, they can have widely different cutoff levels and overall performance, making the comparison of levels in individual patients over time and across populations quite difficult. In the future, we can expect to see improvement in the currently available serologic tests including tissue transglutaminase and deamidated gliadin peptide with expansion of the dynamic range of the tests, and the celiac care community should push for a standardization of assays that would simplify research and patient care. Additionally, current serologic tests are measures of the adaptive immune response in celiac disease but do not directly measure intestinal inflammation. Promising work on intestinal fatty acid-binding protein and other assays which directly measure intestinal damage may complement traditional serologic tests and further improve our ability to noninvasively diagnose and monitor celiac disease. The coming years hold promise for the continuing evolution of serum-based tests in celiac disease with the possibility of substantial improvement of patient care and clinical research.

[PANCREATIC CANCER: TERRA INCOGNITA IN MODERN GASTROENTEROLOGY]

The author presents definition of pancreatic cancer (PC), epidemiological data on its prevalence, risk factors (chronic pancreatitis, viral hepatitis B, smoking, etc.), and clinical symptoms. Modern laboratory and instrumental differential diagnostic methods are discussed. Morphological classification and stages of the neoplastic process are considered with special reference to the methods of its surgical treatment and adjuvant therapy.

Perceived risk as a barrier to appropriate diagnosis of irritable bowel syndrome

AIM: To evaluate perceived risk, diagnostic testing, and acceptance of a diagnosis of irritable bowel syndrome (IBS) among the Korean laypersons.

METHODS: We designed a conceptual framework to evaluate the health-seeking behavior of subjects based on a knowledge, attitude, and practice model. We developed a vignette-based questionnaire about IBS based on a literature review and focused group interviews. The vignette described a 40-year-old woman who meets the Rome III criteria for IBS without red-flag signs. It was followed by questions about demographic characteristics, health behaviors, IBS symptoms, risk perception, perceived need for diagnostic tests, and acceptance of a positive diagnosis of IBS. We planned a nationwide survey targeting laypersons without IBS and between the ages of 20 and 69 years. Survey participants were selected by quota sampling stratified by gender, age, and nationwide location. A multivariate logistic model was constructed based on literature reviews, univariate analysis, and a stepwise selection method to investigate correlations between the perceived risk, need for diagnostic tests, and acceptance of a positive diagnosis.

RESULTS: Of 2354 eligible households, 1000 subjects completed the survey and 983 subjects were analyzed, excluding those who met symptom criteria for IBS. After reading the IBS vignette, the majority of subjects (86.8%) responded that the patient was at increased risk of severe disease. The most frequent concern was colon cancer (59.8%), followed by surgical condition (51.5%). Most subjects responded the patient needs diagnostic tests (97.2%). Colonoscopy was the most commonly required test (79.5%). Less than half of the respondents requested a stool examination (45.0%), blood test (40.7%), abdominal ultrasound (36.0%), or computed tomography (20.2%). The subjects who felt increased risk were more likely to see a need for colonoscopy [adjusted odds ratio (aOR) = 2.10, 95%CI: 1.38-3.18]. When asked about the positive diagnosis, the most frequent response was that “the patient would not be reassured” (65.7%). The increased risk perception group was less likely to be reassured by a positive diagnosis of IBS, compared to the other respondents (aOR = 0.52, 95%CI: 0.34-0.78).

CONCLUSION: For IBS diagnosis, increased risk perception is a possible barrier to the appropriate use of diagnostic tests and to the patient’s acceptance of a positive diagnosis.

Measurement of gastric emptying in diabetes

There has been a substantial evolution of concepts related to disordered gastric emptying in diabetes. While the traditional focus has hitherto related to the pathophysiology and management of upper gastrointestinal symptoms associated with gastroparesis, it is now apparent that the rate of gastric emptying is central to the regulation of postprandial glycemia. This recognition has stimulated the development of dietary and pharmacologic approaches to optimize glycemic control, at least in part, by slowing gastric emptying. With the increased clinical interest in this area, it has proved necessary to expand the traditional indications for gastric emptying studies, and consider the relative strengths and limitations of available techniques. Scintigraphy remains the 'gold standard' for the measurement of gastric emptying, however, there is a lack of standardization of the technique, and the optimal test meal for the evaluation of gastrointestinal symptoms may be discordant from that which is optimal to assess impaired glycemic control. The stable isotope breath test provides an alternative to scintigraphy and can be performed in an office-based setting. The effect of glucagon-like peptide-1 (GLP-1) and its agonists to reduce postprandial glycemia is dependent on the baseline rate of gastric emptying, as well as the magnitude of slowing. Because the effect of exogenous GLP-1 to slow gastric emptying is subject to tachyphylaxis with sustained receptor exposure, 'short acting' or 'prandial' GLP-1 agonists primarily target postprandial glycemia through slowing of gastric emptying, while 'long acting' or 'non-prandial' agents lower fasting glucose primarily through insulinotropic and glucagonostatic mechanisms. Accordingly, the indications for the therapeutic use of these different agents are likely to vary according to baseline gastric emptying rate and glycemic profiles.

[Diagnostic tools of inflammatory bowel diseases]

The diagnosis of inflammatory bowel disease (IBD) is based on the association of clinical, biological, radiological, endoscopic, and histological parameters. This article focuses on the different diagnostic and prognostic tools used in IBD.

Utility of the "harmless acute pancreatitis score" in predicting a non-severe course of acute pancreatitis: a pilot study in an Indian cohort

BACKGROUND

Several severity predictors have been tested for assessing acute pancreatitis (AP). The recently described harmless acute pancreatitis score (HAPS) could be an ideal predictor for Indian patients at the community level. We validate this system in the current study.

METHODS

This was a prospective pilot study conducted at a tertiary center from July 2010 to December 2011. Consecutive directly admitted patients over 18 years with a documented first episode of AP were enrolled and followed for at least 12 months after discharge/till death. HAPS was defined as absence of rebound abdominal tenderness, serum creatinine of <2 mg/dL, and hematocrit of <43 for male and <39.6 for female patients at the time of admission; and it was considered positive if the patient fulfilled all three criteria. Study outcomes included total hospital stay, need for intensive care unit (ICU), ICU stay, development of local complications, organ failure, hospital-acquired infections (including infected necrosis), and in-hospital mortality.

RESULTS

There were a total of 103 patients directly admitted with AP during the study period, out of which, 23 were excluded. Forty-seven (58.8 %) patients were positive for HAPS. Of these, 44 (93.6 %) had an eventual non-severe (mild) clinical course with odds ratio 17.6 (95 % CI 4.5-68.3). Sensitivity, specificity, positive and negative predictive value, and receiver operating characteristics area under the curve of HAPS as a predictor of non-severe disease were 76.3 (66.9-86.4), 85.7 (78.0-96.8), 93.8 (88.5-98.6), 56.6 (45.4-73.6), and 84.8 (76.9-92.7) respectively.

CONCLUSION

This study validated the utility of HAPS for directly admitted patients with AP in India. Large-scale multicenter community-based studies need to be performed.

[Multichannel electrogastrography in pediatrics - progress in standardisation and clinical application]

Electrogastrography (EGG) is a non-invasive method to record gastric myoelectrical activity by means of electrodes placed on the abdominal surface. This technique allows to obtain information about gastric myoelectrical activity and indirectly about gastric motility, without affecting its physiological functions. Except traditional parameters of single channel EGG such as: dominant frequency and power, instability coefficient of dominant frequency and power, percentage of normo-, brady- and tachygastry, the multichannel electrogastrography allows for estimation and registration of the slow waves coupling and propagation as well as to improve detection of abnormalities in gastric myoelectrical activity. Many agents connected with signal detection and analysis, test meal and normative values affect the final result of EGG recording. The trials defining normative data for healthy children and optimal composition of the test meal are conducted. It seems that the establishment of standard protocol of EGG is essential. EGG in children is useful in variety of functional gastrointestinal disorders, as well as gastroesophageal reflux disease and some organic disorders e.g. diabetes mellitus. Some of these diseases are connected with gastric myoelectrical activity abnormalities but others are not easily associable with them and as such are in need of additional investigations. Despite of a rapid development of electrogastrography difficulties in finding correlations between disturbances in myoelectric stomach function and gastric motility, impaired gastric emptying and symptoms of particular disease still remain. On the other hand a normal EGG does not exclude the disease.

Cholestatic liver disease

The care of the patient with cholestasis hinges on identifying the etiology, treating reversible causes, and managing chronic cholestatic processes. PBC and PSC are important causes of chronic cholestasis, and are the most common causes of cholestatic liver disease. Effective therapy is available for patients with PBC, whereas none exists for patients with PSC. Awareness of the complications that may be associated with cholestasis and implementing the appropriate management are essential.

[Differential diagnosis of chronic diarrhoea]

Chronic diarrhoea is a frequent clinical presentation in our population. It may correspond to many gastrointestinal or systemic pathologies. Most frequent causes are irritable bowel syndrome, functional intestinal disorders or lactose intolerance, but organic diseases have also to be searched. Focused patient questioning and some specific aspects of clinical examination play a key-role in diagnosis orientation and the use of complementary explorations. The present paper proposes a structured diagnostic procedure aiming at an optimal use of complementary explorations.

Bile leakage test in liver resection: A systematic review and meta-analysis

AIM: To assess systematically the safety and efficacy of bile leakage test in liver resection.

METHODS: Randomized controlled trials and controlled clinical trials involving the bile leakage test were included in a systematic literature search. Two authors independently assessed the studies for inclusion and extracted the data. A meta-analysis was conducted to estimate postoperative bile leakage, intraoperative positive bile leakage, and complications. We used either the fixed-effects or random-effects model.

RESULTS: Eight studies involving a total of 1253 patients were included and they all involved the bile leakage test in liver resection. The bile leakage test group was associated with a significant reduction in bile leakage compared with the non-bile leakage test group (RR = 0.39, 95%CI: 0.23-0.67; I² = 3%). The white test had superiority for detection of intraoperative bile leakage compared with the saline solution test (RR = 2.38, 95%CI: 1.24-4.56, P = 0.009). No significant intergroup differences were observed in total number of complications, ileus, liver failure, intraperitoneal hemorrhage, pulmonary disorder, abdominal infection, and wound infection.

CONCLUSION: The bile leakage test reduced postoperative bile leakage and did not increase incidence of complications. Fat emulsion is the best choice of solution for the test.

[The study of spatial distribution of Helicobacter pylori infection rate in able-bodied population of Moscow in the course of medical examination of the manufacturing contingents]

Numerous studies have shown that Helicobacter pylori (H. pylori) is a leading etiologic factor in the development of chronic atrophic gastritis, one gastric ulcer and duodenal ulcer and gastric cancer. Effective prevention of gastroduodenal pathology requires the right information about its prevalence in the population and risk factors. The most reliable information can be obtained during medical examination of the able-bodied population, which provides in-depth clinical examination of contingents with the identification of asymptomatic pathology, detection of risk groups, the substantiation ofprophylactic measures and tracking their efficacy.

MATERIAL AND METHODS

During the clinical examination of the manufacturing contingents there was performed a study of the presence of infection Helicobacter pylori (H. pylori) in 2414 people aged 19 to 74 years. For more details on the presence of gastroduodenal pathology 991 people were examined with the use of clinical methods and interviews. The aggregation of information presented in the form of estimates for its geocoding and mapping has been made. Cluster analysis was performed.

RESULTS

H. pylori infection was diagnosed in 2,182 people accounting for 90.4% out of 2414 examined cases. Infections occurred equally in males--91.7% and females--89.6%. The risk of development of gastroduodenal pathology in individuals infected with H. pylori is 4.4 times greater than the risk in seronegative individuals (95%, confidence interval 1.9-6.4). Cluster analysis revealed a statistically significant clusters for the strata with a prevalence of 100% (X2 = 45.5204) and below 50% of infection rate (X2 = 7.36). It is in prospect to analyze in more detail the data relating to these areas in order to identify the factors contributing to the different degree of infection rate of residents, including the assessment of drinking water.

Rectal bleeding in Egyptian children

AIM

In a prospective study to outline the aetiology of bleeding per rectum (BPR) in Egyptian infants and children, a subsidiary aim was to define some of the clinical characteristics of the different aetiologies.

SUBJECTS AND METHODS

194 children with BPR are described. The diagnostic work-up included laboratory investigations, radiological and endoscopic assessment, radio-isotope scanning, angiography and histopathological examination of mucosal biopsies, as appropriate.

RESULTS

Ages ranged from 3 to 192 months with a mean (SD) of 49.8 (43.5). Infectious enterocolitis was the most common cause (37.1%). Others included colorectal polyps (21.1%), chronic colitis (16%) including inflammatory bowel diseases (5.2%), allergic colitis (2.6%), solitary rectal ulcer syndrome (1.5%) and non-specific colitis (6.7%). Intussusception and Meckel's diverticulae were the cause in 7.3% and 2.6%, respectively, while other aetiologies included vascular (6.2%), systemic (3.6%), local anal (3.1%) and upper gastro-intestinal causes (1.5%). In 1.5% of cases, the cause remained 'obscure'.

CONCLUSION

In Egyptian children, infectious enterocolitis followed by colorectal polyps and chronic colitis are major causes of BPR.

Discordance between liver biopsy and FibroTest in assessing liver fibrosis in chronic hepatitis B

BACKGROUND AND AIMS

The FibroTest (FT) demonstrated excellent diagnostic performance in the prediction of liver fibrosis in patients with chronic hepatitis B (CHB). Here, we aimed to identify predictors of discordance between FT and liver biopsy (LB) in Asian patients with CHB.

METHODS

Consecutive patients with CHB who underwent both LB and FT on the same day between 2007 and 2010 were recruited from three medical institutes. Laboratory evaluations including specific parameters for calculating FT score, such as α2-macroglobulin, apolipoprotein A1, haptoglobin, γ-glutamyl transpeptidase, and total bilirubin levels, were obtained. The Batts and Ludwig scoring system was used for histological analysis.

RESULTS

A total of 330 patients (200 male and 130 female) were analyzed. Discordances of at least two fibrosis stages between FT and LB were observed in 30 (9.1%) patients; using FT, fibrosis was underestimated in 25 patients and overestimated in 5 patients with reference to LB. Patients with discordance had a higher proportion of F3-4 (P<0.001) and F4 (P = 0.012) compared with those with nondiscordance. The discordance rate was significantly higher in those with F3-4 than those with F1-2 (15.4% vs. 3.0%, P<0.001). Multivariate analysis demonstrated F3-4 at LB as the only independent factor for discordance (P<0.001; odds ratio 5.95). After adjusting fibrosis stages, neither necroinflammatory activity on histology nor serum ALT level influenced FT values independently.

CONCLUSION

Advanced fibrosis stage (F3-4) is the sole factor of discordance between FT and LB in Asian patients with CHB.

[Clinical features of systemic scleroderma with lesions in respiratory organs]

This retrospective study included 64 patients divided into 2 groups. Group 1 was comprised of 34 patients with systemic scleroderma and signs of interstitial lung lesions (X-ray diagnostics), the control group included 30 patients with scleroderma alone. They were examined by general clinical, biochemical and immunological methods, ECG, Echo-CG, capillaroscopy, standard chest X-ray, spirometry, ultrasound studies of internal organs, oesophageal, gastric and duodenal endoscopy. It was shown that systemic scleroderma with signs of interstitial lung lesions is more frequently accompanied by clinical (cough, dyspnea, bilateral inspirational crepitation) and functional (reduced lung vital capacity) pulmonary disorders. Also, these patients have "pursed mouth" appearance, their skeletal muscles and blood circulatory system are involved in the pathological process which accounts for arterial hypertension and mitral valve sclerosis (Echo-CG), reduced hemoglobin level hypergammaglobilinemia, IgA variations, and leukocyturia.