Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr.

Keywords: abdominal pain, clinical practice guidelines, diarrhea, FDr, functional bowel disorders, functional diarrhea, IBS-D,  irritable bowel syndrome

Dysphagia is a prevalent symptom of the upper gastrointestinal tract causing health related consequences, impacting quality of life and is associated with global economic burden. Swallowing difficulties are classified into oropharyngeal dysphagia (OD) and esophageal dysphagia. Despite its clinical importance, dysphagia is associated with several uncertainties regarding its optimal diagnostic work-up and management, particularly, considering the progress with diagnostic modalities and technologies. A Delphi consensus was performed with experts from various disciplines who conducted a literature summary and voting process on 41 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus was reached for all the statements. The panel agreed with the definition and prevalence of esophageal and OD types. The role of endoscopy, high-resolution manometry, EndoFLIP, barium swallow and other imaging tests in evaluating esophageal dysphagia has reached overall strong agreement. Videofluoroscopic swallow study, alongside fiber-endoscopic evaluation of swallowing, as the methods of choice for the instrumental assessment of oropharyngeal dysfunction is a strong recommendation. Regarding treatment, a weak recommendation was achieved for the use of PPIs, calcium-channel blockers, nitrates, phosphodiesterase type 5 inhibitors, antidepressants or peppermint oil for the treatment of hypercontractile esophagus. A strong recommendation exists for endoscopic and surgical treatment of achalasia, while a weak recommendation is provided for other esophageal motility disorders. Regarding OD, a weak recommendation was achieved for swallow therapy, to improve swallowing mechanics, reduce symptoms, and enhance quality of life. Swallow therapy could be more effective when using validated assessment tools, consistent treatment parameters, and considering long-term follow-up. A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of dysphagia.

ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 – 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.

Strong recommendation, high quality of evidence, level of agreement 100 %.

ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).

Strong recommendation, very low quality of evidence, level of agreement 87.5%.

ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.

Strong recommendation, low quality of evidence, level of agreement 78.6%.

ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.

Strong recommendation, very low quality of evidence, level of agreement 100 %.

ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis.

Strong recommendation, high quality of evidence, level of agreement 92.9%.

ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.

Strong recommendation, low quality of evidence, level of agreement 100 %.

Introduction
The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI.

Methods
These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus.

Results
These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients.

Conclusion
These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Keywords: clinical guidelines, diagnosis, faecal incontinence, fecal incontinence, GRADE, guidelines, ptns, treatment, Sacral neuromodulation, unwanted loss of feces