Introduction

Irritable bowel syndrome (IBS) is a prevalent disorder of gut-brain interaction characterized by abdominal pain and altered bowel movements. While the pathophysiology underlying IBS is incompletely understood, local allergic reactions to foods are a candidate mechanism. Confocal laser endomicroscopy (CLE) has shown acute alterations of the duodenal epithelium in IBS within minutes of local food administration and these findings have been used to identify foods contributing to IBS symptoms. However, the mechanisms and relevance of the observed alterations remain elusive.

Aims & Methods

Aim: To visualize the effect of local food administration on the duodenal mucosa using CLE and assess whether visible changes are associated with altered permeability or markers of mast cell activation ex vivo.
Methods: Non-constipated Rome IV IBS patients with negative serum specific IgE for tested foods underwent baseline gastroscopy (EGD) and CLE performed during a second EGD. Duodenal mucosa was visualized using CLE at baseline and after luminal administration of foods (egg white, soy, milk, wheat, lyophilized fish and shellfish, and nuts solutions sequentially applied in a random order) through the working channel. Altered mucosa was defined as leakage of fluorescein into the lumen and presence of particles (previously termed “cell shedding”). Serum samples were taken at index endoscopy and 30 minutes after acute mucosal alterations. Biopsies were taken at index EGD and after visualized alterations to measure transepithelial electrical resistance (TEER) in Ussing chambers and tryptase levels in biopsy supernatants. Data are reported as mean ± SEM or median and IQR as appropriate.

Results

45 CLE exams were carried out in 28 patients (age 35±2 y, 93%f, BMI 24±1 kg/m2, mean IBS symptom severity score 320±20).
At baseline, mucosal alterations were present in 9% of exams (n=4), whereas all other exams (n=41) demonstrated alterations after food administration. The highest rate of acute alterations was observed after fish/shellfish mix (50%; 10 altered / 20 exposed). The rate of observed alterations per food is presented in the table. TEER was not altered after observed alterations vs baseline (25±0.8 Ωxcm² vs 25±1 Ωxcm²). Serum tryptase was not altered after food exposure vs baseline (ratio after/before = 0.9, IQR= 0.8-1.1, n=13). Tryptase release from biopsies increased after exposure compared to baseline in 5/9 (56%) of patients after one hour and in 13/19 (68%) patients after 24h. Overall, the average tryptase release of the tissue was 1.48-fold increased after food exposure compared to baseline in the first hour after exposure (IQR = 0.3-2.1, n=9) and 1.29-fold following 24h incubation (IQR = 0.9-2.1, n = 19).

Conclusion

In this group of IBS patients, we found a high rate of acute food-induced mucosal alterations as visualized with CLE. Ex vivo permeability was unaltered after observed alterations vs. baseline. Systemic tryptase remained unchanged after acute alterations compared to baseline whereas tryptase release from biopsies was increased following food exposure compared to baseline in more than half of patients.

Introduction

Functional dyspepsia (FD) is a common yet complex gastrointestinal disorder, characterised by postprandial fullness, early satiety, epigastric pain, and burning. With growing evidence linking diet to inflammation and symptoms, our objective was to review the evidence for the impact of dietary factors on FD symptomatology.

Aims & Methods

A systematic review was conducted to identify dietary components influencing FD symptoms in adults. Databases searched included MEDLINE, EMBASE, PsycINFO, Scopus, and Cochrane, covering January 2000 to December 2024. A total of 14 studies met eligibility criteria, with findings synthesised through narrative analysis.

Results

The search strategy yielded 18,424 articles, of which 14 met the inclusion criteria. Analysis identified seven key dietary components associated with FD: (1) a low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet significantly improved symptoms (p = 0.04), while gluten intake was linked to early satiety (p = 0.03); (2) probiotics or prebiotics provided symptom relief (RR 1.15, p = 0.52), with probiotics alone showing a trend toward improved FD scores (RR 1.35, p = 0.061); (3) capsaicin significantly exacerbated symptoms (p < 0.001), and spicy foods were associated with increased gastric fullness (p = 0.001); (4) both peppermint-caraway oil (p < 0.00001) and cinnamon oil (p < 0.001) demonstrated significant symptom relief; (5) ginseng-based herbal porridge led to a higher rate of epigastric symptom remission by day 90 compared to placebo (45.71% vs. 20.69%, p = 0.036), while the STW 5-II formulation (a nine-herb extract) also yielded significant improvement (p = 0.008); (6) prokinetic agents reduced symptom severity (RR 0.81, p < 0.0001), while amitriptyline outperformed both placebo (40%) and escitalopram (38%), relieving symptoms in 53% of patients—particularly those with ulcer-like FD; and (7) ginger/artichoke capsules improved symptoms within 14 days (p = 0.017), while ginger/perilla tablets offered progressive relief over one to two weeks (p < 0.05 and p < 0.01, respectively). Study quality was assessed using ROBIS, RoB 2.0, and ROBINS-I tools. Of the included studies, three were rated as low risk of bias, eight as moderate, and three as serious. Despite adherence to a standardised PRISMA-based search strategy, variability in outcome reporting limited direct comparability across studies.

Table 1

Conclusion

This review highlights dietary interventions as a promising strategy for managing FD. Our findings show that specific dietary components can be implicated in inducing inflammation and symptoms in FD. Since the symptoms are related to inflammation, we propose using “inflammatory dyspepsia” to represent the true presentation of this form of dyspepsia. Large-scale randomised trials are needed to confirm findings and refine dietary guidelines.

Introduction

Nonalcoholic fatty liver disease (NAFLD) is a widespread metabolic disorder associated with intestinal dysbiosis, low-grade systemic inflammation, and small intestinal bacterial overgrowth (SIBO). Targeting the gut-liver axis through microbiome-modulating therapies may represent a promising approach to disease management.

Aims & Methods

The aim was to investigate gut microbiota alterations in NAFLD patients and assess the efficacy of microbiota-based therapy on metabolic, inflammatory, and structural liver parameters. The study included 152 NAFLD patients and 47 controls. Gut microbiota composition was evaluated using qRT-PCR, and SIBO was diagnosed via hydrogen breath testing. The therapeutic protocol included rifaximin (200 mg TID for 14 days), Saccharomyces boulardii CNCM I-745 (1 capsule BID for 30 days), and essential phospholipids (600 mg TID for 30 days). Liver function tests, inflammatory markers, and steatometry were assessed before and after treatment.

Results

Alterations in gut microbiota composition indicative of dysbiosis—including increased Firmicutes/Bacteroides ratio and Actinobacteria abundance—were identified in NAFLD. Strong correlations emerged between the F/B index and triglycerides (r = 0.78), TNF-α (r = 0.77), and between Actinobacteria and hsCRP (r = 0.66). SIBO rates declined significantly post-treatment (51% → 17%). Liver enzymes, inflammatory markers, and steatometric parameters improved substantially (p<0.05).

Conclusion

Microbiota-targeted therapy combining rifaximin, S. boulardii, and phospholipids effectively corrected dysbiosis, reduced inflammation, improved metabolic parameters, and promoted liver structural recovery in NAFLD patients. These findings support incorporating microbiome-focused interventions into routine clinical practice for NAFLD. ​

Introduction

Chronic constipation (CC) is managed differently across global regions due to cultural, dietary, and healthcare system differences. Emerging pharmacological options offer promise, yet real-world adoption remains limited by systemic barriers including cost and availability. This study reports findings from the Bali Chronic Constipation Roundtable, which was conducted in November 2024 to examine the regional practices in Asian and compare them to Western approaches.

Aims & Methods

A multinational expert panel representing gastroenterologists from 12 countries in East, Southeast, and South Asia convened to review survey data, real-world clinical practices, and guideline applicability. All attendees completed a questionnaire exploring the regional epidemiology and challenges related to CC. Key domains assessed included symptom profiles, diagnostic tools, treatment access and practices, and cultural perceptions.

Results

CC prevalence in Asia varied significantly, ranging from 3.5% in Indonesia to up to 40% in Taiwan. Demographic groups disproportionately affected included the elderly (81.0% of respondents), women (45.2%), and children (23.8%). The Rome IV criteria emerged as the most frequently cited CC diagnostic approach (71.4%), followed by physician diagnosis (61.9%), local criteria (19.0%), and Bristol Stool Chart (4.8%). Experts opined that CC prevalence differed based on these varying definitions. Due to regional variations in symptom interpretation, patients frequently associate constipation with predominant symptoms like sensation of incomplete evacuation in Asia (72.1-96.5%) rather than hard stools in Western countries (81.7-100%). Strict adherence to ROME criteria might exclude patients without significant pain, potentially underdiagnosing cases. Colonic transit time is also significantly different in Asia (15.8-24.5 hours) compared to Western countries (30.0-40.0 hours), and similarly for fibre intake (9.7g/day in Asia, 16.0g/day in the USA) owing to regional dietary differences.
In terms of accessibility, experts highlighted a lack of representativeness in internet-based surveys in Asia in rural populations, causing underreporting in population-level data. 100% of respondents expressed a gap in the availability of diagnostic tools and pharmacotherapy in Asia. Access to anorectal manometry and colonic transit studies was limited in lower-resource settings, hindering diagnosis and management. The main challenges were lack of specialized centres (76.2%), patient adherence (66.7%), cost (61.9%), and access to diagnostic tools (57.1%). In terms of pharmacological therapy, osmotic laxatives were the most commonly used initial therapy in CC management (86.7% of respondents), while newer agents such as IBAT inhibitors showed efficacy in refractory cases. However, the use of newer agents was limited due to cost (76.2%) and availability (38.1%).

Key Differences in Chronic Constipation: East and West

Conclusion

Significant differences exist between Asian and Western CC management. Regionally adapted diagnostic criteria and treatment pathways are urgently needed to reflect real-world practice and improve care across Asia.

References

1. Pinto Sanchez MI, Bercik P. Epidemiology and burden of chronic constipation. Canadian Journal of Gastroenterology and Hepatology. 2011;25:11B-5B.
2. Patimah AW, Lee YY, Dariah MY. Frequency patterns of core constipation symptoms among the Asian adults: a systematic review. BMC gastroenterology. 2017 Dec;17:1-2.
3. Jaruvongvanich V, Patcharatrakul T, Gonlachanvit S. Prediction of delayed colonic transit using Bristol stool form and stool frequency in Eastern constipated patients: a difference from the West. Journal of Neurogastroenterology and Motility. 2017 Oct 30;23(4):561.
4. Yu D, Zhao L, Zhao W. Status and trends in consumption of grains and dietary fiber among Chinese adults (1982–2015). Nutrition Reviews. 2020 Aug 1;78(Supplement_1):43-53.
5. Hoy KM, Goldman JD. Dietary fiber intake of the US population. Food Surv Res Gr Diet Data Br No. 2014;12:1-6.
6. Werth BL, Christopher SA. Laxative use in the community: a literature review. Journal of clinical medicine. 2021 Jan 4;10(1):143.

Introduction

Functional dyspepsia (FD) is a common gastrointestinal disorder with limited treatment options. Itopride, a compound that combines dopamine D2 receptor antagonism with inhibition of acetylcholinesterase, may offer benefits over other prokinetics.

Aims & Methods

This meta-analysis evaluates the therapeutic efficacy of Itopride compared to placebo and other prokinetic agents in managing FD symptoms.
A total of 19 randomized controlled trials were included in the analysis, comprising six placebo-controlled studies (n=1981, 976 on placebo and 1005 on Itopride) and 13 trials comparing Itopride to another prokinetic (n=1077, 515 on Itopride and 562 on control prokinetics including mosapride citrate, levosulpiride, metoclopramide, domperidone, and cisapride). Meta-analyses were conducted using a random-effects (DerSimonian and Laird) model. Outcome measures included overall responder rate and symptom assessment, comparing Itopride to 1) all prokinetics and 2) placebo. In addition, Itopride was compared to placebo and domperidone for symptom scores of epigastric pain and early satiation. Results are presented as Cohen’s d (95% CI) or odds ratios(OR) (95% CI).

Results

Analysis of responder rates from seven placebo-controlled and nine active comparator studies showed a statistically significant benefit of Itopride over placebo (OR=1.25, 1.07 to 1.45, p=0.01), with no significant difference when compared to other prokinetics (OR=1.11, 0.93 to 1.34).
When assessing overall symptom scores, three placebo-controlled and four prokinetic-controlled trials were analyzed. Itopride showed a moderate effect size compared to other prokinetics (Cohen’s d=0.51, 0.13 to 0.88, p=0.01) and a large but not statistically significant effect compared to placebo (Cohen’s d=1.14, -0.43 to 2.71).
Early satiation was assessed in six domperidone-controlled trials, yielding a significant odds ratio of 1.37 (1.02 to 2.67, p=0.04). A large but not statistically significant difference was found compared to placebo (two trials, Cohen’s d=1.10, -0.47 to 2.67). For epigastric pain, a moderate but not statistically significant difference was found with placebo (two trials, Cohen’s d=0.68, -0.01 to 1.38) or domperidone (four trials, OR=0.85, 0.63 to 1.16).

Conclusion

This meta-analysis suggests that Itopride provides significant symptom relief in patients with FD compared to placebo, particularly in overall responder rates. While Itopride’s benefits over other prokinetics were modest in general symptom relief, it demonstrated a statistically significant advantage over domperidone for early satiation.