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Introduction

Patients with intestinal failure (IF) have abnormalities of intestinal anatomy, secretion, and/or motility, and physiological protective mechanisms regulating small intestinal bacterial counts are impaired, which can lead to small intestinal bacterial overgrowth. There are five key mechanisms that drive intestinal failure, of which, short bowel syndrome (SBS) following surgical resection is the most common. Less frequent mechanisms include enterocutaneous fistula, dysmotility, obstruction and malabsorption. Small intestinal bacterial overgrowth (SIBO) and catheter related blood stream infections (CRBSI) are two of the most common complications with a direct impact on morbidity and mortality. Parenteral nutrition (PN) use in intestinal failure has also been proposed as an independent risk factor for development of SIBO. However, the reported prevalence of SIBO in patients with IF is variable. We thus conducted a systematic review and meta-analysis aimed to determine the prevalence of SIBO in patients with IF and to identify the risk factors that predict SIBO in this cohort.

Aims & Methods

MEDLINE (PubMed) and Embase electronic databases were searched from inception to April 2023 for studies that reported the prevalence of SIBO in IF. The prevalence rates, odds ratio (OR) and 95% confidence intervals of SIBO in IF were calculated using DerSimonian and Laird random effects model, and further subgroup analysis stratified according to mode of SIBO diagnosis and short-bowel syndrome cause of IF were conducted. This study was registered with PROSPERO (CRD42023414010).

Results

Six prevalence studies reporting on 313 patients with IF were included in this systematic review and meta-analysis. Overall, the prevalence of SIBO in IF was 55.2% (95% CI: 41.5-68.2), with considerable heterogeneity in this analysis (I²=79.2, p=0.0001), with slightly increased SIBO prevalence in IF patients on parenteral nutrition (61.1% 95% CI 31.6-84.3). There was no difference in CRBSI in SIBO positive (45.5%, 95% CI: 28.1-63.6) as compared to SIBO negative IF patients (45.7%, 95%CI 16.7-76.6). Utilizing duodenal aspirate and culture SIBO prevalence in patients with IF was significantly higher as compared to that with glucose breath test (OR 2.59, 95% CI 1.2-5.8, p=0.03), with moderate heterogeneity noted in this analysis (I²=53.9, p=0.054). There was no difference in SIBO prevalence in patients with IF due to SBS (49.1%, 95% CI 42.7-55.4) as compared to IF due to other causes (53.5%, 95%CI 37.7-68.8).

Conclusion

This systematic review and meta-analysis suggests a link between SIBO and IF, with higher SIBO prevalence in patients with IF diagnosed utilizing small bowel aspirate and culture. Parenteral nutrition appeared to be risk factor for SIBO in IF. Moreover, there was no like between SIBO and CRBSI in patients with IF. However, the results need to be interpreted with caution, due to the low sensitivity and specificity of the SIBO diagnostic tests, lack of case control studies and clinical heterogeneity seen in the prevalence studies. Further prospective studies are required to further assess the link between SIBO and IF and explore the risk factors for SIBO in IF.

SMALL INTESTINAL BACTERIAL OVERGROWTH IN INTESTINAL FAILURE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Xiaomin Ma 1, Ayesha Shah 2, Thomas Fairlie 3, Neal Martin 1, Michael P. Jones 4, Natasha A Koloski 5, Mark Morrison 6, Gerald J. Holtmann 2, Angela Tietto 7

1 Princess Alexandra Hospital, Brisbane, Australia|||University of Queensland, Brisbane, Australia

2 Princess Alexandra Hospital, Brisbane, Australia|||University of Queensland, Brisbane, Australia|||Translational Research Institute, Brisbane, Australia

3 Princess Alexandra Hospital, Brisbane, Australia|||Translational Research Institute, Brisbane, Australia

4 Macquarie University, Sydney, Australia

5 Princess Alexandra Hospital, Brisbane, Australia|||University of Queensland, Brisbane, Australia|||University of Newscastle, Newcastle, Australia

6 Princess Alexandra Hospital, Brisbane, Australia|||University of Queensland, Brisbane, Australia|||University of Queensland, Brisbane, Australia

7 University of Padova, Padova, Italy

Conference

UEG Week Copenhagen 2023

Topics

Small Intestine & Nutrition

Submission format

Abstract

Session

The small intestine: A hidden treasure! (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

UEG Standards and Guidelines

Clinical Practice Guideline

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MAIN RECOMMENDATIONS

ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass.
ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures.
ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease.
SGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Antonio Facciorusso

Publisher

European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

Topics

Endoscopy

Citation

Endoscopy 2025; 57: 166-185

Published

2024

UEG Standards and Guidelines

Clinical Practice Guideline

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Abstract

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Juan Enrique Dominguez-Munoz

Publishers

European Society for Primary Care Gastroenterology, European Society of Digestive Oncology, European Society for Paediatric Gastroenterology, Hepatology and Nutrition, The European Society for Clinical Nutrition and Metabolism, European Digestive Surgery, European Pancreatic Club

Guideline

Clinical Practice Guideline

Topics

Pancreas

Citation

United European Gastroenterol J. 2024; 1–48. https://doi.org/10.1002/ueg2.12674

Published

2024

UEG Standards and Guidelines

Consensus

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ABSTRACT

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. A patient's medical and pharmacological history is essential for identifying risk factors. Several examinations such as endoscopy with small intestinal biopsies, non-invasive functional tests and radiological imaging are useful in diagnosing malabsorption. Because of its high prevalence, CD should always be looked for in cases of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in the management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians play a central role in the early detection of malabsorption and should be involved in multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving ten scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

European Consensus on Malabsorption—UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN. Part 1: Definitions, Clinical Phenotypes, and Diagnostic Testing for Malabsorption

Marco Vincenzo Lenti

Publishers

European Society for Paediatric Gastroenterology, Hepatology and Nutrition, The European Society for Clinical Nutrition and Metabolism, European Association for Gastroenterology, Endoscopy and Nutrition, European Society for Primary Care Gastroenterology, Società Italiana di Gastroenterologia ed Endoscopia Digestiva

Guideline

Consensus

Topics

Endoscopy Pancreas Primary Care Small Intestine & Nutrition

Citation

United European Gastroenterol J, 13: 599-613

Published

2025

UEG Standards and Guidelines

Consensus

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ABSTRACT

Malabsorption is a complex and multifaceted condition characterised by the defective passage of nutrients into the blood and lymphatic streams. Several congenital or acquired disorders may cause either selective or global malabsorption in both children and adults, such as cystic fibrosis, exocrine pancreatic insufficiency (EPI), coeliac disease (CD) and other enteropathies, lactase deficiency, small intestinal bacterial overgrowth (SIBO), autoimmune atrophic gastritis, Crohn's disease, and gastric or small bowel resections. Early recognition of malabsorption is key for tailoring a proper diagnostic work-up for identifying the cause of malabsorption. Patient's medical and pharmacological history are essential for identifying risk factors. Several examinations like endoscopy with small intestinal biopsies, non-invasive functional tests, and radiologic imaging are useful in diagnosing malabsorption. Due to its high prevalence, CD should always be looked for in case of malabsorption with no other obvious explanations and in high-risk individuals. Nutritional support is key in management of patients with malabsorption; different options are available, including oral supplements, enteral or parenteral nutrition. In patients with short bowel syndrome, teduglutide proved effective in reducing the need for parenteral nutrition, thus improving the quality of life of these patients. Primary care physicians have a central role in early detection of malabsorption and should be involved into multidisciplinary teams for improving the overall management of these patients. In this European consensus, involving 10 scientific societies and several experts, we have dissected all the issues around malabsorption, including the definitions and diagnostic testing (Part 1), high-risk categories and special populations, nutritional assessment and management, and primary care perspective (Part 2).

European Consensus on Malabsorption—UEG & SIGE, LGA, SPG, SRGH, CGS, ESPCG, EAGEN, ESPEN, and ESPGHAN Part 2: Screening, Special Populations, Nutritional Goals, Supportive Care, Primary Care Perspective

Marco Vincenzo Lenti

Publishers

Guideline

Consensus

Topics

Endoscopy Pancreas Primary Care Small Intestine & Nutrition

Citation

United European Gastroenterol J, 13: 773-797.

Published

2025

UEG Mistakes In Articles

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Jaundice can be caused by abnormalities in any of the steps comprising the formation, metabolism and excretion of bilirubin. In addition, these processes may be functioning properly, but jaundice can be seen because of an obstruction of the biliary tree at any point, from its intrahepatic origins to its end at the ampulla of Vater. For this reason, it is clear that numerous conditions can result in jaundice. When faced with a patient presenting with jaundice a reasonable and careful diagnostic approach is, therefore, warranted to elucidate the underlying cause of this sign. Conventional wisdom may be that “jaundice by itself never killed anyone,” but it is imperative to find the cause as soon as possible, as prompt intervention saves lives in many cases.

Mistakes in acute jaundice and how to avoid them

Spyridon Siakavellas, Georgios Papatheodoridis

Topics

Hepatobiliary

Citation

Siakavellas S and Papatheodoridis G. Mistakes in acute jaundice and how to avoid them. UEG Education 2018; 18: 24–26.

Published

2025

UEG Standards and Guidelines

Clinical Practice Guideline

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Summary

Background & aims

Dementia is accompanied by a variety of changes that result in an increased risk of malnutrition and low-intake dehydration. This guideline update aims to give evidence-based recommendations for nutritional care of persons with dementia in order to prevent and treat these syndromes.

Methods

The previous guideline version was reviewed and expanded in accordance with the standard operating procedure for ESPEN guidelines. Based on a systematic search in three databases, strength of evidence of appropriate literature was graded by use of the SIGN system. The original recommendations were reviewed and reformulated, and new recommendations were added, which all then underwent a consensus process.

Results

40 recommendations for nutritional care of older persons with dementia were developed and agreed, seven at institutional level and 33 at individual level. As a prerequisite for good nutritional care, organizations caring for persons with dementia are recommended to employ sufficient qualified staff and offer attractive food and drinks with choice in a functional and appealing environment. Nutritional care should be based on a written care concept with standardized operating procedures. At the individual level, routine screening for malnutrition and dehydration, nutritional assessment and close monitoring are unquestionable. Oral nutrition may be supported by eliminating potential causes of malnutrition and dehydration, and adequate social and nursing support (including assistance, utensils, training and oral care). Oral nutritional supplements are recommended to improve nutritional status but not to correct cognitive impairment or prevent cognitive decline. Routine use of dementia-specific ONS, ketogenic diet, omega-3 fatty acid supplementation and appetite stimulating agents is not recommended. Enteral and parenteral nutrition and hydration are temporary options in patients with mild or moderate dementia, but not in severe dementia or in the terminal phase of life. In all stages of the disease, supporting food and drink intake and maintaining or improving nutrition and hydration status requires an individualized, comprehensive approach. Due to a lack of appropriate studies, most recommendations are good practice points.

Conclusion

Nutritional care should be an integral part of dementia management. Numerous interventions are available that should be implemented in daily practice. Future high-quality studies are needed to clarify the evidence.

Keywords

Dementia, Malnutrition, Dehydration, Guideline, Nutritional care

ESPEN guideline on nutrition and hydration in dementia – Update 2024

Dorothee Volkert

Publisher

The European Society for Clinical Nutrition and Metabolism

Guideline

Clinical Practice Guideline

Topics

Small Intestine & Nutrition

Citation

Clinical Nutrition 43 (2024) 1599-1626

Published

2024

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