Introduction

IBS prevalence is substantially lower with the current Rome IV criteria than with previous iterations. Previous analyses have suggested that this is primarily explained by the raising of the abdominal pain frequency threshold, followed by removal of the term discomfort from the definition.

Aims & Methods

We aimed to further explore how diagnostic criteria changes influence the prevalence of IBS and associated factors. Subjects from 26 countries who completed the internet survey in the Rome Foundation Global Epidemiology Study (RFGES) ¹ were included.^. We used responses to Rome IV (all 26 countries) and Rome III (14 countries) diagnostic questions, the IBS Symptom Severity Scale (IBS-SSS), quality of life (PROMIS-10 QoL), and health care utilization (“ever consulted a doctor about a bowel problem”). Different definitions of IBS diagnostic criteria were applied: adding discomfort to the definition; changing the frequency threshold of abdominal pain and/or discomfort; removing the requirement that abdominal pain and/or discomfort and changes in bowel habits should be associated in time; and using bloating / abdominal distension as a proxy for discomfort.

Results

A total of 54,127 individuals completed the RFGES Internet survey (49.1% females; mean age 44.3 years, range 18-97 years). Of these, 29,609 completed both the Rome IV and Rome III questionnaires. The prevalence of IBS according to the Rome IV criteria was 4.1%, and 10.1% with Rome III criteria. Lowering the frequency threshold for abdominal pain and/or discomfort from ≥once per week to ≥2-3 days a month, approximately doubled the prevalence rates for the different definitions of IBS. Using the Rome III symptom definition of IBS (abdominal pain and/or discomfort) but retaining the Rome IV frequency threshold (≥once a week) yielded a similar prevalence rate (4.2%) as the Rome IV IBS definition. Removing the required association in time between abdominal pain and/or discomfort and changes in bowel habits did not influence the prevalence rates (Table 1). For all the definitions evaluated there was a female predominance, a reduction in QoL and increases in health care utilization compared with the general global population, and on average moderate IBS symptom severity (Table 1).

Table 1. IBS prevalence, female/male ratio, quality of life, IBS symptom severity and health care utilization with different IBS definitions.

Conclusion

The global prevalence of IBS changes substantially with relatively minor changes in the symptom-based IBS definitions. Specifically, changing the abdominal pain and/or discomfort frequency threshold seems to have the most prominent effect on IBS prevalence. Even with more relaxed IBS definitions, a substantial impact on QoL and health care utilization is still evident. This information will be useful when defining the Rome V criteria for IBS.
Acknowledgment: The study was conducted under the auspices of the Rome Foundation Research Institute.

References

¹Sperber et al Gastroenterology 2021

Introduction

New biologics such as vedolizumab (VDZ) and ustekinumab (UST) have expanded the therapeutic armamentarium for inflammatory bowel diseases (IBD) over the past decade. Head-to-head trials comparing safety to tumor necrosis factor alpha inhibitors (anti-TNF) are limited. Data on safety of biologic sequencing remains scarce.

Aims & Methods

Aim: To assess the impact of different biologics and previous treatments on the incidence of severe adverse events (SAE) in a real-world tertiary IBD patient cohort.
Methods: A retrospective monocentric study was performed at the Ghent University Hospital. Patients starting anti-TNF, VDZ or UST from January 2018 to June 2021 with follow-up until December 2021 were included. SAE were defined as intestinal resection (IR), IBD-inflammation related hospitalization (IBD-hosp), IBD-treatment related hospitalization (e.g. infections) (treat-hosp), malignancy and death. Cox regression analysis was used to explore risk factors (RF) of SAE.

Results

In total 267 patients were included: 84 on VDZ, 69 UST, 60 infliximab (IFX) and 54 adalimumab (ADM). At baseline a significant difference was found between biologic groups for age (younger in IFX and ADM - P=0.001), IBD type (Crohn’s disease (CD): VDZ 51.2%, UST 73.9%, IFX 70%, ADM 77.8% - P=0.003), CRP (in mg/L, med, IQR - VDZ: 5[1.6-12.4], UST: 8.5[2.8-19.3], IFX: 13 [1.87-31.8], ADM:3.2[1-8.1] - P<0.001) and calprotectin (in µg/g, med, IQR) (VDZ: 579 [175- 1801], UST: 707 [244-2889], IFX: 652 [65-2449], ADM 200 [43.7-789] - P=0.021)). Perianal CD rate was higher in anti-TNF and UST patients (P=0.003) and prior disease duration differed significantly (VDZ: 9years, UST10y, IFX 2y,ADM 3.5y - P<0.001)). Concomitant immunomodulator (IMM) use was higher in the IFX group (81.7% vs 25% for all other groups P<0.001)) and corticosteroid (CS) use differed among treatment groups (VDZ 78.6%, UST 68.1%, IFX 70%, ADM 55.6% (P=0.041)). Number of prior biologics was higher in the UST group (P<0.001).
No significant difference in SAE rate could be found between different biologics (UST 37.7%, IFX 33.3%, VDZ 23.8%, ADM 22.2% - P=0.148). Cox regression revealed age ≥60years (aHR 2.00, 95%CI 1.11-3.60, P=0.020) and higher number of previous biologics (aHR 1.29, 95%CI 1.03-1.60, P=0.024) as independent RF for SAE. Considering SAEs types, IR rate was not significantly different between biologic groups (VDZ 4.8%, UST 15.9%, IFX 8.3%, ADM 5.6% - P=0.096). Cox regression revealed previous IMM use as an independent RF for IR (aHR 4.26, 95%CI 1.62-11.19, P=0.003). No significant difference was found between biologics considering IBD-hosp (VDZ 15.5%, UST 30.4%, IFX 21.7%, ADM 14.8% – P=0.087). Higher number of previous biologics was an independent RF for IBD-hosp (aHR 1.32, 95%CI 1.02-1.71, P=0.036). Treat-hosp rate was not significantly different between biologic groups (VDZ 7.1%, UST 10.1%, IFX 6.7%, ADM 5.6% – P=0.811). Age ≥60years was found to be an independent RF of treat-hosp (aHR 4.93, 95%CI 1.91-12.76, P=0.001). Six patients developed malignancy (3 VDZ: colorectal carcinoma, melanoma, low grade appendix neoplasia; 2 IFX: cervix CIN3, gastric adenocarcinoma; 1 ADM: basal cell carcinoma). One patient died due to progressive melanoma while on VDZ.

Conclusion

In this tertiary real-world IBD patient cohort, no influence of type of biologic on the SAE rate could be found. Elderly age (≥60 years) and higher number of previous biologics were an independent RF for SAEs.

Introduction

Fluid therapy (FT) is an essential treatment in the early phase of acute pancreatitis (AP). A complication of FT is fluid overload: signs, symptoms or imaging tests compatible with congestive heart failure due to this treatment. In the WATERFALL clinical trial, aggressive FT was found to be associated with fluid overload.

Aims & Methods

Our main objective is to evaluate which baseline features in our patients are predictors of possible fluid overload. For that purpose,a post hoc analysis of the data obtained from the WATERFALL clinical trial was performed. This was a multicenter randomized clinical trial with a sample size of 249 patients in which 122 patients were included in the aggressive FT group (20 ml/kg lactated ringer solution (LR) bolus over 2 hours and 3 ml/kg/h LR perfusion) and 127 in the moderate FT group (10 ml/kg LR bolus in case of hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml/kg h). Univariate analysis was initially performed to assess the possible association with fluid overload of the different qualitative and quantitative variables collected in the baseline assessment of the patients. Those variables with an association with fluid overload with p<0.1 were included in the multivariate analysis (binary logistic regression). Variables with an independent association for fluid overload were considered to be those with a p<0.05 in the logistic regression.

Results

Of the total number of patients included in the trial (n=249), 33 had fluid overload. Of these, 25 (20.5%) belonged to the aggressive FT group and 8 (6.3%) to the moderate FT group. In univariate analysis, there was a possible association with fluid overload with p<0.1 of the following: treatment arm, age, baseline hypovolemia, ischemic heart disease, diabetes, respiratory rate, systolic pressure, urea, leukocytes at first blood test, pain, abdominal distension, nausea or vomiting, thirst, difficulty eating, or weakness. When exploring these variables in multivariate analysis, only age, baseline hypovolemia and treatment arm showed a statistically significant association (p<0.05). Systolic pressure approached statistical significance with a p=0.057. An age of 70 years is an indicative cutoff point for increased risk of fluid overload (33% vs. 7% in <70 years, p<0.001).

Conclusion

Older patients with baseline hypovolemia who receive aggressive fluid therapy are at risk of fluid overload. Moderate and probably restrictive fluid therapy in elderly patients may avoid this complication.

Introduction

The low fermentable oligosaccharide, disaccharide, monosaccharide and polyol diet (LFD) has been purported as a first line therapeutic treatment for the management of irritable bowel syndrome (IBS)^1,2. Despite the extensive research supporting the efficacy of the LFD^{3 4}, there are few studies exploring the lived experience of people with IBS undertaking a dietitian-led three-phase LFD.

Aims & Methods

This study aimed to explore people’s expectations of and experience with each phase of the LFD, and identify barriers and enablers to successfully completing each phase. A descriptive, qualitative design employed semi-structured interviews with adults with IBS who undertook all or part of a dietitian-led research study on predictors of response to a LFD. Participants underwent LFD restriction, reintroduction and personalisation between October 2020 and April 2022. Interviews examined expectations and experiences of the LFD process, and barriers and enablers to undertaking and completing each phase. Sociodemographic and IBS characteristics were also collected. Thematic analysis summarised key themes.

Results

Seventeen people (32%, 17/53 response rate) aged 37.5 ± 14 years (88% female) completed interviews, of whom 76% (13/17) completed all three phases of the LFD. Duration of experiencing IBS symptoms ranged from one to 40 years with 76% experiencing diarrhoea as the most predominant symptom. Four themes emerged from the data. Firstly, people presented with different IBS and healthcare experiences, and expectations of what the LFD would provide. Previous unsuccessful treatments (pre- and probiotics, gluten elimination, herbal medicine) motivated people to undertake the LFD. Secondly, people’s expectations of outcomes within each phase varied and was related to their symptom response. People expected symptom resolution during the restriction phase and were disappointed that symptoms were not entirely alleviated. Symptoms during the reintroduction phase were a barrier to continuing challenges for some but others felt that symptoms assisted in identifying trigger foods. Despite overall reductions in symptoms during each phase, a residual frustration was felt as symptoms were not eliminated on completion of personalisation. Thirdly, the three-phase process required significant planning, effort and self-efficacy. Ability to adhere to personal tolerance levels of fermentable carbohydrates was an enabler to successful completion of the reintroduction and personalisation phase. Environmental barriers included eating out, multi-person households and altering meals to suit family mealtimes. Personal barriers included perceptions of food triggers, apprehension to try foods that had long been avoided and experiencing symptoms during the reintroduction phase. Lastly, most people incorporated learning and experiences from the LFD into daily life after reintroduction. Those with symptom improvement identified strategies to circumvent FODMAP intake in daily life and were understanding of the interplay between food, the environment and psychological factors on symptoms. Some used the LFD restriction to manage symptom exacerbations.

Conclusion

The LFD process is complex, and personal beliefs, experiences and expectations impact on adherence and completion of each phase. Further personalisation of the LFD to individual circumstances is fundamental to improving the experience and outcome of this therapeutic management strategy in people with IBS. These findings will be used to inform improved implementation to optimise peoples experience and success with the LFD.

References

¹ Clinical Decision Support Tool: IBS Treatment. (2022). Gastroenterology 163(1): 152-152 http://doi.org./10.1053/S0016-5085(22)00536-4
² Vasant, D.H., Paine, P.A., Black, C.J., Houghton, L.A., Everitt, H.A., Corsetti, M., Agrawal, A., Aziz, I., Farmer, A.D., Eugenicos, M.P, Moss-Morris, R., Yiannakou, Y & Ford, A, C. (2021). British Society of Gastroenterology guidelines on the management of irritable bowel syndrome Gut, 70(7), 1214-1240.http://doi.org/10.1136/gutjn-2021-324598
³ Black, C.J., Staudacher, H.M & Ford, A.C. (2022). Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut, 71(6), 1117-1126. doi:10.1136/gutjnl-2021-325214
⁴ Wang, J., Yang, P., Zhang, L and Hou, X. (2021). A low FODMAP diet improves the global symptoms and bowel habits of adult IBS patients: A systematic review and meta-analysis. Frontiers in nutrition, 8. http://doi.org/10.3389/fnut2021.683191

Introduction

There are three main concepts in colorectal carcinogenesis. The first is the well-known “adenoma-carcinoma sequence”, while the second is the “saw-tooth lesion pathway”. In this concept, serrated lesions transform into early carcinomas. The third concept is the “de novo” pathway, in which early carcinomas can develop even in the absence of an adenoma. In this pathway, the cancer is thought to arise directly from the normal epithelium, rather than from an adenoma, and the cancer tends to progress at a faster rate and with a higher grade of malignancy. For diagnosing colorectal cancer, magnified endoscopy, specifically the Pit pattern classification, has proved to be useful. Recently, the endoscopic examination (EC classification) has been developed, and now not only structural atypia but also cellular atypia can be observed in vivo.
In this study, we aimed to clarify the endoscopic characteristics of colorectal cancer and demonstrate the usefulness of pit pattern classification and EC classification. Our study focused mainly on colorectal cancer that is considered to arise through the "de novo" pathway.

Aims & Methods

From April 2001 to December 2022, a total of 45,419 colorectal neoplasms, excluding advanced cancer that were resected endoscopically or surgically at Showa University Northern Yokohama Hospital. Among them, 37,098 were low-grade dysplasia, 6,802 were advanced dysplasia, and 1,519 cases were submucosal invasive carcinoma. In this study, we investigated the characteristics of depressed carcinomas with respect to Pit patterns and EC classification.

Results

Of all the T1 colorectal cancers, depressed lesions accounted for 61.4% (324/528). In contrast, flat and protruding lesions accounted for only 2.9% (575/19,578) and 2.7% (673/25,313) of T1 cancers, respectively. Flat (95.1% (18,619/19,578)) and raised (94.2% (23,844/25,313)) lesions showed mostly type IIIL and type IV pit patterns corresponding to adenomas. Among depressed lesions, 92.2% (486/528) were types IIIS, VI, and VN, corresponding to adenocarcinoma in pit pattern classification. On endoscopy, most of the flat or protruding lesions corresponded to adenomas and were classified as type EC2 in the EC classification, whereas the depressed lesions were mostly classified as EC3a and EC3b (91.2%), indicating invasive carcinoma according to the EC classification.

Conclusion

This study demonstrates that depressed colorectal cancer is prone to invade the submucosa, highlighting the need for magnifying endoscopy and endoscopy, regardless of the size of the lesion. Nonetheless, detecting this type of colorectal cancer can present a significant challenge. Thus, greater attention must be devoted to the morphological characteristics of depressed colorectal cancer during routine colonoscopy.

Introduction

Gastrointestinal involvement is universal among patients with systemic sclerosis (SSc). Small intestinal dysfunction manifests with non-specific gastrointestinal symptoms (abdominal pain, distension, nausea, or vomiting), along with objective signs such as malnutrition, small intestinal bacterial overgrowth, and, in severe cases, chronic intestinal pseudo-obstruction. The pathogenesis of small intestinal dysmotility in SSc has been proposed to follow a sequential progression, beginning with neuropathy, progressing to myopathic damage, and ultimately culminating in fibrosis. Currently, there are no diagnostic techniques available to differentiate between stages of small intestinal involvement.

Aims & Methods

Aim: To assess the discriminative potential of high-resolution jejunal manometry in categorizing small intestinal dysmotility among patients with SSc.

Prospective study evaluating small intestinal motility in consecutive patients with SSc and digestive symptoms between January 2018 and July 2023 and healthy volunteers as controls. A 35-channel high-resolution manometry catheter was trans-nasally inserted into the jejunum under fluoroscopic radiological guidance. Small intestinal motility was continuously recorded for 5 h; 3 h fasting and 2 hours during continuous nutrient perfusion at 2 kcal/min. Tracings were analyzed by conventional qualitative analysis (identifying neuropathic and myopathic motility patterns) and by quantitative analysis of high-resolution parameters (measuring a motility index (MI) that integrates contractile frequency and amplitude over time, and manually counting the number of propagated contractile fronts)

Results

Twenty patients (52 ± 10 years, 95% women) with SSc and 18 healthy subjects (HS) (27 ± 6 years, 78% women) were included. By conventional visual analysis, 6 (30%) patients exhibited abnormal small intestinal motility patterns indicative of neuropathic involvement (uncoordinated bursts n=3 and postprandial minute-rhythm n=3), and 7 (35%) patients showed diminished contractile activity during fasting and after nutrient infusion (mean amplitude <20mmHg), indicative of myopathic involvement. The remaining 7 (35%) patients had apparently normal small intestinal motility.
Quantitative analysis of high-resolution parameters detected additional abnormalities in patients with SSc compared to healthy controls (table 1). A significant decrease in fasting (phase II) propagated fronts was observed in all subgroups, including those with apparently normal motility by conventional analysis. The postprandial response to nutrient infusion was reduced in 15 of 20 patients with SSc. All patients with myopathic involvement had a null response to nutrient infusion. Patients with neuropathic patterns and those with apparently normal motility by conventional analysis also exhibited a poor postprandial response, which was similarly reduced in both groups.

Table 1: Results from quantitative analysis of high-resolution jejunal manometry

Conclusion

High-resolution jejunal manometry detects abnormalities in fasting and postprandial small intestinal motility in patients with systemic sclerosis, even at early stages of intestinal involvement, when neuropathic and myopathic patterns are not evident.

References

Alcala-Gonzalez LG, Malagelada C, Galan C, Nieto A, Accarino A, Azpiroz F. Propagation patterns of jejunal motor activity measured by high-resolution water-perfused manometry. Neurogastroenterol Motil. 2021 Dec;33(12):e14240. doi: 10.1111/nmo.14240. Epub 2021 Aug 11. PMID: 34378830.

Disclosure

Nothing to declare