Introduction

Female sex and increasing age are risk factors for constipation. Studies have found colon transit times to be longer in women. When estrogens decrease, constipation appears or worsens among perimenopausal women. After recommendation of lifestyle changes, second-line treatment are pharmaceutical solutions such as laxatives. However, most laxative agents show limited efficacy for chronic use, especially in people with comorbid conditions or concomitant medication inducing constipation (antihypertensives, calcium supplements to prevent osteoporosis, ...) in addition to potential adverse effects.
Intermittent colonic exoperistalsis (ICE) administered with the MOWOOT medical device, is a non-invasive, non-pharmacological treatment for chronic constipation. It has been developed to facilitate natural bowel movements and reduce the side effects of laxatives, enemas, or other invasive approaches. ICE has been proven safe and effective in constipation from both neurogenic or idiopathic aetiology in a multicentric clinical trial. Here, its use among women with functional chronic constipation was evaluated.

Aims & Methods

Adult women with chronic functional constipation were recruited in 4 hospitals in Germany. The treatment consisted of using the ICE device for 15 to 30min daily, at home. Patient outcomes were self-reported through anonymous, structured feedbacks collected at baseline (F1) and after some time under ICE treatment (F2).

Results

Data resulted from n=17 women(6 aged 18-39 yr, and 11 aged 40-80 yr). Twelve of them had a previous diagnosis of slow colonic transit. The mean time of ICE treatment at F2-feedback collection was 6,60(5,21) months (min 0,5; max 16). No one reported any serious adverse event. Three patients described occasional low self-remitting adverse events which did not affect the treatment compliance.

		Baseline (F1)	Treatment (F2)	Change (F2-F1)	P
Suppositories	Yes(F1)/Same(F2)	12	1	-11	0,0002 a
	No(F1)/No or Less(F2)	5	16
Oral Laxatives	Yes(F1)/Same(F2)	15	6	-9	0,0039 a
	No(F1)/No or Less(F2)	2	11
Number Bowel Movements / week		2,65(1,86)	5,75(2,97)	3,10	<0,0001 b
Time (min) / Bowel Movement		110,4(149,7)	52,4(73,0)	-57,94	0,0314 b
Average Bristol scale (1-7)		2,65(1,54)	3,75(1,73)	1,25	0,0099 c

Results are shown as N or mean(SD). a: Chi² & Fisher's exact test; b: Student's t-Test for paired values; c: Wilcoxon matched-pairs test.

Of the 12 women using suppositories at F1, 11 (92%) had reduced its use at F2, including 9 (75%) that stopped completely. Of the 15 women using oral laxatives, 9 (60%) had reduced its use, including 4 (27%) that fully stopped. Overall, 3 women (25%) had stopped both suppositories and oral laxatives, and only 1 (8%) maintained the same dose of both. In total, 80% (12/15) of women stopped or reduced some form of laxative (Table).
In addition to laxative reduction, bowel movements increased on average by more than 3 per week, fecal consistency ameliorated (Bristol scale), and time spent in each bowel movement was reduced by nearly 1h (Table).

Conclusion

The use of ICE treatment by chronically constipated adult women significantly improved their bowel function. Importantly, this amelioration was accompanied by a notable reduction in laxatives, with a high percentage of women stopping the use of suppositories.
This in-use structured feedback in the out-patient sector points to the clinical benefit of ICE treatment. Therefore, the ICE device has the potential to substitute more invasive and pharmacological approaches in bowel management strategies for women with functional constipation.

References

1. Bharucha AE, Wald A. Chronic Constipation. Mayo Clin Proc. 2019 Nov;94(11):2340-2357.
2. Houghton et al. Age, Gender, and Women’s Health and the Patient. Gastroenterology 2016;150:1332–1343
3. McClurg, D., L. Booth, and I. Herrero-Fresneda, Safety and Efficacy of Intermittent Colonic Exoperistalsis Device to Treat Chronic Constipation: A Prospective Multicentric Clinical Trial. Clin Transl Gastroenterol, 2020. 11(12): p. e00267
4. Special SCI units involved in recruitment: BDH Klinik, Greifswald, GE; Werner-Wicker-Klinic, Bad Wildungen, GE; Zentralkinik, Bad Berka, GE; Klinken Beelitz, Beelitz-Heilstätten, GE.

Disclosure

IHF works as CSO at MOWOOT, USMIMA S.L., the manufacturer of the ICE device. The author would like to thank Dr J. Bremer, Dr. P. Kossmehl, Dr. I. Kurze and Dr. H. Lienhard for their support in the above-mentioned SCI hospitals, and R. Müller for his support regarding the logistics of the study.

Introduction

Celiac disease (CD) is an immune-mediated enteropathy triggered by gluten ingestion in genetically predisposed individuals, characterized by small intestinal inflammation and villous atrophy. Microbial agents such as Helicobacter pylori (H. pylori) may influence autoimmune disorders, including CD, through immune modulation. However, the relationship remains controversial.This study aimed to assess the association between CD and H. pylori infection by comparing the prevalence of H. pylori in patients with and without CD.

Aims & Methods

We conducted a retrospective study from January 2019 to December 2024. Two groups were analyzed: patients with biopsy-confirmed CD and controls without CD who underwent upper endoscopy for dyspeptic or non-specific gastrointestinal symptoms. Exclusion criteria included prior H. pylori eradication, recent use of PPIs, antibiotics, or bismuth compounds, other autoimmune disorders, and incomplete data.

Results

A total of 231 patients were included: 103 with CD (19.4% male, mean age 28.8 ± 12.6 years) and 128 controls (28.1% male, mean age 33.9 ± 11.9 years).
No significant differences were observed in age (p = 0.73) or sex distribution (p = 0.167) between groups.
H. pylori was detected in 67% of CD patients and 50% of controls, with a significantly higher prevalence in the CD group (p = 0.014).

Conclusion

Contrary to some previous reports suggesting a protective effect, this study found a significantly higher prevalence of H. pylori in patients with CD compared to controls.
These findings highlight the need for further investigations into the potential impact of H. pylori on the clinical presentation and management of celiac disease.

Introduction

The gut microbiota plays a crucial role in the pathogenesis and progression of Crohn’s Disease (CD) by maintaining intestinal homeostasis, supporting metabolic and immune functions, and influencing overall health. An imbalance in the gut microbiota is associated with CD, as disruptions in microbial composition can be further impacted by dietary factors, highlighting the connection between nutrition and gut health.

Aims & Methods

This study aimed to evaluate the gut microbiota composition and its interactions with dietary factors to identify potential opportunities for targeted probiotic interventions in CD management. The study included 53 participants, of whom 20 had CD in remission, 18 had active disease, and 15 were healthy controls. CD activity was evaluated by colonoscopy assessment or by nuclear magnetic resonance scan enterography. All participants aged between 18 and 60 years were assessed using 24-hour dietary recall and gut microbiome profiling through 16S rRNA gene sequencing. Patients had confirmed diagnoses of CD with ileal and/or colonic involvement. The local ethics committee approved this study.

Results

Microbial composition analyses (beta diversity) revealed significant differences between groups. At the Operational Taxonomic Unit (OTU) level, healthy microbiome differed significantly from both remission and active CD patients, with healthy controls showing a more similar microbial composition compared to remission (p = 0.001) and active disease (p = 0.001). In addition, Shannon diversity analyses demonstrated that healthy individuals exhibited significantly higher OTU diversity compared to CD patients, further highlighting the microbial imbalance associated with the disease. Among specific taxa, Eubacterium hallii, a key butyrate producer, was significantly reduced in patients with active CD. This microorganism is integral to intestinal metabolic balance, playing essential roles in energy homeostasis, colonic motility, immunomodulation, and inflammation suppression. Furthermore, E. hallii plays a critical role in bile acid and cholesterol metabolism, highlighting its importance in gut health. Disease severity was associated with changes in microbial abundance, with specific taxa colonizing the gut at higher levels as disease activity increased, including Escherichia coli, Escherichia-Shigella, and taxa from the Enterobacteriaceae, Lachnospirales, and Bacteroides. This growth may be linked to inflammatory processes and intestinal dysbiosis, suggesting a potentially pathogenic role. Furthermore, dietary components such as saccharin, an artificial sweetener, were significantly associated with alterations in microbial composition.

Conclusion

These findings underline the potential for probiotics targeting specific taxa, such as E. hallii, to restore microbial balance and improve clinical outcomes in CD. The study also highlights the impact of dietary components, such as saccharin, in disrupting the gut microbiome, suggesting that certain dietary factors may contribute to microbial imbalance and inflammation in CD. Future research should focus on integrating dietary patterns with probiotic development to optimize gut health and mitigate inflammation in CD patients.

References

1. BOLTE, L. A. et al. Long-term dietary patterns are associated with pro-inflammatory and anti-inflammatory features of the gut microbiome. Gut, p. gutjnl-2020-322670, 2 abr. 2021.
2. FAN, Y.; PEDERSEN, O. Gut microbiota in human metabolic health and disease. Nature Reviews Microbiology, v. 19, n. 1, p. 55–71, 4 jan. 2021.
3. GILL, P. A. et al. The Role of Diet and Gut Microbiota in Regulating Gastrointestinal and Inflammatory Disease. Frontiers in Immunology, v. 13, n. April, p. 1–22, 5 abr. 2022.

Introduction

Irritable bowel syndrome (IBS) imposes a substantial burden on patients and healthcare systems globally, with diverse gut symptoms. Its pathophysiology involves disorders in gut-brain interaction and gut barrier dysfunction related to diet and stress. Confocal laser endomicroscopy (CLE) can detect barrier dysfunctions in vivo. Multimodal integrative mind-body medicine-based (MBM) therapy, including stress management, exercise, relaxation, and nutrition, may enhance gut barrier function, symptoms and patient well-being.

Aims & Methods

This study aims to screen IBS patients for prevalent and food-induced gut barrier dysfunction via CLE and explore the impact of a multimodal integrative therapy on barrier integrity, IBS-symptom severity, -quality of life and psychological well-being.
Methods: IBS patients (N=119) admitted between 1 February 2021 and 1 July 2023 at a Clinic for Internal and Integrative Medicine for a two-week inpatient stay underwent esophagogastroduodenoscopy with confocal laser endomicroscopy (CLE) and local food challenge (standardized protocol for egg white, soy, milk, yeast or wheat) to test for a primary prevalent (1°CLE+) or secondary food-induced (2°CLE+) duodenal barrier dysfunction – after exclusion of IgE-mediated food allergy and coeliac disease. All IBS patients received a multimodal MBM therapy. Patients with barrier dysfunction were recommended to adhere to an adjuvant preclinically-tested barrier-stabilising therapy with myrrh, chamomile and coffee charcoal (MYRRHINIL INTEST® 3x4 dragées/ day), and exclusion of CLE-identified barrier-disrupting foods until a voluntary follow-up CLE (2^nd CLE). Pre (=1^st CLE) and Post (=2^nd CLE) intervention, IBS-symptom severity (IBS-SSS), IBS-quality of life (IBS-QoL) and psychological well-being via clinically validated questionnaires were additionally assessed.

Results

Of the 119 IBS patients included in the study, 62% (n=74) showed duodenal barrier dysfunction [1°CLE+: n=27 (23%); 2°CLE+: n=47 (39%)]. Of those, N=35 IBS patients (47%) with barrier dysfunction at 1^st CLE returned for a voluntary 2^nd CLE after 6.3 ± 3.0 months [at 1^st CLE: 1°CLE+: n=15 (43%), 2°CLE+: n=20 (57%); n=25 (71%) female; age 42.9 ± 15.4 yrs, diagnosis age 32.1 ± 15.0 yrs; disease duration 11.1 ± 11.2 yrs]. Of returned IBS patients, n=25 (71%) showed an improved gut barrier integrity, of whom 16 (46%) achieved complete stabilisation of the gut barrier (CLE-).
Pre-intervention, IBS patients were clinically characterized by severe IBS symptom severity (IBS-SSS 304.8 ± 83.4), severely impaired IBS-related quality of life (IBS-QoL 42.7 ± 16.6) and concomitant severe level of anxiety and depression (HADS 19.2 ± 7.7), fatigue (MFI-20 66.8 ± 13.1) and perceived stress (PSS-10 31.3 ± 7.7). Post-intervention, patients exhibited significant and clinically relevant (MCID) improvement in all of these clinical outcomes (IBS-SSS p=<.001, IBS-QoL p=<.001, HADS p=<.001, MFI-20 p=<.001, PSS-10 p=0.004), even allowing the severity score level to be reduced from severe to moderate. Patients reported particular improvement in abdominal pain, change in stool frequency and consistency, abdominal cramps and nausea assessed via 5-point Likert scale.

Conclusion

IBS patients have a high prevalence of existing and food-induced duodenal barrier dysfunction (62%). A multimodal integrative therapy showed a stabilisation of the gut barrier in 71% of IBS patients in a 2^nd CLE as well as significant and clinically relevant improvement in IBS-related symptom severity, quality of life and psychological well-being.

References

1) Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology. 2021;160(1):99-114.e3. doi:10.1053/j.gastro.2020.04.014
2) Martin CR, Osadchiy V, Kalani A, Mayer EA. The Brain-Gut-Microbiome Axis. Cell Mol Gastroenterol Hepatol. 2018 Apr 12;6(2):133-148. doi: 10.1016/j.jcmgh.2018.04.003.
4) Hanning N, Edwinson AL, Ceuleers H, Peters SA, De Man JG, Hassett LC, De Winter BY, Grover M. Intestinal barrier dysfunction in irritable bowel syndrome: a systematic review. Therap Adv Gastroenterol. 2021 Feb 24;14:1756284821993586. doi: 10.1177/1756284821993586.
5) Fritscher-Ravens A, Pflaum T, Mösinger M, Ruchay Z, Röcken C, Milla PJ, Das M, Böttner M, Wedel T, Schuppan D. Many Patients With Irritable Bowel Syndrome Have Atypical Food Allergies Not Associated With Immunoglobulin E. Gastroenterology. 2019 Jul;157(1):109-118.e5. doi: 10.1053/j.gastro.2019.03.046. Epub 2019 May 15.
6) Fritscher-Ravens A, Schuppan D, Ellrichmann M, Schoch S, Röcken C, Brasch J, Bethge J, Böttner M, Klose J, Milla PJ. Confocal endomicroscopy shows food-associated changes in the intestinal mucosa of patients with irritable bowel syndrome. Gastroenterology. 2014 Nov;147(5):1012-20.e4. doi: 10.1053/j.gastro.2014.07.046. Epub 2014 Jul 30.
7) Rosenthal R. et al. Myrrh exerts barrier-stabilising and –protective effects in HT-29/B6 and Caco-2 intestinal epithelial cells. Int J Colorectal Dis (2016)

Disclosure

Jost Langhorst
Fees and lecturing: Falk Foundation; Repha GmbH biological medicines; Dr. Willmar Schwabe; Medice Arzneimittel, Galapagos Pharma, Takeda Pharmaceutical, Janssen Cilag, Dr. Pfleger Arzneimittel
Research funding: Steigerwald Arzneimittelwerke GmbH, Falk Foundation, TechLab, Inc., Dr. Willmar Schwabe, Repha GmbH biological medicines,
Other financial or non-financial benefits: none
Consulting and expert activities: Medical Publishers Stuttgart; Steigerwald Arzneimittelwerke GmbH; Repha GmbH; Ferring Arzneimittel GmbH; Dr. Willmar Schwabe
Corporate investments: none
Other conflicts of interest: None

Miriam Bittel
Fees and lecturing: Falk Foundation; Weber & Weber GmbH
Research funding: Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung (DCCV)
Other financial or non-financial benefits: none
Consulting and expert activities: Weber & Weber GmbH
Corporate investments: none
Other conflicts of interest: None

The other co-authors: no conflicts of interest

Introduction

Large language models, such as ChatGPT-4, have significantly enhanced access to Artificial Intelligence (AI) tools. However, their role in clinical practice of gastroenterology remains uncertain¹. Accurate classification of esophageal varices is pivotal in managing patients with portal hypertension as it directly influences prognosis and treatment².

Aims & Methods

This study aimed to assess the potential of ChatGPT-4 as a diagnostic tool to accurately classify esophageal varices, and to compare its diagnostic accuracy and reliability to experienced and trainee endoscopists.
We collected photos taken during esophagogastroduodenoscopy performed at the Endoscopic Units of six tertiary Italian centers. The images were input into blank sheets of ChatGPT-4, which was asked to classify the varices by size, indicate the presence of red markings, and evaluate image quality in terms of insufflation, clarity and lightning. The same set of images and evaluation criteria was shown to six experienced endoscopists (E1, E2, E3, E4, E5, E6), to four junior endoscopists (J1, J2, J3, J4) and to five trainee endoscopists (T1, T2, T3, T4, T5). The evaluations from the experienced endoscopists were used as a Ground Truth. ChatGPT-4 had not undergone any prior task‐specific training for esophageal varices detection and classification.

Results

We collected 327 photos, of which 279 were considered to be of good quality by the experienced endoscopists. In detecting esophageal varices, ChatGPT-4 showed a lower AUC (0.77, 95% CI 0.66-0.88, Se 86.2%, Sp 68.4%) compared to one of the junior endoscopists (J2 AUC 0.92, 95% CI 0.87-0.98, Se 90.4%, Sp 94.4%; p<0.05) and comparable to other endoscopists (p>0.05). ChatGPT-4 showed a lower AUC (0.75, 95% CI 0.70-0.80, Se 67.6%, Sp 81.7%) than 3/4 junior endoscopist and 3/5 trainee endoscopists in distinguishing small (F1) from large (F2-F3) varices (p<0.05). For the classification of F3 varices, ChatGPT-4 achieved a higher AUC (0.71, 95% CI 0.63-0.80, Se 52.8%, Sp 89.7%) compared to one of the trainee endoscopists (T5 AUC 0.58, 95% CI 0.51-0.65; p<0.05) and comparable to that of all endoscopists (p>0.05). In identifying red signs, ChatGPT-4 (AUC 0.58, 95% CI 0.52-0.65, Se 20.5%, Sp 96.2%) performed less effectively than the endoscopists (p<0.05).

Conclusion

ChatGPT-4 achieved diagnostic accuracy comparable to junior and trainee endoscopists in detecting esophageal varices and classifying F3 varices, but it was overperformed in differentiating small (F1) from large varices (F2–F3) and in identifying red signs. While it cannot replace the clinical judgment of an experienced operator, the model shows potential as a supportive tool for training and preliminary triage of endoscopic images. Further refinement and dedicated training on endoscopic sign interpretation are needed to enhance its reliability and applicability in routine clinical practice.

References

1) Klang E, Sourosh A, Nadkarni GN, Sharif K, Lahat A. Evaluating the role of ChatGPT in gastroenterology: a comprehensive systematic review of applications, benefits, and limitations. Therap Adv Gastroenterol. 2023 Dec 25
2) Nguyen GC, Correia AJ, Thuluvath PJ. The impact of cirrhosis and portal hypertension on mortality following colorectal surgery: a nationwide, population- based study. Dis Colon Rectum. 2009 Aug