Introduction

Irritable bowel syndrome (IBS) is a highly prevalent disorder. According to Rome IV, the diagnosis relies on the presence of abdominal pain in association with a change in stool consistency or frequency. Guidelines recommend minimal testing to exclude other diseases, while advising on therapeutic options. However, the actual application of these guidelines into practice needs confirmation.

Aims & Methods

This study aims to assess the management of IBS by general practitioners (GP) and gastro-enterologists (GE) in their daily practice. Methods: Belgian GP and GE completed an online vignette-based survey between January and July 2022. Apart from data about years of experience, participants indicated their preferred diagnostic modality or therapeutic option for eight cases of diarrhoea-predominant IBS. Cases varied in age (25, 48 and 65 years), cardinal symptom (pain, discomfort, or diarrhoea) and availability of test results (none, limited to biochemistry and ultrasound, or extensive including endoscopy), while stressing out the prolonged duration of the symptoms and the absence of red flags. Frequencies were compared by Chi-square. The main determinants to the diagnosis of IBS were assessed by logistic regression.

Results

Sixty-four gastroenterologists and 31 general practitioners completed the survey. When considering pain and discomfort as cardinal symptoms in a young patient, 87.4% and 84.1% of participants diagnosed IBS, which decreased to 58.3% with diarrhoea. The diagnosis of IBS dropped to 26.8% for a patient of 65 years. In those cases, GP less frequently diagnosed IBS (all p<0.05), except with diarrhoea as cardinal symptom (p=0.78). According to logistic regression, diagnosing IBS was related to patient age, cardinal symptom, availability of prior test results and specialty, and only borderline related to the experience of the practitioner (p<.001, R²=.293). Even when diagnosing IBS, 89.5% ordered one or more additional tests (77.9% biochemistry, 59.3% stool culture and parasites, 60.5% faecal occult blood testing, 17.4% breath testing, 12.8% imaging, 9.3% endoscopy). Upon normal results, 57% would not order further investigations. Both GP and GE opted for spasmolytics (62.3%) and dietary interventions (28.3%) as the preferred first-line treatment for IBS. Second-line treatment consisted of referral to a specialist or colleague (19.4%), dietary intervention (22.6%), neuromodulators (19.4%) and spasmolytics (14.5%). In second-line, GP favoured referral (61.1%) and dietary intervention (22.2%), while GE preferred neuromodulators (27.3%) and spasmolytics (18.2%). No GP initiated modulators. Similar figures were obtained in third-line.

Conclusion

In Belgium, abdominal pain or discomfort are equivalent cardinal symptoms when diagnosing IBS. Diarrhoea as cardinal symptom, older age and absence of prior testing lowered the preference for IBS, especially in GPs. Even when diagnosing IBS, healthcare providers order a large variety of tests. Spasmolytics and dietary interventions are favoured in first-line. Upon failure, only GE prescribe neuromodulators, while GP opt for referral. Future education of GP and GE should focus on harmonising the diagnostic approach and medical treatment of IBS with existing guidelines.

Disclosure

Consultancy for Truvion Healthcare

Introduction

Chronic constipation (CC) is one of the most frequent non-motor features of Parkinson’s Disease (PD). Previous studies highlighted the association of CC with PD duration and severity [1]. Furthermore, gut microbiota changes and brain-gut-axis (BGA) dysregulation are common in PD and these alterations are related with clinical manifestations [2,3]. For this reason, probiotics, balancing the gut microbiota, are emerging as a potential therapeutic approach in PD patients.

Aims & Methods

Objective: To evaluate the patients’ satisfaction rates as well as gastroenterological and neurological effects of the administration of a synbiotic in PD patients with CC.
Methods: This study enrolled patients with stable PD who fulfilled Rome IV Criteria for CC or irritable bowel syndrome with constipation (IBS-C). Patients received a synbiotic treatment (Enterolactis ® duo, 4 sachets/day, containing probiotic Lactobacillus casei and prebiotic inulin) for 12 weeks. Two primary endpoints were chosen to monitor the satisfaction with therapy (SWT). SWT was defined when patients were satisfied (satisfaction score >4 on a 7-point Likert scale) or improved after therapy (increase in the global rating of change scale of at least two points on a -7 to +7 visual analogue scale). In addition, a gastrointestinal (GI) evaluation with the Patient Assessment of Constipation-symptoms questionnaire (PAC-SYM), number of complete bowel movements per week, Bristol stool Scale (BSS) were calculated before and after the treatment. The neuropsychological evaluation was performed by the Montreal Cognitive Assessment (MoCA), Movement Disorder Society-Sponsored Revision of Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), SCales for Outcomes in Parkinson’s disease - Autonomic Dysfunction (SCOPA-AUT), Toronto Alexithymia Scale (TAS-20), Reading the Mind in the Eyes Test (RMET), Parkinson Anxiety Scale (PAS), State-Trait Anxiety Inventory (STAI-Y), Beck Depression Inventory (BDI II), Hamilton depression rating scale (HAM-D) pre- and post-intervention.

Results

30 patients (10 F) were consecutively enrolled. Satisfaction >4 (endpoint 1) significantly changed from 17% to 60% patients after treatment, p = 0.002. The calculated satisfaction score significantly increased from 4(1) to 5(2) (median (IQR), p = 0.003. Improvement after treatment (endpoint 2) was achieved by 83% of patients. The Global Rating of Change Score changed significantly from 0(3) to 4(2)(median (IQR), p < 0.001. Moreover, a beneficial effect of treatment was shown on GI symptoms. Specifically, PAC-SYM Questionnaire score changed from 1.42(0.94) to 0.91(0.77), p < 0.001, number of complete bowel movements per week from 3(3.5) to 5.5(4.1) p < 0.001 and Bristol stool Scale (BSS) from 2(2) to 3(2) p < 0.001. After treatment PD patients performed better in motor and non-motor features. Specifically, the scores (median (IQR) of TAS-20 significantly changed from 55.0 (22) to 49.5 (21), p=0.03, SCOPA-AUT from 17.0 (7) to 13.5 (10), p = 0.002, MDS-UPDRS part 1 from 13.5 (13) to 9.0 (6), p = 0.001, HAM-D score from 12.5(10) to 9.0 (12), p = 0.045. PAS-A showed a trend towards significance from 7.0(6) to 5.0(7), p = 0.06.

Conclusion

Our results showed that a considerable number of PD patients with CC or IBS-C were satisfied with their defecation after treatment. GI symptoms as well as motor and non-motor features in PD patients improved. Our data suggest that the addition of a synbiotic Enterolactis ® duo may be a useful therapeutic approach in PD possibly acting on the gut-brain-gut axis.

References

References
[1] Krogh K, Ostergaard K, Sabroe S, Laurberg S. Clinical aspects of bowel symptoms in Parkinson’s disease. Acta Neurol Scand. 2008;117(1):60-64.
[2] Shen T, Yue Y, He T, Huang C, Qu B, Lv W, Lai HY. The Association Between the Gut Microbiota and Parkinson’s Disease, a Meta-Analysis. Front Aging Neurosci. 2021 Feb 12;13:636545.
[3] Scheperjans F, Aho V, Pereira PA, et al. Gut microbiota are related to Parkinson’s disease and clinical phenotype. Mov Disord. 2015;30(3):350-358.

Introduction

Endoscopic mucosal resection has been associated with lesion recurrence in 16%-27% of cases. Guidelines recommend endoscopic follow-up but it is unclear if endoscopic assessment has to include biopsies.

Aims & Methods

This study aims to evaluate the recurrence prediction of white light endoscopy (WLE) and narrow band imaging (NBI) in the assessment of colorectal mucosal resection scar. We performed a systematic review in PubMed, Embase, Cochrane and Web of Science databases, searching for studies comparing WLE and NBI. Statistical analysis included data pooling and heterogeneity testing. Quality of the included studies was assessed by Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2).

Results

The meta-analysis included 5 studies and 798 mucosal resections. The pooled sensitivity and specificity and AUC for WLE were 80.9% (95% CI 71.8% to 87.5%), 95.6% (95% CI 92.0% to 97.6%) and 0.917 (95% CI 0.885 to 0.972), respectively. The pooled sensitivity and specificity and AUC for NBI were 92.1% (95% CI 87.3 to 95.2%), 94.1% (95% CI 91.9% to 95.7%) and 0.935 (95% CI 0.772 to 0.972), respectively. There was no difference in AUC of WLE and NBI (p=0.633).

Conclusion

Our study demonstrates a high sensitivity, specificity and accuracy for endoscopic diagnosis of recurrent lesions after colorectal mucosal resection, specially with NBI. In all cases of low confidence assessment, biopsy is required.

References

1. Desomer L, Tutticci N, Tate D, Williams S, McLeod D, Bourke M. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointest Endosc. 2017 Mar;85(3):518–26.
2. Kandel P, Brand EC, Pelt J, Ball CT, Chen WC, Bouras EP, et al. Endoscopic scar assessment after colorectal endoscopic mucosal resection scars: when is biopsy necessary (EMR Scar Assessment Project for Endoscope (ESCAPE) trial). Gut. 2019 Sep;68(9):1633–41.
3. Pu L, Chiam K, Yamamura T, Nakamura M, Berzin T, Mir F, et al. Narrow-band imaging for scar (NBI-SCAR) classification: From conception to multicenter validation. J Gastroenterol Hepatol. 2019 Sep;34:227–8.
4. Riu Pons F, Andreu M, Gimeno Beltran J, Álvarez-Gonzalez MA, Seoane Urgorri A, Dedeu JM, et al. Narrow band imaging and white light endoscopy in the characterization of a polypectomy scar: A single-blind observational study. World J Gastroenterol. 2018 Dec 7;24(45):5179–88.

Introduction

Vedolizumab (VDZ) is approved in Europe and the USA for the treatment of moderately to severely active ulcerative colitis (UC). Real-world evidence is needed to assess the effectiveness and benefit–risk profile of VDZ for UC outside clinical trial settings. A systematic literature review (SLR) and meta-analysis published in 2018 confirmed the real-world effectiveness and positive benefit–risk profile of VDZ treatment for up to 1 year in patients with inflammatory bowel disease.¹ Further real-world evidence is required to support the long-term (> 1 year) effectiveness of VDZ in patients with UC.

Aims & Methods

The aims of the current meta-analysis based on the SLR were to evaluate the rates of treatment persistence at 1 and at 2 years and of mucosal healing and corticosteroid-free clinical remission at 1 year (overall and stratified by biologic-naive versus biologic-experienced patients). Literature searches identified studies published from 2014 to 2022. For the SLR overall, outcomes of interest included clinical remission, mucosal healing, treatment patterns (including treatment persistence) and safety. Data on adults with UC treated with vedolizumab in a real-world setting were extracted for meta-analysis if there were at least 2 studies for each timepoint and population. Weighted proportions and corresponding 95% confidence intervals (CIs) were calculated using the DerSimonian-Laird random-effects model to account for between-study heterogeneity.

Results

Data from 68 studies of 21 774 patients with UC had at least one outcome of interest for analysis. The mean age ranged from 34.0–53.0 years (16 studies), the mean disease duration ranged from 4.9–10.4 years (5 studies) and the mean partial Mayo score ranged from 4.1–6.1 (6 studies). In the 28 and 9 studies that assessed treatment persistence at 1 and at 2 years, the rates of treatment persistence were 72.4% (95% CI 68.7–75.8) and 64.2% (95% CI 55.3–72.2), respectively. Similar treatment persistence rates at 1 year were observed among biologic-naive vs biologic-experienced patients, but at 2 years higher rates were observed for biologic-naive patients vs overall (Table). The overall mucosal healing rate at 1 year (assessed in 29 studies) was 42.6% (95% CI 37.0–48.3), and similar rates were observed in biologic-naive vs biologic-experienced patients (Table). The corticosteroid-free clinical remission rates at 1 year were 42.7% (95% CI 38.4–47.1; 22 studies) and at 2 years 43.4% (95% CI 27.9–60.2; 5 studies); higher rates were observed among biologic-naive vs biologic-experienced patients at 1 year (Table).

Conclusion

This meta-analysis of real-world studies of VDZ demonstrated high rates of long-term treatment persistence, mucosal healing and corticosteroid-free clinical remission in patients with UC, indicating effective disease management for these outcomes. However, the assessment of mucosal healing rates may not have been systematically conducted across all studies.
This study was funded by Takeda Pharmaceuticals International AG, Zurich, Switzerland.
Writing assistance provided by E Sugrue, PhD, of Oxford PharmaGenesis.

References

Schreiber S et al. J Gastroenterol. 2018;53:1048–64.

Disclosure

MC has served as a speaker or consultant, or has received funding for research or education, from AbbVie, Biogen, Dr Falk Pharma, Eli Lilly, Ferring, Gilead, Hospira, Janssen, MSD, Pfizer, Shire Pharmaceuticals, Takeda and Tillotts Pharma.
AA has received advisory board/lecture fees from AbbVie, Amgen, Arena, AstraZeneca, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion Healthcare, Dr Falk Pharma, Eli Lilly, Ferring, Galapagos, Gilead, Janssen, Lion Health, MSD, Nestlé, Novartis, Pfizer, Protagonist Therapeutics, Roche, Samsung Bioepis, Sandoz, Takeda, Teva Pharmaceuticals and Tillots Pharma.
PB is an employee and stockholder of Takeda Pharmaceuticals International AG, Zurich, Switzerland.
MM is an employee and stockholder of Takeda Pharma AG, Zurich, Switzerland.
ER is an employee of Putnam Associates, which received funding for this study from Takeda Pharmaceuticals International AG, Zurich, Switzerland.
CS is an employee of Putnam Associates, which received funding for this study from Takeda Pharmaceuticals International AG, Zurich, Switzerland.
SS has received personal fees from AbbVie, Amgen, Arena, Biogen, Bristol Myers Squibb, Celgene, Celltrion Healthcare, Dr Falk Pharma, Fresenius, Galapagos/Gilead, Hikma, I-Mab, Janssen, MSD, Mylan, Pfizer, Protagonist Therapeutics, ProventionBio, Takeda, Theravance Biopharma and Ventyx.
SV has received financial support for research from AbbVie, Galapagos, J&J, Pfizer and Takeda, and speakers’ and/or consultancy fees from AbbVie, Abivax, AbolerISPharma, AgomAb, Alimentiv, Arena Pharmaceuticals, AstraZeneca, Bristol Myers Squibb, Boehringer Ingelheim, Celgene, Cytoki Pharma, Dr Falk Pharma, Eli Lilly, Ferring, Galapagos, Genentech-Roche, Gilead, GSK, Hospira, Imidomics, Janssen, J&J, Materia Prima, Mestag Therapeutics, MiroBio, Morphic, MrMHealth, Mundipharma, MSD, Pfizer, Prodigest, Progenity, Prometheus, Robarts Clinical Trials, Surrozen, Takeda, Theravance Biopharma, Tillots Pharma AG, VectivBio, Ventyx and Zealand Pharma.

Introduction

The modality for colorectal cancer (CRC) screening has transferred from guaiac fecal occult blood testing (gFOBT) to fecal immunochemical testing (FIT), but its sensitivity remains lower. While total colonoscopy (TCS) has been anticipated as a new modality for CRC screening, conclusive results based on randomized controlled trials (RCTs) are still pending. Test performance RCTs have been utilized to predict the effectiveness of new modalities for CRC screening. They were adopted for the evaluation of cancer screening using a stepwise approach in the World Endoscopic Evaluation (Young et al. Cancer 2016).

Aims & Methods

A systematic review of test performance RCTs for CRC screening was conducted. Candidate articles were searched from inception to October 14, 2023, using Ovid MEDLINE, Cochrane Central Registry, Embase, and Ichushi-web. We compared the test performance of TCS screening, referring to the following modalities: gFOBT, FIT, flexible sigmoidoscopy (FS), and CT colonography (CTC). Single and multiple rounds were searched. Test performance indicators included participation rates in CRC screening, advanced neoplasia (AN) detection rates, and CRC detection rates. The primary results were evaluated using an intention-to-screen (ITS) based network meta-analysis, and a per-protocol analysis was also performed.

Results

Seventeen RCTs (13 from Europe, two from the US, and one each from Israel and China), involving a total of 341,123 healthy screening invitees, were included. The median participation rates for the programs based on FIT, FS, and TCS were 50.4 % (28.6-94.0%), 32.3% (7.9-52.1%), and 21.5% (10.0-42.5%), respectively. In the network meta-analysis, participation rates for TCS screening were significantly lower than the programs based on FS (RR=0.58; CI: 0.37-0.89), FIT (RR=0.45; CI: 0.31-0.65), and gFOBT (RR=0.45; CI: 0.30-0.69). Detection rates for AN were consistently higher for TCS than for FIT (RR= 2.18, 95%CI:1.46-3.26) but not statistically significant for FS (RR=1.06, 95CI: 0.65-1.73). Similarly, TCS had higher CRC detection rates compared to FIT (RR= 1.80, 95%CI:1.04-3.12) and FS (RR= 1.52, 95%CI:0.87-2.64). While AN and CRC detection rates for TCS were higher than those of CTC, the differences were not statistically significant (AN: RR= 1.02, 95%CI:0.65-1.73, CRC: RR= 0.73 95%CI: 0.32-1.64). The follow-up period of single-round RCTs was limited until diagnosis, but the screening frequency varied depending on the follow-up duration, which could affect effectiveness. Screening intervals were typically two years for FIT, five years for FS, and ten years for CS. One quasi-experimental study combined the following arms from different RCTs with extended follow-up: one-time CS, one-time FS, and four rounds of FIT (Grobbee et al. Clin Gastroenterol Hepatol 2020). The participation rate was higher for FIT (73%) compared to FS (31%) and CS (24%). Cumulative AN and CRC detection rates were higher for FIT (AN = 4.5%, 95%CI:4.2-4.9, CRC =0.5% 95%CI: 0.4–0.6), but nearly equivalent for CS (AN = 2.2%, 95%CI:1.8-2.6, CRC =0.2% 95%CI: 0.1–0.3) and FS (AN = 2.3%, 95%CI:2.0-2.7, CRC =0.2% 95%CI: 0.1–0.3).

Conclusion

The single-round test performance of colonoscopy screening might be superior to that of other modalities. To confirm the priority of TCS, it is insufficient to draw conclusions based on the results of a single-round performance, given variations in screening intervals and frequencies among other modalities. Cumulative effects among different modalities should be compared within the same follow-up period.

References

Young GP, Senore C, Mandel JS, et al. Recommendations for a step-wise comparative approach to the evaluation of new screening tests for colorectal cancer. Cancer. 2016;122(6):826-39.

Grobbee EJ, van der Vlugt M, van Vuuren AJ, et al. Diagnostic yield of one-time colonoscopy vs one-time flexible sigmoidoscopy vs multiple rounds of mailed fecal immunohistochemical tests in colorectal cancer screening. Clin Gastroenterol Hepatol. 2020;18(3):667-75.

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality [1-3]. Upper gastrointestinal endoscopy is currently recommended as the gold standard modality for both diagnosis and treatment [4]. As historically played a limited role in the diagnosis of acute NVUGIB, multidetector-row computed tomography angiography (MDCTA) is emerging as a promising tool in the diagnosis of NVUGIB, especially for severe cases [5-6]. However, to date, evidence concerning the role of MDCTA in the NVUGIB diagnosis is still lacking.

Aims & Methods

The purpose of this study was to retrospectively investigate the diagnostic performance of emergent MDCTA performed prior to any diagnostic modality or following urgent upper endoscopy to identify the status, the site and the underlying etiology of severe NVUGIB. Institutional databases were reviewed in order to identify severe acute NVUGIB patients who were admitted to our bleeding unit and were referred for emergent MDCTA prior to any hemostatic treatment (<3 hours) or following (<3 hours) endoscopy, between December 2019 and October 2022. The study aim was to evaluate the diagnostic performance of MDCTA to detect the status, the site and the etiology of severe NVUGIB with endoscopy, digital subtraction angiography, surgery, pathology or a combination of them as reference standards.

Results

A total of 68 patients (38 men, median age 69 years [range 25–96]) were enrolled. The overall MDCTA sensitivity, specificity, and accuracy to diagnose bleeding status were 77.8% (95% CI: 65.5-87.3), 40% (95% CI: 5.3-85.3), and 75% (95% CI: 63.0-84.7), respectively (Table 1). Finally, the overall MDCTA sensitivity to identify the bleeding site and the bleeding etiology were 92.4% (95% CI: 83.2-97.5) and 79% (95% CI: 66.8-88.3), respectively.

Table 1. The diagnostic performance of MDCTA in detecting bleeding status.

Conclusion

MDCTA seems to be a feasible and effective modality in detecting the site, the status and the etiology of severe acute NVUGIB. It may play a crucial role in the management of selected cases of NVUGIB, especially those clinically severe and/or secondary to rare and extraordinary rare sources, effectively guiding timing and type of treatment. However, further large prospective studies are needed to clarify the role of MDCTA in the diagnostic process of acute NVUGIB.

References

1. Wuerth BA, Rockey DC. Changing Epidemiology of Upper Gastrointestinal Hemorrhage in the Last Decade: A Nationwide Analysis. Dig Dis Sci 2018; 63: 1286–1293.
2. Laine L, Yang H, Chang S-C, et al. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol 2012; 107: 1190–1195; quiz 1196.
3. Sanders DS, Perry MJ, Jones SGW, et al. Effectiveness of an upper-gastrointestinal haemorrhage unit: a prospective analysis of 900 consecutive cases using the Rockall score as a method of risk standardisation. Eur J Gastroenterol Hepatol 2004; 16: 487–494.
4. Gralnek IM, Stanley AJ, Morris AJ, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2021. Endoscopy 2021; 53: 300–332.
5. Napoli A, Fleischmann D, Chan FP, et al. Computed tomography angiography: state-of-the-art imaging using multidetector-row technology. J Comput Assist Tomogr 2004; 28 Suppl 1: S32-45.
6. Wu L-M, Xu J-R, Yin Y, et al. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: a meta-analysis. World J Gastroenterol 2010; 16: 3957–3963.

Disclosure

No conflict of interest to declare.