Introduction

A considerable proportion of patients with disorders of gut-brain interaction suffer from carbohydrate intolerances. The European Guideline¹ recommends a diagnostic evaluation that combines malabsorption testing using hydrogen breath tests with symptom assessment using the validated aCPQ². This study evaluates 1) the relationship between the severity of abdominal symptoms (pain, nausea, bloating, flatulence, diarrhea) in patients' histories and the results of malabsorption and intolerance testing, and 2) the response to a diet in patients diagnosed with carbohydrate intolerance (positive aCPQ) with or without malabsorption (pos. or neg. breath test).

Aims & Methods

This is a retrospective analysis of 1,139 tests performed between February 2017 and June 2024in 708 patients (62% female; mean age 42 ± 16 years) referred for evaluation of suspected carbohydrate intolerance at the Medical Universities of Graz and Vienna. Malabsorption was evaluated by breath tests (H₂ maximum rise above baseline and area under the curve), and intolerance by the aCPQ after ingestion of 50 g lactose (n=588), 25 g fructose (n=550) or 25 g trehalose (n=1). Symptom intensities over the preceding six months for diarrhea, bloating, nausea, flatulence, and abdominal pain were assessed using the Bowel Disease Questionnaire (BDQ; VAS scale 0–100 mm). 63 patients with intolerance completed a 4- to 12-week diet. Symptoms after the diet were evaluated using identical VAS scales, with symptom intensity assessed within the previous 10 days. The difference between the VAS scores of each symptom (deltaVAS) before and after diet was determined.

Results

625 tests revealed intolerance (pos aCPQ), 373 malabsorption (pos. breath test), 273 tests a combination of intolerance and malabsorption and 414 tests were negative in both tests. In patients with intolerance weak positive correlations were found between each of the five symptoms in the preceding six months and maximum symptom intensity of the respective symptom on the aCPQ (r ranging from 0.17 to 0.31; p<0.001); the strongest correlation was observed for bloating and the weakest for diarrhea. This applied for the lactose and fructose groups. These correlations were present whether or not malabsorption was detected in the breath test. No significant correlation was observed between BDQ symptom severity and breath test results. The table shows symptom severity by VAS scoring before and after diet in patients with aCPQ-diagnosed intolerance: dietary intervention led to a significant improvement in all symptom severities (p>0.001). For all of the five symptoms strong correlations were observed between baseline symptom severity in the preceding 6 months (BDQ) and the extent of symptom improvement after the diet (delta VAS; *p<0.001). Malabsorption detected by breath test did not predict dietary response. Weak positive correlations were noted between aCPQ symptom severity and deltaVAS for nausea (r=0.32; p=0.012) and bloating (r=0.37; p=0.003).

Conclusion

Diagnosis of intolerance using the aCPQ identifies patients who benefit from dietary intervention. Patients who have the most severe baseline symptom history respond the best. Symptom history is a weak predictor of carbohydrate intolerance, and breath tests are not useful for explaining baseline symptom history or guiding treatment.

References

1. Hammer HF et al. European guideline on indications, performance and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: EAGEN, ESNM and ESPGHAN consensus. United European Gastroenterol J. 2022;10:15-40 https://doi.org/10.1002/ueg2.12133
2. Hammer J et al. Carbohydrate induced gastrointestinal symptoms: development and validation of a test-specific symptom questionnaire for an adult population, the Adult Carbohydrate Perception Questionnaire aCPQ. Eur J Gastroenterol Hepatol 2021:32(2):171-177. doi: 10.1097/MEG.0000000000001880.

Introduction

The colorectal cancer (CRC) incidence and mortality might be influenced by the screening and diagnostic methods related to the precancerous lesion (adenomatous polyps) and colorectal neoplasia identification. In the Czech Republic, there are two methods available. First is the annual (in age 50–54) or biennial (in age over 50) immunochemical fecal occult blood test (FIT), followed by FIT+ colonoscopy, if positive. The second one is screening colonoscopy (in age over 50) which might be repeated in 10 years interval. Besides these screening methods, diagnostic FIT and colonoscopy are available for symptomatic patients.

Aims & Methods

Evaluation of the CRC incidence and mortality trends between years 2000 (introduction of the screening program) and 2021 (most recent data available) and target population coverage (three years interval) by screening and diagnostic FIT and colonoscopy (CRC-affecting methods) in last 10 years (2012-2022). The analysis was performed using the National Registry of Reimbursed Health Services in the Czech Republic (data since 2010) and the Registry of Preventive Colonoscopies (data since 2006).

Results

In years 2000–2021, the decrease in CRC incidence and mortality by 31.6% and 46.3%, respectively, was noticed. Target population (individuals age over 50) coverage of all CRC-affecting methods have risen in years 2012-2022 from 43.0% to 47.8%. In year 2022, the target population consists of 4,140,725 individuals and screening FITs were performed in 1,490,661 persons (36.0%), screening colonoscopies in 109,200 individuals (2.6%), diagnostic FITs in 97,505 patients (2.4%) and diagnostic colonoscopies in 283,462 patients (6.8%). In years 2006–2022, 474,063 preventive colonoscopies were done, adenomas were removed in 179,478 patients (37.9%) and colorectal cancers were diagnosed in 13,428 patients (2.8%) (48,8% of them in stage I).

Conclusion

The indirect evidence shows the probable impact of the high numbers of the screening and diagnostic fecal immunochemical tests and colonoscopies performed, adenomas removed, and early-stage cancers diagnosed on the continuous decrease of the colorectal cancer incidence and mortality in the Czech Republic.

References

Supported by program projects of the Ministry of Health of the Czech Republic with reg. no. NU22-08-00424, MO1012 and Cooperatio.