Introduction

Functional bowel disorders are among the most frequent gastrointestinal complaints. As a first step in clinical therapy, current guidelines are clear in indicating the least invasive, reversible and low morbidity treatments. In this context, soluble dietary fibers are included on some constipation and fecal incontinence guidelines.
A simple way to assess normal intestinal transit is through fecal consistency, commonly demonstrated by the Bristol Stool Scale (BSS). Hard stools (BSS types 1 and 2) can often indicate slowed intestinal transit. Similarly, individuals with normal stools (BSS 3 and 4) tend to have a lower incidence of gastrointestinal symptoms.

Aims & Methods

Objective: To evaluate the clinical response to the use of partially hydrolyzed guar gum and inulin, according to fecal consistency, as the first approach in the treatment of functional intestinal disorders.
Methods: Prospective study of 648 patients with functional bowel disorders (functional constipation, functional diarrhea, irritable bowel syndrome and anal incontinence) consecutively treated on an outpatient basis by the same researchers.
Patients were asked to take one measuring spoon (5g) of a mixture composed of partially hydrolyzed guar gum (60%) and inulin (40%) added to water, tea or juice, two times a day for a 30-day period, and to drink it within the first minute.
If BSS was 1 to 2, patients were told to mix the measuring spoon to 250 - 300 mL of water, tea, or juice. If BSS was 5 to 7, to mix it to 50 mL, and finally, if BSS was 3 to 4, to mix the measuring spoon to 200 mL.
Mean BSS, global improvement percentage, complication rate, Constipation Scoring System (CSS) and Cleveland Clinic Incontinence Score (CCIS) were applied by the authors to the patients during the first appointment and during the 30-day follow-up appointment.
All patients accepted to participate by signing the informed consent form.

Results

Of the 648 patients, 61.9% were female, with a mean age of 48.1 years. All patients informed no difficulty in complying with the soluble fiber protocol.
Initial mean CSS was 12,0 (+-4,8) and CCIS was 2 (+-1). Mean BSS of constipation patients was 2 (+- 1) of functional diarrhea and fecal incontinence was 5 (+-1) and to irritable bowel syndrome was 5 (+-1), respectively.
By the time of the 30-day follow-up appointment, 71.7% of the patients had BSS types 3 and 4, associated with 63.1% (+- 18.4) of overall improvement, while in the patients who presented the other types of fecal consistency (28.3%), the overall improvement was only 21.8% (+-14.3).Mean CSS was 6,7 (+-3,9) and CCIS was 1 (+1), p < 0,01.

Conclusion

Achieving normal fecal consistency is associated with significant overall improvement. Oral soluble fibers use according to fecal consistency are a valid tool in treating functional bowel disorders.

References

1 Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features, and Rome IV. Gastroenterology. 2016; 16: 223-7.
2 Benet LZ, Bowman CM, Koleske ML, Rinaldi CL, Sodhi JK. Understanding drug-drug interaction and pharmacogenomic changes in pharmacokinetics for metabolized drugs. J Pharmacokinet Pharmacodyn. 2019; 46: 155-63.
3 Froehner Junior I. Oral soluble fibers as a first approach to low anterior resection syndrome treatment. Neurogastroenterol Motil. 2023; 35: 77-8.
4 Froehner Junior I, Buzato JN. Fecal consistency as a marker of good response in the treatment of functional bowel movement disorders and the role of soluble fibers. [Presentation on 8º Latin American Pelvic Floor International Congress - ALAPP; 2024 fev 21-24; Panamá City, Panamá, onsite]
5 Axelrod CH, Saps M. The role of fiber in the treatment of functional gastrointestinal disorders in children. Nutrients. 2018; 10: 1650-66.
6 Ingemansson A, Walter SA, Jones MP, Sjödahl J. Defecation symptoms in relation to stool consistency significantly reflect the dyssynergy pattern in high-resolution anorectal manometry in constipated patient. J Clin Gastroenterol. 2024; 58: 57-63.
7 Heaton KW, Radvan J, Cripps H, Mountford RA, Braddon FEM, Hughes AO. Defecation frequency and timing, and stool form in the general population: a prospective study. Gut. 1992; 33: 818-24.

Introduction

Patients after laparoscopic anti-reflux surgery (LARS) report an improvement in their quality of life and significant decrease in their symptoms. In our previous study, we showed that LARS increases tissue resistance and decreases permeability (1). However, the molecular effects of this operation on mucosal integrity, which is responsible for stopping reflux attacks, are not yet understood.

Aims & Methods

In this study, changes in intercellular adhesion proteins and dilated intercellular spaces were investigated in patients before and after anti-reflux surgery. The study included 22 GERD patients (10 ERD-AB, 6 ERD-CD, 6 NERD) who received approval for LARS and 16 healthy controls (HC) without GI symptoms and with normal 24-h MII-pH monitoring & upper GI endoscopy. All patients have pathological reflux attacks. Upper GIl endoscopy was performed on HC and GERD patients before and after surgery (2-18 months later), and esophageal biopsies were obtained. The expressions of E-cadherin (CDH1), Occludin (OCLN), Claudin 1 (CLDN1), Claudin 4 (CLDN4), ZO-1 and ZO-2 were studied in the biopsies and dilated intercellular spaces (DIS) were also examined by double-blinded under light microscopy.

Results

Gene expressions of CDH1 (+1.7) and ZO-2 (+2.9) increased in GERD patients, while CDH1 (+1.7), OCLN (+3.9), ZO-1 (+3.5), and ZO-2 (+2.9) increased in Post-LARS. When compared before and after surgery, ZO-1 expression was significantly increased by 1.8-fold in Post-LARS. Post-LARS biopsies were also divided as 2-6 months and 6-18 months before and after surgery. No difference was observed in the gene expressions of patients who evaluated for follow-up within 6 months after surgery, but those who evaluated after 6 months showed a 1.5-fold increase in OCLN expression in Post-LARS biopsies. Patients were divided into phenotypes, and post-surgery results were examined. In the ERD-CD group, OCLN expression increased by 1.5 times after surgery compared to pre-LARS, while ZO-1 (-1.6) and ZO-2 (-1.7) expression decreased in the NERD group. No changes were observed in the ERD-AB group. The patients were separated into 18-45 and 45-74 age groups, it was found that Post-LARS resulted in a 1.5-fold increase in OCLN expression in individuals under 45 years old, but there was no difference in individuals over 45 years old. When the DIS characteristics of all patients were examined, it was observed that DIS of HC group was significantly lower than Pre-LARS (1.31±0.5 µm) and Post-LARS (1.26±0.6 µm) (p<0.001), but there was no significant difference between Pre-LARS and Post-LARS. No difference was found between age groups in DIS.

Conclusion

ZO-1 plays an important role in mucosal repair, and its increase in Post-LARS compared to pre-LARS may indicate improvement following cessation of acid-peptic attacks. Although no significant differences were observed in the short term after surgery (<6 months), OCLN expression increased in the long term (>6 months), which could be a molecule that contributes to the decreased permeability observed after Post-LARS. The upregulation of this gene was also observed in the ERD-CD group after LARS. Furthermore, OCLN was significantly higher in individuals under 45 years of age. This gene, which contributes to decreased permeability, appears to be activated in response to repair mechanisms in severely damaged groups and is more active in younger individuals. In the NERD group, where mucosal integrity was not compromised, the downregulation of ZO genes may be due to the absence of repair mechanisms. The lack of change in DIS after LARS suggests that the dilatations between cells might be irreversible.

References

1. Ergun P., Kipcak S., Bor S. Transepithelial tissue permeability in esophageal epithelium decreases in patients with gastroesophageal reflux disease following anti-reflux surgery. 27th UEG Week 2019: Barcelona, Spain, October 2019. United European Gastroenterology Journal. 2019;7(8_suppl):1-3 (page 708).

Introduction

Dynamic transperineal ultrasound (DTP-US) enables the calculation of the pubo-rectal muscle (PR) length and the ano-rectal angle (ARA) width, offering a static and dynamic evaluation of the pelvic floor. DTP-US is usually followed by a Gel Expulsion Test (GET), in the same way that high-resolution anorectal manometry (HR-AM) is usually followed by balloon expulsion test (BET).
DTP-US+GET may be an innovative way of testing constipated patients for functional defecation disorders (FDD) diagnosis.

Aims & Methods

Our aims were: to determine normal values for DTP-US; to explore accuracy of DTP-US+GET in diagnosing a Rome IV FDD. To obtain normal values, 17 healthy females (HVs) underwent DTP-US+GET.
Fifty-six females meeting Rome IV criteria for functional constipation (FC) underwent DTP-US+GET.
Measurements were acquired in supine (SUP) and left lateral (LL) positions. At rest, during squeezing and during straining were evaluated: PR length; ARA width; variation in length of PR and in width of ARA between rest and squeezing or straining (expressed as a percentage of the resting measurement).
All 56 FC patients previously underwent HR-AM+BET. DTP-US examiners were blinded to HR-AM+BET result.
GET was performed in a sitting position filling the rectum with ultrasound gel (120 ml). GET was considered positive if patient was unable to evacuate gel after 30 seconds.

Results

No differences were observed in mean age between HVs and FC groups (p=0.57).
Thirty-eight patients (67.86%) showed a FDD on HR-ARM+BET. Thirty-eight patients showed a positive GET. No HVs failed GET.
DTP-US straining results are summarized in Table-1. FDD patients showed different mean values for straining measurements compared with HVs (p<0.001): HVs showed an increase in PR length and an increase in ARA; FDD showed a length reduction in PR and a closure of ARA.
To diagnose FDD, at least 3 out of 4 abnormal values on percentage variations during straining and a positive GET were needed: abnormal DTP-US+GET showed a strong association with FDD (OR 198.33), with a sensibility of 92.11%, a specificity of 94.44% and an accuracy of 94.42% in diagnosing FDD.

Table-1 –DTP-US values and differences between HV and FDD group

Conclusion

DTP-US+GET is an innovative and promising new technique to diagnose FDD in constipated patients. It can be performed by a skilled gastroenterologist, is not expensive and requires only a convex probe, with no radiation exposure. In this pilot study, we provided normal values for DTP-US and tested these values to diagnose FDD in a set of constipated patients, obtaining a diagnostic accuracy of 94.42%.

Introduction

Critically ill patients are at high risk for upper gastrointestinal (GI) bleeding.¹ Proton pump inhibitors (PPIs) are commonly used for prophylaxis, but their safety and efficacy compared to histamine-2 receptor antagonists (H2 blockers) and placebo remain unclear.^1–4

Aims & Methods

Our systematic review and meta-analysis aims to assess the safety and efficacy of PPIs for preventing upper GI bleeding in critically ill adults. We conducted a comprehensive search of Scopus, Web of Science, PubMed, and Cochrane Central for relevant randomized controlled trials (RCTs) from inception until March 2024. Data were extracted from eligible studies and pooled as mean difference (MD) for continuous outcomes and Odds ratio (OR) for dichotomous data in a random-effect model meta-analysis, using R software.

Results

Nineteen RCTs were included in this meta-analysis with a total of 62221 patients. Our study showed that PPI was superior to control in terms of GI bleeding [RR 0.55, (95% CI, 0.42 to 0.72); P = <0.01]. However, the overall effect did not favor either of the two groups in terms of ICU, mortality rate, and nosocomial infection [MD -1.45, (95% CI, -5.31 to 2.42); P = 0.4], [RR 1.04, (95% CI, 1.00 to 1.09); P = 0.07], and [RR 1.27, (95% CI, 0.98 to 1.65); P = 0.07], respectively.

Conclusion

In conclusion, our findings demonstrated a significant reduction in GI bleeding risk associated with PPI use. At the same time, we did not find a statistically significant difference between PPI and control groups regarding ICU mortality rate, overall mortality rate, or nosocomial infection rates. These findings suggest that PPIs may be effective in reducing upper GI bleeding in critically ill patients. However, further research might be necessary to definitively determine the impact of PPIs on mortality and infection risks in this population.

References

.1. Wang Y, Ye Z, Ge L, et al. Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: Systematic review and network meta-analysis. The BMJ. 2020;368. doi:10.1136/bmj.l6744
2. Kondo Y, Ohbe H, Matsui H, Fushimi K, Tanaka H, Yasunaga H. Proton pump inhibitors versus histamine-2 receptor antagonists for stress ulcer prophylaxis during extracorporeal membrane oxygenation: a propensity score-matched analysis. BMJ Open. 2020;10(9):e037534. doi:10.1136/bmjopen-2020-037534
3. Alshamsi F, Belley-Cote E, Cook D, et al. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: A systematic review and meta-analysis of randomized trials. Crit Care. 2016;20(1). doi:10.1186/S13054-016-1305-6
4. Jung YS, Park JH, Park CH. Impact of proton pump inhibitors on the risk of small bowel or colorectal bleeding: A systematic review and meta-analysis. United European Gastroenterol J. 2023;11(9):861-873. doi:10.1002/ueg2.12448

Introduction

Standard-of-care treatments for gastroesophageal reflux disease (GERD) include proton pump inhibitor (PPI)-based medical management and conventional antireflux surgery (i.e., Nissen fundoplication). However, these modalities are associated with a significant burden of unmet needs, such as irresponsiveness and postoperative adverse events (AEs), respectively. This study presents the results of 158 patients managed with RefluxStop in Germany.

Aims & Methods

One-hundred fifty-eight reflux patients were treated with RefluxStop between July 2021 and November 2023. Clinical endpoints included GERD Health-Related Quality of Life (GERD-HRQL), postoperative AEs, and change in PPI use.

Results

Baseline characteristics are shown in Table 1. Median GERD-HRQL score improved by 90.9% from a baseline of 22 (IQR 19-31.5) to 2 (IQR 0-2) at 20±7-month follow-up (p<.001). A 96.3% reduction in PPI use was also observed; baseline PPI use in 96.5% of n=113 decreased to 3.6% of n=110 at follow-up. All cases of preoperative dysphagia (n=18) resolved after surgery. New-onset dysphagia occurred in five patients (3.2%) postoperatively but did not require esophageal dilation. Hiatal hernia recurred in 1.3% (n=2) of patients and was managed with device repositioning. Device penetration and migration occurred in 1.3% (n=2) of patients due to excessively tight suturing of the fundic pouch in which the device was invaginated. One of these patients was later treated by Toupet fundoplication.

Table 1 Baseline characteristics

Conclusion

This report demonstrates the promising clinical effectiveness of RefluxStop as a novel treatment principle in management of GERD. Additional evaluation is necessary to enhance the evidence supporting this new antireflux procedure.

Disclosure

The authors disclose travel grants and speaking honoraria from Implantica (Zug, Switzerland).

Introduction

Helicobacter pylori eradication with standard triple therapy fails in ≥20% of the cases, mainly due to bacterial antibiotic resistances. Non-bismuth quadruple concomitant therapy is among the most widely used first-line treatments against H. pylori infection, even in high clarithromycin resistance areas.

Aims & Methods

To evaluate the efficacy and safety of non-bismuth quadruple concomitant therapy (proton pump inhibitor, clarithromycin, amoxicillin and nitroimidazole) in the treatment of H. pylori infection, and to compare it with other triple and quadruple regimens.
Bibliographical searches were performed in PubMed up to April 2024. We performed a meta-analysis of the studies evaluating the concomitant therapy as a first-line regimen, and of the randomised controlled trials comparing concomitant vs. standard triple, sequential, hybrid, and bismuth quadruple therapies.

Results

115 studies (78 randomised trials) were included (23,454 patients); 39 studies compared concomitant vs triple (13,494 patients), 38 studies vs sequential (11,907 patients), 12 studies vs hybrid (3,719 patients) and 11 studies vs bismuth quadruple (3,258 patients). Concomitant regimen achieved an overall eradication rate of 86% (95%CI=85-86%) by intention-to-treat, and 90% (90-91%) by per-protocol. Concomitant therapy achieved high eradication rates even in single clarithromycin resistant (89%) and metronidazole resistant (95%) patients, but poor cure rates in dual (clarithromycin and metronidazole) resistance (68%). The overall efficacy by intention-to-treat with concomitant therapy was significantly higher as compared to both triple therapy (risk difference [RD]=0.11; 95%CI=0.09-0.14; 39 studies) and sequential therapy (RD=0.04; 0.02-0.06; 38 studies); however, in the latter comparison, when only 14-day prescriptions were considered, no significant differences were observed (RD=0.01; -0.05-0.06; 4 studies). Likewise, the overall efficacy of concomitant therapy was similar to hybrid (RD=0.01; -0.01-0.03; 12 studies), and to bismuth quadruple therapy (encompassing the classical form and the single-capsule (RD=0.01; -0.03, 0.06; 11 studies). The overall incidence of adverse events with concomitant therapy was 37% (36-38%) (85 studies). When comparing only the studies with the same treatment durations, the incidence of adverse events with concomitant therapy was similar to that of triple (RD=0.04; -0.01-0.09; 15 studies), sequential (RD=0.03; -0.00-0.06; 16 studies), and bismuth quadruple therapies (RD=0.02; -0.06-0.09; 7 studies), but higher than that of hybrid therapies (RD=0.10; 0.04-0.15; 7 studies).

Conclusion

Non-bismuth quadruple concomitant therapy is highly effective for H. pylori eradication (achieving a cure rate of approximately 90%), even in the presence of clarithromycin or metronidazole resistance, being superior to standard triple and sequential therapies, and similar to hybrid and bismuth quadruple regimens. The incidence of adverse events with concomitant treatment is relatively high (37%), similar to that of triple and bismuth quadruple regimens.

Disclosure

Javier P. Gisbert has served as speaker, consultant, and advisory member for or has received research funding from: Mayoly, Allergan/Abbvie, Diasorin, Richen, Juvisé and Biocodex.
Olga P. Nyssen received research funding from: Mayoly, Allergan/Abbvie, Richen, Juvisé and Biocodex.