Gastroenterology最新文献

Background & aims: The optimal timing for direct endoscopic necrosectomy (DEN) following endoscopic ultrasound (EUS)-guided transmural drainage of symptomatic necrotizing pancreatitis remains unknown. We hypothesized that immediate DEN following EUS-guided drainage might reduce the time to disease resolution compared with a drainage-oriented step-up approach.

Methods: This study was a multicenter, open-label, superiority randomized trial (WONDER-01). Among patients who received EUS-guided treatment for symptomatic necrotizing pancreatitis, eligible patients were randomly assigned 1:1 to receive either immediate DEN or the drainage-oriented step-up approach. The primary endpoint was the time from randomization to clinical success, defined as a decrease in collection size to ≤3 cm and an improvement in inflammatory markers.

Results: Seventy patients were enrolled in this study: 33 in the immediate DEN arm and 37 in the step-up arm. Immediate DEN was associated with a shorter time to clinical success than the step-up approach (P = .009), with median times (95% confidence interval) of 29 (19-34) and 44 (38-52) days, respectively. All patients in the immediate DEN arm received DEN compared to 46% in the step-up approach arm, but the rates of procedure-related adverse events were comparable (24% vs 22%, respectively; P = .79). No significant differences were noted between the treatment arms in terms of technical success (100% vs 97%, P > .99) and mortality (12% vs 5.4%, P = .41).

Conclusion: Compared with the step-up approach, immediate DEN following EUS-guided drainage of necrotizing pancreatitis reduced time to clinical success without increasing adverse outcomes but required more DEN procedures (ClinicalTrials.gov, Number: NCT05451901).

Bowel Disorders (BDs), previously termed functional bowel disorders, are highly prevalent disorders worldwide. These disorders affect individuals across all demographic and socioeconomic groups and have substantial economic, in addition to a significantly reducing quality of life. Since the Rome IV publication in 2016 research in the basic and clinical sciences has provided new insights in epidemiology, etiology, pathophysiology, diagnosis, and treatment of BDs, creating the need to revise the diagnostic framework of BDs. This article presents the updated Rome V classification of BDs in 6 distinct categories: irritable bowel syndrome, chronic constipation, functional diarrhea, functional abdominal bloating, unclassified BD and opioid-induced constipation. Each disorder is defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, pathophysiology and treatment. It is in hope that the Rome V BD Committee will assist clinicians and researchers in improving diagnosis, patient care and scientific endeavors of these common and burdensome disorders.

The digestive tract plays a key role in maintaining homeostasis and the general well-being of the human body via complex physiological functions. These gastrointestinal functions include motility; mixing of ingesta with pancreatic, biliary, and enteric secretions; absorption of digested nutrients; and disposal of undigested residues. Such processes usually occur without conscious perception. However, about 30-40% of the general population complain of digestive symptoms, often triggered by meal intake. Most of these people will be labelled as having a disorder of gut-brain interaction (DGBI). The pathophysiology of DGBI is complex, and not only involves bidirectional dysregulation of gut-brain interaction (via the gut-brain axis) but also microbial dysbiosis within the gut, altered mucosal immune function, increased epithelial barrier permeability, visceral hypersensitivity, and abnormal gastrointestinal motility. In this article, normal physiology and pathophysiology of GI function, and processes underlying symptom generation are reviewed. This article provides a thorough appraisal of symptom profiles, pathogenesis and functional tests of the wide array of DGBI.

This article describes the development of the Rome V adult and pediatric diagnostic questionnaires. Important updates from the Rome IV versions included improved response scaling, new questions to diagnose 3 additional adult DGBI and 14 additional pediatric DGBI (compared to the Rome IV questionnaires), extra questions to clarify the context of DGBI symptoms for research purposes, and the addition of anatomical images to enhance response accuracy. The performance of the Rome V adult questionnaire was tested in Internet surveys in 15 countries, and the pediatric questionnaires in 4 countries. The results indicate that the new questionnaires generally identify DGBI to a similar degree and with the same demographic patterns as the prior Rome IV versions. The Rome V Questionnaire Committee concluded that these new diagnostic questionnaire versions are well suited for epidemiologic and clinical research of DGBI in the Rome V era for both adult and pediatric populations.

Dysfunctional Gallbladder Disorder (DGBD) and Sphincter of Oddi Disorder (SOD) are possible causes of abdominal pain, biliary obstruction, and acute pancreatitis, and are often invoked when a structural etiology is not obvious. Diagnosis was traditionally based on gallbladder scintigraphy and sphincter of Oddi manometry, both of which have fallen out of favor and are no longer part of the Rome diagnostic criteria. For DGBD, the presence of typical biliary pain and persistence of symptoms despite watchful waiting, and for SOD, objective evidence of biliary obstruction and pancreatitis are now central to the diagnosis. With growing recognition that these disorders have traditionally been over-diagnosed and their treatments - which are risky - have been overused, the approach to cholecystectomy and endoscopic retrograde cholangiopancreatography has become progressively more restrictive. This trend continues in Rome V, although predictors of response to therapy, especially for biliary and pancreatic SOD, are desperately needed.

Symptoms that can be attributed to the gastroduodenal area are classified into five categories: (1) Functional Dyspepsia, with two subcategories that can overlap: Postprandial Distress Syndrome, with meal-induced symptoms of postprandial fullness or early satiation and Epigastric Pain Syndrome, with epigastric pain or burning that does not occur exclusively postprandially; (2) Nausea and Vomiting Disorders, which include three subcategories: chronic nausea and vomiting syndrome; cyclic vomiting syndrome; and cannabinoid hyperemesis syndrome; (3) Excessive Belching Disorders, defined as audible escapes of air from the esophagus or the stomach and classified into 2 subcategories depending on the origin of the refluxed gas: gastric or supragastric belching; (4) Inability to Belch Syndrome, a new category defined by the self-reported inability to belch; and (5) rumination syndrome, defined by the repetitive, effortless regurgitation of recently ingested food into the mouth followed by the reswallowing or expulsion of the food bolus.

This article defines diagnostic criteria, and reviews clinical evaluation and management of fecal incontinence, anorectal pain, dyssynergic defecation (DD), and rectal hyposensitivity and hypersensitivity. Diagnostic evaluation includes anorectal manometry, balloon expulsion test (BET), anal ultrasound, magnetic resonance imaging, defecography and neurophysiology testing. FI is defined as recurrent uncontrolled passage of fecal material for 3 months. Management includes antidiarrheals, Kegels exercise, biofeedback therapy, dextranomer injection, surgery, sacral nerve stimulation and translumbosacral neuromodulation therapy (TNT). Anorectal pain lasting seconds to minutes is defined as proctalgia fugax whereas pain lasting more than 30 minutes with puborectalis tenderness is defined as levator ani syndrome. Biofeedback and TNT may be useful. DD is defined by both symptoms of difficult defecation and objective evidence of dyssynergia. Biofeedback therapy is efficacious in DD. Rectal sensory disorders are defined by both anorectal symptoms and increased (hyposensitivity) or decreased (hypersensitivity) sensory thresholds during rectal balloon distension, and sensory biofeedback is useful.

Upper gastrointestinal Disorders of Gut-Brain Interaction (DGBI) present from infancy through adolescence. The Rome V criteria have expanded to include DGBI of the esophagus, disorders of air-transit and feeding disorders as well as rumination syndrome, cyclic vomiting, chronic nausea syndrome and functional dyspepsia. This expansion provides a diagnostic framework for patients presenting with chest and throat pain, feeding difficulties, belching, pain with eating, nausea and vomiting. Given the advances in impedance technology and high-resolution manometry, testing plays a greater role in these diagnostic criteria than they have in past Rome iterations. This harmony between symptoms and testing results in more precision in therapeutic approaches that are critically multidisciplinary. The ability to assign new, positive diagnoses across the upper gastrointestinal tract offers new opportunities for pediatric-focused therapeutic trials.