Journal of Neurogastroenterology and Motility最新文献

Background/aims: The evidence suggests that a shorter esophageal length (EL) in gastroesophageal reflux disease (GERD) patients is associated with the presence of hiatal hernia (HH). However, there are no reports of this association in patients with achalasia. The aim is to (1) determine the prevalence of hiatal hernia in achalasia patients, (2) compare achalasia EL with GERD patients and healthy volunteers (HV), (3) measure achalasia manometric esophageal length to height (MELH) ratio, and (4) determine if there are differences in symptoms between patients with and without hiatal hernia.

Methods: This retrospective and cross-sectional study consist of 87 pre-surgical achalasia patients, 22 GERD patients, and 30 HV. High-resolution manometry (HRM), barium swallow, and upper endoscopy were performed to diagnose HH. The EL and MELH ratio were measured by HRM. Symptoms were assessed with Eckardt, Eating Assessment Tool, and GERD-health-related quality of life questionnaires.

Results: The HH in GERD's prevalence was 73% vs 3% in achalasia patients (P < 0.001). Achalasia patients had a longer esophagus and a higher MELH ratio than HV and GERD patients (P < 0.001). GERD patients had a lower MELH ratio than HV (P < 0.05). EAT-10 (P < 0.0001) and Eckardt (P < 0.05) scores were higher in achalasia without HH vs HH.

Conclusions: The prevalence of HH in achalasia is significantly lower than in GERD. The longer EL and the higher MELH ratio in achalasia could explain the lower prevalence of HH. Despite the low prevalence of HH in achalasia patients, the surgeon should be encouraged not to rule out HH since the risk of postoperative reflux may increase if this condition is not identified and corrected.

Background/aims: It remains unclear which maintenance treatment modality is most appropriate for mild gastroesophageal reflux disease (GERD). We aimed to compare on-demand treatment with continuous treatment using a proton pump inhibitor (PPI) in the maintenance treatment for patients with non-erosive GERD or mild erosive esophagitis.

Methods: Patients whose GERD symptoms improved after 4 weeks of standard dose PPI treatment were prospectively enrolled at 25 hospitals. Subsequently, the enrolled patients were randomly assigned to either an on-demand or a continuous maintenance treatment group, and followed in an 8-week interval for up to 24 weeks.

Results: A total of 304 patients were randomized to maintenance treatment (continuous, n = 151 vs on-demand, n = 153). The primary outcome, the overall proportion of unwillingness to continue the assigned maintenance treatment modality, failed to confirm the non-inferiority of on-demand treatment (45.9%) compared to continuous treatment (36.1%). Compared with the on-demand group, the GERD symptom and health-related quality of life scores significantly more improved and the overall satisfaction score was significantly higher in the continuous treatment group, particularly at week 8 and week 16 of maintenance treatment. Work impairment scores were not different in the 2 groups, but the prescription cost was less in the on-demand group. Serum gastrin levels significantly elevated in the continuous treatment group, but not in the on-demand group.

Conclusions: Continuous treatment seems to be more appropriate for the initial maintenance treatment of non-erosive GERD or mild erosive esophagitis than on-demand treatment. Stepping down to on-demand treatment needs to be considered after a sufficient period of continuous treatment.

Constipation is a frequent symptom in patients with chronic kidney disease (CKD). This review outlines the mechanisms and management of constipation in patients with CKD from a physician's perspective. Common causes of constipation in patients with CKD include concomitant medications, low dietary fiber intake, water-restricted diet, lack of physical activity, altered gut microbiota, and reduced gastrointestinal motility. Constipation has a negative impact on overall health, and, in particular, the presence of constipation has been associated with worsening kidney function and increased risk of developing advanced stages of CKD. Although lifestyle and dietary modifications may not always be practical for patients with CKD, they are recommended because they are beneficial as they lower mortality in patients with CKD. The use of laxatives containing magnesium salts, bulking agents, and osmotic laxatives may have insufficient efficacy and may be associated with adverse effects. In contrast, lactulose and lubiprostone have been shown to exhibit reno-protective effects. Linaclotide and plecanatide have very limited systemic absorption and appear safe in patients with CKD. Tenapanor reduces paracellular intestinal phosphate absorption in addition to blocking sodium uptake by enterocytes, and provides additional benefit in patients patients with CKD who have hyperphosphatemia and constipation. Prucalopride leads to improvements in bowel function and constipation-related symptoms in cases in which response to conventional laxatives are inadequate. However, the dose of prucalopride should be reduced to 1 mg once daily for patients with CKD. In conclusion, there are important advances on the impact and treatment of constipation in patients with CKD.

Background/aims: Dilated intercellular spaces (DISs) facilitate the diffusion of noxious agents into the deep layers of the esophageal epithelium. The role of DIS in heartburn pathogenesis is still controversial. Therefore, we aim to reinvestigate DIS in an extensively evaluated group of patients and healthy controls (HCs).

Methods: We classified 149 subjects into the following groups: 15 HC, 58 mild erosive reflux disease (ERD), 17 severe ERD, 25 nonerosive reflux disease (NERD), 15 reflux hypersensitivity (RH), and 19 functional heartburn (FH). A total of 100 length measurements were performed for each patient's biopsy.

Results: The overall intercellular spaces (ISs) value of gastroesophageal reflux disease (GERD) patients was higher than that of HC (P = 0.020). In phenotypes, mild ERD (vs HC [P = 0.036], NERD [P = 0.004], RH [P = 0.014]) and severe ERD (vs HC [P = 0.002], NERD [P < 0.001], RH [P = 0.001], FH [P = 0.004]) showed significantly higher IS. There was no significant difference between the HC, NERD, RH, and FH groups. The 1.12 μm DIS cutoff value had 63.5% sensitivity and 66.7% specificity in the diagnosis of GERD. There was a weak correlation (r = 0.302) between the IS value and acid exposure time, and a weak correlation (r = -0.359) between the IS value and baseline impedance. A strong correlation was shown between acid exposure time and baseline impedance (r = -0.783).

Conclusions: Since the IS length measurement had better discrimination power only in erosive groups, it is not feasible to use in daily routine to discriminate other nonerosive phenotypes and FH. The role of DIS in heartburn in nonerosive patients should be reconsidered.

Background/aims: An increase in postprandial intestinal gas plays a role in bloating symptoms. We aim to study the utility of spot breath hydrogen (H₂) level in predicting the response to a low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) diet.

Methods: Patients with functional gastrointestinal disorders diagnosed by Rome IV criteria with bothersome bloating for > 6 months were prospectively enrolled. Patients completed 7-day food diaries and collected a breath sample 2 hours after their usual lunch at baseline and 4 weeks after low FODMAPs dietary advice by a dietitian. The responder was defined as an improvement of ≥ 30% bloating scores in the fourth week.

Results: Thirty-eight patients (32 female, 52.6 ± 13.8 years; 22 irritable bowel syndrome) completed the study. Twenty-one patients (55%) were classified as responders. Baseline global gastrointestinal symptoms, bloating, abdominal pain scores, and numbers of high FODMAPs items were similar between responders and non-responders. Both groups significantly decreased high FODMAPs items intake with similar numbers at the follow-up. The area under the curve for predicting low FODMAPs responsiveness using baseline H₂ levels was 0.692 (95%CI, 0.51-0.86; P < 0.05), with the best cutoff at 8 parts per million (sensitivity 66.7%, specificity 82.4%). 66% of responders had baseline H₂ level > 8 parts per million vs 17% of non-responders (P < 0.05). The baseline spot hydrogen level in responders was 9.5 (3.3-17.3) vs 4.5 (3.3-6.3) in non-responders (P < 0.05).

Conclusions: A higher baseline breath hydrogen level was associated with bloating improvement after low FODMAPs dietary advice. A spot breath test after lunch, a simple point-of-care test, is possibly helpful in managing patients with bloating.

The gut-brain axis describes the bidirectional communication between the gut, the enteric nervous system, and the central nervous system. The gut-brain axis has attracted increasing attention owing to its regulatory effect on dysbiosis and a wide range of related diseases. Several types of nutrients, such as curcumin, have been proposed as regulators of the dysbiotic state, and preclinical experiments have suggested that curcumin is not only beneficial but also safe. This review focuses on the interplay between curcumin and the gut microbiota. Moreover, it provides a comprehensive review of the crosstalk between the gut-brain axis and disease, whilst also discussing curcumin-mediated gut-brain axis-dependent and -independent signaling about modulation of gut microbiota dysbiosis. This will help to define the utility of curcumin as a novel therapeutic agent to regulate intestinal microflora dysbiosis.

Background/aims: Extended wireless pH monitoring (WPM) is used to investigate gastroesophageal reflux disease (GERD) as subsequent or alternative investigation to 24-hour catheter-based studies. However, false negative catheter studies may occur in patients with intermittent reflux or due to catheter-induced discomfort or altered behavior. We aim to investigate the diagnostic yield of WPM after a negative 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring study and to determine predictors of GERD on WPM given a negative MII-pH.

Methods: Consecutive adult patients (> 18 years) who underwent WPM for further investigation of suspected GERD following a negative 24-hour MII-pH and upper endoscopy between January 2010 and December 2019 were retrospectively included. Clinical data, endoscopy, MII-pH, and WPM results were retrieved. Fisher's exact test, Wilcoxon rank sum test, or Student's t test were used to compare data. Logistic regression analysis was used to investigate predictors of positive WMP.

Results: One hundred and eighty-one consecutive patients underwent WPM following a negative MII-pH study. On average and worst day analysis, 33.7% (61/181) and 34.2% (62/181) of the patients negative for GERD on MII-pH were given a diagnosis of GERD following WPM, respectively. On a stepwise multiple logistic regression analysis, the basal respiratory minimum pressure of the lower esophageal sphincter was a significant predictor of GERD with OR = 0.95 (0.90-1.00, P = 0.041).

Conclusions: WPM increases GERD diagnostic yield in patients with a negative MII-pH selected for further testing based on clinical suspicion. Further studies are needed to assess the role of WPM as a first line investigation in patients with GERD symptoms.

Background/aims: A high prevalence of GERD has been reported in patients with supragastric belching. We aim to evaluate reflux characteristics and explore the temporal relationship between supragastric belches (SGBs) and reflux episodes in GERD patients with excessive belching.

Methods: Twenty-four hour esophageal pH-impedance monitoring was analyzed. Reflux episodes were classified into: refluxes preceded by SGBs, followed by SGBs, and lone refluxes. Reflux characteristics were compared between patients with pH-positive (pH+) and pH-negative(pH-).

Results: Forty-six patients (34 Female, age 47 ± 13 years) were included. Fifteen patients (32.6%) had pH+. Almost half (48.1 ± 21.0%) of refluxes were preceded by SGBs. The number of SGBs significantly correlated with the number of reflux episodes preceded by SGBs (r = 0.43, P < 0.05) and % time pH < 4 at the distal esophagus (r = 0.41, P < 0.05). Patients with pH+ had significantly more SGBs and reflux episodes preceded by SGBs/day than pH- patients (P < 0.05). The difference in the number of refluxes between pH+ and pH- patients was caused by reflux episodes preceded by SGBs, but not lone refluxes and refluxes followed by SGBs. The proportion of SGBs followed by reflux/total SGBs was similar between patients with pH+ and pH- (P > 0.05). Reflux episodes preceded by SGBs and followed by SGBs extended more proximal and had longer bolus and acid contact time than lone refluxes (P < 0.05).

Conclusions: In patients with GERD and SGB, the number of SGBs positively correlates with the number of reflux episodes preceded by SGBs. Identifying and managing SGB may be beneficial and more likely to improve GERD.