Journal of Neurogastroenterology and Motility最新文献

Background/aims: Evidence regarding the diagnostic value of non-to-minimally invasive investigations for identifying sliding hiatal hernia (HH) in patients with morbid obesity is limited. Herein, we aimed to evaluate the diagnostic performance of preoperative high-resolution esophageal manometry (HREM) compared with that of upper gastrointestinal (UGI) series in this patient population.

Methods: In this retrospective comparative-paired design study at a university hospital, we analyzed data from 149 consecutive patients with morbid obesity who underwent bariatric surgery (BS) between 2020 and 2024. All patients underwent preoperative workup, including HREM, UGI series, and esophagogastroduodenoscopy. Diagnostic performance was evaluated and compared between the diagnostic tests using intraoperative HH diagnosis as a reference standard.

Results: After excluding 12 patients, BS confirmed sliding HHs in 26 of 137 patients (19.0%). HREM showed a superior predictive capacity for identifying intraoperative HH than UGI series, showing area under the receiver operating characteristic curves of 0.93 (95% confidence interval [CI], 0.87-0.99; P < 0.01) and 0.63 (95% CI, 0.53-0.73; P < 0.01), respectively. Furthermore, HREM demonstrated significantly higher sensitivity (92.31% vs 42.31%), specificity (93.70% vs 83.78%), positive likelihood ratio (14.64; 95% CI, 7.09-30.24 vs 2.61; 95% CI, 1.41-4.83), and diagnostic accuracy (93.43% vs 75.91%) than UGI series (all P < 0.05). HREM identified a major esophageal motility disorder in 3/137 (2.2%) patients, which guided specific treatment before undergoing BS. No serious procedure-related complications occurred.

Conclusion: HREM has high diagnostic performance in detecting sliding HH; thus, HREM should be considered as an important part of the preoperative work-up for patients with morbid obesity.

The low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet is an evidence-based diet therapy for irritable bowel syndrome that is recommended in multiple clinical guidelines worldwide. While in Western countries, this diet is well accepted among health professionals and widely applied in clinical practice, uptake of the diet is more limited in Asian countries, likely due to research, clinical, practical, and cultural barriers. This review explores the challenges of implementing a FODMAP diet in Asian countries, including the lack of local efficacy studies, the limited availability of specialist dietitians, the lack of FODMAP composition data for local foods, language barriers and traditional dietary practices that are at odds with the principles of the FODMAP diet. Potential solutions include building local capacity in dietary research and clinical practice; expanding the analysis of Asian foods for FODMAP content; fostering interdisciplinary training opportunities for health professionals using a train-the-trainer approach; adapting educational resources so they are linguistically and culturally appropriate; and developing practical resources for patients to facilitate recipe adaptation and meal planning. Addressing these barriers will improve access to the FODMAP diet for patients in Asia and may provide a framework to adapt other dietary therapies to suit culturally diverse groups.

Functional dyspepsia and gastroparesis are common gastrointestinal conditions that can significantly impact a patient's quality of life. Management of these conditions can be challenging for the treating physician due to overlap in symptomatology and incomplete response to conventional medications such as proton pump inhibitors and prokinetics. There is a growing trend in the use of management strategies such as neuromodulators, psycho-behavioral therapy, and other alternative treatments including acupuncture. Notably, differences exist in the epidemiology, symptom expression, and disease management in Western versus Asian patients. These differences stem from varying accessibility to investigation tests and medications, dietary habits and cultural beliefs. This review article comprehensively summarizes the latest knowledge on the approach to the evaluation and management of functional dyspepsia and gastroparesis, and explores the different factors influencing management practices in the West as compared to in Asia.

Background/aims: The association between diet and triggering the symptoms of functional gastrointestinal disorders (FGIDs) has been well recognized. This study aims to evaluate the impact of enhanced dietary education (EDE) on gastrointestinal symptoms in patients with FGIDs.

Methods: This was a multicenter, prospective pilot study. Subjects diagnosed with FGIDs were allocated to either 'EDE' group or 'standard dietary education (SDE)' group. Simplified EDE program developed by the Korean Society of Neurogastroenterology and Motility was used for the dietary guidance. Routine prescription of medications was allowed and the symptoms were compared between 'EDE' and 'SDE' group after 4 weeks. Subjects with SDE group also received EDE after 4 weeks and the pre-post change of symptoms was assessed in each group. The degree of gastrointestinal symptoms was evaluated using the Korean version of validated questionnaires. The 36-item Short Form survey was used for the measurement of health-related quality of life.

Results: In total, 91 subjects (65 in 'EDE'/26 in 'SDE' group) were included (27 were lost to follow-up). There was no significant difference in the symptom scores or health-related life quality scores between 'EDE' and 'SDE' group at 4 weeks. Pre-post change in these scores was not significant without education. However, pre-post decrease in symptom scores and increase of health-related life quality scores were significant after EDE in subjects with gastroesophageal reflux disease and functional constipation.

Conclusion: Although, EDE has the potential to help improving the symptoms in patients with FGIDs, further research is needed to prove the usefulness of this program.

Background/aims: Gastroesophageal reflux disease (GERD) is a chronic, heterogeneous condition that impairs quality of life. Extra-esophageal symptoms (eg, globus sensation, chronic cough, hoarseness, wheezing) often persist despite proton pump inhibitor (PPI) therapy. Tricyclic antidepressants are recommended for such refractory cases, but supporting evidence is limited. This study aims to evaluate the efficacy of low-dose amitriptyline in treating extra-esophageal GERD symptoms.

Methods: We conducted a single-center, single-blind, randomized, controlled crossover pilot trial. Forty patients with both typical GERD symptoms and one or more atypical symptom unresponsive to ≥ 4 weeks of PPI therapy were randomized to receive either lansoprazole 30 mg daily plus amitriptyline 10 mg at bedtime or lansoprazole alone for 4 weeks, followed by crossover to the alternate regimen. The primary outcome was symptom improvement assessed by numeric rating scale. Secondary outcome included changes in quality of life (QoL) measured by the 36-item Short Form survey.

Results: All 40 patients completed the trial. Overall, 75% reported symptom improvement: 65% in the amitriptyline group vs 85% in the PPI group (P = 0.273). Both groups showed significant reductions in symptom severity (between-group P = 0.904) and improvements in QoL (physical and mental summary scores; P = 0.600 and 0.410, respectively). These improvements persisted post-crossover.

Conclusions: Adding low-dose amitriptyline to PPI therapy did not offer a short-term advantage over PPI alone. Both treatments improved symptoms and QoL. Given the challenging nature of GERD's extra-esophageal manifestations and mixed evidence for neuromodulator therapy, further studies are needed to identify patient subgroups that may benefit from adjunctive neuromodulator therapy.

Background/aims: Proximal esophageal dysmotility and high psychological burden are common in individuals with esophageal or laryngopharyngeal reflux symptoms. However, the clinical significance of abnormal proximal motility remains unclear. Given that proximal esophagus consists of skeletal muscle, proximal esophageal motility may be influenced by psychological burden. This study aims to explore the relationship between psychological burden and proximal esophageal motility.

Methods: Patients with esophageal or laryngopharyngeal reflux symptoms were retrospectively included. Esophageal hypervigilance and anxiety scale (EHAS) was used to evaluate the psychological burden in patients. Demographics, endoscopic findings, proximal and distal esophageal manometric parameters, and reflux burden were compared between patients with and without esophageal hypervigilance and anxiety. Multivariate logistic regression analysis was conducted to determine the relationship between psychological burden and proximal esophageal motility.

Results: A total of 341 subjects were enrolled. A greater proportion of patients with high EHAS had elevated upper esophageal sphincter (UES) basal pressure than those with normal EHAS (21.5% vs 11.8%, P = 0.024), while no significant difference was found in other proximal manometric parameters between the 2 groups. On multivariate analysis, high EHAS was independently associated with elevated UES basal pressure (OR, 2.19, P = 0.034).

Conclusions: Elevated UES basal pressure is more frequently seen in symptomatic patients with high esophageal hypervigilance and anxiety. When encountering patients with unexplained high UES basal pressure, psychological burden may play a potential role in these cases.

Background/aims: Assessment of treatment response of achalasia often involves multiple procedures. We aim to investigate innovative metrics based on 4-dimensional high-resolution impedance manometry (4D HRM) to assess treatment response in achalasia patients.

Methods: Patients with achalasia treated by pneumatic dilation or myotomy who underwent follow-up evaluations were included. All patients completed high-resolution impedance manometry before and after treatment. 4D HRM analysis based on developed python program measured clearance ratio, intrabolus pressure (IBP), maximum esophagogastric junction diameter, and distensibility index. Good treatment outcomes were defined as barium column height of < 5 cm at 5 minutes on timed barium esophagram (TBE) and Eckardt score ≤ 3.

Results: Fifty-three patients with achalasia were included: 40% type I, 51% type II, and 9% type III. Change of clearance ratio and IBP on 4D HRM had superior performance in predicting abnormal TBE at 5 minutes (area under the receiver operating characteristic [AUROC] curve, 95% confidence interval: 0.76, 0.59-0.93; 0.74, 0.57-0.92). The combination of clearance ratio (increase with a threshold of 0.1) and IBP (reduction with a threshold of 8.9 mmHg) had a high positive predictive value for normal TBE outcome (93%), and a modest negative predictive value for abnormal TBE outcome (73%). Receiver operating characteristics of metrics related to poor symptomatic outcome only yielded AUROCs (95% CI) of 0.82 (0.68-0.96) for esophageal hypervigilance and anxiety scale posttreatment.

Conclusions: IBP and clearance ratio help to identify abnormal barium retention in patients after treatment. 4D manometry can be an alternative or complementary approach to characterize and assess treatment response of Achalasia, in additional to TBE or functional lumen imaging probe.

Background/aims: Chronic intestinal pseudo-obstruction (CIPO), characterized by dilated small or large intestine on CT, has a high postoperative recurrence rate. In contrast, focal hypoganglionosis with adult-onset megacolon (FHAM) generally shows a good postoperative prognosis. This study aims to evaluate the utility of cine-MRI in differentiating between these 2 diseases by assessing small bowel (SB) motility and its correlation with clinical outcomes.

Methods: The clinical features and outcomes of 41 prospectively enrolled patients suspected of having CIPO who underwent cine-MRI were reviewed. Multi-slice cine-MRI was conducted.

Results: Of 41 patients suspected of having CIPO, 17 showed SB dilatation on CT, while 24 did not. According to cine-MRI, 3 exhibited decreased SB motility, while 38 showed no motility reduction. Among the 17 patients with dilated SB on CT, only 3 demonstrated decreased SB motility on cine-MRI. By contrast, all patients with nondilated SB on CT exhibited normal SB motility on cine-MRI. Patients with decreased SB motility showed a higher rate of postoperative disease recurrence (P = 0.011) and continuation of medication after surgery (P = 0.020) than in those with normal SB motility.

Conclusions: Cine-MRI is useful in assessing SB motility that cannot be detected on CT. Its usefulness extends to aiding surgical decision-making, particularly in differentiating between FHAM and CIPO.