RESUMEN

Background: Guidelines fail to recommend objective measures to assist with treatment of neurogenic bowel dysfunction (NBD) in spinal cord injury (SCI). Objectives: The main objective was to review the literature to identify the objective measures used in all NBD populations and to present their results and any correlations performed to validated subjective measures. Methods: A systematic review of the literature was performed in accordance with PRISMA (2020) guidelines, including all records from January 2012 to May 2023 with MeSH terms like "neurogenic bowel" indexed in the following databases: PubMed, EMBASE, CINAHL, Cochrane Central Trials Register, and ClinicalTrials.gov. Abstracts were excluded if they did not include objective measures or if they only mentioned the esophagus, stomach, and/or small bowel. Records were screened independently by at least two collaborators, and differences were resolved by unanimous agreement. Results: There were 1290 records identified pertaining to NBD. After duplicates were removed, the remaining records were screened for a total of 49 records. Forty-one records (82%) included subjective measures. Two-thirds of the articles involved the population with SCI/disease (n = 552) and one-third were non-SCI NBD (n = 476). Objective measures were categorized as (1) transit time, (2) anorectal physiology testing, and (3) miscellaneous. Of the 38 articles presenting results, only 16 (42%) performed correlations of objective measures to subjective measures. Conclusion: There is an abundance of literature supporting the use of objective outcome measures for NBD in SCI. Strong correlations of subjective measures to objective outcome measures were generally lacking, supporting the need to use both measures to help with NBD management.

Asunto(s)

RESUMEN

Immune checkpoint inhibitors (ICIs) can cause myenteric plexopathy, which could result in delayed gastric emptying (GE) and possibly gastroparesis. We assessed the clinical outcomes of patients who had pre-existing gastroparesis or who developed symptoms of delayed GE following ICI therapy. We retrospectively identified adults with ICD-9 and ICD-10 codes for gastroparesis who received ICI therapy between 1 January 2020 and 31 December 2022 at a tertiary cancer center. Of 76 eligible patients, 37 had pre-existing gastroparesis; 39 (0.2% of the more than 18,000 screened) developed symptoms of delayed GE after ICI therapy, of which 27 (69%) patients had an alternative etiology for delayed GE. Four patients (11%) with pre-existing gastroparesis had a flare-up after ICI, and the median time to flare-up was 10.2 months (IQR, 0.7-28.6 months); for patients with new onset of suspected delayed GE after ICI, the median time to symptom onset was 12.8 months (IQR, 4.4-35.5 months). The clinical symptom duration of patients without an alternative etiology (74.5 days (IQR, 21.5-690 days)) and those with an alternative etiology (290 days (IQR, 147-387 days)) did not differ significantly (p = 1.00). Delayed GE after ICI therapy is a rare presentation but has a late onset and a prolonged symptom duration.

RESUMEN

BACKGROUND: Gastroesophageal reflux disease (GERD) is common. Treatment is to manage symptoms, but medication nonadherence is common. To date, little emphasis has been on understanding patient behaviors and reasons for medication nonadherence. METHODS: We performed a cross-sectional survey study among expert gastroenterologists specializing in esophageal disease. Survey studies consisted of a 6-item questionnaire measuring physician knowledge of patient activation, the Clinician Support for Patient Activation Measure (CS-PAM), and an adapted 20-item Patient Assessment of Chronic Illness Care (PACIC). All question stems were specified to GERD management. RESULTS: Thirty-six experts participated. Most indicated hearing the term patient engagement before this survey (88.9%), but fewer were aware of the term patient activation (33.3%). Respondents were then made aware of the clinical significance of patient activation and asked, based on this knowledge, the likelihood that patients' activation level before the clinic would impact their communication. Responses varied between "to a great extent" and "not at all." Overall, CS-PAM activation scores were high, indicating a high level of support for patient activation. Lastly, respondents indicated their frequency of participating in partnership-building behaviors with patients. More than half (52.8%) of expert physicians "almost always" asked how GERD affected their lives, while less often asked patients about their health habits (22.2%), help set specific goals to improve their eating or exercise lifestyle (19.4%), or refer patients to a dietician, health educator, or counselor for their GERD (11.1%). CONCLUSION: Patient activation is an important strategy and may provide a behavioral approach to address medication adherence in GERD.

RESUMEN

BACKGROUND: The functional lumen imaging probe (FLIP) is a Food and Drug Administration approved tool to aid the diagnosis and management of esophageal disorders. However, widespread adoption of FLIP remains limited and its utility in high-volume practices remains unclear. AIM: To analyze large sample data on clinical use of FLIP and provide insight on several technical aspects when performing FLIP. METHODS: We conducted a retrospective comparative and descriptive analysis of FLIP procedures performed by a single provider at an academic medical center. There was a total of 398 FLIP procedures identified. Patient medical records were reviewed and data regarding demographics and procedural details were collected. Statistical tests, including chi-squared, t-test, and multivariable logistic and linear regression, were performed. RESULTS: There was an increase in FLIP cases with each successive time period of 13 months (n = 68, 146, 184, respectively) with notable rises specifically for indications of dysphagia and gastroesophageal reflux disease. There was a shift toward use of the longer FLIP balloon catheter for diagnostic purposes (overall 70.4% vs 29.6%, P < 0.01). Many cases (42.8%) were performed in conjunction with other diagnostics/interventions, such as dilation and wireless pH probe placement. Procedures were nearly equally performed with anesthesia vs moderate sedation (51.4% anesthesia), with no major complications. Patients who had anesthesia were less likely to have recurrent antegrade contractions [odds ratio (OR) = 0.4, 95%CI: 0.3-0.8] and were also more likely to have absent contractility (OR = 2.4, 95%CI: 1.3-4.4). CONCLUSION: FLIP cases have increased in our practice with expanding indications for its use. Given limited normative data, providers should be aware of several potential technical issues, including the possible impact of sedation choice when assessing esophageal motility patterns.

RESUMEN

BACKGROUND/AIMS: Patients with chronic constipation (CC) exhibit symptoms and functional abnormalities upon testing, but their relationship to age and gender is unclear. We assessed age- and gender-related differences in symptoms, colon transit time, and anorectal motility, sensation, and expulsion. PATIENTS AND METHODS: Retrospective, post hoc data analysis of patients with CC, who underwent Wireless Motility Capsule (WMC), High-Resolution Anorectal Manometry (HR-ARM), Balloon Expulsion Test (BET) and Rectal Sensory Testing (RST). Clinical assessment was made by questionnaires. Standard WMC criteria for colonic transit time (CTT) and the London classification was used for HR-ARM analyses, and regression plots between age, gender, CTT, HR-HRM, RST and BET were calculated. RESULTS: We studied 75 women and 91 men. Abdominal pain, infrequent defecation, incomplete evacuation, defecatory straining, and multiple motility and anorectal function abnormalities were common. Abdominal pain was least frequently, and straining was most frequently associated with a motility abnormality. For each symptom, the highest prevalence was associated with failed BET. There was a significant increase in CTT with age only in men (p = 0.0006). In men, for each year of age there was a CTT increase of 1.02 h. The prevalence of abdominal pain and incomplete evacuation for females was significantly higher than that for males (both P < 0.05). The prevalence of low anal squeeze pressure for females was significantly higher than that for males, and the prevalence of poor rectal sensation for males was significantly higher than that for females (both P < 0.05). A significant decrease in basal anal and squeeze pressures with age occurred in women (p < 0.0001); an increase in age of one year was associated with a decrease in anal base pressure of 1.2 mmHg. Abnormal CTT and HR-ARM tests were associated with increased symptom frequency, but not severity. CONCLUSIONS: There are significant age- and gender-related differences in symptoms, CTT, and HR-HRM parameters, rectal sensation, and expulsion, that may influence the multifaceted management of constipation.

Asunto(s)

Asunto(s)

RESUMEN

BACKGROUND: Whether patients with defecatory disorders (DDs) with favorable response to a footstool have distinctive anorectal pressure characteristics is unknown. We aimed to identify the clinical phenotype and anorectal pressure profile of patients with DDs who benefit from a footstool. METHODS: This is a retrospective review of patients with high resolution anorectal manometry (HR-ARM) and balloon expulsion test (BET) from a tertiary referral center. BET was repeated with a 7-inch-high footstool in those who failed it after 120 s. Data were compared among groups with respect to BET results. KEY RESULTS: Of the 667 patients with DDs, a total of 251 (38%) had failed BET. A footstool corrected BET in 41 (16%) of those with failed BET. Gender-specific differences were noted in anorectal pressures, among patients with and without normal BET, revealing gender-based nuances in pathophysiology of DDs. Comparing patients who passed BET with footstool with those who did not, the presence of optimal stool consistency, with reduced instances of loose stools and decreased reliance on laxatives were significant. Additionally, in women who benefited from a footstool, lower anal pressures at rest and simulated defecation were observed. Independent factors associated with a successful BET with a footstool in women included age <50, Bristol 3 or 4 stool consistency, lower anal resting pressure and higher rectoanal pressure gradient. CONCLUSION & INFERENCES: Identification of distinctive clinical and anorectal phenotype of patients who benefited from a footstool could provide insight into the factors influencing the efficacy of footstool utilization and allow for an individualized treatment approach in patients with DDs.

Asunto(s)

RESUMEN

BACKGROUND: Vitamin-D is essential for musculoskeletal health. We aimed to determine whether patients with fecal incontinence (FI): (1) are more likely to have vitamin-D deficiency and, (2) have higher rates of comorbid medical conditions. METHODS: We examined 18- to 90-year-old subjects who had 25-hydroxy vitamin-D levels, and no vitamin-D supplementation within 3 months of testing, in a large, single-institutional electronic health records dataset, between 2017 and 2022. Cox proportional hazards survival analysis was used to assess association of vitamin-D deficiency on FI. KEY RESULTS: Of 100,111 unique individuals tested for serum 25-hydroxy vitamin-D, 1205 (1.2%) had an established diagnosis of FI. Most patients with FI were female (75.9% vs. 68.7%, p = 0.0255), Caucasian (66.3% vs. 52%, p = 0.0001), and older (64.2 vs. 53.8, p < 0.0001). Smoking (6.56% vs. 2.64%, p = 0.0001) and GI comorbidities, including constipation (44.9% vs. 9.17%, p = 0.0001), irritable bowel syndrome (20.91% vs. 3.72%, p = 0.0001), and diarrhea (28.55% vs. 5.2%, p = 0.0001) were more common among FI patients. Charlson Comorbidity Index score was significantly higher in patients with FI (5.5 vs. 2.7, p < 0.0001). Significantly higher proportions of patients with FI had vitamin-D deficiency (7.14% vs. 4.45%, p < 0.0001). Moreover, after propensity-score matching, rate of new FI diagnosis was higher in patients with vitamin-D deficiency; HR 1.9 (95% CI [1.14-3.15]), p = 0.0131. CONCLUSION & INFERENCES: Patients with FI had higher rates of vitamin-D deficiency along with increased overall morbidity. Future research is needed to determine whether increased rate of FI in patients with vitamin-D deficiency is related to frailty associated with increased medical morbidities.

Asunto(s)

RESUMEN

PURPOSE OF REVIEW: Gastroesophageal reflux disease (GERD) is very common in the general population and poses a large societal socio-economic burden. In this article, we review the evidence supporting non-ablative radiofrequency treatment (Stretta) for the endoscopic management of GERD and we compare it to pharmacologic and other minimally invasive and surgical interventions. RECENT FINDINGS: Proton pump inhibitors (PPI) are a key therapy for GERD. For patients without associated significant sliding hiatal hernia, who have inadequate relief of their reflux symptoms, Stretta and other endoscopic therapies, such as transoral fundoplication (TIF), may improve symptoms and GERD-related quality of life. Unfortunately, there are no recent large randomized controlled trials, and most of the evidence is based on meta-analyses and small scale, prospective and retrospective single center efforts. Comparisons of Stretta efficacy to other anti-reflux endoscopic modalities and anti-reflux surgery (ARS) are also presented. There are several endoscopic and minimally invasive modalities to manage PPI-refractory GERD acting through various mechanisms that have been found effective in managing GERD symptoms and quality of life. Among them, Stretta has the longest track record of efficacy and safety. Larger-scale and longer-term comparative efficacy trials in selected populations of patients with acid reflux with and without hiatal hernia will be needed.

Asunto(s)

RESUMEN

BACKGROUND: Classification of chronic constipation (CC) into its three subtypes of slow transit constipation, defecation disorder and normal transit constipation, may improve its multifaceted management. We assessed the merits of the London classification in patients with CC, who were studied by both wireless motility capsule (WMC) and high-resolution anorectal manometry (HR-ARM), examining their relative utilities in decision-making.s PATIENTS AND METHODS: Retrospective, community-based study of prospectively collected data on patients with CC by Rome IV criteria, who underwent WMC and HR-ARM, Balloon Expulsion Test, and Rectal Sensory Testing. Clinical assessment was made by standard questionnaires. On WMC, standard criteria for colonic transit time (CTT) were used (normal CTT < 59 h). The hierarchical London classification was used for HR-ARM analyses. RESULTS: Of 1261 patients with CC, 166 (91 M; ages 22-86) received technically satisfactory WMC and HR-ARM, formed the analyzed study cohort, of whom 84 had normal CTT and 82 had prolonged CTT (> 59 h). Patients with slow CTT were significantly older and had longer duration and more severe disease. Using the London classification criteria for disorders of anorectal function, we noted a high prevalence of anorectal dysfunction, regardless of CTT. Except for lower rate of anal hypertonicity in patients with slow CTT, disorders of recto-anal coordination, and rectal sensation were seen at a comparable rate in patients with CC, regardless of CTT. CONCLUSION: There is a significant overlap of anorectal disorders in patients with slow CTT. There is questionable specificity and utility of WMC and HR-ARM in assessing patients with CC. More work is needed to demonstrate the value of these studies as surrogate markers of the disease and its response to multifaceted therapy.

Asunto(s)

RESUMEN

INTRODUCTION: The natural history of rectal intussusception (RI) is poorly understood. We hypothesized that decline in pelvic floor integrity and function leads to increasing RI grades. METHODS: Retrospective analysis of a registry of patients with defecatory disorders with high-resolution anorectal manometry and magnetic resonance defecography was performed. Association of risk factors on increasing RI grades was assessed using logistic regression. RESULTS: Analysis included a total of 238 women: 90 had no RI, 43 Oxford 1-2, 49 Oxford 3, and 56 Oxford 4-5. Age ( P = 0.017), vaginal delivery ( P = 0.008), and prior pelvic surgery ( P = 0.032) were associated with increased Oxford grades. Obstructive defecation symptoms and dyssynergic defecation were observed at relatively high rates across groups. Increased RI grades were associated with less anal relaxation at simulated defecation yet, higher rates of normal balloon expulsion ( P < 0.05), linked to diminished anal sphincter. Indeed, increased RI grades were associated with worsening fecal incontinence severity, attributed to higher rates of anal hypotension. Levator ani laxity, defined by increased levator hiatus length and its excessive descent at straining, was associated with increasing RI grades, independent of age, history of vaginal delivery, and pelvic surgeries and could independently predict increased RI grades. Concurrent anterior and posterior compartments, and visceral prolapse were associated with higher Oxford grades. DISCUSSION: Our data suggest that decline in pelvic floor integrity with abnormal levator ani laxity is associated with increased RI grades, a process that is independent of age, history of vaginal deliveries, and/or pelvic surgeries, and perhaps related to dyssynergic defecation.

RESUMEN

BACKGROUND METHODS: The question prompt list content was derived through a modified Delphi process consisting of 3 rounds. In round 1, experts provided 5 answers to the prompts "What general questions should patients ask when given a new diagnosis of Barrett's esophagus" and "What questions do I not hear patients asking, but given my expertise, I believe they should be asking?" Questions were reviewed and categorized into themes. In round 2, experts rated questions on a 5-point Likert scale. In round 3, experts rerated questions modified or reduced after the previous rounds. Only questions rated as "essential" or "important" were included in Barrett's esophagus question prompt list (BE-QPL). To improve usability, questions were reduced to minimize redundancy and simplified to use language at an eighth-grade level (Fig. 1). RESULTS: Twenty-one esophageal medical and surgical experts participated in both rounds (91% males; median age 52 years). The expert panel comprised of 33% esophagologists, 24% foregut surgeons, and 24% advanced endoscopists, with a median of 15 years in clinical practice. Most (81%), worked in an academic tertiary referral hospital. In this 3-round Delphi technique, 220 questions were proposed in round 1, 122 (55.5%) were accepted into the BE-QPL and reduced down to 76 questions (round 2), and 67 questions (round 3). These 67 questions reached a Flesch Reading Ease of 68.8, interpreted as easily understood by 13 to 15 years olds. CONCLUSIONS: With multidisciplinary input, we have developed a physician-derived BE-QPL to optimize patient-physician communication. Future directions will seek patient feedback to distill the questions further to a smaller number and then assess their usability.

Asunto(s)

Asunto(s)

RESUMEN

Introduction: Gastrointestinal dysfunction, particularly constipation, is among the most common non-motor manifestations in Parkinson's Disease (PD). We aimed to identify high-resolution anorectal manometry (HR-ARM) abnormalities in patients with PD using the London Classification. Methods: We conducted a retrospective review of all PD patients at our institution who underwent HR-ARM and balloon expulsion test (BET) for evaluation of constipation between 2015 and 2021. Using age and sex-specific normal values, HR-ARM recordings were re-analyzed and abnormalities were reported using the London Classification. A combination of Wilcoxon rank sum and Fisher's exact test were used. Results: 36 patients (19 women) with median age 71 (interquartile range [IQR]: 69-74) years, were included. Using the London Classification, 7 (19%) patients had anal hypotension, 17 (47%) had anal hypocontractility, and 3 women had combined hypotension and hypocontractility. Anal hypocontractility was significantly more common in women compared to men. Abnormal BET and dyssynergia were noted in 22 (61%) patients, while abnormal BET and poor propulsion were only seen in 2 (5%). Men had significantly more paradoxical anal contraction and higher residual anal pressures during simulated defecation, resulting in more negative recto-anal pressure gradients. Rectal hyposensitivity was seen in nearly one third of PD patients and comparable among men and women. Conclusion: Our data affirms the high prevalence of anorectal disorders in PD. Using the London Classification, abnormal expulsion and dyssynergia and anal hypocontractility were the most common findings in PD. Whether the high prevalence of anal hypocontractility in females is directly related to PD or other confounding factors will require further research.

RESUMEN

We define mixed esophageal disease (MED) as a disorder of esophageal structure and/or function that produces variable signs or symptoms, simulating-fully or in part other well-defined esophageal conditions, such as gastroesophageal reflux disease, esophageal motility disorders, or even neoplasia. The central premise of the MED concept is that of an overlap syndrome that incorporates selected clinical, endoscopic, imaging, and functional features that alter the patient's quality of life and affect natural history, prognosis, and management. In this article, we highlight MED scenarios frequently encountered in medico-surgical practices worldwide, posing new diagnostic and therapeutic challenges. These, in turn, emphasize the need for better understanding and management, aiming towards improved outcomes and prognosis. Since MED has variable and sometimes time-evolving clinical phenotypes, it deserves proper recognition, definition, and collaborative, multidisciplinary approach, be it pharmacologic, endoscopic, or surgical, to optimize therapeutic outcomes, while minimizing iatrogenic complications. In this regard, it is best to define MED early in the process, preferably by teams of clinicians with expertise in managing esophageal diseases. MED is complex enough that is increasingly becoming the subject of virtual, multi-disciplinary, multi-institutional meetings.

Asunto(s)

RESUMEN

The impact of race/ethnicity (RE) or socioeconomic status (SES) on progression from Barrett's esophagus (BE) to esophageal cancer (EC) is not well established. We aimed to evaluate the association between demographic factors and SES on EC diagnosis in an ethnically diverse BE cohort. Patients aged 18-63 with incident BE diagnosed in October 2015-March 2020 were identified in the Optum Clinformatics DataMart Database. Patients were followed until the diagnosis of prevalent EC <1 year or incident EC ≥1 year from BE diagnosis, or until the end of their continuous enrollment period. Cox proportional hazards analysis was used to determine associations between demographics, SES factors, BE risk factors, and EC. Demographics of the 12,693 patients included mean age of BE diagnosis 53.0 (SD 8.5) years, 56.4% male, 78.3% White/10.0% Hispanic/6.4% Black/3.0% Asian. The median follow-up was 26.8 (IQR 19.0-42.0) months. In total, 75 patients (0.59%) were diagnosed with EC (46 [0.36%] prevalent EC; 29 [0.23%] incident EC), and 74 patients (0.58%) developed high-grade dysplasia (HGD) (46 [0.36%] prevalent HGD; 28 [0.22%] incident HGD). Adjusted HR (95% CI) for prevalent EC comparing household net worth ≥$150,000 vs. <$150,000 was 0.57 (0.33-0.98). Adjusted HRs (95% CI) for prevalent and incident EC comparing non-White vs. White patients were 0.93 (0.47-1.85) and 0.97 (0.21-3.47), respectively. In summary, a lower SES, captured by the household net worth, was associated with prevalent EC. There was no significant difference in prevalent or incident EC among White vs. non-White patients. EC progression in BE may be similar among racial/ethnic groups, but SES disparities may impact BE outcomes.

Asunto(s)

RESUMEN

BACKGROUND: Integrated relaxation pressure (IRP) calculation depends on the selection of a single gastric reference sensor. Variable gastric pressure readings due to sensor selection can lead to diagnostic uncertainty. This study aimed to examine the effect of gastric reference sensor selection on IRP measurement and diagnosis. METHODS: We identified high-resolution manometry (HRM) conducted between January and November 2017 with at least six intragastric reference sensors. IRP measurements and Chicago Classification 3.0 (CCv3) diagnoses were obtained for each of six gastric reference sensors. Studies were categorized as "stable" (no change in diagnosis) or "variable" (change in diagnosis with gastric reference selection). Variable diagnoses were further divided into "variable normal/dysmotility" (≥1 normal IRP measurement and ≥1 CCv3 diagnosis), or "variable dysmotility" (≥1 CCv3 diagnosis, only elevated IRP measurements). Bland-Altman plots were used to compare IRP measurements within HRM studies. KEY RESULTS: The analysis included 100 HRM studies, among which 18% had variable normal/dysmotility, and 10% had variable dysmotility. The average IRP difference between reference sensors was 6.7 mmHg for variable normal/dysmotility and 5.9 mmHg for variable dysmotility. The average difference between the proximal-most and distal-most sensors was -1.52 mmHg (lower limit of agreement -10.03 mmHg, upper limit of agreement 7.00 mmHg). CONCLUSIONS & INFERENCES: IRP values can vary greatly depending on the reference sensor used, leading to inconsistent diagnoses in 28% of HRM studies. Choosing the correct gastric reference sensor is crucial for accurate test results and avoiding misdiagnosis. Standardization of reference sensor selection or supportive testing for uncertain results should be considered.

Asunto(s)

Asunto(s)

RESUMEN

Most processing of the human diet occurs in the small intestine. Metabolites in the small intestine originate from host secretions, plus the ingested exposome1 and microbial transformations. Here we probe the spatiotemporal variation of upper intestinal luminal contents during routine daily digestion in 15 healthy male and female participants. For this, we use a non-invasive, ingestible sampling device to collect and analyse 274 intestinal samples and 60 corresponding stool homogenates by combining five mass spectrometry assays2,3 and 16S rRNA sequencing. We identify 1,909 metabolites, including sulfonolipids and fatty acid esters of hydroxy fatty acids (FAHFA) lipids. We observe that stool and intestinal metabolomes differ dramatically. Food metabolites display trends in dietary biomarkers, unexpected increases in dicarboxylic acids along the intestinal tract and a positive association between luminal keto acids and fruit intake. Diet-derived and microbially linked metabolites account for the largest inter-individual differences. Notably, two individuals who had taken antibiotics within 6 months before sampling show large variation in levels of bioactive FAHFAs and sulfonolipids and other microbially related metabolites. From inter-individual variation, we identify Blautia species as a candidate to be involved in FAHFA metabolism. In conclusion, non-invasive, in vivo sampling of the human small intestine and ascending colon under physiological conditions reveals links between diet, host and microbial metabolism.

Asunto(s)