Askin Erdogan

Small intestinal bacterial overgrowth: duodenal aspiration vs glucose breath test

The diagnosis of small intestinal bacterial overgrowth (SIBO) remains challenging. Our aim was to examine the diagnostic yield of duodenal aspiration/culture and glucose breath test (GBT), and effects of gender, race and demographics on prevalence of SIBO.

High Resolution and High Definition Anorectal Manometry and Pressure Topography: Diagnostic Advance or a New Kid on the Block?

The recent development of closely spaced circumferential solid state transducers has paved the way for novel technology that includes high resolution anorectal manometry and topography (HRAM) and 3-D high definition anorectal manometry (HDAM). These techniques are increasingly being used for the assessment of anorectal neuromuscular function. However, whether they constitute a diagnostic advantage or a mere refinement of an old technology is unknown. Unlike the traditional manometry that utilized 3 or 6 unidirectional sensors, the closely spaced circumferential arrangement facilitates superior spatiotemporal mapping of pressures at rest and during various dynamic maneuvers. HDAM can provide knowledge of the three muscles that govern the anal continence namely, the puborectalis, and the internal and external anal sphincters, and can show how they mediate the rectoanal inhibitory reflex and sensorimotor responses and the spatiotemporal orientation of these muscles. Also, anal sphincter defects can be mapped and readily detected using 3-D technology. Similarly, HRAM has facilitated confirmation and development of phenotypes of dyssynergic defecation. Recently, normative data have also been reported with HRAM and HDAM, together with the influence of age, gender, and test instructions. The greater yield of anatomical and functional information may supersede the limitations of costs, fragility, and shorter life-span associated with these new techniques. Thus, HDAM and HRAM are not just new gadgets but constitute a significant and novel diagnostic advance. However, more prospective studies are needed to better define anorectal disorders with these techniques and to confirm their superiority.

How to Assess Regional and Whole Gut Transit Time With Wireless Motility Capsule

Assessment of transit through the gastrointestinal tract provides useful information regarding gut physiology and patho-physiology. Although several methods are available, each has distinct advantages and limitations. Recently, an ingestible wireless motility capsule (WMC), similar to capsule video endoscopy, has become available that offers a less-invasive, standardized, radiation-free and office-based test. The capsule has 3 sensors for measurement of pH, pressure and temperature, and collectively the information provided by these sensors is used to measure gastric emptying time, small bowel transit time, colonic transit time and whole gut transit time. Current approved indications for the test include the evaluation of gastric emptying in gastroparesis, colonic transit in constipation and evaluation of generalised dysmotility. Rare capsule retention and malfunction are known limitations and some patients may experience difficulty with swallowing the capsule. The use of WMC has been validated for the assessment of gastrointestinal transit. The normal range for transit time includes the following: gastric emptying (2–5 hours), small bowel transit (2–6 hours), colonic transit (10–59 hours) and whole gut transit (10–73 hours). Besides avoiding the use of multiple endoscopic, radiologic and functional gastrointestinal tests, WMC can provide new diagnoses, leads to a change in management decision and help to direct further focused work-ups in patients with suspected disordered motility. In conclusion, WMC represents a significant advance in the assessment of segmental and whole gut transit and motility, and could prove to be an indispensable diagnostic tool for gastrointestinal physicians worldwide.

Treatment of esophageal (noncardiac) chest pain: an expert review.

BACKGROUND & AIMS Chest pain is a common and frightening symptom. Once cardiac disease has been excluded, an esophageal source is most likely. Pathophysiologically, gastroesophageal reflux disease, esophageal dysmotility, esophageal hypersensitivity, and anxiety disorders have been implicated. However, treatment remains a challenge. Here we examined the efficacy and safety of various commonly used modalities for treatment of esophageal (noncardiac) chest pain (ECP) and provided evidence-based recommendations. METHODS We reviewed the English language literature for drug trials evaluating treatment of ECP in PubMed, Cochrane, and MEDLINE databases from 1968-2012. Standard forms were used to abstract data regarding study design, duration, outcome measures and adverse events, and study quality. RESULTS Thirty-five studies comprising various treatments were included and grouped under 5 broad categories. Patient inclusion criteria were extremely variable, and studies were generally small with methodological concerns. There was good evidence to support the use of omeprazole and fair evidence for lansoprazole, rabeprazole, theophylline, sertraline, trazodone, venlafaxine, imipramine, and cognitive behavioral therapy. There was poor evidence for nifedipine, diltiazem, paroxetine, biofeedback therapy, ranitidine, nitrates, botulinum toxin, esophageal myotomy, and hypnotherapy. CONCLUSIONS Ideally, treatment of ECP should be aimed at correcting the underlying mechanism(s) and relieving symptoms. Proton pump inhibitors, antidepressants, theophylline, and cognitive behavioral therapy appear to be useful for the treatment of ECP. However, there is urgent and unmet need for effective treatments and for rigorous, randomized controlled trials.

Randomised clinical trial: mixed soluble/insoluble fibre vs. psyllium for chronic constipation.

Fibre supplements are useful, but whether a plum‐derived mixed fibre that contains both soluble and insoluble fibre improves constipation is unknown.

Optimal Testing for Diagnosis of Fructose Intolerance: Over-dosage Leads to False Positive Intolerance Test

TO THE EDITOR: We read with interest the recent article by Goebel-Stengel et al1 and wish to express our appreciation and enthusiasm for their work on small intestinal bacterial overgrowth (SIBO) and carbohydrate intolerance in patients with irritable bowel syndrome (IBS). However, we have significant concerns regarding their methodology and basis for diagnosis of fructose intolerance.

How to Perform and Assess Colonic Manometry and Barostat Study in Chronic Constipation

Management of chronic constipation with refractory symptoms can be challenging. Although new drugs and behavioral treatments have improved outcome, when they fail, there is little guidance on what to do next. At this juncture, typically most doctors may refer for surgical intervention although total colectomy is associated with morbidity including complications such as recurrent bacterial overgrowth. Recently, colonic manometry with sensory/tone/compliance assessment with a barostat study has been shown to be useful. Technical challenges aside, adequate preparation, and appropriate equipment and knowledge of colonic physiology are keys for a successful procedure. The test itself appears to be safe with little complications. Currently, colonic manometry is usually performed with a 6–8 solid state or water-perfused sensor probe, although high-resolution fiber-optic colonic manometry with better spatiotemporal resolutions may become available in the near future. For a test that has evolved over 3 decades, normal physiology and abnormal findings for common phenotypes of chronic constipation, especially slow transit constipation, have been well characterized only recently largely through the advent of prolonged 24-hour ambulatory colonic manometry studies. Even though the test has been largely restricted to specialized laboratories at the moment, emerging new technologies and indications may facilitate its wider use in the near future.

Sa2026 Small Intestinal Fungal Overgrowth (SIFO): A Cause of Gastrointestinal Symptoms

Background: Fungi may colonize the small intestine and may be pathogenic and/or cause GI symptoms. In one study, 27% of patients with unexplained GI symptoms had SIFO (Jacobs et al). Whether SIFO causes symptoms and whether symptom profiles differ between those with or without SIFO is unknown. Our aim was to determine the presence of fungal overgrowth in patients with unexplained GI symptoms and to compare the symptom profiles of SIFO +ve and -ve patients. Methods: Patients with chronic gastrointestinal (GI) symptoms and negative endoscopy and computerized abdominal tomography (CAT) scan referred to motility center, underwent duodenal aspiration/culture. Under aseptic precautions, 3mL of duodenal juice was aspirated from the 3rd/4th parts of duodenum during esophagogastroduodenoscopy by using a 2mm Liguory catheter and cultured for fungi. Patients scored the frequency, intensity and duration of abdominal pain, belching, bloating, fullness, indigestion, nausea, diarrhea, vomiting, gas for previous 2 weeks on a Likert-like scale from 0-3 (frequency: 0=none, 1= 1 episode/wk. intensity: 0 = no symptoms, 1 = mild, 2 = moderate, 3 = severe symptom. Duration: 0 = none, 1= 30 min.). Mann-Whitney U test was used to compare symptom scores of SIFO +ve vs SIFO -ve patients. Results: 150 patients (F/M=117/33), mean age 47 years, and symptom duration of >6 months were enrolled. Duodenal culture yielded a positive fungal culture in 25.3% (38/150) patients. 37 (97.4%) were Candida spp.; 31 (83.8%) Candida Albicans, 6 (16.2%) Candida Glabrata, and 1 (2.6%) was Penicillum spp. 16 (42.1%) grew ≥102 CFU/ mL, 11 (28.9%) grew ≥103 CFU/mL, 4 (10.5%) grew ≥104 CFU/mL, and 3 (7.9%) grew ≥105 CFU/mL. Predominant symptoms were abdominal pain, bloating, fullness, nausea and gas, but symptom scores were not different between patients with or without SIFO, all p= ns (Table 1). Median total symptom scores were not significantly different in SIFO +ve vs SIFO -ve group; 45.043 vs 46.428 (p=0.651). Conclusion: Approximately 25% of patients with chronic GI symptoms may have SIFO. Symptoms do not appear to differentiate between those with or without SIFO and duodenal culture appears to be the only method of identifying this problem. Table 1:

Anorectal Manometry in Defecatory Disorders: A Comparative Analysis of High-resolution Pressure Topography and Waveform Manometry

Background/Aims Whether high-resolution anorectal pressure topography (HRPT), having better fidelity and spatio-temporal resolution is comparable to waveform manometry (WM) in the diagnosis and characterization of defecatory disorders (DD) is not known. Methods Patients with chronic constipation (Rome III) were evaluated for DD with HRPT and WM during bearing-down “on-bed” without inflated rectal balloon and “on-commode (toilet)” with 60-mL inflated rectal balloon. Eleven healthy volunteers were also evaluated. Results Ninety-three of 117 screened participants (F/M = 77/16) were included. Balloon expulsion time was abnormal (> 60 seconds) in 56% (mean 214.4 seconds). A modest correlation between HRPT and WM was observed for sphincter length (R = 0.4) and likewise agreement between dyssynergic subtypes (κ = 0.4). During bearing down, 2 or more anal pressure-segments (distal and proximal) could be appreciated and their expansion measured with HRPT but not WM. In constipated vs healthy participants, the proximal segment was more expanded (2.0 cm vs 1.0 cm, P = 0.003) and of greater pressure (94.8 mmHg vs 54.0 mmHg, P = 0.010) during bearing down on-commode but not on-bed. Conclusions Because of its better resolution, HRPT may identify more structural and functional abnormalities including puborectal dysfunction (proximal expansion) than WM. Bearing down on-commode with an inflated rectal balloon may provide additional dimension in characterizing DD.

Editorial: mixed soluble fibre in chronic constipation – something new? Authors’ reply

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