Riadh Sadik

Small intestinal motility disturbances and bacterial overgrowth in patients with liver cirrhosis and portal hypertension

OBJECTIVES:Altered small bowel motility and a high prevalence of small intestinal bacterial overgrowth (SIBO) has been observed in patients with liver cirrhosis. Our aim was to explore the relationship between motility abnormalities, portal hypertension, and SIBO.METHODS:Twenty-four patients with liver cirrhosis were included. Twelve had portal hypertension (PH) and 12 had liver cirrhosis (LC) alone. Child-Pugh score was the same in the groups. Antroduodenojejunal pressure recordings were performed, and noninvasive variceal pressure measurements were undertaken. Thirty-two healthy volunteers served as a reference group. Bacterial cultures were obtained from jejunal aspirates.RESULTS:The PH group had a higher proportion of individual pressure waves that were retrograde in the proximal duodenum during phase II (52% vs 13% vs 8% of propagated contractions; p < 0.001) as well as postprandially (49% vs 18% vs 13%; p < 0.01) compared with LC and controls, respectively. Long clusters were more common in PH than in controls (9.1 ± 2.1 vs 4.9 ± 0.8; p < 0.05), and a higher motility index in phase III in the proximal and distal duodenum was seen in the PH as compared with the other groups. The mean variceal pressure was 21 ± 1 mm Hg. Motor abnormalities were not correlated to the level of variceal pressure. Thirty-three percent of the patients in the PH group but none in the LC group had SIBO.CONCLUSIONS:Abnormal small bowel motility and SIBO is common in patients with liver cirrhosis with concomitant portal hypertension. Portal hypertension per se might be significantly related to small bowel abnormalities observed in patients with liver cirrhosis.

Gender differences in gut transit shown with a newly developed radiological procedure.

Background: Gut transit measurements are essential for understanding the pathophysiology of many gastrointestinal disorders. The ideal bowel transit test should be easy to perform, widely accessible, reproducible, non-invasive and inexpensive and the risks should be minimal. These requirements prompted us to develop a procedure for simultaneous measurement of gastric emptying, small-bowel transit and colonic transit at one visit. We assessed the influence of gender, body mass index, age, menopause and smoking on gastrointestinal transit in healthy subjects. Methods: Eighty-three healthy subjects (43 women) were included. Colonic transit was based on 10 radiopaque rings given daily for 6 days with fluoroscopy on day 7. Then, the subjects had a test meal containing 20 radiopaque markers. Using fluoroscopy, gastric emptying and small-bowel transit of the markers were followed until they reached the colon. Results: Gastric emptying, small-bowel transit and colonic transit were significantly slower in female healthy subjects compared to males (2.9 (1.6-4.9) h, median and percentile 10-90, versus 2.4 (0.7-3.7) h, P = 0.005; 4.4 (2.1-11.1) h versus 3.2 (1.5-6.0) h, P = 0.00l; 1.5 (1.0-3.7) days versus 1.3 (0.8-1.9) days P = 0.002), respectively. Small-bowel transit was significantly faster in women with overweight and in postmenopausal women compared to lean and premenopausal women, respectively. Conclusion: This procedure meets most of the requirements of the ideal bowel transit test and is easily performed at one visit. Small-bowel transit as well as gastric emptying and colonic transit were significantly slower for women.

Accelerated regional bowel transit and overweight shown in idiopathic bile acid malabsorption.

OBJECTIVES:Overweight has recently been shown to accelerate small bowel transit. The role of gut transit and body weight in idiopathic bile acid malabsorption (IBAM) is unclear. We have prospectively studied gastrointestinal transit and body mass index (BMI) in patients with IBAM.METHODS:One hundred and ten patients with chronic diarrhea were prospectively included for transit measurements. All patients underwent a gastroscopy and colonoscopy, 75SeHCAT test for detection of bile acid malabsorption and calculation of BMI. Forty-three patients (15 men) had IBAM. A newly developed radiological procedure was used to measure gastrointestinal transit during one visit. The results were compared to results obtained in 83 healthy subjects.RESULTS:Colonic transit in women with IBAM was 0.8 (0.3–1.5) days versus 1.5 (1.0–3.7) days in healthy women (median and percentile 10 and 90; p < 0.0001). In men with IBAM it was 0.8 (0.1–1.0) days; in healthy men it was 1.3 (0.8–1.9) days, p < 0.0001. Segmental colonic transit was accelerated only in the distal colon in men and women with IBAM compared with healthy subjects. Small bowel transit time in women with IBAM was 1.9 (1.1–3.0) h versus 3.3 (1.5–6.3) h in healthy women, p = 0.0002. In men with IBAM it was 2.1 (1.2–3.2) h and 2.5 (1.4–4.3) h in healthy men (p = 0.04). BMI in patients with IBAM was 27.3 (20.4–33.8) kg/m2 and in healthy subjects it was 23.8 (20.5–26.2) kg/m2, p < 0.0001.CONCLUSION:Accelerated small bowel and distal colonic transit as well as overweight are probably involved in the pathophysiology of IBAM.

Gastrointestinal transit abnormalities are frequently detected in patients with unexplained GI symptoms at a tertiary centre

Abstract  The aim of this prospective study was to analyse the yield and utility of a gastrointestinal (GI) transit measurement procedure in clinical practice. Patients referred by gastroenterologists to a tertiary centre for detailed transit measurements were prospectively included. All together 243 patients were enrolled. Body mass index was recorded. The patients were categorized according to the predominant symptom into five groups: diarrhoea, constipation, nausea, vomiting and abdominal pain. The patients recorded their bowel movements and GI symptoms daily during the week before the transit measurement. Percentiles 5 and 95 of the transit values in 83 healthy subjects served as reference values. Widespread abnormalities were found in the five patient groups and 63% of the patients had at least one transit abnormality. The abnormalities were more frequent in men compared with women. Patients with underweight had more motility disturbances compared with other patients. In male and female patients with vomiting a significant delay of transit in the ascending colon was observed compared with healthy subjects. Large‐scale transit measurements frequently detect transit abnormalities in clinical practice and may elucidate the relationship between some GI symptoms and abnormal motility.

EUS-guided drainage is more successful in pancreatic pseudocysts compared with abscesses

AIM To compare the results for endoscopic ultrasound (EUS)-guided drainage of clear fluid pancreatic pseudocysts with the results for abscess drainage. METHODS All patients referred for endoscopic drainage of a fluid collection were prospectively included. The outcome was recorded. RESULTS Altogether 26 pseudocysts or abscesses were treated in 25 (6 female) patients. One endoscopist performed the procedures. Non-infected pseudocysts were present in 15 patients and 10 patients had infected fluid collections. The cyst size ranged between 28 cm × 13 cm and 5 cm × 5 cm. The EUS drainage was successful in 94% of the pseudocysts and in 80% of the abscesses (P = 0.04). The complication rate in pseudocysts was 6% and in abscesses was 30% (P = 0.02). Recurrence of a pseudocyst occurred in one patient (4%) after 6 mo; the patient was successfully retreated. CONCLUSION EUS-guided drainage of pseudocysts is associated with a higher success rate and a lower complication rate compared with abscess drainage.

The relationship between symptoms, body mass index, gastrointestinal transit and stool frequency in patients with irritable bowel syndrome.

Background and aims Motility disturbances are involved in the pathophysiology of the irritable bowel syndrome (IBS). Population-based studies have shown an association between increasing body mass index (BMI) and different gastrointestinal (GI) symptoms. The aim of this prospective study was to characterize the relationships between symptoms in IBS, GI transit, as a measure of GI motility, and BMI. Methods We included 96 IBS patients in which 34 patients had diarrhea predominance (D-IBS), 16 had predominant constipation (C-IBS) and 46 had alternating bowel habits (A-IBS). All patients completed a GI symptom questionnaire and underwent a measurement of gastric emptying, small bowel residence and colonic transit. Transit values in 83 healthy individuals served as reference. BMI was calculated. Results At least one transit abnormality was found in 49 of 96 patients (51%). Increasing severity of urgency, loose stools and reflux were associated with higher BMI. Moreover, patients overweight had significantly faster colonic and rectosigmoid transit and higher stool frequency compared with normal weight patients. The symptom severities of pain/discomfort and bloating were associated with colonic transit abnormalities. In women, transit in the small bowel and colon was significantly slower in C-IBS compared with D-IBS. Conclusion GI transit is of relevance for the symptom pattern in patients with IBS. High BMI is associated with fast regional bowel transit and may therefore influence some stool-related symptoms in IBS.

How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy

BACKGROUND Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and 50 for surgical residents, and 130 and 140 for gastroenterology fellows, respectively. The purpose of this study was to challenge the methods used to determine proficiency in flexible endoscopy. METHODS Global assessment of gastrointestinal endoscopic skills (GAGES) was used to evaluate 139 procedures. Scores for UE were compared using self-reported case numbers and grouped according to requirements for each discipline. C scores were compared using the requirements to define novice and experienced endoscopists. Procedure volumes were plotted against GAGES scores. RESULTS Three groups were compared for UE based on case volumes: fewer than 35 cases (group 1), 35 to 130 cases (group 2), and more than 130 cases (group 3). There was no difference between group 2 (17.8 +/- 1.8) and group 3 (19.1 +/- 1.1), but both scored higher than group 1 (14.4 +/- 3.7; P < .05). For C, the scores were 11.8 +/- 3.8 (novices) and 18.8 +/- 1.34 (experienced; P < .001) at a 50-case minimum and 12.4 +/- 4.2 and 18.8 +/- 1.3 (P < .001) for a 140-case proficiency cut-off level, respectively. The curve of procedures versus GAGES plateaued at 50 (UE) and 75 (C). CONCLUSIONS The surgical and gastroenterology case recommendations may not represent the experience needed to achieve proficiency. GAGES scores could help define proficiency in basic endoscopy.

Intervention to increase physical activity in irritable bowel syndrome shows long-term positive effects.

AIM To assess the long-term effects of physical activity on irritable bowel syndrome (IBS) symptoms and on quality of life, fatigue, depression and anxiety. METHODS Seventy-six patients from a previous randomized controlled interventional study on increased physical activity in IBS were asked to participate in this long-term follow-up study. The included patients attended one visit in which they filled out questionnaires and they underwent a submaximal cycle ergometer test. The primary end point was the change in the IBS Severity Scoring System (IBS-SSS) at baseline, i.e., before the intervention and at follow-up. The secondary endpoints were changes in quality of life, fatigue, depression and anxiety. RESULTS A total of 39 [32 women, median age 45 (28-61) years] patients were included in this follow-up. Median follow-up time was 5.2 (range: 3.8-6.2) years. The IBS symptoms were improved compared with baseline [IBS-SSS: 276 (169-360) vs 218 (82-328), P = 0.001]. This was also true for the majority of the dimensions of psychological symptoms such as disease specific quality of life, fatigue, depression and anxiety. The reported time of physical activity during the week before the visit had increased from 3.2 (0.0-10.0) h at baseline to 5.2 (0.0-15.0) h at follow-up, P = 0.019. The most common activities reported were walking, aerobics and cycling. There was no significant difference in the oxygen uptake 31.8 (19.7-45.8) mL per min per kg at baseline vs 34.6 (19.0-54.6) mL/min per kg at follow-up. CONCLUSION An intervention to increase physical activity has positive long-term effects on IBS symptoms and psychological symptoms.

Proteomic Mucin Profiling for the Identification of Cystic Precursors of Pancreatic Cancer

Background Pancreatic cystic lesions (PCLs) are increasingly frequent radiological incidentalomas, with a considerable proportion representing precursors of pancreatic cancer. Better diagnostic tools are required for patients to benefit from this development. Methods To evaluate whether cyst fluid mucin expression could predict malignant potential and/or transformation in PCLs, a proteomic method was devised and prospectively evaluated in consecutive patients referred to our tertiary center for endoscopic ultrasound-guided aspiration of cystic lesions from May 2007 through November 2008 (discovery cohort) and from December 2008 through October 2012 (validation cohort). Cytology and cyst fluid carcinoembryonic antigen (CEA; premalignancy > 192ng/mL, malignancy > 1000ng/mL) were routinely analyzed, and samples were further processed as follows: one-dimensional gel electrophoresis, excision of high-mass areas, tryptic digestion and nano-liquid chromatography–tandem mass spectrometry, with peptide identification by Mascot software and an in-house mucin database. All diagnostic evaluations were blinded to proteomics results. Histology was required to confirm the presence/absence of malignant transformation. All statistical tests were two-sided. Results Proteomic mucin profiling proved statistically significantly more accurate (97.5%; 95% confidence interval [CI] = 90.3% to 99.6%) than cytology (71.4%; 95% CI = 59.8% to 80.9%; P < .001) and cyst fluid CEA (78.0%; 95% CI = 65.0% to 87.3%; P < .001) in identifying the 37 (out of 79; 46.8%) lesions with malignant potential (ie, premalignant or malignant tumors). The accuracy of proteomics was nearly identical (96.6% vs 98.0%) between the discovery (n = 29) and validation (n = 50) cohorts. Furthermore, mucin profiling predicted malignant transformation, present in 16 out of 29 (discovery cohort: 9, validation cohort: 20) lesions with available histology, with 89.7% accuracy (95% CI = 71.5% to 97.3%) (for the validation cohort only: 95.0%; 95% CI = 73.1% to 99.7%). This markedly exceeded corresponding results for cytology (51.7%; 95% CI = 32.9% to 70.1%; P = .003) and CEA (57.1%; 95% CI = 34.4% to 77.4%; P = .02). Conclusions Proteomic cyst fluid mucin profiling robustly discriminates benign, premalignant, and malignant PCLs. Consequently, it may improve pancreatic cancer prevention and reduce the morbidity burden of unwarranted pancreatic surgery.

Gut Transit Is Associated With Gastrointestinal Symptoms and Gut Hormone Profile in Patients With Cirrhosis

BACKGROUND & AIMS Liver cirrhosis is associated with increased prevalence of gastrointestinal symptoms, insulin resistance, and altered gut transit. We aimed to assess the prevalence of gut transit abnormalities in patients with cirrhosis, compared with healthy controls, and to evaluate the relation of gut transit with gastrointestinal symptoms and postprandial glucose and hormone profiles. METHODS Half gastric emptying, small bowel residence, and colonic filling times were measured with a validated radiologic procedure in 42 consecutive patients with cirrhosis. In a subgroup of 25 patients, gastrointestinal symptoms were evaluated by using a validated questionnaire and a caloric satiation test. Postprandial glucose, insulin, leptin, ghrelin, glucagon-like peptide 1, and PYY responses were also studied. Eighty-three healthy subjects served as controls for the transit studies and 10 for the hormone analyses. RESULTS Of patients with cirrhosis, 24% had delayed gastric emptying and 38% had prolonged small bowel transit (P < .05 compared with controls). Delayed gastric emptying was related to postprandial fullness and prolonged small bowel transit to diarrhea and abdominal pain (P < .05 for all). The patients with cirrhosis had increased postprandial glucose, insulin, and glucagon-like peptide 1 responses and reduced postprandial ghrelin. Delayed gastric emptying was related to increased postprandial glucose and reduced postprandial ghrelin. Prolonged small bowel transit was related to increased postprandial glucose and insulin and reduced postprandial ghrelin. CONCLUSIONS A high proportion of patients with cirrhosis exhibit delayed gastric emptying or small bowel transit, which is related to gastrointestinal symptoms. Postprandial hyperglycemia, hyperinsulinemia, and hypoghrelinemia might be linked to delayed gut transit in cirrhosis.