Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests.

BACKGROUND AND AIMS: Defecation Disorders (DD) are a frequent cause of refractory chronic constipation. DD diagnosis requires anorectal physiology testing. Our aim was to evaluate the accuracy and Odds Ratio (OR) of a straining question (SQ) and a digital rectal examination (DRE) augmented by abdomen palpation on predicting a DD diagnosis in refractory CC patients. METHODS: Two hundred and thirty-eight constipated patients were enrolled. Patients underwent SQ, augmented DRE and balloon evacuation test before entering the study and after a 30-day fiber/laxative trial. All patients underwent anorectal manometry. OR and accuracy were calculated for SQ and augmented DRE for both dyssynergic defecation and inadequate propulsion. RESULTS: "Anal Muscles" response was associated to both dyssynergic defecation and inadequate propulsion, with an OR of 13.6 and 5.85 and an accuracy of 78.5% and 66.4%, respectively. "Failed anal relaxation" on augmented DRE was associated with dyssynergic defecation, with an OR of 21.4 and an accuracy of 73.1%. "Failed abdominal contraction" on augmented DRE was associated with inadequate propulsion with an OR >100 and an accuracy of 97.1%. CONCLUSIONS: Our data support screening constipated patients for DD by SQ and augmented DRE to improve management and appropriateness of referral to biofeedback.

Rifaximin in diverticulosis and diverticular disease: a national survey among Italian gastroenterologists and general practitioners.

The management of patients with diverticular disease remains challenging. The aim of this national survey was to assess how gastroenterologists and general practitioners use rifaximin to manage diverticulosis and diverticular disease. Members of the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO) and the Italian Federation of General Practitioners (FIMMG) were invited to complete a 39-item online survey concerning the use of rifaximin in five clinical settings: (1) diverticulosis; (2) reducing symptoms in symptomatic uncomplicated diverticular disease; (3) reducing the occurrence of diverticulitis in patients with symptomatic uncomplicated diverticular disease (primary prevention); (4) reducing the recurrence of diverticulitis in patients with previous attacks of diverticulitis (secondary prevention); (5) treatment of uncomplicated acute diverticulitis. A total of 1094 physicians completed the survey. Overall, 25.1%, 83.5%, 68%, 74.2%, and 63% of physicians prescribed rifaximin for the clinical settings 1, 2, 3, 4, and 5, respectively. In each clinical setting, the dosage of rifaximin most frequently used was 800 mg/day, the most common duration of therapy was 7 days, and the cyclic administration of treatment (expressed in months) most frequently used was > 24 months. These results highlight that a reappraisal of the use of rifaximin in patients with diverticulosis and diverticular disease is required to reduce the gap between the evidence available and the daily clinical practice, optimizing also the use of healthcare resources.

Nutritional Pearls and Pitfalls of Gastrointestinal Diseases.

Since ancient times, food has been considered a possible therapy for treating a wide range of diseases [...].

Role of Low-FODMAP diet in functional dyspepsia: "Why", "When", and "to Whom".

Functional dyspepsia (FD) is a frequent disorder of gut-brain interaction, affecting 5-7% of people globally, with significant impairment in quality of life. The management of FD is challenging due to the lack of specific therapeutic approaches. Although food seems to play a role in symptom production, its pathophysiologic role in patients with FD is not fully understood. Most FD patients report that their symptoms are triggered by food, especially in the post-prandial distress syndrome (PDS) group, although evidence to support the use of dietary interventions are limited. FODMAPs can increase production of gas in the intestinal lumen, through fermentation by intestinal bacteria, can exert osmotic effects by increasing water volume and can cause an excessive production of short-chain fatty acids (propionate, butyrate, and acetate). Emerging scientific evidence, confirmed by recent clinical trials, suggest that FODMAPs could be involved in the pathogenesis of FD. Given the consolidated approach of the Low-FODMAP Diet (LFD) in irritable bowel syndrome (IBS) management and emerging scientific evidence regarding the LFD in FD, a therapeutic role of this diet may be hypothesized also in FD, either alone or in combination with other therapies.

Robotic Colonoscopy and Beyond: Insights into Modern Lower Gastrointestinal Endoscopy.

Lower gastrointestinal endoscopy is considered the gold standard for the diagnosis and removal of colonic polyps. Delays in colonoscopy following a positive fecal immunochemical test increase the likelihood of advanced adenomas and colorectal cancer (CRC) occurrence. However, patients may refuse to undergo conventional colonoscopy (CC) due to fear of possible risks and pain or discomfort. In this regard, patients undergoing CC frequently require sedation to better tolerate the procedure, increasing the risk of deep sedation or other complications related to sedation. Accordingly, the use of CC as a first-line screening strategy for CRC is hampered by patients' reluctance due to its invasiveness and anxiety about possible discomfort. To overcome the limitations of CC and improve patients' compliance, several studies have investigated the use of robotic colonoscopy (RC) both in experimental models and in vivo. Self-propelling robotic colonoscopes have proven to be promising thanks to their peculiar dexterity and adaptability to the shape of the lower gastrointestinal tract, allowing a virtually painless examination of the colon. In some instances, when alternatives to CC and RC are required, barium enema (BE), computed tomographic colonography (CTC), and colon capsule endoscopy (CCE) may be options. However, BE and CTC are limited by the need for subsequent investigations whenever suspicious lesions are found. In this narrative review, we discussed the current clinical applications of RC, CTC, and CCE, as well as the advantages and disadvantages of different endoscopic procedures, with a particular focus on RC.

Misinterpreting Diarrhea-Predominant Irritable Bowel Syndrome and Functional Diarrhea: Pathophysiological Highlights.

Irritable bowel syndrome with predominant diarrhea (IBS-D) and functional diarrhea (FD) are disorders of gut-brain interaction characterized by recurring symptoms which have a serious impact on the patient's quality of life. Their pathophysiology is far from being completely understood. In IBS-D growing evidence suggests that bile acid malabsorption (BAM) could be present in up to 30% of patients. Microscopic colitis (MC) is a well-known cause of watery diarrhea and some patients, at first, can be diagnosed as IBS-D or FD. Both BAM and MC are often responsible for the lack of response to conventional treatments in patients labelled as "refractory". Moreover, because BAM and MC are not mutually exclusive, and can be found in the same patient, they should always be considered in the diagnostic workout when a specific treatment for BAM or MC is unsatisfactory. In the present review the possible shared pathogenetic mechanisms between BAM and MC are discussed highlighting how MC can induce a secondary BAM. Moreover, a brief overview of the current literature regarding the prevalence of their association is provided.

Diets including Animal Food Are Associated with Gastroesophageal Reflux Disease.

Gastroesophageal reflux disease (GERD) is a clinical condition with a prevalence of up to 25% in Western countries. Typical GERD symptoms include heartburn and retrosternal regurgitation. Lifestyle modifications, including diet, are considered a first-line therapeutic approach. To evaluate the impact of life habits on GERD in this cross-sectional study, we used data collected through an online survey from 1146 participants. GERD was defined according to the Montreal Consensus. For all participants, clinical and lifestyle characteristics were recorded. Overall, 723 participants (63.1%) consumed a diet including animal food (non-vegans), and 423 participants (36.9%) were vegans. The prevalence of GERD was 11% (CI 95%, 9-14%) in non-vegans and 6% (CI 95%, 4-8%) in vegans. In the multivariate analysis, after adjusting for confounding factors, subjects on a non-vegan diet were associated with a two-fold increase in the prevalence of GERD compared to vegans (OR = 1.96, CI 95%, 1.22-3.17, p = 0.006). BMI and smoking habits were also significantly associated with GERD. This study shows that an animal food-based diet (meat, fish, poultry, dairy, and eggs) is associated with an increased risk of GERD compared to a vegan diet. These findings might inform the lifestyle management of patients with GERD-related symptoms.

Translational Gap between Guidelines and Clinical Medicine: The Viewpoint of Italian General Practitioners in the Management of IBS.

Irritable bowel syndrome (IBS) guidelines are generally developed by experts, with the possibility of a translational gap in clinical medicine. The aim of our study was to assess an Italian group of general practitioners (GPs) for their awareness and use of criteria for the diagnosis and management of IBS. For this purpose, a survey was carried out involving 235 GPs, divided into two groups according to their years of activity: 65 "junior general practitioners" (JGPs) (≤10 years) and 170 "senior general practitioners" (SGPs) (>10 years). JGPs were more familiar with the Rome IV Criteria and Bristol Scale than SGPs. Abdominal pain, bowel movement frequency and bloating were the symptoms most frequently used to make a diagnosis. The most probable causes of IBS were reported to be abnormal gastrointestinal motility and psychological triggers. SGPs reported more frequently than JGPs that challenging management and patient's request were motivations for a gastroenterological consultation. The practice of clinical medicine is still far from the guidelines provided by the specialists. Abdominal pain related to defecation and changes in bowel frequency are considered to be the more important symptoms for IBS diagnosis, but most GPs, both JGPs and SGPs, like to consider abdominal bloating as another useful symptom. Involving both gastroenterologists and GPs in developing shared guidelines would be highly desirable in order to improve IBS management strategies in everyday clinical practice.

Refractory Gastroesophageal Reflux Disease: A Management Update.

Gastroesophageal reflux disease (GERD) is one of the most frequent gastrointestinal disorders. Proton pump inhibitors (PPIs) are effective in healing lesions and improving symptoms in most cases, although up to 40% of GERD patients do not respond adequately to PPI therapy. Refractory GERD (rGERD) is one of the most challenging problems, given its impact on the quality of life and consumption of health care resources. The definition of rGERD is a controversial topic as it has not been unequivocally established. Indeed, some patients unresponsive to PPIs who experience symptoms potentially related to GERD may not have GERD; in this case the definition could be replaced with "reflux-like PPI-refractory symptoms." Patients with persistent reflux-like symptoms should undergo a diagnostic workup aimed at finding objective evidence of GERD through endoscopic and pH-impedance investigations. The management strategies regarding rGERD, apart from a careful check of patient's compliance with PPIs, a possible change in the timing of their administration and the choice of a PPI with a different metabolic pathway, include other pharmacologic treatments. These include histamine-2 receptor antagonists (H2RAs), alginates, antacids and mucosal protective agents, potassium competitive acid blockers (PCABs), prokinetics, gamma aminobutyric acid-B (GABA-B) receptor agonists and metabotropic glutamate receptor-5 (mGluR5) antagonists, and pain modulators. If there is no benefit from medical therapy, but there is objective evidence of GERD, invasive antireflux options should be evaluated after having carefully explained the risks and benefits to the patient. The most widely performed invasive antireflux option remains laparoscopic antireflux surgery (LARS), even if other, less invasive, interventions have been suggested in the last few decades, including endoscopic transoral incisionless fundoplication (TIF), magnetic sphincter augmentation (LINX) or radiofrequency therapy (Stretta). Due to the different mechanisms underlying rGERD, the most effective strategy can vary, and it should be tailored to each patient. The aim of this paper is to review the different management options available to successfully deal with rGERD.

Irritable Bowel Syndrome prevalence and work ability in a sample of healthcare workers exposed to occupational stress.

OBJECTIVE: Occupational stress represents a significant precipitating factor in different diseases but its role in Irritable Bowel Syndrome (IBS) needs to be clarified. The present cross-sectional study aimed at investigating the prevalence of IBS diagnosis in a sample of health workers and exploring the potential relationships between IBS, work-related stress levels and work ability. METHODS: 653 health workers undergoing periodical occupational health surveillance at the Occupational and Preventive Medicine Unit of a major University Hospital in central Italy, were consecutively recruited and screened for IBS diagnosis, according to ROMA IV criteria. The rating scales IBS Severity Scoring System (IBS-SSS), Demand-Control-Support Questionnaire (DCSQ) and Work Ability Index (WAI) were used to assess respectively IBS severity, occupational stress and work ability levels. RESULTS: IBS prevalence in the sample was 16.8%. Participants suffering from IBS were characterized by a higher prevalence of psychiatric diagnosis and sleep disturbances, higher levels of job strain and isostrain as well as by lower levels of work ability compared to non affected subjects. Moreover, the severity of IBS correlated positively with occupational stress and both were negatively associated with work ability. CONCLUSIONS: The present results suggest the need for preventive, organizational and management strategies at workplace aimed at protecting the health and well-being but also productivity of the worker with IBS.

Use of GELSECTAN® in Patients with Irritable Bowel Syndrome (IBS): an Italian Experience.

Irritable bowel syndrome is a chronic functional gastrointestinal disorder characterized by recurrent chronic abdominal pain and impaired bowel habits, which affects daily activity and work productivity, and is associated with a significant healthcare economic burden as well as an impaired quality of life and psycho-affective profile. Management of patients is a great challenge for physicians; at the present, the therapeutic strategy aimed to treat the different symptoms, and no medical therapy is proven to modify the natural history of the disease. GELSECTAN® (xyloglucan, pea protein and tannins, xylo-oligosaccharides) is a medical device with both protective and prebiotic actions on the intestinal mucosa, able to restore intestinal permeability and to improve gastrointestinal symptoms, controlling diarrhoea, abdominal pain and bloating in adult patients with irritable bowel syndrome. We report and discuss four cases of different patients with irritable bowel syndrome successfully managed with Gelsectan in the real clinical practice. Literature data, as well as these case reports, show that this device is effective and safe in improving symptoms and bowel habits associated to irritable bowel syndrome; its efficacy and safety were confirmed for the long-term use too. Agents with film-forming protective properties, such as Gelsectan, represent a new alternative therapeutic option for the management of patients with irritable bowel syndrome.