European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus.

INTRODUCTION: Measurement of breath hydrogen (H2 ) and methane (CH4 ) excretion after ingestion of test-carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. METHODS: This consensus-based clinical practice guideline defines the clinical indications, performance, and interpretation of H2 -CH4 -breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. RESULTS: The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro-cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2 -CH4 -breath tests in these indications and recommends approaches to mitigate these issues. CONCLUSION: This clinical practice guideline should facilitate pan-European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.

Management of Chronic Diarrhea in Primary Care: The Gastroenterologists' Advice.

BACKGROUND: Chronic diarrhea is defined as more than 3 bowel movements per day, or loose stools, or stool weight >200 g/day for at least 4 weeks. Accompanying symptoms may include urgency, abdominal pain, or cramps. SUMMARY: A number of causes have to be considered, including inflammatory, neoplastic, malabsorptive, infective, vascular, and functional gastrointestinal diseases. Other causes include food intolerances, side effects of drugs, or postsurgical conditions. Diarrhea may also be symptom of a systemic disease, like diabetes or hyperthyroidism. Special patient groups, like the very elderly and immunocompromised patients, pose special challenges. This review follows a question-answer style and addresses questions raised on the intersection of primary and secondary care. What do you mean by diarrhea? Why is it important to distinguish between acute or chronic diarrhea? How shall the patient with chronic diarrhea be approached? How can history and physical exam help? How can routine laboratory tests help in categorizing diarrhea? Which additional laboratory tests may be helpful? How to proceed in undiagnosed or intractable diarrhea? What are the treatment options in patients with chronic diarrhea? Key Messages: Acute diarrhea is usually of infectious origin with the main treatment goal of preventing water and electrolyte disturbances. Chronic diarrhea is usually not of infectious origin and may be the symptom of a large number of gastrointestinal and general diseases or drug side effects. In undiagnosed or intractable diarrhea, the question shall be raised whether the appropriate tests have been performed and interpreted correctly.

International consensus on the diagnosis and management of dumping syndrome.

Dumping syndrome is a common but underdiagnosed complication of gastric and oesophageal surgery. We initiated a Delphi consensus process with international multidisciplinary experts. We defined the scope, proposed statements and searched electronic databases to survey the literature. Eighteen experts participated in the literature summary and voting process evaluating 62 statements. We evaluated the quality of evidence using grading of recommendations assessment, development and evaluation (GRADE) criteria. Consensus (defined as >80% agreement) was reached for 33 of 62 statements, including the definition and symptom profile of dumping syndrome and its effect on quality of life. The panel agreed on the pathophysiological relevance of rapid passage of nutrients to the small bowel, on the role of decreased gastric volume capacity and release of glucagon-like peptide 1. Symptom recognition is crucial, and the modified oral glucose tolerance test, but not gastric emptying testing, is useful for diagnosis. An increase in haematocrit >3% or in pulse rate >10 bpm 30 min after the start of the glucose intake are diagnostic of early dumping syndrome, and a nadir hypoglycaemia level <50 mg/dl is diagnostic of late dumping syndrome. Dietary adjustment is the agreed first treatment step; acarbose is effective for late dumping syndrome symptoms and somatostatin analogues are preferred for patients who do not respond to diet adjustments and acarbose.

EAGEN and UEG: A Long-Term Partnership with a Focus on Education.

EAGEN is one of the 7 founding sisters and an ordinary member society of UEG. EAGEN members have contributed significantly to the development of UEG in leading positions within UEG. The significant impact of UEG board members on science, education, and organization of European gastroenterology is demonstrated by the remarkable list of EAGEN board members who have received major UEG awards or prizes. The focus of EAGEN within UEG has been on postgraduate education. In this function, EAGEN has developed educational formats which after their establishment were handed over to UEG. EAGEN has established itself as an important provider of education in gastroenterology including pancreatic-biliary diseases, GI oncology, endoscopic procedures, nutrition, and intestinal microbiology. EAGEN has the goal to identify educational needs, fill existing gaps in medical education, and advance the quality of education. To fulfill these tasks, EAGEN is in close cooperation with the UEG education committee and UEG member societies. EAGEN puts a focus on reduction of pan-European health inequalities, provision of equal opportunity, promotion of young talent, and improvement of clinical standards and guidelines.

Multicentre, non-interventional study of the efficacy and tolerability of linaclotide in the treatment of irritable bowel syndrome with constipation in primary, secondary and tertiary centres: the Alpine study.

OBJECTIVES: We evaluated the effectiveness and tolerability of linaclotide, a minimally absorbed guanylate cyclase-C agonist, in patients with irritable bowel syndrome with constipation (IBS-C) in routine clinical practice. SETTING: A multicentre, non-interventional study conducted between December 2013 and November 2015 across 31 primary, secondary and tertiary centres in Austria and Switzerland. PARTICIPANTS: The study enrolled 138 patients aged ≥18 years with moderate-to-severe IBS-C. Treatment decision was at the physician's discretion. Patients with known hypersensitivity to the study drug or suspected mechanical obstruction were excluded. The mean age of participants was 50 years, and >75% of the patients were women. 128 patients completed the study. PRIMARY AND SECONDARY OUTCOME MEASURES: Data were collected at weeks 0 and 4 in Austria and weeks 0, 4 and 16 in Switzerland. The primary effectiveness endpoints included severity of abdominal pain and bloating (11-point numerical rating scale [0=no pain/bloating to 10=worst possible pain/bloating]), frequency of bowel movements and physicians' global effectiveness of linaclotide. Treatment-related adverse events (AEs) were recorded. RESULTS: Following a 4-week treatment period, the mean intensity score of abdominal pain was reduced from 5.8 at baseline to 2.7, while the bloating intensity score was reduced from 5.8 at baseline to 3.1e (both indices p<0.001). The frequency of mean weekly bowel movements increased from 2.1 at baseline to 4.5 at week 4 (p<0.001). Global effectiveness and tolerability of linaclotide were assessed by the treating physicians as 'good' or 'excellent' in >70% of patients. In total, 31 AEs were reported in 22 patients, the most common being diarrhoea, reported by 6 (7%) and 8 (15.4%) patients in Austria and Switzerland, respectively. CONCLUSIONS: Patients with IBS-C receiving linaclotide experienced effective treatment of moderate-to-severe symptoms in routine clinical practice. Linaclotide was safe and well tolerated and no new safety concerns were raised, supporting results from previous clinical trials.

Distribution, size and shape of colorectal adenomas as determined by a colonoscopist with a high lesion detection rate: Influence of age, sex and colonoscopy indication.

BACKGROUND: Increasing attention is focused on polyp-related features that may contribute to the operator-dependent nature of colonoscopy. Few data on polyps are available from high-yield colonoscopies, which may serve as a benchmark for quality control. OBJECTIVES: Describe regional distribution, histology, size and shape of polyps, and the influence of patient age and gender, in colonoscopies performed by a colonoscopist with high lesion detection rate. METHODS: Analysis of 698 consecutive patients with diagnostic, screening or surveillance colonoscopies. RESULTS: In 704 colonoscopies, 1908 polyps were removed (360 were protruded and 1548 flat; 1313 were hyperplastic, 562 adenomas, 5 serrated adenomas and 8 mixed). There were 232 adenomas in female patients and 343 in male patients; 39% of the adenomas were protruded and 61% were flat. The peak adenoma detection rate (ADR) was 51% in patients beyond age 79 years. Men older than 49 years had a higher ADR than women. In men and women, respectively: 40% and 32% of adenomas were in the right colon, 31% and 22% were in the transverse colon, and 30% and 47% were in the left colon. Beyond age 59 years, the majority of adenomas were in the proximal colon. CONCLUSIONS: An excess of adenomas in the proximal colon started at age 60 and this was more pronounced in men than in women. In all colonic regions, the majority of adenomas had a shape that was flat and smaller than 6 mm.

[Exocrine pancreatic insufficiency and diabetes mellitus]. / Exokrine Pankreasinsuffizienz und Diabetes mellitus.

Exocrine pancreatic insufficiency (EPI) in diabetic patients is frequent. Studies based on fecal elastase-1 measurement give prevalence rates of 10‒30 % of severe and 22‒56 % of moderate EPI in type 1 and rates of 5‒46 % in type 2 diabetic patients. Nevertheless, not all patients report typical symptoms like diarrhea, steatorrhea and weight loss. For noninvasive testing the determination of fecal elastase-1 has the highest sensitivity and specificity. This test should be performed at least in all symptomatic patients. As differential diagnosis celiac disease (with a prevalence of about 3-5 % of type 1 diabetic patients), autonomic neuropathy, but also diseases like irritable bowel syndrome and gastrointestinal tumors have to be taken into account. Patients with symptoms and a fecal elastase-1 < 100 µg/g should be treated with pancreatic enzymes in adequate daily doses administered at main meals. Treatment improves symptoms significantly, supply with fat soluble vitamins is normalised, risk for osteoporosis is reduced. However, improvement of glucose metabolism has not been demonstrated consistently. A pancreatogenic diabetes, also termed as type 3c diabetes, has not necessarily to be treated with insulin, often-at least initially-treatment with oral antidiabetic drugs is sufficient.

Diet therapy for inflammatory bowel diseases: The established and the new.

Although patients with inflammatory bowel diseases (IBD) have a strong interest in dietary modifications as part of their therapeutic management, dietary advice plays only a minor part in published guidelines. The scientific literature shows that dietary factors might influence the risk of developing IBD, that dysbiosis induced by nutrition contributes to the pathogenesis of IBD, and that diet may serve as a symptomatic treatment for irritable bowel syndrome-like symptoms in IBD. The role of nutrition in IBD is underscored by the effect of various dietary therapies. In paediatric patients with Crohn's disease (CD) enteral nutrition (EN) reaches remission rates similar to steroids. In adult patients, however, EN is inferior to corticosteroids. EN is not effective in ulcerative colitis (UC). Total parenteral nutrition in IBD is not superior to steroids or EN. The use of specific probiotics in patients with IBD can be recommended only in special clinical situations. There is no evidence for efficacy of probiotics in CD. By contrast, studies in UC have shown a beneficial effect in selected patients. For patients with pouchitis, antibiotic treatment followed by probiotics, like VSL#3 or Lactobacillus GG, is effective. When probiotics are used, the risk of bacterial translocation and subsequent bacteremia has to be considered. More understanding of the normal intestinal microflora, and better characterization of probiotic strains at the phenotypic and genomic levels is needed as well as clarification of the mechanisms of action in different clinical settings. A FODMAP reduced diet may improve symptoms in IBD.

[Position paper: Exocrine pancreatic insufficiency and diabetes mellitus]. / Positionspapier: Exokrine Pankreasinsuffizienz und Diabetes mellitus.

Exocrine pancreatic insufficiency in diabetic patients is frequent. Studies based on fecal elastase-1 measurement give prevalence rates of about 50 % in type 1 and 33 % in type 2 diabetic patients. Nevertheless, not all patients report typical symptoms like diarrhea, steatorrhea and weight loss. For indirect testing the determination of fecal elastase-1 has the highest sensitivity and specificity. This test should be performed at least in all symptomatic patients. For differential diagnosis celiac disease (with a prevalence of about 3-5 % of type 1 diabetic patients), autonomic neuropathy, but also diseases like irritable colon and gastrointestinal tumors have to be taken into account. Patients with symptoms and a fecal elastase-1 < 100 µg/g should be treated with pancreas enzymes in adequate daily doses administered at main meals. Treatment improves symptoms significantly, supply with fat soluble vitamins is normalised, risk for osteoporosis is reduced. An improvement of glucose metabolism is but not seen in all studies. A pancreatogenic diabetes, also termed as type 3c diabetes, has not primarily to be treated with insulin, often-at least initially-treatment with oral antidiabetic drugs is possible and sufficient.

Medical complications of bariatric surgery: focus on malabsorption and dumping syndrome.

Gastroenterologists increasingly see patients with symptoms after bariatric surgery. A number of gastrointestinal or extra-gastrointestinal symptoms should raise the suspicion of malabsorption or dumping syndrome. Little is known about long-term consequences of disordered intestinal anatomy and physiology resulting from bariatric surgical procedures. The latency phase of clinical problems is unknown, but may potentially be long, and postoperative courses over many decades have to be considered regarding the consequences of surgical alterations of gastrointestinal structure and function. Long-term nutritional requirements in patients with bariatric procedures are incompletely understood. This review focuses on the pathophysiology of long-limb Roux-en-Y gastric bypass (RYGB) because it has become the most common bariatric procedure in many parts of the world. Although several potential mechanisms for nutritional deficiencies after RYGB like deficiency of dietary intake, lack of gastric secretions, exclusion of proximal duodenum and jejunum, or asynergia between food bolus and biliopancreatic secretions have been postulated, it was only very recently that in-depth studies have been carried out to measure the extent to which the long-limb RYGB causes malabsorption. In order to improve care for these patients, specialists who are trained in understanding pathophysiological changes in digestion and absorption after bariatric surgery and who recognize and treat clinical symptoms and nutritional deficits after bariatric surgery are needed. In addition, clinical researchers should take advantage of the experimental setups provided by standardized surgical procedures, and scientific societies should design courses and scientific meetings which combine the expertise in gastroenterology, surgery and nutrition.

Reflux symptom index and reflux finding score in otolaryngologic practice.

OBJECTIVES: To evaluate whether patients with abnormal Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) benefit from proton pump inhibitor (PPI) therapy. STUDY DESIGN: Open, multicenter, prospective longitudinal cohort study. METHODS: Patients with suspected reflux-associated laryngologic symptoms were evaluated by 40 community practice otolaryngologists using RSI and RFS. Patients were treated with pantoprazole 40-80 mg/d for 8-12 weeks if RSI was greater than 9 and RFS greater than 7. Pre- and posttherapeutic RSI and RFS were compared using Wilcoxon signed rank test and additionally controlled with the symmetry test of Bowker. RESULTS: A total of 1044 patients were included over a period of 20 months. Median total score of RSI before therapy was 12 and decreased to 3 (P≪0.001). Median total score of RFS before therapy was 16 and decreased to 6 (P≪0.001). Assessment of the treatment effect by otolaryngologists and patients was judged as being excellent in at least 50%. In 2% of the patients, gastrointestinal side effects were documented. CONCLUSION: RSI and RSF are easy to administer in the routine care of patients suspected of having laryngopharyngeal reflux. Patients identified by positive results of these tests have a high likelihood of excellent improvement after 8-12 weeks of PPI treatment. By implementation of RFS and RSI in daily use, most patients may not need time-consuming and cost-intensive examinations in the first-line assessment of LPR. These examinations can be reserved for nonresponders, and uncontrolled prescription of PPIs can be restricted.

Pancreatic exocrine insufficiency: diagnostic evaluation and replacement therapy with pancreatic enzymes.

In chronic pancreatitis over a course of years to decades, pancreatic parenchyma is gradually lost and pain is gradually decreasing as signs and symptoms of malabsorption appear. Appearance of calcifications is a late sign and in many cases coincides with appearance of steatorrhea. Decreasing output of insulin and glucagon results in diabetes mellitus, which is characterized by a high risk of hypoglycemias ('brittle' diabetes). In most instances, measurement of fecal concentration of elastase may be sufficient to diagnose exocrine pancreatic insufficiency. Fecal fat analysis is useful to establish malabsorption and to monitor pancreatic enzyme replacement therapy. Components essential to the optimal management of chronic pancreatitis are control of pain, improvement of maldigestion, management of diabetes and of complications like cysts or strictures, and alcohol and nicotine abstinence. Patients with pain are evaluated for structural abnormalities which can be treated endoscopically or surgically. Conservative treatment of pain includes fat-reduced diet, nonnarcotic analgesics, alcohol and smoking cessation, and, if not successful, an 8-week trial of high-dose pancreatic enzymes. Pancreatic enzymes are used for the treatment of maldigestion. Digestion of fat is the determining factor in pancreatic insufficiency. Treatment success is defined clinically by improved body weight and consistency of feces. Modern pancreatin preparations are engineered as acid-resistant, pH-sensitive microspheres. Using such preparations, most patients will reduce their steatorrhea to <15 g fat per day during supplementation of 25,000-40,000 IU of lipase per meal, but in selected cases larger doses may be needed, depending on size of the meal and severity of the disease. Efficacy of enzyme replacement therapy is influenced by denaturation of lipase by gastric acid, improper timing of enzymes, coexisting small-intestinal mucosal disease, rapid intestinal transit and effects of diabetes. This review focuses on pathophysiology, diagnosis and treatment of pancreatic steatorrhea.

Reflux-associated laryngitis and laryngopharyngeal reflux: a gastroenterologist's point of view.

Laryngopharyngeal reflux of liquid and gaseous gastric contents should be considered in every patient with unexplained hoarseness. Pathophysiology and treatment of reflux-associated laryngitis are different from those of reflux esophagitis and therefore remain an unsolved puzzle. The laryngeal mucosa is considerably more sensitive to acid and pepsin than the mucosa of the esophagogastric junction. Therefore definitions of acid and nonacid reflux used for gastroesophageal reflux disease may not be helpful for explaining pathophysiologic mechanisms in the larynx or pharynx. A reflux symptom index and reflux finding score may be useful in helping to select the minority of patients who may benefit from acid-suppressive therapy; however, further research is needed. Further research is also needed to identify those patients who may require higher doses or prolonged duration of proton pump inhibitors or alternative treatments like prokinetics or alginate, or those patients who may benefit from surgical treatment of gastroesophageal reflux. Since symptoms of laryngopharyngeal reflux may predict esophageal adenocarcinoma, every patient with laryngopharyngeal reflux should have an upper gastrointestinal endoscopy, even if no classical symptoms of gastroesophageal reflux disease are present.