Asociación Española de Neurogastroenterología y Motilidad (ASENEM) updated review on the management of functional abdominal pain. / Documento de puesta al día de la Asociación Española de Neurogastroenterología y Motilidad (ASENEM) sobre el manejo del dolor abdominal funcional.

Functional abdominal pain is a disorder in which central and peripheral sensitization processes converge, leading to hypersensitivity and allodynia. Differential diagnosis is made with organic digestive, renal, gynecological, endocrine, or neurological diseases. Treatment should be individualized for each patient. In cases of debilitating pain, therapy combining drugs with different mechanisms of action can be initiated, while in less severe cases, therapy with a progressive introduction of drugs based on clinical response is advised. The first line includes general lifestyle advice and antispasmodic substances, like peppermint oil, anticholinergic/antimuscarinic, and calcium channels antagonists. In the second line of treatment, neuromodulating agents are added. Finally, when these measures fail, third-line treatments such as gabapentine and atypical antipsychotics are considered. Psychological interventions should be considered if specialized therapists are available to manage these disorders.

COVID-19 detection prior to motility examinations: Prospective evaluation of pre-test questionnaires and PCR-testing.

BACKGROUND/AIMS: COVID-19 pandemic has produced an increased burden for motility laboratories due to the need to implement measures to minimize infection risk during examinations. International Societies have proposed algorithms for evaluation of active infection risk using symptom questionnaires or performing COVID-19 specific detection tests. The aim of the present study is to evaluate prospectively the independent value of a symptom-based questionnaire and RT-PCR test to detect COVID-19 infection before a digestive motility examination. PATIENTS/METHODS: All patients referred for a motility study during a 4 month period with high incidence of COVID-19 in the community were prospectively evaluated with a symptom-questionnaire administered by phone one week before the examination, and a PCR test performed 48h before the examination, following international guidelines recommendations. RESULTS: The symptom questionnaire could be obtained from 435 patients, 7 patients referred COVID-19 symptoms, but only 1 of them had a positive PCR. From 481 PCR tests performed, 8 were positive. Only 1 patient had reported symptoms in the previous questionnaire, and 2 additional patients developed COVID-19 symptoms later. Hence, 435 telephonic questionnaires should be done for one COVID-19 case detection (detection tax 0.22%); and 60 PCR should be performed for one COVID-19 case detection (detection tax 1.66%). CONCLUSIONS: The use of screening strategies prior to a motility exploration results in a low rate of infection detection, especially the use of subjective symptom questionnaires, and the correct protection measures during motility explorations with aerosol generation remain the cornerstone to prevent COVID-19 infections.

Incidence, risk factors and clinical outcomes of multidrug-resistant microorganism infections among patients admitted for decompensated cirrhosis: A prospective study.

BACKGROUND: Bacterial infections remain one of the main complications in cirrhosis and worsen patients' prognosis and quality of life. An increase in multidrug resistant microorganism (MDRM) infections among patients with cirrhosis, together with infection-related mortality rates, have been reported in recent years. Therefore, adaptation of the initial empiric antibiotic approach to different factors, particularly the local epidemiology of MDRM infections, has been recommended. We aim to describe the main features, outcomes and risk factors of MDRM infections in patients with cirrhosis. METHODS: Prospective registry of all episodes of in-hospital infections occurring among cirrhotic patients admitted within a 2-year period at a single center. Clinical and microbiological data were collected at the time of infection diagnosis, and the in-hospital mortality rate of the infectious episode was registered. RESULTS: A total of 139 infectious episodes were included. The disease-causing microorganism was identified in 90 episodes (65%), of which 31 (22%) were caused by MDRM. The only two factors independently associated with MDRM infections were rectal colonization by MDRM and a nosocomial or healthcare-associated source. The infection-related mortality rate was 18.7%. MDRM infection and a past history of hepatic encephalopathy were independently associated with in-hospital mortality. CONCLUSIONS: Almost one fourth of bacterial infections occurring in admitted cirrhotic patients were due to MDRM. Rectal colonization was the most important risk factor for MDRM infections in decompensated cirrhosis. Screening for MDRM rectal colonization in patients admitted for decompensated cirrhosis should be assessed as a tool to improve local empiric antibiotic strategies.

Appropriateness of routine pre-endoscopic SARS-CoV-2 screening with RT-PCR in asymptomatic individuals and its impact on delayed diagnosis.

AIMS: Endoscopy units are considered to be at an increased risk of infection by SARS-CoV-2. Our aim is to assess the correlation between pre-endoscopic screening with reverse-transcription-polymerase-chain-reaction (RT-PCR) in asymptomatic individuals scheduled for elective endoscopy and the epidemiological data published by the local Health Administration. PATIENTS AND METHODS: Observational retrospective study collecting the results of our screening strategy spanning June/2020-June/2021, the effective potential growth (EPG), an index measuring the outbreak risk, and the 7 and 14-day cumulative incidence (CI). Indication, delay and the findings of the endoscopic examinations were registered for RT-PCR positive patients. RESULTS: A total of 5808 tests were performed, yielding 125 positive results (2.15%). All positive tests occurred in weeks of high/very high risk (EPG>100) with the highest monthly rate being 9.36%, recorded in January/2021. A significant correlation (rho=0.796; p<0.001) between weekly positive rates and EPG was observed, and a significantly lower weekly number of positive tests was recorded when EPG<100. Planning the screening strategy one week ahead according to EPG>100 would have avoided up to 826 tests with only one positive result to account for. One hundred and thirteen individuals tested positive and 89 endoscopies were delayed. The most common findings were colon polyps, colorectal cancer and gastric metaplasia. Oncological diagnosis was delayed 50±3 days. CONCLUSIONS: No positive RT-PCR test were registered out of high-risk periods. Epidemiological administrative data in the preceding two weeks showed a significant correlation with screening results and could be useful to plan pre-endoscopic screening and avoid unnecessary tests.

Nutritional challenges in patients with gastroparesis.

PURPOSE OF REVIEW: Our purpose was to review the most recent publications on nutritional management in gastroparesis, and their relevance for global management of gastroparesis. RECENT FINDINGS: The last months, several reviews on gastroparesis have been published as well as excellent reviews on the nutritional management of patients suffering this condition. In these publications, the relevance of nutrition in management of gastroparesis has been highlighted. However, alarming studies have been published from several authors from Europe and the United States showing that a majority of patients did not follow any dietary advice from a specialist in nutrition, most patients start restrictive diets by their own, and that as much as 60% of patients have a caloric-deficient diet. In addition, recent studies show that some of the recommendations, like a radical exclusion of fibers from the diet, may be reconsidered taking into account the potential beneficial effects of fibers in global health. SUMMARY: Nutritional interventions are one of the cornerstones in management of gastroparesis. Consequently, an interdisciplinary approach, with managing teams composed by gastroenterologist and specialist in nutrition should be the correct strategy to achieve the best outcomes in symptom control and prevention of complications related to nutritional deficits. VIDEO ABSTRACT: http://links.lww.com/COCN/A17.

Spacing the Administration Interval of Anti-TNF Agents: A Valid Strategy for Patients with Inflammatory Bowel Disease?

BACKGROUND: Increasing the interval of administration of anti-TNF agents over the duration specified in the data sheet is not common in inflammatory bowel disease (IBD). AIM: To evaluate the outcomes of IBD patients treated with this strategy. METHODS: Patients with IBD who were treated with infliximab or adalimumab at intervals > 8 weeks or > 2 weeks, respectively, because of persistent clinical remission, were identified at local databases of the ENEIDA registry (a nationwide registry promoted by the Spanish Working Group in Crohn's disease and Ulcerative Colitis-GETECCU) of two referral centers. Treatment success was considered if patients remained in clinical remission with the same schedule or without biological therapy at the end of follow-up, and if no return to the conventional schedule, dose-escalation, change in biological agent, or a course of systemic corticosteroids or surgery were required. RESULTS: Eighty-five patients were included, 60 treated with infliximab and 25 with adalimumab. The spaced schedule was initiated after a median of 25 months on anti-TNF treatment (IQR 14-49). Throughout a median follow-up of 34 months (IQR 21-47), fifty patients (59%) fulfilled the success criteria of the spaced strategy. No differences were found regarding type of IBD or anti-TNF agent. Baseline C-reactive protein levels and disease duration at the time of starting anti-TNF treatment were the only factors associated with treatment success. CONCLUSIONS: Anti-TNF administration at longer intervals than those provided in the data sheet may be an efficacious, convenient, and cheaper treatment option, particularly in patients in whom anti-TNF treatment was initiated early.

Effect of Iberogast (STW5) on tolerance to colonic gas in patients with irritable bowel syndrome: A randomized, double-blind, placebo control clinical trial.

BACKGROUND: STW5 is an herbal medicinal product that, in previous studies, reduced abdominal pain in irritable bowel syndrome (IBS). The effect of STW5 on gas-related abdominal symptoms is unknown. AIM: To determine the effects of STW5, compared to placebo, on the responses to colonic gas in IBS. METHODS: Using a cross-over design, two gas challenge tests were performed in 10 patients with IBS and bloating after 2-weeks treatment with (a) STW5 and (b) placebo. The challenge test consisted in continuous infusion of gas into the colon (24 mL/min for 60 min), followed by a 30-min free evacuation period. Gas evacuation, symptom perception, and abdominal distension were continuously registered. RESULTS: Colonic gas filling was associated to a significant rise in abdominal symptom perception, that was significantly greater when patients were on-placebo (score increment 4.0 ± 0.3) compared with on-STW5 (score increment 3.2 ± 0.4; p = 0.035). Gas filling was associated to a progressive abdominal distension that was similar with both treatments. Opening of the rectal cannula produced a massive gas evacuation, similar after both treatments, associated to a return of abdominal perception and distension to basal levels when patients were on-STW5 (score increment -0.1 ± 0.4; distension 0.3 ± 0.2 cm; p = 0.399, and p = 0.112 vs. basal), whereas both remained increased on-placebo (score increment 0.5 ± 0.3; distension 0.8 ± 0.3 cm; p = 0.048, and p = 0.016 vs. infusion start). CONCLUSIONS: STW5 improves colonic gas tolerance in IBS patients with bloating without a significant effect on gas retention and evacuation. This medicinal product can be beneficious for treatment of gas-related abdominal symptoms in patients with bloating. EudraCT: 2019-003976-38.

Benefit of extending the protocol for high resolution manometry according to the version 4.0 of the Chicago criteria. A multicenter study.

BACKGROUND: The last version of the Chicago Criteria for high resolution esophageal manometry proposes an expanded protocol including complementary maneuvers to improve the diagnostic yield of the exploration. Our aim was to determine the diagnostic gain of the CCv4.0 protocol compared to the CCv3.0 protocol. METHODS: All manometry recordings performed in 4 reference centers during the first 10 months after the implementation of the new protocol were retrospectively reviewed. The time spent to complete the protocol was measured, and the changes in diagnosis resulting from the new CCv4.0 were compared to CCv3.0. KEY RESULTS: From a total of 756 HRM performed, 606 studies could be properly analyzed. The duration of the studies was 18.3 ± 4.3 min. From these, 11.3 ± 3.4 min were spent to complete the CCv3.0 protocol, and 7.4 ± 3.6 min were spent for the remaining maneuvers. A discordant diagnosis between CCv3.0 and CCv4.0 was obtained in 12% of patients: 32% of patients with ineffective esophageal motility turned to normal motility; 24% of patients with esophagogastric junction outlet obstruction (EGJOO) turned to a non-obstructive disorder; and 1% of patients with an apparently normal EGJ relaxation, turned to an obstructive disorder. EGJOO according to CCv4.0 was more prevalent in patients referred for dysphagia (11%) than those referred for GERD (4%; p = 0.003). CONCLUSIONS AND INFERENCES: Prolongation of the time spent to complete the CCv4.0 protocol leads to a change in the diagnosis of 12% of patients. Clinically relevant changes are mainly related to the evaluation of EGJOO.