High-resolution colonic manometry interobserver analysis trial.

INTRODUCTION: Colonic high-resolution manometry (HRM) is a novel, not widely used diagnostic method used in the final workup of chronic constipation before surgery. Since its introduction, different motor patterns have been defined. However, it remains to be established whether these patterns are easily and reproducibly identified by different investigators. METHODS: The primary aim of this study was to determine agreement for motor pattern identification with HRM. To calculate the interobserver agreement (IOA), the Fleiss's kappa statistic for multiple observers was used. Seven participants analyzed 106 one-min time frames, derived from five measurements in healthy volunteers and five in patients with chronic constipation. The time frames were chosen to show a variety and combination of motor patterns consisting of short antegrade, short retrograde, cyclic anterograde, cyclic retrograde, long antegrade, long retrograde, slow retrograde motor pattern, high-amplitude propagating motor patterns, and pancolonic pressurizations. All of the measurements were performed with a solid-state colonic HRM catheter, comprising 40 pressure sensors spaced 2.5 cm apart. RESULTS: A median of 10.25 h (range 6-20) were required to analyze all time frames. High-amplitude propagating contractions achieved an almost perfect level of agreement (k = 0.91). Several motor patterns achieved substantial agreement; these included the short antegrade (k = 0.63), long antegrade (k = 0.68), cyclic retrograde (k = 0.70), slow retrograde motor pattern (k = 0.80), and abdominal pressure or movement artifacts (k = 0.67). Moderate agreement was found for short retrograde (k = 0.57), cyclic anterograde (k = 0.59), long retrograde motor patterns (k = 0.59) and simultaneous pressure waves (k = 0.59). CONCLUSION: For the majority of motor patterns, the overall IOA for colonic manometry was substantial or high. This high level of agreement supports the use of colonic manometry application in clinical and research settings. Harmonization has the potential to improve agreement for long anterograde motor patterns with high amplitudes and for mixed direction patterns.

Irritable bowel syndrome: diagnosis and management.

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders (FGIDs) encountered in clinical practice. In the absence of an accurate biomarker for the disorder, IBS is mainly diagnosed based symptomology using the Rome criteria. Due to the heterogeneity of the disorder, finding the correct treatment option is often challenging. In general, lifestyle and dietary changes, including the low-FODMAP of gluten-free diet, are the first-in-line treatment for all patients. Issues with dietary changes are the strict elimination of multiple food products and hence difficult compliance to the diet. When lifestyle changes do not lead to adequate symptom relief, patients should be treated according to their predominant bowel habits and most prominent symptoms. Laxatives or prokinetics and antidiarrheals are used to treat constipation and diarrhea respectively, but have little effect on abdominal pain. To treat gastro-intestinal (GI) symptoms, antispasmodics can be attributed. Low doses of neuromodulators can help gain control over GI and central symptoms, but are also prone to more severe side effects, restricting their widespread use. Refractory IBS symptoms can be treated with probiotics, antibiotics, histamine-receptor antagonists or alternative therapy, including psychotherapy, hypnotherapy, acupuncture or phytomedicines. However, for many of these options, scientific evidence is sparse and high-quality research is often lacking, leading to inconclusive results. In general, all of the available treatment options only provide symptom relief for a subset of patients. This review provides a full overview of the diagnostic process and currently available treatment options for IBS.

Functional Constipation: Individualising Assessment and Treatment.

Chronic constipation is one of the five most common symptoms seen by gastroenterologist. In the absence of alarm symptoms, a confident symptom-based diagnosis can often be made using the Rome criteria. Three different subtypes have been identified to date: normal transit constipation, defaecatory disorders and slow transit constipation. Differentiation between these subtypes can be made through functional testing using tests such as anorectal manometry with balloon expulsion and a radio-opaque marker test. In general, patients are initially advised to increase their fluid and fibre intake. When these general lifestyle recommendations do not improve patients' symptoms, a step-wise and add-on treatment approach should be applied. This review summarises the diagnostic criteria to differentiate functional constipation from other causes of chronic constipation. In addition, current drug treatment options, including discussion of new therapeutic targets are discussed. Further, practical treatment approaches (choice and dosing), include discussion of combination/augmentation, treatment failure (adherence/expectations), and relapse prevention are mentioned. Finally, treatment and management of pain and bloating aspects are included.

Prevalence and impact of self-reported painful and non-painful constipation in the general population.

INTRODUCTION: Chronic constipation, defined by the Rome IV criteria, is a highly prevalent functional bowel disorder with major overlap with other bowel disorders. Therefore, a pooled-analysis to evaluate the presence of self-reported constipation in the general population was conducted. Further, its association with other bowel symptoms and its health-economic impact was analyzed. METHODS: Collection of information on bowel symptoms' prevalence and their impact was done through an Internet survey (Medistrat Internet panel). The analysis focused on patients who reported constipation symptoms over the last 12 months. Firstly, participants who with or without constipation were compared. Secondly, subjects reporting constipation with (PC) or without abdominal pain (NPC) were studied. KEY RESULTS: A total of 1012 subjects (45.2 ± 0.5 years old, 62% females), of whom 217 (21%) reported constipation, completed the survey. Women were significantly more represented in the group reporting constipation compared to those with other bowel symptoms (81.57% vs 56.60%, P < .0001). Subjects reporting constipation experienced more additional bowel symptoms than those who did not report constipation [3(2-6) vs 2(1-4), P < .0001]. Of those with constipation, 134 patients reported NPC compared to 83 patients with PC. The presence of PC was associated with higher prevalence of diarrhea symptoms, alternating bowel movements, bloating, cramps, gas, and altered stool frequency and consistency (all P < .01). Out of 83 PC patients, 38 (45.24%) fulfilled the Rome IV IBS criteria. CONCLUSION: Self-reported constipation, often associated with other bowel symptoms, is a highly prevalent condition in the Belgian general population. Especially when abdominal pain is present, this generates major healthcare costs.

A survey on the impact of the COVID-19 pandemic on motility and functional investigations in Europe and considerations for recommencing activities in the early recovery phase.

BACKGROUND: The COVID-19 pandemic, declared by WHO on March 13, 2020, had a major global impact on the healthcare system and services. In the acute phase, the presence of the SARS-CoV-2 virus in the aerodigestive tract limited activities in the gastroenterology clinic and procedures to emergencies only. Motility and function testing was interrupted and as we enter the recovery phase, restarting these procedures requires a safety-focused approach with adequate infection prevention for patients and healthcare professionals. METHODS: We summarized knowledge on the presence of the SARS-CoV-2 virus in the aerodigestive tract and the risk of spread with motility and functional testing. We surveyed 39 European centers documenting how the pandemic affected activities and which measures they are considering for restarting these measurements. We propose recommendations based on current knowledge as applied in our center. RESULTS: Positioning of catheters for gastrointestinal motility tests carries a concern for aerosol-borne infection of healthcare workers. The risk is low with breath tests. The surveyed centers stopped almost all motility and function tests from the second half of March. The speed of restarting and the safety measures taken varied highly. CONCLUSIONS AND INFERENCES: Based on these findings, we provided recommendations and practical relevant information for motility and function test procedures in the COVID-19 pandemic era, to guarantee a high-quality patient care with adequate infection prevention.

Targeting mu opioid receptors to modulate gastrointestinal function: what have we learnt so far from the studies in functional bowel disorders?

Opioids have recently received much attention because of the epidemic in their use in some countries such as the USA and the UK. Concerns have been raised about the possibility that they can increase mortality in patients when used on a long-term basis. Moreover, they are known to induce paradoxical hyperalgesia as well as alterations of gut function. The analgesic properties of opioids are mediated by receptors located in the brain, but as opioid receptors are also expressed in the gastrointestinal tract, new drugs acting on these receptors have recently been developed to treat two functional disorders, namely irritable bowel syndrome with diarrhoea and opioid-induced constipation. The aim of this article is to highlight some interesting observations resulting from the development of these drugs in the field of functional gastrointestinal disorders.

First translational consensus on terminology and definitions of colonic motility in animals and humans studied by manometric and other techniques.

Alterations in colonic motility are implicated in the pathophysiology of bowel disorders, but high-resolution manometry of human colonic motor function has revealed that our knowledge of normal motor patterns is limited. Furthermore, various terminologies and definitions have been used to describe colonic motor patterns in children, adults and animals. An example is the distinction between the high-amplitude propagating contractions in humans and giant contractions in animals. Harmonized terminology and definitions are required that are applicable to the study of colonic motility performed by basic scientists and clinicians, as well as adult and paediatric gastroenterologists. As clinical studies increasingly require adequate animal models to develop and test new therapies, there is a need for rational use of terminology to describe those motor patterns that are equivalent between animals and humans. This Consensus Statement provides the first harmonized interpretation of commonly used terminology to describe colonic motor function and delineates possible similarities between motor patterns observed in animal models and humans in vitro (ex vivo) and in vivo. The consolidated terminology can be an impetus for new research that will considerably improve our understanding of colonic motor function and will facilitate the development and testing of new therapies for colonic motility disorders.

New developments in the treatment of opioid-induced gastrointestinal symptoms.

Chronic pain affects a large part of the global population, leading to an increase of opioid use. Opioid-induced constipation (OIC), a highly prevalent adverse effect of opioid use, has a major impact on patients' quality of life. Thanks to the introduction of new drugs for chronic constipation, which can also be used in OIC, and the development of peripherally acting mu-opioid receptor blockers, specifically for use in OIC, therapeutic options have seen major development. This review summarises current and emerging treatment options for OIC based on an extensive bibliographical search. Efficacy data for laxatives, lubiprostone, prucalopride, linaclotide, oxycodone/naloxone combinations, methylnaltrexone, alvimopan, naloxegol, naldemedine, axelopran, and bevenopran in OIC are summarised.