Digital Rectal Exams Are Infrequently Performed Prior to Anorectal Manometry.

BACKGROUND: Digital rectal examination should be performed prior to anorectal manometry; however, real-world data is lacking. AIMS: Characterize real world rates of digital rectal and their sensitivity for detecting dyssynergia compared to anorectal manometry and balloon expulsion test. METHODS: A retrospective single-center study was conducted to examine all patients who underwent anorectal manometry for chronic constipation between 2021 and 2022 at one tertiary center with motility expertise. Primary outcomes consisted of the rate of digital rectal exam prior to anorectal manometry; and secondary outcomes included the sensitivity of digital rectal exam for dyssynergic defecation. RESULTS: Only 42.3% of 142 patients had digital rectal examinations prior to anorectal manometry. Overall sensitivity for detecting dyssynergic defecation was 46.4%, but significantly higher for gastroenterology providers (p = .004), and highest for gastroenterology attendings (82.6%). CONCLUSIONS: Digital rectal examination is infrequently performed when indicated for chronic constipation. Sensitivity for detecting dyssynergic defecation may be impacted by discipline and level of training.

Esophagogastroduodenoscopy findings that do no not explain dysphagia are associated with underutilization of high-resolution manometry.

In patients with dysphagia that is not explained by upper endoscopy, high-resolution esophageal manometry (HRM) is the next logical step in diagnostic testing. This study investigated predictors of failure to refer for HRM after an upper endoscopy that was performed for but did not explain dysphagia. This was a retrospective cohort study of patients >18 years of age who underwent esophagogastroduodenoscopy (EGD) for dysphagia from 2015 to 2021. Patients with EGD findings that explained dysphagia (e.g. esophageal mass, eosinophilic esophagitis, Schatzki ring, etc.) were excluded from the main analyses. The primary outcome was failure to refer for HRM within 1 year of the index non-diagnostic EGD. We also investigated delayed referral for HRM, defined as HRM performed after the median. Multivariable logistic regression modeling was used to identify risk factors that independently predicted failure to refer for HRM, conditioned on the providing endoscopist. Among 2132 patients who underwent EGD for dysphagia, 1240 (58.2%) did not have findings to explain dysphagia on the index EGD. Of these 1240 patients, 148 (11.9%) underwent HRM within 1 year of index EGD. Endoscopic findings (e.g. hiatal hernia, tortuous esophagus, Barrett's esophagus, surgically altered anatomy not involving the gastroesophageal junction, and esophageal varices) perceived to explain dysphagia were independently associated with failure to refer for HRM (adjusted odds ratio 0.45, 95% confidence interval 0.25-0.80). Of the 148 patients who underwent HRM within 1 year of index EGD, 29.7% were diagnosed with a disorder of esophagogastric junction outflow, 17.6% with a disorder of peristalsis, and 2.0% with both disorders of esophagogastric outflow and peristalsis. The diagnosis made by HRM was similar among those who had incidental EGD findings that were non-diagnostic for dysphagia compared with those who had completely normal EGD findings. Demographic factors including race/ethnicity, insurance type, and income were not associated with failure to refer for HRM or delayed HRM. Patients with dysphagia and endoscopic findings unrelated to dysphagia have a similar prevalence of esophageal motility disorders to those with normal endoscopic examinations, yet these patients are less likely to undergo HRM. Provider education is indicated to increase HRM referral in these patients.

Management of Adults With Esophageal Atresia.

Esophageal atresia (EA) with or without trachea-esophageal fistula is relatively common congenital malformation with most patients living into adulthood. As a result, care of the adult patient with EA is becoming more common. Although surgical repair has changed EA from a fatal to a livable condition, the residual effects of the anomaly may lead to a lifetime of complications. These include effects related to the underlying deformity such as atonicity of the esophageal segment, fistula recurrence, and esophageal cancer to complications of the surgery including anastomotic stricture, gastroesophageal reflux, and coping with an organ transposition. This review discusses the occurrence and management of these conditions in adulthood and the role of an effective transition from pediatric to adult care to optimize adult care treatment.

Optimizing the Management Algorithm for Heartburn in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis.

BACKGROUND AND AIMS: Heartburn is the most common symptom seen in gastroenterology practice. We aimed to optimize cost-effective evaluation and management of heartburn. METHODS: We developed a decision analytic model from insurer and patient perspectives comparing 4 strategies for patients failing empiric proton pump inhibitors (PPIs): (1) PPI optimization without testing, (2) endoscopy with PPI optimization for all patients, (3) endoscopy with PPI discontinuation when erosive findings are absent, and (4) endoscopy/ambulatory reflux monitoring with PPI discontinuation as appropriate for phenotypic management. Health outcomes were respectively defined on systematic reviews of clinical trials. Cost outcomes were defined on Centers for Medicare and Medicaid Services databases and commercial multipliers for direct healthcare costs, and national observational studies evaluating healthcare utilization. The time horizon was 1 year. All testing was performed off PPI. RESULTS: PPI optimization without testing cost $3784/y to insurers and $3128 to patients due to lower work productivity and suboptimal symptom relief. Endoscopy with PPI optimization lowered insurer costs by $1020/y and added 11 healthy days/y by identifying erosive reflux disease. Endoscopy with PPI discontinuation added 11 additional healthy days/y by identifying patients without erosive reflux disease that did not need PPI. By optimizing phenotype-guided treatment, endoscopy/ambulatory reflux monitoring with a trial of PPI discontinuation was the most effective of all strategies (gaining 22 healthy days/y) and saved $2183 to insurers and $2396 to patients. CONCLUSIONS: Among patients with heartburn, endoscopy with ambulatory reflux monitoring (off PPI) optimizes cost-effective management by matching treatment to phenotype. When erosive findings are absent, trialing PPI discontinuation is more cost-effective than optimizing PPI.

The Association Between Acidification Time on Wireless Motility Capsule and Gastroesophageal Reflux Disease.

BACKGROUND AND AIMS: Gastric physiological characteristics such as fundus accommodation, gastric distention, emptying/transit time, and basal acid output may contribute to the pathogenesis of gastroesophageal reflux disease (GERD). Wireless motility capsule (WMC) uses pH data to determine gastric transit time but has not been used in the evaluation of GERD. Certain metrics such as acidification time, nadir pH, and gastric transit time may provide insight into the mechanisms of GERD related to gastric physiology, allowing WMC to be a complementary tool in the diagnosis of GERD. We aimed to determine whether pH data and transit time on WMC tests correlated with the presence of GERD on ambulatory reflux testing. STUDY: This was a retrospective study of 28 patients who had undergone both WMC and reflux testing via wireless pH or pH/impedance. Acidification time (time from capsule ingestion to pH<2), nadir postprandial pH, and gastric transit time were manually determined from the WMC capsule proprietary software. Spearman correlation was used to compare these metrics with gastric transit time, percent esophageal acid exposure, and DeMeester score. RESULTS: Acidification time moderately correlated with gastric transit time, R : 0.44, P =0.02, but not nadir pH, percent esophageal acid exposure, or DeMeester score. Patients with an abnormal reflux test had a significantly longer median acidification time (135.5 vs. 78.5 min, P =0.021). After stratifying by patients with normal versus prolonged gastric transit time, there was a trend toward longer acidification time in patients with positive reflux testing in both groups, but this was not statistically significant. Patients with prolonged gastric transit time >300 minutes were not more likely to have a positive reflux test (38% vs. 35%, P =1). CONCLUSIONS: The acidification time on WMC was significantly longer in patients with proven GERD and acidification time positively correlated with gastric transit time. Larger studies are needed to determine whether WMC could be used as a complementary tool in investigating patients with GERD symptoms.

Risk Factors and Outcomes for Gastroparesis After Lung Transplantation.

BACKGROUND: Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation. METHODS: This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3 years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes. RESULTS: Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3 years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43). CONCLUSION: While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD.

Coexisting Abnormal Esophageal Body Motility Predicts Clinical Symptoms and Bolus Transit in Patients With Esophagogastric Junction Outflow Obstruction (EGJOO).

GOAL: The goal of this study was to compare the clinical presentations of esophagogastric junction outflow obstruction (EGJOO) with coexisting abnormal esophageal body motility (EBM) to isolated EGJOO. BACKGROUND: The clinical significance and management of EGJOO remain debated, as patients may have varied to no symptoms. The effect of coexisting abnormal EBM in EGJOO is unclear. We hypothesized that a concomitant EBM disorder is associated with clinical symptoms of EGJOO. STUDY: This was a retrospective cohort study of consecutive adults diagnosed with EGJOO on high-resolution impedance-manometry (HRIM) at 2 academic centers in March 2018 to September 2018. Patients with prior treatment for achalasia, foregut surgery, or evidence of obstruction were excluded. Subjects were divided into EGJOO with abnormal EBM per Chicago classification v3.0 and isolated EGJOO. Statistical analyses were performed using Fisher-exact or Student t test (univariate) and logistic or linear regression (multivariate). RESULTS: Eighty-two patients (72% women, age 61.1±10.7 y) were included. Thirty-one (37.8%) had abnormal EBM, including 16 (19.5%) ineffective esophageal motility and 15 (18.2%) hypercontractile esophagus. Esophageal symptoms (heartburn, regurgitation, chest pain, dysphagia) were more prevalent among those with abnormal EBM (90.3% vs. 64.7%, P=0.01). On logistic regression adjusting for age, gender, body mass index, and opioid use, abnormal EBM remained predictive of esophageal symptoms (adjusted odds ratio [aOR] 7.51, P=0.007). On separate models constructed, HE was associated with chest pain (aOR 7.45, P=0.01) and regurgitation (aOR 4.06, P=0.046), while ineffective esophageal motility was predictive of heartburn (aOR 5.84, P=0.009) and decreased complete bolus transit (ß-coefficient -0.177, P=0.04). CONCLUSION: Coexisting abnormal EBM is associated with esophageal symptoms and bolus transit in patients with EGJOO.

Type II Achalasia Is Increasing in Prevalence.

BACKGROUND: Three manometric subtypes of achalasia were defined in the Chicago Classification approximately 10 years ago: type I (aperistalsis), type II (pan-pressurization), and type III (spastic). Since the widespread use of this classification scheme, the evolving prevalence of these subtypes has not been elucidated. We aim to determine the prevalence of each subtype a decade after the adoption of the Chicago Classification. METHODS: This is a retrospective cohort analysis of patients diagnosed with achalasia on high-resolution manometry (HRM) at two major academic medical centers between 2015 and 2018. Patients were excluded if they had a diagnosis of another esophageal motility disorder, previously treated achalasia, or foregut surgery. Demographic data, manometric subtype, and esophageal dilatation grade on endoscopy were obtained. Prevalence of achalasia subtypes was compared with a published historical control population (2004-2007). Fischer's exact and t tests were used for analysis. RESULTS: Of 147 patients in the contemporary cohort and 99 in the historical control cohort, the prevalence of type I achalasia was 8% versus 21%, type II 63% versus 50%, and type III 29% versus 29%, respectively (p = 0.01). The mean age in our population was 58 years compared to 57 years in the historical control, and the proportion of men 48% versus 47%, respectively (p = 0.78). Mean endoscopic dilatation grade in the contemporary cohort was 1.5 for type I patients, 0.9 for type II, and 0.4 for type III, compared with 1.5, 0.6, and 0.4, respectively. Overall mean dilatation grade was 0.8 in our cohort versus 0.7 in the historical control (p = 0.58). CONCLUSION: The prevalence of type II achalasia was significantly greater and prevalence of type I significantly less in our patient population compared to our predefined historical control. Other characteristics such as age and sex did not appear to contribute to these differences. Histopathological evidence has suggested that type II achalasia may be an earlier form of type I; thus, the increased prevalence of type II achalasia may be related to earlier detection of the disease. The adoption of HRM, widespread use of the Chicago Classification, and increased disease awareness in the past decade may be contributing to these changes in epidemiology.

Association of patient gender and gastroenterologists' diagnosis and management choices in gastroesophageal reflux disease.

Symptom severity and prevalence of erosive disease in gastroesophageal reflux disease (GERD) differ between genders. It is not known how gastroenterologists incorporate patient gender in their decision-making process. We aimed to evaluate how gender influences the diagnosis and management recommendations for patients with GERD. We invited a nationwide sample of gastroenterologists via voluntary listservs to complete an online survey of fictional patient scenarios presenting with different GERD symptoms and endoscopic findings. Patient gender for each case was randomly generated. Study participants were asked for their likelihood of a diagnosis of GERD and subsequent management recommendations. Results were analyzed using chi-square tests, Fisher Exact tests, and multivariable logistic regression. Of 819 survey invitations sent, 135 gastroenterologists responded with 95.6% completion rate. There was no significant association between patient gender and prediction for the likelihood of GERD for any of the five clinical scenarios when analyzed separately or when all survey responses were pooled. There was also no significant association between gender and decision to refer for fundoplication, escalate PPI therapy, or start of neuromodulation/behavioral therapy. Despite documented symptomatic and physiologic differences of GERD between the genders, patient gender did not affect respondents' estimates of GERD diagnosis or subsequent management. Further outcomes studies should validate whether response to GERD treatment strategies differ between women and men.

Donning a New Approach to the Practice of Gastroenterology: Perspectives From the COVID-19 Pandemic Epicenter.

The COVID-19 pandemic seemingly is peaking now in New York City and has triggered significant changes to the standard management of gastrointestinal diseases. Priorities such as minimizing viral transmission, preserving personal protective equipment, and freeing hospital beds have driven unconventional approaches to managing gastroenterology (GI) patients. Conversion of endoscopy units to COVID units and redeployment of GI fellows and faculty has profoundly changed the profile of most GI services. Meanwhile, consult and procedural volumes have been reduced drastically. In this review, we share our collective experiences regarding how we have changed our practice of medicine in response to the COVID surge. Although we review our management of specific consults and conditions, the overarching theme focuses primarily on noninvasive measures and maximizing medical therapies. Endoscopic procedures have been reserved for those timely interventions that are most likely to be therapeutic. The role of multidisciplinary discussion, although always important, now has become critical. The support of our faculty and trainees remains essential. Local leadership can encourage well-being by frequent team check-ins and by fostering trainee development through remote learning. Advancing a clear vision and a transparent process for how to organize and triage care in the recovery phase will allow for a smooth transition to our new normal.

Patterns of Marijuana Use Among Patients With Celiac Disease in the United States: A Population-based Analysis of the NHANES Survey.

BACKGROUND: Marijuana use has been assessed in patients with chronic gastrointestinal disorders and may contribute to either symptoms or palliation. Use in those with celiac disease (CD) has not been assessed. Our aim was to evaluate patterns of marijuana use in a large population-based survey among patients with CD, people who avoid gluten (PWAG), and controls. STUDY: We analyzed data from the National Health and Nutrition Examination Survey from 2009 to 2014. χ tests and multivariable logistic regression were used to compare participants with CD and PWAG to controls regarding the use of marijuana. RESULTS: Among respondents who reported ever using marijuana (overall 59.1%), routine (at-least monthly) marijuana use was reported by 46% of controls versus 6% of participants with diagnosed CD (P=0.005) and 66% undiagnosed CD as identified on serology (P=0.098) and 51% of PWAG (P=0.536). Subjects with diagnosed CD had lower odds of routine marijuana use compared with controls (odds ratio, 0.08; 95% confidence interval, 0.01-0.73), whereas participants with undiagnosed CD had increased odds of routine use (odds ratio, 2.26; 95% confidence interval, 0.83-6.13), which remained elevated even after adjusting for age, sex, race/ethnicity, health insurance status, alcohol, tobacco use, educational level, and poverty/income ratio. CONCLUSIONS: In all groups, marijuana use was high. Although there were no differences among subjects with CD, PWAG, and controls who ever used marijuana, subjects with diagnosed CD appear to have decreased routine use of marijuana when compared with controls and PWAG. Those with undiagnosed CD have significantly higher rates of regular use. Future research should focus on the utilization of marijuana as it may contribute to further understanding of symptoms and treatments.

Ineffective Esophageal Motility Is Associated with Impaired Bolus Clearance but Does Not Correlate with Severity of Dysphagia.

BACKGROUND: Ineffective esophageal motility (IEM) is defined as a distal contractile integral < 450 mmHg/s/cm in at least 50% of ten liquid swallows on high-resolution esophageal manometry (HREM). Whether this latest definition correlates with degree of symptoms has not been studied. METHODS: Patients presenting for HREM prospectively rated their symptoms using the Eckardt score. Topography plots were retrospectively reviewed and classified according to the latest Chicago Classification. Patients with non-obstructive dysphagia and an Eckardt score of at least 1 were included. Patients with major motility disorders were excluded. Scores between patients with IEM (group A) and patients with normal classification (group B) were compared using two-tailed t-tests. Spearman's correlation coefficient was calculated to determine correlation between symptoms and percent bolus clearance. RESULTS: A total of 241 patients were screened; 33 patients met criteria for group A and 44 patients for group B. There was no difference between the two groups in mean symptom severity for dysphagia (1.63 vs. 1.61, P = 0.89), chest pain (0.67 vs. 0.75, P = 0.64), regurgitation (1.06 vs. 0.85, P = 0.32), or weight loss (0.85 vs. 0.49, P = 0.11). The percent bolus clearance was significantly lower in group A (46.5% vs. 76.7%, P > 0.01). There was a moderate inverse correlation between dysphagia and percent bolus clearance (R = - 0.37) in group A, but none in group B (R = 0.09). CONCLUSION: The classification of IEM did not discriminate from normal studies for symptom severity in our cohort. However, patients with IEM did have an inverse correlation between dysphagia score and bolus clearance, but those without IEM did not. Adding impedance information to the motor pattern classification should be considered in the symptom assessment in minor motility disorders.

Strategies for Effective Discontinuation of Proton Pump Inhibitors.

PURPOSE OF REVIEW: Proton pump inhibitors (PPIs) are effective for many conditions but are often overprescribed. Recent concerns about long-term risks have made patients re-evaluate their need to take PPIs chronically, though these population-based studies have methodological weaknesses. The goal of this review is to provide evidenced-based strategies for discontinuation of PPI therapy. RECENT FINDINGS: Given that some patients experience rebound symptoms when abruptly stopping continuous PPI therapy due to its effect on hypergastrinemia, strategies focus on avoiding rebound. Tapering the PPI and then initiating a "step-down" approach with the use of alternative medications may be effective. "On-demand therapy" provides patients with the option to take intermittent PPI courses, reducing overall use and cost while preserving patient satisfaction. It is important for providers to consider ambulatory pH or pH/impedance testing to rule out diagnoses that may require alternative medications like neuromodulators. A number of studies reviewed here can provide guidance in counseling patients on PPI discontinuation. It is important for the provider to obtain a baseline needs assessment for PPI therapy and to elucidate predictors of difficulty in discontinuation prior to initiating a strategy.

High-resolution anorectal manometry and dynamic pelvic magnetic resonance imaging are complementary technologies.

BACKGROUND AND AIM: Dynamic pelvic magnetic resonance imaging (DP-MRI) offers a comprehensive evaluation of pelvic organ structure in addition to functional information regarding evacuation. Opportunity to apply this technology can be limited due to regional lack of availability. Ideally, clues from standard anorectal testing could predict abnormalities on DP-MRI, leading to its efficient use. The aim of this study is to determine whether high-resolution anorectal manometry (HR-ARM) correlates with findings on DP-MRI. METHODS: This is a retrospective study of HR-ARM performed on patients with constipation who also underwent DP-MRI. Studies were reviewed for significant findings including posterior pelvic organ prolapse, rectocele > 3 cm, rectal intussusception, and anorectal angle. Statistical analysis was performed using Pearson's correlation coefficient, Student's t-test, and Fisher's exact test. RESULTS: Twenty-three patients undergoing HR-ARM (age range 25-78) also underwent DP-MRI. All were female; 76% were Caucasian. Twenty had significant structural findings: small pelvic prolapse (n = 2), moderate pelvic prolapse (n = 10), large pelvic prolapse (n = 9), rectocele (n = 8), or rectal intussusception (n = 3). Only intrarectal pressure on HR-ARM weakly correlated with size of rectocele (r = 0.46; P = 0.03) and degree of pelvic organ prolapse (r = 0.48; P = 0.02). The remainder of the HR-ARM parameters did not significantly correlate with DP-MRI findings. Patients with dyssynergy were not more likely to have rectoceles > 3 cm (44.4% versus 35.7%; P = 0.5) or large prolapses (44.4% versus 50%, P = 1.0), compared with those without dyssynergy, on HR-ARM. CONCLUSION: We were unable to find a correlation between HR-ARM findings and structural pelvic defects on DP-MRI. Therefore, these two technologies provide complementary information in the evaluation of defecatory dysfunction.

Multichannel intraluminal impedance-pH testing is clinically useful in the management of patients with gastroesophageal reflux symptoms.

BACKGROUND: Multichannel intraluminal impedance-pH testing (MII-pH) allows for the detection of acid and non-acid reflux, thus, increasing yield over pH testing. Limited data exist on how physicians use test results in practice. AIM: The aim of our study was to evaluate the influence of MII-pH testing on patient care. METHODS: We reviewed records of patients with symptoms of gastroesophageal reflux disease who underwent MII-pH testing. Management decisions evaluated included changes in prescribed medications and surgical consultation for anti-reflux surgery. Statistical analysis was performed using Pearson Chi square test, and multivariable logistic regression. RESULTS: MII-pH testing resulted in a medication change in 41% of patients, surgical consultation in 19.7%, and anti-reflux surgery in 11.1%. In patients who were not on proton pump inhibitor (PPI) therapy, MII-pH results were most useful in the decision to start a PPI. On PPI therapy, results were more often used to decide whether to increase (32.3%) or switch the PPI (23.5%) in patients with continued acid reflux. Results were most useful to stop the PPI in normal studies (11.1%). More patients with non-acid reflux (14.3%) and normal results (19.7%) were started on a neuromodulator compared to other diagnoses. The MII-pH result was most useful in the decision to start baclofen or bethanecol when the patient was found to have non-acid reflux (25%). Patients with an abnormal MII-pH or abnormal MII alone were more likely to be referred to surgery (OR 19.5, p < 0.001; OR 19.77, p < 0.001). CONCLUSIONS: MII-pH testing impacted medical or surgical management in over half the patients tested.

Biofeedback therapy for defecatory dysfunction: "real life" experience.

BACKGROUND: Biofeedback therapy (BF) is a well-established treatment modality for patients with dyssynergic defecation and fecal incontinence (FI). Randomized controlled trials from highly specialized tertiary care centers report response rates of 70% to 80% for dyssynergic defecation and 55% to 75% for FI. Whether this therapy is as successful outside of clinical trials or specialized biofeedback referral centers remains unclear. AIM: Our primary aim was to determine what percentage of patients referred for BF actually complete therapy and identify barriers to treatment. Our secondary aim was to determine the clinical response rate in a heterogeneous population of patients undergoing BF at our institution and a variety of regional locations. METHODS: We retrospectively reviewed patients who underwent high resolution anorectal manometry between 2007 and 2010 for symptoms of defecatory dysfunction. BF was recommended at the time of manometry analysis based on findings of dyssynergy, impaired or heightened rectal sensation, or poor augmentation of sphincter on squeeze maneuvers. Clinical response was recorded after a course of BF (≥ 5 sessions). RESULTS: Two hundred three patients (78% female, 72% white; median age 52) underwent anorectal manometry for symptoms of constipation (130), FI (54), combination (12), and rectal pain (7). BF was recommended in 119 cases (58.6%): constipation (80), FI (27), combination (9), and rectal pain (3). Only 39 out of 80 (48%) patients with constipation ultimately underwent BF. Of the 27 FI cases, only 12 (44%) patients underwent BF. Barriers to BF included lack of insurance coverage, distance to local treatment facilities, and acute medical issues taking precedence. Of those who underwent at least 5 BF sessions, subjective short-term response rates based on patient opinion were 17/28 (60%) in the constipation group and 8/10 (80%) in the FI group. Age, sex, and race had no effect on whether the patients attended biofeedback or whether they responded to treatment. The location of BF also did not predict response to therapy. CONCLUSIONS: In a heterogeneous patient population, less than half of patients recommended for BF ultimately underwent therapy. Despite this, the response rates in this small population undergoing BF in the "real world" are only slightly less than published randomized control trials. Prospective studies are warranted to further elucidate and eliminate barriers to BF, especially given that "real world" BF response rates may be comparable with those seen in clinical trials.

A perspective on the clinical relevance of weak or nonacid reflux.

BACKGROUND: Advances in ambulatory esophageal reflux monitoring that incorporated impedance electrodes to pH catheters have resulted in better characterization of retrograde bolus flow in the esophagus. With pH-impedance monitoring, in addition to acid reflux episodes identified by pH drops below 4.0, weakly acid reflux (WAR, pH 4-7) and nonacid reflux (NAR, pH >7.0) are also recognized, although both may be included under the umbrella term NAR. However, despite identification of ambulatory pH-impedance monitoring, data on clinical relevance and prognostic value of NAR are limited. The Lyon Consensus, an international expert review that defines conclusive metrics for gastroesophageal reflux disease (GERD), identifies NAR as "supportive" but not conclusive for GERD. PURPOSE: This review provides perspectives on whether NAR fulfills three criteria for clinical relevance: whether NAR sufficiently explains pathogenesis of symptoms, whether it is associated with meaningful manifestations of GERD, and whether it can predict treatment efficacy.

Human Mpox Virus Proctitis With Persistent Rectal Ulcers on Sigmoidoscopy.

The 2022 Mpox outbreak has caused public health concerns worldwide. Mpox infection often manifests as papular skin lesions; other systemic complications have also been reported. We present the case of a 35-year-old man with HIV who presented with rectal pain and hematochezia and was found to have severe ulceration and exudate on sigmoidoscopy consistent with Mpox proctitis.

Diet for Functional Gastrointestinal Disorders/Disorders of Gut-Brain Interaction.

Dietary interventions may alleviate symptoms related to functional gastrointestinal disorders, now termed disorders of gut-brain interaction. We reviewed which interventions have high-quality data to support their use in gastroesophageal reflux disease (GERD), functional dyspepsia (FD), irritable bowel syndrome, and chronic idiopathic constipation.

Prevalence and risk factors for gastrointestinal symptoms after recovery from COVID-19.

BACKGROUND: COVID-19 frequently presents with acute gastrointestinal (GI) symptoms, but it is unclear how common these symptoms are after recovery. The purpose of this study was to estimate the prevalence and characteristics of GI symptoms after COVID-19. METHODS: The medical records of patients hospitalized with COVID-19 between March 1 and June 30, 2020, were reviewed for the presence of GI symptoms at primary care follow-up 1 to 6 months later. The prevalence of new GI symptoms was estimated, and risk factors were assessed. Additionally, an anonymous survey was used to determine the prevalence of new GI symptoms among online support groups for COVID-19 survivors. KEY RESULTS: Among 147 patients without pre-existing GI conditions, the most common GI symptoms at the time of hospitalization for COVID-19 were diarrhea (23%), nausea/vomiting (21%), and abdominal pain (6.1%), and at a median follow-up time of 106 days, the most common GI symptoms were abdominal pain (7.5%), constipation (6.8%), diarrhea (4.1%), and vomiting (4.1%), with 16% reporting at least one GI symptom at follow-up (95% confidence interval 11 to 23%). Among 285 respondents to an online survey for self-identified COVID-19 survivors without pre-existing GI symptoms, 113 (40%) reported new GI symptoms after COVID-19 (95% CI 33.9 to 45.6%). CONCLUSION AND INFERENCES: At a median of 106 days after discharge following hospitalization for COVID-19, 16% of unselected patients reported new GI symptoms at follow-up. 40% of patients from COVID survivor groups reported new GI symptoms. The ongoing GI effects of COVID-19 after recovery require further study.