Microscopic Colitis: A Diagnostic Challenge in Patients with Irritable Bowel Syndrome.

BACKGROUND AND AIMS: Irritable Bowel Syndrome (IBS) is one of the most frequently diagnosed gastrointestinal disease with a prevalence of 4.1% in the general population. It is diagnosed using the Rome IV criteria. Microscopic colitis (MC), collagenous/lymphocytic colitis is a cause of chronic, watery, non-bloody diarrhea. It is a real challenge to diagnose MC in patients with IBS. The aims of the study were to determine the prevalence of MC in patients initially diagnosed with IBS, as well as to correlate fecal calprotectin levels with the endoscopic findings and microscopic inflammation in MC. METHODS: This is a retrospective study conducted in a single tertiary center with over 89 IBS patients for a period of 4 years. The patients included were patients diagnosed with IBS predominant diarrhea (IBS-D) and mixed IBS (IBS-M) using the Rome IV criteria. Total colonoscopy was performed in these patients, multiple biopsies being taken and calprotectin levels were measured. RESULTS: Out of a total of 89 IBS-D patients, 58 patients (65.2%) had no microscopic lesions, 12 patients (13.5%) had diverticular disease, 9 patients (10.1%) had non-specific chronic inflammation of the colon mucosa and 10 patients (11.2%) were diagnosed with MC. The calprotectin levels ranged from 49 µg/g to 213 µg/g. Of a total of 10 patients diagnosed with MC, 6 (60%) of them had calprotectin levels <100 µg/g and 4 (40%) had calprotectin levels >100 µg/g. The fecal calprotectin levels were higher in patients diagnosed with MC compared to those who had no microscopic lesions at the histological exam and it was also correlated with the grade of colonic microscopic inflammation. CONCLUSIONS: Microscopic colitis is less familiar to physicians and can be clinically misdiagnosed as IBS-D. An early and correct diagnosis is important for an accurate therapy.

Is C-section a risk factor for the early onset of irritable bowel syndrome?

Background and aim: There are controversial data in literature regarding the influence of abdominal and pelvic surgery on the onset of gastrointestinal symptoms. The aim of this study was to assess whether women who had a C-section (cesarean section) are more likely to develop irritable bowel syndrome (IBS) early after delivery than those who have given birth naturally. Method: A cross-sectional study investigated women who had undergone C-section and were compared with a control group of women who had natural delivery. Data were obtained from Maternity Ward of Korce Hospital, in Albania. We conducted a telephone interview based on a questionnaire containing items to diagnose IBS based on the Rome IV criteria. The interviews were conducted 9 to 12 months after delivery. Results: The prevalence of IBS in both groups taken together 4.6%. In the C-section group, prevalence of IBS was 4.3%, while in the control group it was 5.2%. All the patients with IBS had subtype with predominance of constipation. The RR 0.814 (CI 95%, 0.1423-4.66) does not confirm the hypothesis that C-section may induce early onset of IBS more often than natural birth. Conclusion: The prevalence of IBS was (4.6%), within the known range of the Rome Foundation Global Study. Delivery by C-section does not have a role in developing IBS symptoms more than delivery by natural way in this group of Albanian women.

Update on the Role of Rifaximin in Digestive Diseases.

Various environmental factors affecting the human microbiota may lead to gut microbial imbalance and to the development of pathologies. Alterations of gut microbiota have been firmly implicated in digestive diseases such as hepatic encephalopathy, irritable bowel syndrome and diverticular disease. However, while these three conditions may all be related to dysfunction of the gut-liver-brain axis, the precise pathophysiology appears to differ somewhat for each. Herein, current knowledge on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease are reviewed, with a special focus on the gut microbiota modulation associated with these disorders during therapy with rifaximin. In general, the evidence for the efficacy of rifaximin in hepatic encephalopathy appears to be well consolidated, although it is less supported for irritable bowel syndrome and diverticular disease. We reviewed current clinical practice for the management of these clinical conditions and underlined the desirability of more real-world studies to fully understand the potential of rifaximin in these clinical situations and obtain even more precise indications for the use of the drug.

New diagnostic and therapeutic procedures applied in pediatric esophageal achalasia in a pediatric tertiary center: A case series.

Achalasia is an esophageal motor disorder that is rare in children. While the condition is uncommon, it is especially difficult to diagnose in pediatric patients; however, the ability to form a diagnosis has progressed markedly with the advent of esophageal high-resolution manometry (HRM). The aim of the present study was to highlight particularities of the diagnosis, based on esophageal HRM, as well as the treatment of achalasia in children. The current study analyzed cases of achalasia from a single pediatric tertiary center, Clinical Emergency Hospital for Children (Cluj-Napoca, Romania). The clinical data and the results of the investigations of seven children with achalasia, the first children to be evaluated using esophageal HRM in the center, were reported. The patients were aged between 11 and 18 years. All the patients were newly diagnosed with achalasia, except for one. The duration of symptoms was between 4 months and 2 years in the newly diagnosed patients. All the patients were assessed with conventional esophageal manometry and/or esophageal HRM. A multidisciplinary team contributed to the diagnosis and the management of achalasia. A total of 4 children diagnosed with type II achalasia were treated with peroral endoscopic myotomy (POEM) and 3 of the patients were treated with pneumatic dilations. Overall, achalasia is a rare but challenging condition in children. A diagnosis starts with a clinical suspicion based on swallowing disorders and upper digestive endoscopy, and is confirmed by esophageal HRM. Therapy should be adapted to the type of achalasia, the age of the children and the severity. In the present study, a relatively recent treatment option, POEM, was applied in pediatric patients with minor immediate adverse events. The report of these cases adds to the limited experience of using HRM and POEM in children with achalasia.

Assessment of defecation disorders using high-resolution MRI-defecography.

AIMS: The aim of this retrospective study was to try to find correlations between different diagnoses established by clinical examination, anorectal manometry and MRI-defecography and, the association with psychiatric disorders. METHODS: 44 patients (median age 53.81 years) presenting with intestinal motility disorders and who underwent clinical, biological and psychiatric examination, dynamic defecographic-MRI (resting, squeezing, straining, defecation and evacuation phases), anorectal manometry, colonoscopy. MRI was performed using the 1,5 T. RESULTS: MRI-defecography revealed the following changes: anismus (16), rectocele (12), pelvic floor dysfunction (6), peritoneocele (2), cervical-cystic-ptosis (1), rectal prolapse (6), and in 1 case the examination was normal. Hypertonic anal sphincter (16) and lack of defecation reflex (12) at anorectal manometry correlated with anismus in all patients at MRI-defecography. Lack of inhibitor anal reflex (6) was associated with rectocele (4), cervix-cysto-ptosis (1) and peritoneocele (2). Anxiety (11), depression (6) and anxiety-depressive disorders (10) were found in 27/44, somatization disorders in 9/44 and no psychiatric changes in 8/44 cases. CONCLUSION: As multiparous women are at risk for outlet obstruction constipation, MRI-defecography is suggested in this category. There is good correlation between diagnosis using anorectal manometry and MRI-defecography in patients with terminal constipation and anismus. Lower defecation dysfunction is often associated with psychiatric disorders.

Automatic Diagnosis of High-Resolution Esophageal Manometry Using Artificial Intelligence.

BACKGROUND AND AIMS: High-resolution esophageal manometry (HREM) is the gold standard procedure used for the diagnosis of esophageal motility disorders (EMD). Artificial intelligence (AI) might provide an efficient solution for the automatic diagnosis of EMD by improving the subjective interpretation of HREM images. The aim of our study was to develop an AI-based system, using neural networks, for the automatic diagnosis of HREM images, based on one wet swallow raw image. METHODS: In the first phase of the study, the manometry recordings of our patients were retrospectively analyzed by three experienced gastroenterologists, to verify and confirm the correct diagnosis. In the second phase of the study raw images were used to train an artificial neural network. We selected only those tracings with ten test swallows that were available for analysis, including a total of 1570 images. We had 10 diagnosis categories, as follows: normal, type I achalasia, type II achalasia, type III achalasia, esophago-gastric junction outflow obstruction, jackhammer oesophagus, absent contractility, distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis, based on Chicago classification v3.0 for EMDs. RESULTS: The raw images were cropped, binarized, and automatically divided in 3 parts: training, testing, validation. We used Inception V3 CNN model, pre-trained on ImageNet. We developed a custom classification layer, that allowed the CNN to classify each wet swallow image from the HREM system into one of the diagnosis categories mentioned above. Our algorithm was highly accurate, with an overall precision of more than 93%. CONCLUSION: Our neural network approach using HREM images resulted in a high accuracy automatic diagnosis of EMDs.

How Can the EU Beating Cancer Plan Help in Tackling Lung Cancer, Colorectal Cancer, Breast Cancer and Melanoma?

Cancer is the second leading cause of mortality in EU countries, and the needs to tackle cancer are obvious. New scientific understanding, techniques and methodologies are opening up horizons for significant improvements in diagnosis and care. However, take-up is uneven, research needs and potential outstrip currently available resources, manifestly beneficial practices-such as population-level screening for lung cancer-are still not generalised, and the quality of life of patients and survivors is only beginning to be given attention it merits. This paper, mainly based on a series of multistakeholder expert workshops organised by the European Alliance for Personalised Medicine (EAPM), looks at some of those specifics in the interest of planning a way forward. Part of this exercise also involves taking account of the specific nature of Europe and its constituent countries, where the complexities of planning a way forward are redoubled by the wide variations in national and regional approaches to cancer, local epidemiology and the wide disparities in health systems. Despite all the differences between cancers and national and regional resources and approaches to cancer care, there is a common objective in pursuing broader and more equal access to the best available care for all European citizens.

Automated Chicago Classification for Esophageal Motility Disorder Diagnosis Using Machine Learning.

The goal of this paper is to provide a Machine Learning-based solution that can be utilized to automate the Chicago Classification algorithm, the state-of-the-art scheme for esophageal motility disease identification. First, the photos were preprocessed by locating the area of interest-the precise instant of swallowing. After resizing and rescaling the photos, they were utilized as input for the Deep Learning models. The InceptionV3 Deep Learning model was used to identify the precise class of the IRP. We used the DenseNet201 CNN architecture to classify the images into 5 different classes of swallowing disorders. Finally, we combined the results of the two trained ML models to automate the Chicago Classification algorithm. With this solution we obtained a top-1 accuracy and f1-score of 86% with no human intervention, automating the whole flow, from image preprocessing until Chicago classification and diagnosis.

Exclusion Diets in Functional Dyspepsia.

Functional dyspepsia represents one of the most common and prevalent disorders of the brain-gut interaction, with a large number of widespread risk factors being identified. With an intricate pathogenesis and symptomatology, it heavily impacts the quality of life and, due to the limited efficacy of traditional pharmacological agents, patients are likely to seek other medical and non-medical solutions to their problem. Over the last few years, significant research in this domain has emphasized the importance of various psychological therapies and nutritional recommendations. Nevertheless, a correlation has been established between functional dyspepsia and food intolerances, with more and more patients adopting different kinds of exclusion diets, leading to weight loss, restrictive eating behaviour and an imbalanced nutritional state, further negatively impacting their quality of life. Thus, in this systematic review, we aimed at analysing the impact and efficiency of certain exclusion diets undertook by patients, more precisely, the gluten-free diet and the low-FODMAP diet.

Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. METHODS: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. RESULTS: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. CONCLUSIONS: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

Neuromodulators in the Brain-Gut Axis: their Role in the Therapy of the Irritable Bowel Syndrome.

Irritable bowel syndrome (IBS) is a clinically well-defined chronic condition that is now understood as a disorder of gut-brain regulation, as established in the work of the Rome IV committees coordinated by Drossman, 2016. People with IBS often report high disability levels and poor health-related quality of life. Drug therapy focuses on reducing main symptoms and disability and improving health-related quality of life. Central neuromodulators reduce IBS symptoms by targeting dysregulated pain and motility related to gut-brain dysregulation. It can also treat associated mental health symptoms. Based on their multiple effects on central and peripheral mechanisms, neuromodulators have been used to treat IBS patients. This review presents the rationale supporting medication treatments for specific IBS symptoms, discusses evidence-based management of IBS with central neuromodulators, and reviews the progress in the research for new neuromodulators.

Helicobacter pylori infection and positive Rome IV criteria for functional dyspepsia in Romanian medical students.

Recent data suggest that the prevalence of Helicobacter pylori (HP) infection in Romania has been declining in the last 30 years. However, there are no studies regarding HP prevalence among medical students. The objectives of this study were to estimate the prevalence of HP infection and assess the prevalence of dyspepsia in medical students and the relationship between dyspepsia and infection. We included 150 students from the Iuliu Hatieganu University of Medicine and Pharmacy of Cluj-Napoca, Romania (102 females and 48 males, mean age 21 years). Each student completed a lifestyle questionnaire, personal history, family history as well as the Rome IV questionnaire for functional dyspepsia. The status of HP infection was determined using the C13-urea respiratory test. The prevalence of HP infection was 25.33%, and 18% met the Rome IV criteria for functional dyspepsia. 37% of students with functional dyspepsia had a positive HP test. Of all students, 8% had a history of HP infection. Those with a history of HP infection had a 4.45% (95% CI 1.6 - 12.37) higher risk of having positive Rome IV criteria for functional dyspepsia than those with no previous history of infection (p=0.008). Thus, the present study adds to the body of evidence regarding HP prevalence among medical students, 25.33% being positive. We found no statistically significant correlation between HP infection and functional dyspepsia. Those with a history of HP infection had a higher risk of functional dyspepsia.

Gaucher disease - therapeutic aspects in Romania.

Gaucher disease is a rare autosomal recessive disease caused by the beta-glicosidase activity deficiency, which will lead to substrate accumulation mainly in the liver, spleen or bone marrow. The main symptoms are liver and spleen enlargement, anemia and low platelet count, bone crisis and fatigue. Several treatment options are available, as enzyme replacement therapy, substrate reduction therapy, or chaperones treatment whose effect is still studied. There are 77 adult patients treated at this time in Romania, 54 with intravenous enzyme replacement ant 23 with oral substrate reduction therapy. No severe adverse effects have been reported by now. All patients had improved disease related symptoms after the receiving of the treatment.

Gaucher disease - bone involvement.

Gaucher disease (GD) is a rare genetic disease caused by the enzymatic deficiency of beta-glucocerebrosidase. This will lead to the accumulation of sphingolipids in various organs, such as liver, spleen, bone marrow. Bone involvement is frequent in Gaucher patients, leading to bone pain, necrosis and even fractures or growth deficiency in children, with painful surgeries and progressively decreasing quality of life. The early treatment initiation in symptomatic patients is very important in lowering bone complications frequency and improve general status. We present the case of a young patient whose first manifestation of GD was a bone cystic lesion and the clinical evolution until treatment.

Epidemiology of Irritable Bowel Syndrome in Albania.

BACKGROUND AND AIMS: Irritable bowel syndrome (IBS) is a chronic condition, with a relatively high prevalence and represents a burden for the healthcare budgets. Knowing the prevalence of IBS is important for scientific and practical estimation of its impact. The recent Rome IV global study has shed light on the prevalence of IBS in many countries, but reports are lacking from other countries. The aim of this study was to assess the prevalence of IBS in Albania, a country from which we do not have relevant information. METHOD: A prospective study was carried out in order to find out the prevalence of IBS in Albania. The target population was a sample of at least 500 Albanian adults (from a population of 2.2 million adults in this country. The questionnaires were distributed to the general population through three University centers from different areas of the country, through family doctors, chosen randomly, and by door to door by volunteer medical students. The questionnaires were self-completed by the participants and included 29 items: biographical data, IBS symptoms based on the Rome IV criteria, the symptoms that accompany IBS and the quality of life (QoL). The prevalence of IBS in the studied population, the sex ratio, the subtypes of IBS and the prevalence of different symptoms were calculated. RESULTS: We sent out 550 questionnaires and we received answers from 502 subjects (response rate 91%, 312 females, median age: 42 years). IBS was present in 43 cases (8.6%), without gender predominance. The IBS subtypes had the following values: IBS-C 58%, IBS-D 28% and IBS-M 14%. Women had a relatively higher risk for subtype IBS predominant constipation (OR=1.13, 95%CI: 0.32-3.95, p=0.84) but men appeared to be more prone to IBS predominant diarrhea (OR=1.3, 95%CI: 0.33-5.08, p=0.7). The most affected age was over 50 years and the least affected was between 18-30 years. Bloating was present in 81.4% of IBS respondents. The pain significantly influenced the daily activity in IBS: OR=12.9:1 (95% CI: 6.18-27.31, p<0.0001). Education seems to be an important risk factor; people with only middle school education or less had an OR=4.5 (95% CI: 2-10.54, p=0.0003) of developing IBS than people with a higher education. CONCLUSIONS: These are the first reported data on IBS in Albania. IBS in Albania is of 8.6%, more than the average data in the Rome IV global study, but in the range obtained from other studies. The most common type is IBS-C; there is no gender predominance; it is more common in less educated persons; the influence of pain on daily activity is higher in IBS.

Disorders of the brain-gut interaction and eating disorders.

BACKGROUND: Eating disorders (ED) involve both the nervous system and the gastrointestinal tract. A similar double involvement is also found in disorders of the brain-gut interaction (DGBI) and symptoms are sometimes similar. AIM: To find out where there is an association and a cause-effect relationship, we looked for the comorbidity of DGBI and ED. METHODS: A systematic review was undertaken. A literature search was performed. Inclusion criteria for the articles retained for analysis were: Observational cohort population-based or hospital-based and case-control studies, examining the relationship between DGBI and ED. Exclusion criteria were: Studies written in other languages than English, abstracts, conference presentations, letters to the Editor and editorials. Selected papers by two independent investigators were critically evaluated and included in this review. RESULTS: We found 29 articles analyzing the relation between DGBI and ED comprising 13 articles on gastroparesis, 5 articles on functional dyspepsia, 7 articles about functional constipation and 4 articles on irritable bowel syndrome. CONCLUSION: There is no evidence for a cause-effect relationship between DGBI and ED. Their common symptomatology requires correct identification and a tailored therapy of each disorder.

The value of abdominal ultrasonography compared to colonoscopy and faecal calprotectin in following up paediatric patients with ulcerative colitis.

AIM: To evaluate the value of abdominal ultrasonography (US) in the follow-up of paediatric patients with ulcerative colitis (UC) compared to faecal calprotectin (FC) and colonoscopy. MATERIAL AND METHOD: In this retrospective study we enrolled 30 paediatric patients previously diagnosed with UC, examined by abdominal US and colonoscopy within the same week. FC was also determined during the same week. Disease activity was established using the paediatric ulcerative colitis activity index (PUCAI). The global endoscopic activity was evaluated using the Mayo endoscopic subscore. RESULTS: Endos-copy revealed pathological findings of active disease in 27 out of 30 patients; 3 patients were in endoscopic remission. Only 18 of them had clinical active disease (PUCAI >10), [sensitivity (Se) 66.7% and specificity (Sp) 33% of PUCAI in detecting endoscopic active disease). Twenty-three (76.7%) patients had FC >250 mcg/g, but in 2 of these cases the colonoscopy was normal (Se 77.8% and Sp 33.3% in detecting active disease). At US examination, pathological findings (increased bowel wall thickness, hypervascularity, lymphadenopathies, and/or mesenteric inflammatory fat) were found in 27 patients (90%), all with endoscopic active disease (agreement US - colonoscopy, at patient level, k=1.0, p<0.001, Se 100% and Sp 100%). At seg-ment level (totally 180 bowel segments examined by US), the overall agreement between US and colonoscopy was k=0.767, p<0.001, Se 86.5%, Sp 90.1%. Of the 27 patients with US pathological findings in any of colonic segments, 23 had FC >250 mcg/g (85.1%). The inter-observer agreement for the US measurements had an overall ICC of 0.926 with p<0.001. CONCLUSION: Abdominal US findings demonstrate a good to excellent concordance with endoscopic examination and are correlated with elevated FC levels. Therefore, US appears as an accurate technique in assessing activity in patients with UC and might replace colonoscopic evaluation for the follow-up.

Integrated Relaxation Pressure Classification and Probe Positioning Failure Detection in High-Resolution Esophageal Manometry Using Machine Learning.

High-resolution esophageal manometry is used for the study of esophageal motility disorders, with the help of catheters with up to 36 sensors. Color pressure topography plots are generated and analyzed and using the Chicago algorithm a final diagnosis is established. One of the main parameters in this algorithm is integrated relaxation pressure (IRP). The procedure is time consuming. Our aim was to firstly develop a machine learning based solution to detect probe positioning failure and to create a classifier to automatically determine whether the IRP is in the normal range or higher than the cut-off, based solely on the raw images. The first step was the preprocessing of the images, by finding the region of interest-the exact moment of swallowing. Afterwards, the images were resized and rescaled, so they could be used as input for deep learning models. We used the InceptionV3 deep learning model to classify the images as correct or failure in catheter positioning and to determine the exact class of the IRP. The accuracy of the trained convolutional neural networks was above 90% for both problems. This work is just the first step in fully automating the Chicago Classification, reducing human intervention.

B cell-activating factor (BAFF) in children with inflammatory bowel disease.

BACKGROUND: Assessing the inflammation is important in the follow-up of paediatric patients with inflammatory bowel disease (IBD). We aim to evaluate the value of B cell-activating factor (BAFF) in paediatric IBD as a potential biomarker for follow-up. METHOD: We determined BAFF in serum and faeces and faecal calprotectin (CP) in 32 IBD children-16 Crohn's disease (CD) and 16 ulcerative colitis (UC). Twenty-six healthy children and 10 children with irritable bowel syndrome (IBS) were included as controls. RESULTS: No differences were found in serum BAFF between IBD, IBS, and healthy group: 1037.35, 990.9 and 979.8 pg/ml, respectively, all p > 0.05, but faecal BAFF was higher in the IBD group: 15.1, 8.5 and 8.2 pg/ml, respectively, p < 0.05, and higher in the UC group (55.975 pg/ml) compared to the CD group (10.95 pg/ml), p = 0.015. Splitting the IBD group in relation to the CP level, the serum BAFF had no significantly different values between the subgroups, but the faecal BAFF was significantly higher in the >250 µg/g subgroup. Cut-off values of BAFF were calculated. CONCLUSION: Faecal BAFF is a promising marker for monitoring the children with IBD, higher levels of BAFF being correlated with high CP. IMPACT: Faecal BAFF is a promising marker in monitoring the children with IBD, higher levels of BAFF being correlated with high faecal calprotectin. To our knowledge, this is the first paediatric study concerning BAFF evaluation in IBD. Faecal BAFF levels could be considered a potential non-invasive marker in monitoring IBD activity in paediatric population with clinically mild or inactive disease.