The Efficiency of Serum Biomarkers in Predicting the Clinical Outcome of Patients with Mesenteric Ischemia during Follow-Up: A Systematic Review.

The initial clinical manifestation of acute mesenteric ischemia poses a diagnostic challenge, often leading to delays in identification and subsequent surgical intervention, contributing to adverse outcomes. Serum biomarkers, offering insights into the underlying pathophysiology, hold promise as prognostic indicators for acute mesenteric ischemia. This systematic review comprehensively explores the role of blood biomarkers in predicting clinical outcomes during follow-up for patients with mesenteric ischemia. A thorough literature search across the PubMed, Cochrane Library, and EMBASE databases yielded 33 relevant publications investigating the efficacy of serum biomarkers in predicting outcomes for mesenteric ischemia. Numerous studies underscore the utility of blood biomarkers in swiftly and accurately differentiating between causes of mesenteric ischemia, facilitating a prompt diagnosis. Elevated levels of specific biomarkers, particularly D-dimers, consistently correlate with heightened mortality risk and poorer clinical outcomes. While certain serum indicators exhibit substantial potential in associating with mesenteric ischemia, further research through rigorous human trials is imperative to enhance their consistent predictive ability during the follow-up period. This study underscores the diagnostic and prognostic significance of specific biomarkers for mesenteric ischemia, emphasizing the necessity for standardized procedures in future investigations.

Difficult defecation in constipated patients: Diagnosis by minimally invasive diagnostic tests.

BACKGROUND AND AIMS: Defecation Disorders (DD) are a frequent cause of refractory chronic constipation. DD diagnosis requires anorectal physiology testing. Our aim was to evaluate the accuracy and Odds Ratio (OR) of a straining question (SQ) and a digital rectal examination (DRE) augmented by abdomen palpation on predicting a DD diagnosis in refractory CC patients. METHODS: Two hundred and thirty-eight constipated patients were enrolled. Patients underwent SQ, augmented DRE and balloon evacuation test before entering the study and after a 30-day fiber/laxative trial. All patients underwent anorectal manometry. OR and accuracy were calculated for SQ and augmented DRE for both dyssynergic defecation and inadequate propulsion. RESULTS: "Anal Muscles" response was associated to both dyssynergic defecation and inadequate propulsion, with an OR of 13.6 and 5.85 and an accuracy of 78.5% and 66.4%, respectively. "Failed anal relaxation" on augmented DRE was associated with dyssynergic defecation, with an OR of 21.4 and an accuracy of 73.1%. "Failed abdominal contraction" on augmented DRE was associated with inadequate propulsion with an OR >100 and an accuracy of 97.1%. CONCLUSIONS: Our data support screening constipated patients for DD by SQ and augmented DRE to improve management and appropriateness of referral to biofeedback.

Herbal Remedies for Constipation-Predominant Irritable Bowel Syndrome: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Constipation-predominant irritable bowel syndrome (IBS-C) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits. Conventional treatments for IBS-C often provide limited efficiency, leading to an increasing interest in exploring herbal remedies. This systematic review aims to evaluate the efficacy and safety of herbal remedies in the management of IBS-C. MATERIALS AND METHODS: A comprehensive search of PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library was conducted to identify relevant studies published up to July 2023 and data extraction was performed independently by two reviewers. RESULTS: Overall, the included studies demonstrated some evidence of the beneficial effects of herbal remedies on IBS-C symptoms, including improvements in bowel frequency, stool consistency, abdominal pain, and quality of life. However, the heterogeneity of the interventions and outcome measures limited the ability to perform a meta-analysis. CONCLUSION: This systematic review suggests that herbal remedies may have potential benefits in the management of IBS-C. However, the quality of evidence is limited, and further well-designed, large-scale RCTs are needed to establish the efficacy and safety of specific herbal remedies for IBS-C. Clinicians should exercise caution when recommending herbal remedies and consider individual patient characteristics and preferences.

The Effect of Polyphenols, Minerals, Fibers, and Fruits on Irritable Bowel Syndrome: A Systematic Review.

BACKGROUND: Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by abdominal pain, bloating, and changes in bowel habits. Various dietary factors have been implicated in the pathogenesis and management of IBS symptoms. This systematic review aims to evaluate the effects of polyphenols, minerals, fibers, and fruits on the symptoms and overall well-being of individuals with IBS. MATERIALS AND METHODS: A comprehensive literature search was conducted in several electronic databases, including PubMed, Scopus, and Web of Science. Studies published up until July 2023 were included. RESULTS: The selected studies varied in terms of study design, participant characteristics, intervention duration, and outcome measures. Overall, the findings suggest that dietary interventions involving polyphenols, minerals, fibers, and fruits can have a positive impact on IBS symptoms. Dietary fiber supplementation, particularly soluble fiber, has been associated with reduced bloating and enhanced stool consistency. CONCLUSIONS: This systematic review provides evidence supporting the beneficial effects of polyphenols, minerals, fibers, and fruits in IBS patients. These dietary components hold promise as complementary approaches for managing IBS symptoms. However, due to the heterogeneity of the included studies and the limited number of high-quality randomized controlled trials, further well-designed trials are warranted to establish the optimal dosages, duration, and long-term effects of these interventions. Understanding the role of specific dietary components in IBS management may pave the way for personalized dietary recommendations and improve the quality of life for individuals suffering from this complex disorder.

Applications of Artificial Intelligence in the Automatic Diagnosis of Focal Liver Lesions: A Systematic Review.

BACKGROUND AND AIMS: Focal liver lesions (FLLs) are defined as abnormal solid or liquid masses differentiated from normal liver, frequently being clinically asymptomatic. The aim of this systematic review is to provide a comprehensive overview of current artificial intelligence (AI) applications, deep learning systems and convolutional neural networks, capable of performing a completely automated diagnosis of FLLs. METHODS: We searched PubMed, Cochrane Library, EMBASE, and WILEY databases using predefined keywords. Articles were screened for relevant publications about AI applications capable of automated diagnosis of FLLs. The search terms included: (focal liver lesions OR FLLs OR hepatic focal lesions OR liver focal lesions OR liver tumor OR hepatic tumor) AND (artificial intelligence OR machine learning OR neural networks OR deep learning OR automated diagnosis OR ultrasound OR US OR computer scan OR CT OR magnetic resonance imaging OR MRI OR computer-aided diagnosis OR automated computer tomography OR automated magnetic imaging). RESULTS: Our search identified a total of 32 articles analyzing complete automated imagistic diagnosis of FLLs, out of which 14 studies analyzing liver ultrasound images, 8 studies analyzing computer tomography images and 10 studies analyzing images obtained from magnetic resonance imaging. CONCLUSIONS: We found significant evidence demonstrating that implementing a complete automated system for FLLs diagnosis using AI-based applications is currently feasible. Various automated AI-based applications have been analyzed. However, there is no clear evidence about the superiority of any of the systems.

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.

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.

Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility.

Irritable bowel syndrome with diarrhoea (IBS-D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS-D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work-up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS-D and FDr. In terms of diagnosis, the consensus supports a symptom-based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C-reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo-, di-, monosaccharides and polyols, gut-directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5-hydroxytryptamine-3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS-D and FDr.

Supragastric belching: Pathogenesis, diagnostic issues and treatment.

Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It becomes pathologic if it is excessive and becomes bothersome. According to Rome IV diagnostic criteria, there is a belching disorder when one experiences bothersome belching (severe enough to impact on usual activities) more than 3 days a week. Esophageal impedance can differentiate between gastric and supragastric belching. The aim of this review was to provide data on pathogenesis and diagnosis of supragastric belching and study its relationship with gastroesophageal reflux disease and psychological factors. Treatment options for supragastric belching are also presented.

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.

Guideline for the diagnosis and treatment of Faecal Incontinence-A UEG/ESCP/ESNM/ESPCG collaboration.

INTRODUCTION: The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI. METHODS: These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus. RESULTS: These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients. CONCLUSION: These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Guideline for the diagnosis and treatment of faecal incontinence: a UEG/ESCP/ESNM/ESPCG collaboration [Pré-print]

The goal of this project was to create an up-to-date joint European clinical practice guideline for the diagnosis and treatment of faecal incontinence (FI), using the best available evidence. These guidelines are intended to help guide all medical professionals treating adult patients with FI (e.g., general practitioners, surgeons, gastroenterologists, other healthcare workers) and any patients who are interested in information regarding the diagnosis and management of FI. These guidelines have been created in cooperation with members from the United European Gastroenterology (UEG), European Society of Coloproctology (ESCP), European Society of Neurogastroenterology and Motility (ESNM) and the European Society for Primary Care Gastroenterology (ESPCG). These members made up the guideline development group (GDG). Additionally, a patient advisory board (PAB) was created to reflect and comment on the draft guidelines from a patient perspective. Relevant review questions were established by the GDG along with a set of outcomes most important for decision making. A systematic literature search was performed using these review questions and outcomes as a framework. For each predefined review question, the study or studies with the highest level of study design were included. If evidence of a higher-level study design was available, no lower level of evidence was sought or included. Data from the studies were extracted by two reviewers for each predefined important outcome within each review question. Where possible, forest plots were created. After summarising the results for each review question, a systematic quality assessment using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) approach was performed. For each review question, we assessed the quality of evidence for every predetermined important outcome. After evidence review and quality assessment were completed, recommendations could be formulated. The wording used for each recommendation was dependent on the level of quality of evidence. Lower levels of evidence resulted in weaker recommendations and higher levels of evidence resulted in stronger recommendations. Recommendations were discussed within the GDG to reach consensus. These guidelines contain 45 recommendations on the classification, diagnosis and management of FI in adult patients. These multidisciplinary European guidelines provide an up-to-date comprehensive evidence-based framework with recommendations on the diagnosis and management of adult patients who suffer from FI.

Pelvic floor biofeedback is an effective treatment for severe bloating in disorders of gut-brain interaction with outlet dysfunction.

BACKGROUND: The pathophysiology of bloating is partially understood. We investigated in patients with disorders of gut-brain interaction (DGBI) the relationship between severity of bloating, abdominal girth changes and defecation pattern, and the efficacy of pelvic floor biofeedback treatment on bloating. METHODS: Disorders of gut-brain interaction patients with severe bloating as the main complaint were prescribed 2 weeks dietary advice and underwent abdominal girth measurements. At the first visit, all patients underwent a questionnaire on the subjective improvement of bloating, a (0-100) VAS abdominal bloating, and abdominal girth measurement. Patients reporting inadequate bloating relief underwent a standardized balloon expulsion test. Furthermore, they were invited to undergo pelvic floor electromyography and biofeedback treatment previously used for constipation due to dyssynergic defecation. The primary outcome was bloating improvement on a 5-point Likert scale. The secondary outcomes were the effect of diet intervention and pelvic floor biofeedback treatment on bloating severity and quality of life changes as well as the effect of pelvic floor biofeedback treatment on BET and EMG on straining. KEY RESULTS: One hundred and fifty six patients (129 F, 39.3 ± 11.7 mean age) completed the 2-week run-in period. 105 patients were diet non-responder and underwent balloon expulsion test, with the vast majority (64%) failing the test. Patients who scored higher bloating on VAS had a significant association with failed balloon expulsion test (adjusted B 0.4 [95% CI 10.8-25.7], p < 0.0001). 63% agreed to perform pelvic floor biofeedback treatment at Verona center, 54% became responders reporting fair or major improvement/cure (ITT analysis, McNemar test, p < 0.0001), and all of them showed a 50% decrease in bloating severity. CONCLUSIONS AND INFERENCES: Disordered defecation is a prevalent etiology in DGBI patients with bloating unresponsive to conservative measures; pelvic floor biofeedback treatment to improve the defecation effort significantly relieved bloating (http://www.isrctn.com, ISRCTN17004079).

Beyond biologics: advanced therapies in inflammatory bowel diseases.

INTRODUCTION: Inflammatory bowel diseases (IBDs) are conditions affecting the gut at different levels characterized by an abnormal activation of the intestinal immune system. In this narrative review, we will provide the reader with an update on the efficacy and safety of new pharmacological strategies to treat IBD patients. EVIDENCE ACQUISITION: We performed a thorough literature review via PubMed, EMBASE, MEDLINE and Science Direct databases addressing studies reporting on new therapies for IBD management published in the last ten years (January 2010-December 2020). Data from pharmaceutical companies and abstracts of conferences/meetings have also been considered. EVIDENCE SYNTHESIS: The discovery of monoclonal antibodies blocking pro-inflammatory cytokines, e.g., tumor necrosis factor-α (TNF-α) radically changed the management of IBDs. Anti-TNF-α agents represent the prototype molecule of "biologics"/"biologicals." These compounds have significantly improved the therapeutic management of IBDs refractory to standard medications as they provide clinical remission, mucosal healing and prevent extra-intestinal manifestations. However, about 50% of patients treated with biologicals experienced drawbacks, including primary failure or loss of response, requiring new effective treatments. Translational studies have identified new strategies, different from the TNF-α blockade, and new molecules, e.g. sphingosine-1-phosphate agonists and the JAK kinase inhibitors, have been proposed as potential therapeutic options for IBDs. CONCLUSIONS: With the availability of novel approaches reviewed in this article, physicians and especially gastroenterologists will increase the therapeutic options to provide a better management of IBD patients, particularly those poorly responsive to biologicals.