Good clinical practice recommendations for the diagnosis and treatment of gastroesophageal reflux disease. An expert review from the Asociación Mexicana de Gastroenterología.

INTRODUCTION: Gastroesophageal reflux disease (GERD) is very prevalent in the general population, with a broad spectrum of clinical manifestations, requiring accurate diagnosis and treatment. AIM: The aim of this expert review is to establish good clinical practice recommendations for the diagnosis and personalized treatment of GERD. METHODS: The good clinical practice recommendations were produced by a group of experts in GERD, members of the Asociación Mexicana de Gastroenterología (AMG), after carrying out an extensive review of the published literature and discussing each recommendation at a face-to-face meeting. This document does not aim to be a clinical practice guideline with the methodology such a document requires. RESULTS: Fifteen experts on GERD formulated 27 good clinical practice recommendations for recognizing the symptoms and complications of GERD, the rational use of diagnostic tests and medical treatment, the identification and management of refractory GERD, the overlap with functional disorders, endoscopic and surgical treatment, and GERD in the pregnant woman, older adult, and the obese patient. CONCLUSIONS: An accurate diagnosis of GERD is currently possible, enabling the prescription of a personalized treatment in patients with this condition. The goal of the good clinical practice recommendations by the group of experts from the AMG presented in this document is to aid both the general practitioner and specialist in the process of accurate diagnosis and treatment, in the patient with GERD.

Efficacy and safety of lubiprostone for the treatment of chronic idiopathic constipation: A phase 3, randomized, placebo-controlled study.

INTRODUCTION: Chronic idiopathic constipation (CIC) negatively impacts quality of life and increases healthcare costs. Lubiprostone stimulates the secretion of intestinal fluid, in turn facilitating the passage of stools and alleviating associated symptoms. Lubiprostone has been available in Mexico since 2018, but its clinical efficacy has not been studied in a Mexican population. AIM: To evaluate the efficacy of lubiprostone, assessed by changes in spontaneous bowel movement (SBM) frequency after one week of treatment with 24 µg oral lubiprostone (b.i.d.), as well as its safety, over four weeks of treatment. STUDY: Randomized, double-blind, placebo-controlled study on 211 adults with CIC in Mexico. RESULTS: The increase in SBM frequency, after one week of treatment, was significantly higher in the lubiprostone group than in the placebo group (mean: 4.9 [SD: 4.45] vs. 3.0 [3.14], p = 0.020). Secondary efficacy endpoints revealed a significantly higher proportion of SBM frequency/week in the lubiprostone group at weeks 2, 3, and 4. There was a better response within 24 h after the first dose with lubiprostone vs. placebo (60.0% vs. 41.5%; OR: 2.08, CI95%: [1.19, 3.62], p = 0.009) and the lubiprostone group also had significant improvement, with respect to straining, stool consistency, abdominal bloating, and Satisfaction Index. The main adverse events were gastrointestinal disorders in 13 (12.4%) lubiprostone-treated subjects and 4 (3.8%) control subjects. CONCLUSIONS: Our data confirm the efficacy and safety of lubiprostone for the treatment of CIC in a Mexican population. Lubiprostone treatment induces relief from the most bothersome symptoms associated with constipation.

The Mexican consensus on fecal incontinence.

Fecal incontinence is the involuntary passage or the incapacity to control the release of fecal matter through the anus. It is a condition that significantly impairs quality of life in those that suffer from it, given that it affects body image, self-esteem, and interferes with everyday activities, in turn, favoring social isolation. There are no guidelines or consensus in Mexico on the topic, and so the Asociación Mexicana de Gastroenterología brought together a multidisciplinary group (gastroenterologists, neurogastroenterologists, and surgeons) to carry out the «Mexican consensus on fecal incontinence¼ and establish useful recommendations for the medical community. The present document presents the formulated recommendations in 35 statements. Fecal incontinence is known to be a frequent entity whose incidence increases as individuals age, but one that is under-recognized. The pathophysiology of incontinence is complex and multifactorial, and in most cases, there is more than one associated risk factor. Even though there is no diagnostic gold standard, the combination of tests that evaluate structure (endoanal ultrasound) and function (anorectal manometry) should be recommended in all cases. Treatment should also be multidisciplinary and general measures and drugs (lidamidine, loperamide) are recommended, as well as non-pharmacologic interventions, such as biofeedback therapy, in selected cases. Likewise, surgical treatment should be offered to selected patients and performed by experts.

Dietary fiber and the microbiota: A narrative review by a group of experts from the Asociación Mexicana de Gastroenterología.

Dietary fiber intake is one of the most influential and efficacious strategies for modulating the gut microbiota. Said fiber can be digested by the microbiota itself, producing numerous metabolites, which include the short-chain fatty acids (SCFAs). SCFAs have local and systemic functions that impact the composition and function of the gut microbiota, and consequently, human health. The aim of the present narrative review was to provide a document that serves as a frame of reference for a clear understanding of dietary fiber and its direct and indirect effects on health. The direct benefits of dietary fiber intake can be dependent on or independent of the gut microbiota. The use of dietary fiber by the gut microbiota involves several factors, including the fiber's physiochemical characteristics. Dietary fiber type influences the gut microbiota because not all bacterial species have the same capacity to produce the enzymes needed for its degradation. A low-fiber diet can affect the balance of the SCFAs produced. Dietary fiber indirectly benefits cardiometabolic health, digestive health, certain functional gastrointestinal disorders, and different diseases.

Outcomes of radiofrequency ablation for anal high-grade squamous intraepithelial lesions.

BACKGROUND: Radiofrequency ablation (RFA) of high-grade squamous intraepithelial lesions (HSIL) is a promising minimally invasive technique but its oncologic and functional outcomes are not well studied. The primary outcome was the efficacy of RFA, and the secondary outcomes were the functional and anatomical anal changes related to RFA. METHODS: This was a retrospective analysis of our prospectively collected database of patients who had RFA for HSIL at our institution, between August 2018 and March 2020. To be eligible for RFA, all patients had impairment of their immune function. Targeted ablation was applied in all cases, with 5 overlapping pulsations at the targeted HSILs (delivering 12 J/cm2 per application) followed by circumferential, 2-pulsation (12 J/cm2) overlapping anal ablation, to cover the entire anal transition zone. Patients were assessed for recurrence or metachronous disease at 3-month intervals by means of high-resolution anoscopy (HRA) and targeted biopsies. Anorectal manometry, endoanal ultrasound, the 36-Item Short Form and Massachusetts General Hospital-Sexual Functioning Questionnaire (MGH-SFQ) were assessed at baseline and 12 months after intervention. RESULTS: We included a total of 12 patients with anal HSILs. The mean age was 38.6 (± 7.68) years, and 7 (58.3%) were males. Six were HIV positive, 2 had a primary immunodeficiency disease, and 4 were receiving immunosuppressive therapy. A mean of 2.1 anal HSILs per patient were treated. At 12 months, high-resolution anoscopy showed that 7/12 (58.3%) patients had normal high-resolution anoscopy, 3/12 patients had recurrent HSILs, and 2/12 had a persistent lesion. Those lesions were treated with electrocautery, and reached complete response in the following the 6 months (total of 18 months). In particular, there were no metachronous lesions detected. Patients reported moderate to severe pain during the first 24 h after RFA, but only mild discomfort was present at 30 days. Patients were asymptomatic at their 6- and 12-month visits. RFA was not associated with changes in anorectal manometry or ultrasound examination. The 36-SF survey reported improvement in the general health domain (p = 0.038), while the MGH-SFQ showed improvements in sexual function. CONCLUSIONS: In this study, targeted plus circumferential RFA had a 58.3% efficacy rate for the treatment of anal HSIL in immunocompromised patients, achieving 100% eradication after adding electrocautery ablation. No metachronous lesions were detected. Patients presented relatively mild symptoms after the procedure, no changes in anorectal anatomy or function, and some improvements in their sexual function. These results seem promising in light of the high recurrence reported after HSIL treatment. Larger studies are needed to validate our results.

The importance of lactose intolerance in individuals with gastrointestinal symptoms. / Importancia de la intolerancia a la lactosa en individuos con síntomas gastrointestinales.

Lactose intolerance is a condition with an elevated prevalence worldwide, especially in Latin American, Asian, and African countries. The aim of the present narrative review was to highlight the importance of accurately diagnosing lactose intolerance to prevent self-diagnosis that results in the unnecessary elimination of milk and dairy products from the diet and the consequent deprivation of nutrients that could be essential at certain stages of life. The pathophysiologic mechanism of deficient lactose absorption in the intestine can be primary, secondary to other enteropathies, or coexistent with other intestinal diseases with similar symptoms, such as irritable bowel syndrome, bacterial overgrowth syndrome, or celiac disease, causing confusion in relation to diagnosis and treatment. Lactose intolerance consists of a set of symptoms attributed to the consumption of milk and dairy products that are assumed to be due to deficient digestion of that disaccharide. A wide range of tests have been validated to detect deficient digestion that include blood tests, genetic mutation analyses, breath tests, and recently, a urine test, all of which are described in the present article. Nevertheless, there are few validated questionnaires for symptom evaluation and measurement, partly due to the heterogeneity of concepts and the subjectivity of each of the symptoms.

The Mexican consensus on non-cardiac chest pain. / Consenso mexicano sobre dolor torácico no cardiaco.

INTRODUCTION: Non-cardiac chest pain is defined as a clinical syndrome characterized by retrosternal pain similar to that of angina pectoris, but of non-cardiac origin and produced by esophageal, musculoskeletal, pulmonary, or psychiatric diseases. AIM: To present a consensus review based on evidence regarding the definition, epidemiology, pathophysiology, and diagnosis of non-cardiac chest pain, as well as the therapeutic options for those patients. METHODS: Three general coordinators carried out a literature review of all articles published in English and Spanish on the theme and formulated 38 initial statements, dividing them into 3 main categories: (i)definitions, epidemiology, and pathophysiology; (ii)diagnosis, and (iii)treatment. The statements underwent 3rounds of voting, utilizing the Delphi system. The final statements were those that reached >75% agreement, and they were rated utilizing the GRADE system. RESULTS AND CONCLUSIONS: The final consensus included 29 statements. All patients presenting with chest pain should initially be evaluated by a cardiologist. The most common cause of non-cardiac chest pain is gastroesophageal reflux disease. If there are no alarm symptoms, the initial approach should be a therapeutic trial with a proton pump inhibitor for 2-4weeks. If dysphagia or alarm symptoms are present, endoscopy is recommended. High-resolution manometry is the best method for ruling out spastic motor disorders and achalasia and pH monitoring aids in demonstrating abnormal esophageal acid exposure. Treatment should be directed at the pathophysiologic mechanism. It can include proton pump inhibitors, neuromodulators and/or smooth muscle relaxants, psychologic intervention and/or cognitive therapy, and occasionally surgery or endoscopic therapy.

Technical position on milk and its derivatives in adult health and disease from the Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Gerontología y Geriatría. / Posición técnica sobre la leche y derivados lácteos en la salud y en la enfermedad del adulto de la Asociación Mexicana de Gastroenterología y la Asociación Mexicana de Gerontología y Geriatría.

Milk is a liquid food that possesses an important quantity of highly bioavailable macronutrients. In addition, it is readily accessible, as well as relatively inexpensive. Given that the knowledge of physicians about nutrition and food composition is deficient, in general, many of the dietary interventions recommended in diverse clinical settings lack a scientific basis. The aim of the present review was to produce a technical opinion that serves as a frame of reference to best sustain recommendations for consuming milk and dairy products as daily nutrition in the adult and older adult. The effects of milk and dairy products during the pediatric stage are not addressed in the present work. The Asociación Mexicana de Gastroenterología and the Asociación Mexicana de Gerontología y Geriatría jointly discussed and analyzed topics dealing with the legal designation of milk, the classification and nutritional profile of cow's milk, its nutritional characteristics, its consumption in the adult, intolerance to cow's milk, and associations of milk consumption with digestive tract alterations and other conditions. Finally, certain aspects of milk consumption in the older adult and its relation to overall health are briefly discussed.

The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon. / Consenso mexicano sobre el diagnóstico y tratamiento de la enfermedad diverticular del colon.

Since the publication of the 2008 guidelines on the diagnosis and treatment of diverticular disease of the colon by the Asociación Mexicana de Gastroenterología, significant advances have been made in the knowledge of that disease. A systematic review of articles published in the medical literature from January 2008 to July 2018 was carried out to revise and update the 2008 guidelines and provide new evidence-based recommendations. All high-quality articles in Spanish and English published within that time frame were included. The final versions of the 43 statements accepted in the three rounds of voting, utilizing the Delphi method, were written, and the quality of evidence and strength of the recommendations were established for each statement, utilizing the GRADE system. The present consensus contains new data on the definition, classification, epidemiology, pathophysiology, and risk factors of diverticular disease of the colon. Special emphasis is given to the usefulness of computed tomography and colonoscopy, as well as to the endoscopic methods for controlling bleeding. Outpatient treatment of uncomplicated diverticulitis is discussed, as well as the role of rifaximin and mesalazine in the management of complicated acute diverticulitis. Both its minimally invasive alternatives and surgical options are described, stressing their indications, limitations, and contraindications. The new statements provide guidelines based on updated scientific evidence. Each statement is discussed, and its quality of evidence and the strength of the recommendation are presented.

Consenso mexicano sobre el diagnóstico y tratamiento de la enfermedad diverticular del colon / The Mexican consensus on the diagnosis and treatment of diverticular disease of the colon

Desde la publicación en 2008 de las guías de diagnóstico y tratamiento de la enfermedad diverticular del colon de la Asociación Mexicana de Gastroenterología ha habido avances significativos en el conocimiento de esta enfermedad. Se realizó una revisión sistemática de la literatura en PubMed de enero de 2008 a julio de 2018 con el fin de revisar y actualizar las guías 2008 y proporcionar nuevas recomendaciones basadas en la evidencia. Se incluyeron todas las publicaciones en español e inglés, de alta calidad. Se redactaron los enunciados, que fueron votados utilizando el método Delphi. Se estableció la calidad de la evidencia y la fuerza de las recomendaciones según el sistema GRADE para cada enunciado. Cuarenta y tres enunciados fueron finalmente votados y calificados. Se informan nuevos datos sobre definición, clasificación, epidemiología, fisiopatología y factores de riesgo. Se revisó con especial énfasis la utilidad de la tomografía computarizada y de la colonoscopia, así como los métodos endoscópicos para el control de la hemorragia. Se discutió sobre el tratamiento ambulatorio de la diverticulitis no complicada, el papel de la rifaximina y la mesalazina, en el manejo de la diverticulitis aguda complicada tanto en sus alternativas mínimamente invasivas hasta las opciones quirúrgicas con énfasis en sus indicaciones, limitaciones y contraindicaciones. Los nuevos enunciados proporcionan directrices basadas en la evidencia actualizada. Se presentan la discusión, el grado y la fuerza de la recomendación de cada uno de ellos.

Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico. / Guía clínica para diagnóstico y tratamiento de la enfermedad celíaca en México.

Celiac disease, celiac sprue, or gluten-sensitive enteropathy, is a generalized autoimmune disease characterized by chronic inflammation and atrophy of the small bowel mucosa. It is caused by dietary exposure to gluten and affects genetically predisposed individuals. In Mexico, at least 800,000 are estimated to possibly have the disease, prompting the Asociación Mexicana de Gastroenterología to summon a multidisciplinary group of experts to develop the "Clinical guidelines on the diagnosis and treatment of celiac disease in Mexico" and establish recommendations for the medical community, its patients, and the general population. The participating medical professionals were divided into three working groups and were given the selected bibliographic material by the coordinators (ART, LUD, JMRT), who proposed the statements that were discussed and voted upon in three sessions: two voting rounds were carried out electronically and one at a face-to-face meeting. Thirty-nine statements were accepted, and once approved, were developed and revised by the coordinators, and their final version was approved by all the participants. It was emphasized in the document that epidemiology and risk factors associated with celiac disease (first-degree relatives, autoimmune diseases, high-risk populations) in Mexico are similar to those described in other parts of the world. Standards for diagnosing the disease and its appropriate treatment in the Mexican patient were established. The guidelines also highlighted the fact that a strict gluten-free diet is essential only in persons with confirmed celiac disease, and that the role of gluten is still a subject of debate in relation to nonceliac, gluten-sensitive patients.

The Mexican consensus on chronic constipation. / Consenso mexicano sobre estreñimiento crónico.

INTRODUCTION: Significant advances have been made in the knowledge and understanding of the epidemiology, pathophysiology, diagnosis, and treatment of chronic constipation, since the publication of the 2011 guidelines on chronic constipation diagnosis and treatment in Mexico from the Asociación Mexicana de Gastroenterología. AIMS: To present a consensus review of the current state of knowledge about chronic constipation, providing updated information and integrating the new scientific evidence. METHODS: Three general coordinators reviewed the literature published within the time frame of January 2011 and January 2017. From that information, 62 initial statements were formulated and then sent to 12 national experts for their revision. The statements were voted upon, using the Delphi system in 3 voting rounds (2 electronic and one face-to-face). The statements were classified through the GRADE system and those that reached agreement >75% were included in the consensus. RESULTS AND CONCLUSIONS: The present consensus is made up of 42 final statements that provide updated knowledge, supplementing the information that had not been included in the previous guidelines. The strength of recommendation and quality (level) of evidence were established for each statement. The current definitions of chronic constipation, functional constipation, and opioid-induced constipation are given, and diagnostic strategies based on the available diagnostic methods are described. The consensus treatment recommendations were established from evidence on the roles of diet and exercise, fiber, laxatives, new drugs (such as prucalopride, lubiprostone, linaclotide, plecanatide), biofeedback therapy, and surgery.

Mexican consensus on dyspepsia / Consenso mexicano sobre la dispepsiaMexican consensus on dyspepsia

Desde la publicación de las guías de dispepsia 2007 de la Asociación Mexicana de Gastroenterología ha habido avances significativos en el conocimiento de esta enfermedad. Se realizó una revisión sistemática de la literatura en PubMed (01/2007 a 06/2016) con el fin de revisar y actualizar las guías 2007 y proporcionar nuevas recomendaciones basadas en evidencia. Se incluyeron todas las publicaciones en español e inglés, de alta calidad. Se redactaron enunciados que fueron votados utilizando el método Delphi. Se estableció la calidad de la evidencia y la fuerza de las recomendaciones según el sistema GRADE para cada enunciado. Treinta y un enunciados fueron redactados, votados y calificados. Se informan nuevos datos sobre definición, clasificación, epidemiología y fisiopatología. La endoscopia debe realizarse en dispepsia no investigada cuando hay datos de alarma o falla al tratamiento. Las biopsias gástricas y duodenales permiten confirmar infección por Helicobacter pylori y excluir enfermedad celiaca, respectivamente. Establecer una fuerte relación médico-paciente, cambios en la dieta y en el estilo de vida son útiles como medidas iniciales. Los bloqueadores H2, inhibidores de la bomba de protones, procinéticos y fármacos antidepresivos son efectivos. La erradicación de H. pylori puede ser eficaz en algunos pacientes. Con excepción de Iberogast y rikkunshito, las terapias complementarias y alternativas carecen de beneficio. No existe evidencia con respecto a la utilidad de prebióticos, probióticos o terapias psicológicas. Los nuevos enunciados proporcionan directrices basadas en la evidencia actualizada. Se presenta la discusión, el grado y la fuerza de la recomendación de cada uno de ellos.

Abstract Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H. pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement. © 2017 Asociacion Mexicana de Gastroenterologiia.

Mexican consensus on dyspepsia. / Consenso mexicano sobre la dispepsia.

Since the publication of the 2007 dyspepsia guidelines of the Asociación Mexicana de Gastroenterología, there have been significant advances in the knowledge of this disease. A systematic search of the literature in PubMed (01/2007 to 06/2016) was carried out to review and update the 2007 guidelines and to provide new evidence-based recommendations. All high-quality articles in Spanish and English were included. Statements were formulated and voted upon using the Delphi method. The level of evidence and strength of recommendation of each statement were established according to the GRADE system. Thirty-one statements were formulated, voted upon, and graded. New definition, classification, epidemiology, and pathophysiology data were provided and include the following information: Endoscopy should be carried out in cases of uninvestigated dyspepsia when there are alarm symptoms or no response to treatment. Gastric and duodenal biopsies can confirm Helicobacter pylori infection and rule out celiac disease, respectively. Establishing a strong doctor-patient relationship, as well as dietary and lifestyle changes, are useful initial measures. H2-blockers, proton-pump inhibitors, prokinetics, and antidepressants are effective pharmacologic therapies. H.pylori eradication may be effective in a subgroup of patients. There is no evidence that complementary and alternative therapies are beneficial, with the exception of Iberogast and rikkunshito, nor is there evidence on the usefulness of prebiotics, probiotics, or psychologic therapies. The new consensus statements on dyspepsia provide guidelines based on up-to-date evidence. A discussion, level of evidence, and strength of recommendation are presented for each statement.

The Mexican consensus on probiotics in gastroenterology. / Consenso mexicano sobre probióticos en gastroenterología.

INTRODUCTION: Probiotics are frequently prescribed in clinical practice. Their efficacy in treating gastrointestinal disorders is supported by a significant number of clinical trials. However, the correct prescription of these agents is hampered due to a lack of knowledge of the scientific evidence and to the different presentations and microbial compositions of the probiotics that are currently available. AIM: To provide the clinician with a consensus review of probiotics and recommendations for their use in gastroenterology. MATERIALS AND METHODS: Controlled clinical trials, meta-analyses, and systematic reviews published up to 2015 were selected, using the MESH terms: probiotics, gastrointestinal diseases, humans, adults, AND children. The Delphi method was employed. Eighteen gastroenterologists treating adult patients and 14 pediatric gastroenterologists formulated statements that were voted on until agreement>70% was reached. The level of evidence based on the GRADE system was evaluated for each statement. RESULTS AND CONCLUSIONS: Eleven statements on the general concepts of probiotics and 27 statements on the use of probiotics in gastrointestinal diseases in both adults and children were formulated. The consensus group recommends the use of probiotics under the following clinical conditions: the prevention of diarrhea associated with antibiotics, the treatment of acute infectious diarrhea, the prevention of Clostridium difficile infection and necrotizing enterocolitis, the reduction of adverse events from Helicobacter pylori eradication therapy, relief from irritable bowel syndrome symptoms, the treatment of functional constipation in the adult, and the induction and maintenance of remission in patients with ulcerative colitis and pouchitis, and the treatment of covert and overt hepatic encephalopathy.

Post-fundoplication symptoms and complications: Diagnostic approach and treatment. / Síntomas y complicaciones posfunduplicatura: abordaje diagnóstico y tratamiento.

Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

Randomised clinical trial: mixed soluble/insoluble fibre vs. psyllium for chronic constipation.

BACKGROUND: Fibre supplements are useful, but whether a plum-derived mixed fibre that contains both soluble and insoluble fibre improves constipation is unknown. AIM: To investigate the efficacy and tolerability of mixed soluble/insoluble fibre vs. psyllium in a randomized double-blind controlled trial. METHODS: Constipated patients (Rome III) received mixed fibre or psyllium, 5 g b.d., for 4 weeks. Daily symptoms and stool habit were assessed using stool diary. Subjects with ≥1 complete spontaneous bowel movement/week above baseline for ≥2/4 weeks were considered responders. Secondary outcome measures included stool consistency, bowel satisfaction, straining, gas, bloating, taste, dissolvability and quality of life (QoL). RESULTS: Seventy-two subjects (mixed fibre = 40; psyllium = 32) were enrolled and two from psyllium group withdrew. The mean complete spontaneous bowel movement/week increased with both mixed fibre (P < 0.0001) and psyllium (P = 0.0002) without group difference. There were 30 (75%) responders with mixed fibre and 24 (75%) with psyllium (P = 0.9). Stool consistency increased (P = 0.04), straining (P = 0.006) and bloating scores decreased (P = 0.02) without group differences. Significantly more patients reported improvement in flatulence (53% vs. 25%, P = 0.01) and felt that mixed fibre dissolved better (P = 0.02) compared to psyllium. QoL improved (P = 0.0125) with both treatments without group differences. CONCLUSIONS: Mixed fibre and psyllium were equally efficacious in improving constipation and QoL. Mixed fibre was more effective in relieving flatulence, bloating and dissolved better. Mixed fibre is effective and well tolerated.