Solid Swallow Examination During High Resolution Manometry and EGJ-Distensibility Help Identify Esophageal Outflow Obstruction in Non-obstructive Dysphagia.

Single water swallow (SWS) high-resolution manometry (HRM) may miss relevant esophageal motility disorders. Solid test meal (STM) during HRM and lately the functional lumen imaging probe (FLIP) have been shown to be of diagnostic value in the assessment of motility disorders. We aimed to assess the diagnostic yield of STM and FLIP in non-obstructive dysphagia (NOD). Patients assessed for dysphagia with both HRM and FLIP between April 2016 and August 2019 were analyzed for signs of non-obstructive EGJ outflow obstruction (EGJOO) according to Chicago Classification 3.0 (CCv3) and CC adapted for the use with solid swallows (CC-S), followed by an individual group-specific analysis. Five subjects without dysphagia served as control group. Standard HRM- and FLIP-values as well as esophagograms and Eckardt Scores were analyzed. Forty-two patients were identified (male/female, 14/36, median age 62). Twenty-five (59.5%) were diagnosed with EGJOO during STM only (= SWS-negative patients; CC-S). The EGJ distensibility index (EGJ-DI) of symptomatic patients was significantly lower compared to the control group (p = 0.006). EGJ-DI was < 3mm2/mmHg in 67% and 88% of patients diagnosed according to CC-S and CCv3, respectively. The IRP during STM showed a significant association to the corresponding EGJ-DI values (p < 0.001). Seventy-six percent of patients received treatment because of additional STM evaluation with a favorable clinical response rate of 89%. STM and FLIP identify EGJOO in symptomatic patients with normal SWS during HRM. STM resembles an inexpensive and clinically meaningful option to diagnose motility disorders and helps to select patients for interventional treatment.

Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms.

BACKGROUND AND AIMS: The role of decreased pyloric distensibility in gastroparesis as measured by the endolumenal functional luminal imaging probe (EndoFLIP) has been receiving increasing attention. In this study, we present clinical outcomes to pyloric dilation with the esophageal FLIP (EsoFLIP) in regard to gastric emptying, symptom evolution, and FLIP metrics. METHODS: Patients evaluated for gastroparesis (gastric emptying studies of t1/2 ≥180 minutes during 13C-octanoic acid breath test and/or gastric remnants during gastroscopy after a sufficient fasting period) were scheduled for EsoFLIP controlled pyloric dilation. Pre- and postprocedural gastric emptying studies, questionnaires (Patient Assessment of Upper GI Symptoms Severity Index [PAGI-SYM; including the Gastroparesis Cardinal Symptom Index] and Patient Assessment of Quality of Life Index [PAGI-QOL]), and FLIP metrics were documented. Dilation was conducted according to a self-developed algorithm. RESULTS: Forty-six patients were analyzed (72% women; median age, 39 years [range, 18-88]). Etiologies of gastroparesis were diabetic in 10 patients (22%), idiopathic in 33 (72%), and postoperative in 3 (6%). Postprocedural gastric emptying time decreased from a median of 211 minutes to 179 minutes (P = .001). In accordance, pyloric distensibility, PAGI-SYM, PAGI-QOL, and Gastroparesis Cardinal Symptom Index values improved significantly. After a median follow-up of 3.9 months, 57% of all treated patients with returned questionnaires reported improved symptoms. CONCLUSIONS: Pyloric EsoFLIP controlled dilation shows value in the treatment of gastroparesis, both subjectively and objectively. Long-term follow-up to assess efficacy and comparative trials are warranted.

Better response to low FODMAP diet in disorders of gut-brain interaction patients with pronounced hydrogen response to a nutrient challenge test.

BACKGROUND AND AIM: Previous studies have shown a reduction of gastrointestinal symptoms in irritable bowel syndrome (IBS) patients following a low FODMAP diet (LFD). It remains unknown which disorders of gut-brain interaction (DGBI) patients would benefit most from LFD. We aimed to analyze LFD response regarding a preceding nutrient challenge test (NCT). METHODS: Data of 110 consecutive DGBI patients undergoing NCT and LFD between August 2015 and August 2018 were analyzed retrospectively. LFD response was assessed by changes in IBS Symptom Severity Score (IBS-SSS). In mixed-effects linear regression models, the impact of hydrogen values and abdominal symptoms during NCT, performed with 30-g lactulose and 400-mL liquid test meal, on IBS-SSS changes were analyzed. RESULTS: Low FODMAP diet induced a significant IBS-SSS reduction of 78 points (95% confidence interval [CI] 50-96; P < 0.001). Patients with higher NCT-induced hydrogen increase during proximal intestinal transit had a significantly better LFD response (-66 IBS-SSS reduction per 10-ppm hydrogen increase, 95% CI -129 to -4, P = 0.045). Additionally, the higher the NCT-induced maximum hydrogen increase during mid-distal and distal intestinal transit, the better are the responses to LFD (-6 IBS-SSS per 10-ppm maximum delta hydrogen, 95% CI -11 to -1, P = 0.040). There was no association of LFD response with abdominal symptom generation during NCT. CONCLUSIONS: Our study is the first one analyzing and demonstrating significant associations between NCT results and LFD response. These findings are of high clinical importance, as they identify a subgroup of DGBI patients that may profit most from a restrictive LFD as first-line therapy.

Vancomycin pre-soaking of the graft reduces postoperative infection rate without increasing risk of graft failure and arthrofibrosis in ACL reconstruction.

PURPOSE: To investigate whether pre-soaking the graft in vancomycin during anterior cruciate ligament reconstruction (ACLR) reduces the postoperative infection rate and if this technique is associated with an increased rate of complications, including graft failure or arthrofibrosis. METHODS: A retrospective review of a prospective database was performed in 1779 patients who underwent ACLR over a period of 5 years, analysing the rate of postoperative deep knee infection. Group 1 and 2 both received perioperative IV antibiotics, while only group 2 underwent ACLR with grafts pre-soaked in a 5 mg/ml vancomycin solution. To analyse possible side effects associated with vancomycin use, 500 patients out of the overall study population (100 patients per year) were randomly selected and retrospectively interviewed for further postoperative complications including graft failure and arthrofibrosis as well as subjective evaluation of their knee by completing the IKDC form with a minimum mean follow-up of 37 months. RESULTS: In group 1, 22 out of 926 (2%) patients suffered a postoperative deep knee infection. In contrast, there were no postoperative infections in the second group of 853 patients (0%). 16 of 22 infections (73%) were caused by coagulase-negative Staphylococcus. Statistical analysis revealed a significantly reduced postoperative infection rate when bathing the autograft in vancomycin (p < 0.01). Analysis of the random sample revealed a significant decrease of graft failure with 8 reruptures in 257 patients (3%) in the vancomycin group compared to 16 cases of graft failure in 167 patients (10%) in the control group (p < 0.05). No differences were found in the rate of postoperative arthrofibrosis, Tegner or subjective outcome scores. CONCLUSION: Prophylactic vancomycin pre-soaking of autografts during ACLR appears to be a viable, cost-effective and safe option to reduce the rate of deep infection compared to systemic antibiotics alone. LEVEL OF EVIDENCE: III.

Clarithromycin-based Helicobacter pylori eradication therapy is not associated with higher treatment failure compared with non-clarithromycin-based regimens in a tertiary referral hospital in Switzerland.

BACKGROUND AND AIMS: Due to increasing antibiotic resistance, various Helicobacter pylori eradication regimens other than clarithromycin-based therapies have been proposed. However, detailed data on which therapies were employed and their eradication success is lacking. The purpose of this study was to analyse the response rates of different eradication therapy schemes. METHODS: In this retrospective cohort study, we analysed data of 1721 patients and included 608 patients undergoing H. pylori eradication therapy at the Department of Gastroenterology at the University Hospital Zurich between 2004 and 2018. The primary endpoint was the success rates of clarithromycin- and non-clarithromycin-containing H. pylori eradication regimens. We furthermore analysed factors with potential impact on the outcome of H. pylori eradication therapies, such as demographics, and smoking and social status. RESULTS: The most common therapy scheme (71% of all cases) was proton pump inhibitor (PPI)-amoxicillin-metronidazole, followed by PPI-amoxicillin-clarithromycin (21%) and PPI-metronidazole-clarithromycin (6%). There was no difference between the H. pylori eradication success of clarithromycin vs non-clarithromycin-containing therapies (71% vs 71%, p = 0.764). CONCLUSION: Despite increasing clarithromycin resistance globally, there was no difference in the eradication success of clarithromycin- and non-clarithromycin-containing therapy regimens in Switzerland. As varying triple therapies do not increase eradication rates in real-world settings, other primary therapy options such as quadruple therapies should be explored.

Altered sensorimotor processing in irritable bowel syndrome: Evidence for a transdiagnostic pathomechanism in functional somatic disorders.

Objective: A recent hypothesis suggests that functional somatic symptoms are due to altered information processing in the brain, with rigid expectations biasing sensorimotor signal processing. First experimental results confirmed such altered processing within the affected symptom modality, e.g., deficient eye-head coordination in patients with functional dizziness. Studies in patients with functional somatic symptoms looking at general, trans-symptomatic processing deficits are sparse. Here, we investigate sensorimotor processing during eye-head gaze shifts in irritable bowel syndrome (IBS) to test whether processing deficits exist across symptom modalities. Methods: Study participants were seven patients suffering from IBS and seven age- and gender-matched healthy controls who performed large gaze shifts toward visual targets. Participants performed combined eye-head gaze shifts in the natural condition and with experimentally increased head moment of inertia. Head oscillations as a marker for sensorimotor processing deficits were assessed. Bayes statistics was used to assess evidence for the presence or absence of processing differences between IBS patients and healthy controls. Results: With the head moment of inertia increased, IBS patients displayed more pronounced head oscillations than healthy controls (Bayes Factor 10 = 56.4, corresponding to strong evidence). Conclusion: Patients with IBS show sensorimotor processing deficits, reflected by increased head oscillations during large gaze shifts to visual targets. In particular, patients with IBS have difficulties to adapt to the context of altered head moment of inertia. Our results suggest general transdiagnostic processing deficits in functional somatic disorders.

Adding a liquid test meal to a standardized lactulose hydrogen breath test significantly influences abdominal symptom generation and hydrogen values.

OBJECTIVE: While single sugar tests are controversially discussed, combination tests with meals are gaining more attention. The aim of this study was to analyze the impact of adding a test meal to lactulose hydrogen breath tests (LHBT) on hydrogen values and abdominal symptoms in patients with functional gastrointestinal disorders (FGIDs). METHODS: Data of 81 FGID patients between 2014-2018 were analyzed. Patients underwent LHBT with 30 g lactulose + 300 mL water and a nutrient challenge test (NCT) including 400 mL liquid test meal + 30 g lactulose. To statistically assess the effect of a test meal on abdominal symptoms and H2, mixed-effect models were used. RESULTS: Adding a test meal to LHBT showed a significant increase in nausea [odds ratio (OR) 1.4; 95% confidence interval (CI), 1.1-1.7], decrease in abdominal pain (OR 0.7; 95% CI, 0.6-0.9), borborygmi (OR 0.5; 95% CI, 0.4-0.6), diarrhea (OR 0.4; 95% CI, 0.3-0.6), and H2 production (estimate -5.3, SE 0.7, P < 0.001). The effect on bloating was only significant in functional dyspepsia, irritable bowel syndrome-functional dyspepsia mixed type and functional abdominal pain/bloating (OR 0.1; 95% CI, 0.0-0.2; OR 1.7; 95% CI, 1.2-2.3 resp OR 4.4; 95% CI, 1.8-10.6). CONCLUSIONS: Significant effects on abdominal symptoms and H2 production by adding a test meal to LHBT in FGID patients are shown. Increased occurrence of nausea may be caused by gastric/duodenal hypersensitivity; decreased H2, diarrhea and borborygmi by slower and more physiologic gastric emptying resulting in later arrival of the test substance in the bowel. We recommend NCTs instead of LHBT to more physiologically represent FGID patients' meal-induced burden.