Spot Hydrogen Breath Test for Predicting Response to Low Fermentable Oligo-, Di-, Mono-saccharides, and Polyols Dietary Advice in Patients With Bloating

Background/Aims@#An increase in postprandial intestinal gas plays a role in bloating symptoms. We aim to study the utility of spot breath hydrogen (H 2 ) level in predicting the response to a low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) diet. @*Methods@#Patients with functional gastrointestinal disorders diagnosed by Rome IV criteria with bothersome bloating for > 6 months were prospectively enrolled. Patients completed 7-day food diaries and collected a breath sample 2 hours after their usual lunch at baselineand 4 weeks after low FODMAPs dietary advice by a dietitian. The responder was defined as an improvement of ≥ 30% bloatingscores in the fourth week. @*Results@#Thirty-eight patients (32 female, 52.6 ± 13.8 years; 22 irritable bowel syndrome) completed the study. Twenty-one patients (55%) were classified as responders. Baseline global gastrointestinal symptoms, bloating, abdominal pain scores, and numbers of high FODMAPs items were similar between responders and non-responders. Both groups significantly decreased high FODMAPs items intake with similar numbers at the follow-up. The area under the curve for predicting low FODMAPs responsiveness using baseline H2 levels was 0.692 (95%CI, 0.51-0.86; P 8 parts per million vs 17% of non-responders (P < 0.05). The baseline spot hydrogen level in responders was 9.5 (3.3-17.3) vs 4.5 (3.3-6.3) in non-responders (P< 0.05). @*Conclusions@#A higher baseline breath hydrogen level was associated with bloating improvement after low FODMAPs dietary advice. A spot breath test after lunch, a simple point-of-care test, is possibly helpful in managing patients with bloating.

Gastroesophageal Reflux Characteristics in Supragastric Belching Patients With Positive Versus Negative pH Monitoring: An Evidence of Secondary Gastroesophageal Reflux Disease From Excessive Belching

Background/Aims@#A high prevalence of GERD has been reported in patients with supragastric belching. We aim to evaluate reflux characteristics and explore the temporal relationship between supragastric belches (SGBs) and reflux episodes in GERD patients with excessive belching. @*Methods@#Twenty-four hour esophageal pH-impedance monitoring was analyzed. Reflux episodes were classified into: refluxes preceded by SGBs, followed by SGBs, and lone refluxes. Reflux characteristics were compared between patients with pH-positive (pH+) and pH-negative (pH–). @*Results@#Forty-six patients (34 Female, age 47 ± 13 years) were included. Fifteen patients (32.6%) had pH+. Almost half (48.1 ± 21.0%) of refluxes were preceded by SGBs. The number of SGBs significantly correlated with the number of reflux episodes preceded by SGBs (r = 0.43, P 0.05). Reflux episodes preceded by SGBs and followed by SGBs extended more proximal and had longer bolus and acid contact time than lone refluxes (P < 0.05). @*Conclusions@#In patients with GERD and SGB, the number of SGBs positively correlates with the number of reflux episodes preceded by SGBs. Identifying and managing SGB may be beneficial and more likely to improve GERD.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

2020 Seoul Consensus on the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a condition in which gastric contents regurgitate into the esophagus or beyond, resulting in either troublesome symptoms or complications. GERD is heterogeneous in terms of varied manifestations, test findings, and treatment responsiveness. GERD diagnosis can be established with symptomatology, pathology, or physiology. Recently the Lyon consensus defined the “proven GERD” with concrete evidence for reflux, including advanced grade erosive esophagitis (Los Angeles classification grades C and or D esophagitis), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal esophageal acid exposure time > 6% on 24-hour ambulatory pH-impedance monitoring. However, some Asian researchers have different opinions on whether the same standards should be applied to the Asian population. The prevalence of GERD is increasing in Asia. The present evidence-based guidelines were developed using a systematic review and meta-analysis approach. In GERD with typical symptoms, a proton pump inhibitor test can be recommended as a sensitive, cost-effective, and practical test for GERD diagnosis.Based on a meta-analysis of 19 estimated acid-exposure time values in Asians, the reference range upper limit for esophageal acid exposure time was 3.2% (95% confidence interval, 2.7-3.9%) in the Asian countries. Esophageal manometry and novel impedance measurements, including mucosal impedance and a post-reflux swallow-induced peristaltic wave, are promising in discrimination of GERD among different reflux phenotypes, thus increasing its diagnostic yield. We also propose a long-term strategy of evidence-based GERD treatment with proton pump inhibitors and other drugs.

Second Asian Consensus on Irritable Bowel Syndrome

BACKGROUND/AIMS: There has been major progress in our understanding of the irritable bowel syndrome (IBS), and novel treatment classes have emerged. The Rome IV guidelines were published in 2016 and together with the growing body of Asian data on IBS, we felt it is timely to update the Asian IBS Consensus. METHODS: Key opinion leaders from Asian countries were organized into 4 teams to review 4 themes: symptoms and epidemiology, pathophysiology, diagnosis and investigations, and lifestyle modifications and treatments. The consensus development process was carried out by using a modified Delphi method. RESULTS: Thirty-seven statements were developed. Asian data substantiate the current global viewpoint that IBS is a disorder of gut-brain interaction. Socio-cultural and environmental factors in Asia appear to influence the greater overlap between IBS and upper gastrointestinal symptoms. New classes of treatments comprising low fermentable oligo-, di-, monosacharides, and polyols diet, probiotics, non-absorbable antibiotics, and secretagogues have good evidence base for their efficacy. CONCLUSIONS: Our consensus is that all patients with functional gastrointestinal disorders should be evaluated comprehensively with a view to holistic management. Physicians should be encouraged to take a positive attitude to the treatment outcomes for IBS patients.

Prediction of Delayed Colonic Transit Using Bristol Stool Form and Stool Frequency in Eastern Constipated Patients: A Difference From the West

BACKGROUND/AIMS: The correlation between the Bristol stool form scale (BSFS) and colonic transit time (CTT) has been reported in Western populations. Our study aims to study the relationship between BSFS, stool frequency, and CTT in Eastern patients with chronic constipation. METHODS: A total of 144 chronic functional constipation patients underwent colonic transit study by using radio-opaque markers, anorectal manometry, and balloon expulsion test. Stool diary including stool forms and frequency was recorded. Delayed CTT was defined as the retention of more than 20.0% of radio-opaque markers in the colon on day 5. RESULTS: Twenty-five patients (17.4%) had delayed colonic transit. Mean 5-day BSFS (OR, 0.51; 95% CI, 0.34–0.79; P = 0.021) and stool frequency (OR, 0.60; 95% CI, 0.44–0.83; P = 0.002) were independently associated with delayed CTT by logistic regression analysis. Mean 5-day BSFS (area under the curve [AUC], 0.73; 95% CI, 0.62–0.84; P < 0.001) and stool frequency (AUC, 0.75; 95% CI, 0.63–0.87; P < 0.001) fairly predicted delayed CTT. The optimal mean 5-day BSFS of ≤ 3 provided 68.0% sensitivity, 69.7% specificity, and 69.4% accuracy, and the optimal stool frequency ≤ 2 bowel movements in 5 days provided 64.0% sensitivity, 83.1% specificity, and 84.0% accuracy for predicting delayed CTT. CONCLUSIONS: Both stool form and frequency were significantly associated with delayed CTT. Stool frequency ≤ 2 and BSFS 1–3 rather than BSFS 1–2 that was used in the Westerners could be used as surrogate for delayed CTT in Eastern patients with constipation.

Development, Translation and Validation of Enhanced Asian Rome III Questionnaires for Diagnosis of Functional Bowel Diseases in Major Asian Languages: A Rome Foundation-Asian Neurogastroenterology and Motility Association Working Team Report

BAome III criteria. METHODS: After EAR3Q was developed by Asian experts by cCKGROUND/AIMS: The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Ronsensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean, and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations. RESULTS: Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700-1.000) except in Korean (0.300-0.500) and Indonesian (0.100-0.400) languages at the initial and 2-week follow-up visit. CONCLUSIONS: Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.

Normal Solid Gastric Emptying Values Measured by Scintigraphy Using Asian-style Meal: A Multicenter Study in Healthy Volunteers

BACKGROUND/AIMS: To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers. METHODS: One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours. RESULTS: One hundred and eighty-nine volunteers (99 females, age 43 +/- 14 years) completed the study. The medians (5-95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5-39.1) minutes, 68.7 (45.1-107.8) minutes, 16.3% (2.7-49.8%) and 1.1% (0.2-8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48-115] minutes vs. 63 (41-96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66-102] mintes vs. 69 [50-120] minutes or 72 [47-109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44-80] minutes vs. 67 [44-100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values. CONCLUSIONS: A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

Effects of Chili Treatment on Gastrointestinal and Rectal Sensation in Diarrhea-predominant Irritable Bowel Syndrome: A Randomized, Double-blinded, Crossover Study

BACKGROUND/AIMS: Whether, chronic chili ingestion can desensitize transient receptor potential vanilloid type 1 receptors in gastrointestinal (GI) tract leading to decrease GI symptoms and sensation in diarrhea-predominant irritable bowel syndrome (IBS-D) patients has not been well explored. The aim of this study was to determine the effects of 6-week chili treatment on postprandial GI symptoms and rectal sensation in response to balloon distention in IBS-D patients. METHODS: Sixteen IBS-D patients received placebo or chili capsules before meals 3 times/day for 6 weeks in a randomized, double-blinded, crossover fashion with 4-week washout period. Postprandial GI symptoms were evaluated. All patients underwent a rectal barostat study to evaluate rectal sensory threshold at the end of each treatment. RESULTS: The maximum postprandial abdominal burning scores were similar between both treatments at baseline (1.4 [0.0-2.0] vs. 1.1 [0.0-2.8], P > 0.05) but were significantly decreased after chili (0.0 [0.0-0.5] vs. 0.3 [0.0-1.6], P < 0.05) at the end of treatment. The chili treatment significantly increased sensory threshold for the first rectal sensation (median [interquartile range]:16 [12-16] mmHg vs. 8 [8-16] mmHg, P < 0.05) however, there was no significant effect on rectal compliance (7.3 +/- 1.0 vs. 7.1 +/- 1.8 mL/mmHg). Other postprandial GI symptoms did not vary significantly between both treatments at baseline and the end of treatment. CONCLUSIONS: In IBS-D patients, 6-week chili ingestion significantly decreased postprandial abdominal burning and increased the rectal sensory threshold. These findings suggest a desensitization effect of chili ingestion on transient receptor potential vanilloid type 1 receptors in the proximal gut and rectum.

Technique of Functional and Motility Test: How to Perform Antroduodenal Manometry

Antroduodenal manometry is one of the methods to evaluate stomach and duodenal motility. This test is a valuable diagnostic tool for gastrointestinal motility disorders especially small intestinal pseudo-obstruction which is difficult to make definite diagnosis by clinical manifestations or radiologic findings. Manometric findings that have no evidence of mechanical obstruction and suggestive of pseudo-obstruction with neuropathy or myopathy can avoid unnecessary surgery and the treatment can be directly targeted. Moreover, among patients who have clinically suspected small intestinal pseudo-obstruction but with normal manometric findings, the alternative diagnosis including psychiatric disorder or other organic disease should be considered. The application of this test to the patients with functional gastrointestinal symptoms especially to find the association of motor abnormalities to the symptom has less impressive yield. Antroduodenal manometry is now readily available only in some tertiary care centers. The aim of this review is to describe the antroduodenal manometry technique, interpretation and clinical utility.

Primary Care Management of Chronic Constipation in Asia: The ANMA Chronic Constipation Tool

Chronic constipation (CC) may impact on quality of life. There is substantial patient dissatisfaction; possible reasons are failure to recognize underlying constipation, inappropriate dietary advice and inadequate treatment. The aim of these practical guidelines intended for primary care physicians, and which are based on Asian perspectives, is to provide an approach to CC that is relevant to the existing health-care infrastructure. Physicians should not rely on infrequent bowel movements to diagnose CC as many patients have one or more bowel movement a day. More commonly, patients present with hard stool, straining, incomplete feeling, bloating and other dyspeptic symptoms. Physicians should consider CC in these situations and when patients are found to use laxative containing supplements. In the absence of alarm features physicians may start with a 2-4 week therapeutic trial of available pharmacological agents including osmotic, stimulant and enterokinetic agents. Where safe to do so, physicians should consider regular (as opposed to on demand dosing), combination treatment and continuous treatment for at least 4 weeks. If patients do not achieve satisfactory response, they should be referred to tertiary centers for physiological evaluation of colonic transit and pelvic floor function. Surgical referral is a last resort, which should be considered only after a thorough physiological and psychological evaluation.

Asian Consensus Report on Functional Dyspepsia

BACKGROUND/AIMS: Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared to the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia. METHODS: Consensus team members were selected from Asian experts and consensus development was carried out using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using keypad voting system. A grade of evidence and a strength of recommendation were applied to each statement according to the method of the GRADE Working Group. RESULTS: Twenty-nine consensus statements were finalized, including 7 for definition and diagnosis, 5 for epidemiology, 9 for pathophysiology and 8 for management. Algorithms for diagnosis and management of functional dyspepsia were added. CONCLUSIONS: This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians.

The Therapeutic and Diagnostic Value of 2-week High Dose Proton Pump Inhibitor Treatment in Overlapping Non-erosive Gastroesophageal Reflux Disease and Functional Dyspepsia Patients

BACKGROUND/AIMS: To evaluate the value of a 2-week high dose proton pump inhibitor (PPI) treatment on patients with overlapping non-erosive gastroesophageal reflux disease (NERD) and functional dyspepsia (FD). METHODS: Sixty overlapping NERD and FD patients with symptom onset > 3 months prior underwent 24-hour esophageal pH monitoring studies. All patients received rabeprazole 20 mg b.i.d. for 2 weeks. The reflux and dyspeptic symptoms were evaluated using a symptom questionnaire with 4-point Likert scales before and at the end of treatment. A positive PPI test was defined as score improvement in > or = 50% from the baseline in the typical reflux symptoms. RESULTS: The prevalence of each reflux and dyspeptic symptom did not differ significantly between patients with positive and negative pH tests. After the PPI treatment, epigastric burning, acid regurgitation, heartburn, nausea, vomiting and chest discomfort scores were significantly improved compared to pretreatment values (P < 0.05), whereas postprandial abdominal fullness, early satiation, belching and food regurgitation were not. The proportion of patients who responded to the PPI treatment did not differ significantly between patients with positive and negative pH tests. The sensitivity, specificity, PPV, NPV and accuracy of 2-week high dose rabeprazole treatment for diagnosing gastroesophageal reflux disease were 47%, 38%, 50%, 35% and 43%, respectively. CONCLUSIONS: The two-week high dose PPI treatment was not effective for early satiation, postprandial abdominal fullness, regurgitation or belching symptoms in patients with overlapping NERD and FD. Acid exposure in the distal esophagus could not predict the response of symptoms to PPI. In addition, the 2-week PPI test provided limited value for gastroesophageal reflux disease diagnosis in patients with overlapping NERD and FD.

Rice and Spicy Diet: Author's Reply

No abstract available.

Are Rice and Spicy Diet Good for Functional Gastrointestinal Disorders?

Rice- and chili-containing foods are common in Asia. Studies suggest that rice is completely absorbed in the small bowel, produces little intestinal gas and has a low allergenicity. Several clinical studies have demonstrated that rice-based meals are well tolerated and may improve gastrointestinal symptoms in functional gastrointestinal disorders (FGID). Chili is a spicy ingredient commonly use throughout Asia. The active component of chili is capsaicin. Capsaicin can mediate a painful, burning sensation in the human gut via the transient receptor potential vanilloid-1 (TRPV1). Recently, the TRPV1 expressing sensory fibers have been reported to increase in the gastrointestinal tract of patients with FGID and visceral hypersensitivity. Acute exposure to capsaicin or chili can aggravate abdominal pain and burning in dyspepsia and IBS patients. Whereas, chronic ingestion of natural capsaicin agonist or chili has been shown to decrease dyspeptic and gastroesophageal reflux disease (GERD) symptoms. The high prevalence of spicy food in Asia may modify gastrointestinal burning symptoms in patients with FGID. Studies in Asia demonstrated a low prevalence of heartburn symptoms in GERD patients in several Asian countries. In conclusion rice is well tolerated and should be advocated as the carbohydrate source of choice for patients with FGID. Although, acute chili ingestion can aggravate abdominal pain and burning symptoms in FGID, chronic ingestion of chili was found to improve functional dyspepsia and GERD symptoms in small randomized, controlled studies.

The Reproducibility of (99m)Tc-Pertechnetate Single Photon Emission Computed Tomography (SPECT) for Measurement of Gastric Accommodation in Healthy Humans: Evaluation of the Test Results Performed at the Same Time and Different Time of the Day

BACKGROUND/AIMS: Technetium-99m ((99m)Tc)-pertechnetate single photon emission computed tomography (SPECT) allows non-invasive measurement of gastric accommodation (GA) and has been reported to provide the results comparable to the gold standard barostat. The reproducibility of the test when it is performed at different time of the day is not known. The aim of this study was to assess the reproducibility of GA measurement by (99m)Tc-pertechnetate SPECT at the same and different time of the day. METHODS: Three GA studies were performed in each of 20 healthy volunteers (9 males, age 35 +/- 9 years), 2 studies in the morning and 1 study in the afternoon. Each study was performed on separate days at least 3 days apart, in random order. The fasting gastric scintigraphy images were acquired using SPECT at 30 minutes after iv (99m)Tc-pertechnetate. Then, the scintigraphic images were acquired 50 minutes after liquid meal (250 mL, Ensure(R)) ingestions. Gastric volumes were calculated from transaxial gastric images using Image J software. The GA was defined as the maximum postprandial gastric volume minus fasting gastric volume. RESULTS: GA measurement by SPECT show good reproducibility at both the same and different time of the day. The intraclass correlation coefficients of GA results for the same time, the first different time and the second different time studies were 0.681, 0.630 and 0.774, respectively, and the intra-subject coefficients of variation were 13.9%, 14.1% and 8.7%, respectively. CONCLUSIONS: GA measurement by (99m)Tc-pertechnetate SPECT shows good reproducibility at both the same and different time of the day. This result suggests that the schedule time does not appear to extremely affect the gastric accommodation value.