BACKGROUND:A frequent, although not universal, feature of irritable bowel syndrome (IBS) is heightened sensitivity to mechanical stimulation of the rectum, termed rectal hypersensitivity (RH). Differences in RH-based on sex, IBS subtype, IBS diagnostic criteria and age of population studied are incompletely understood. We aimed to determine whether IBS population had lower pain thresholds than healthy controls. METHODS:We searched MEDLINE and EMBASE databases (1970-2021). Prospective studies that compared pain/discomfort thresholds to mechanical rectal stimuli in IBS and healthy controls were included. Data were pooled for meta-analyses and effect sizes were calculated with 95% confidence interval (CIs). RESULTS:Our search strategy identified 809 studies of which 32 studies met the inclusion criteria. Reduced rectal pain thresholds was more common in IBS patients compared to healthy controls with an effect size of 1.00 95% CIs (0.77-1.24) (p < 0.0001) (I2  = 78.6%). The pediatric IBS population had lower pain thresholds than adult IBS populations (p = 0.05) but no difference based on IBS diagnostic criteria, subtype or sex. CONCLUSION & INFERENCES:The results suggest that reduced rectal pain threshold to experimental stimulation is far more common in IBS patients than healthy controls. Further research is required to understand the pathophysiological and therapeutic implications of rectal sensitivity such as its role in measuring response to treatment and prognosis in IBS.

Introduction Oesophagogastroduodenoscopy (OGD) is commonly performed and trans-oral OGD is a very safe procedure. However, it requires nursing support, patient sedation, a dedicated endoscopy suite, and is disliked by patients. The national census by the Joint Advisory Group on Gastrointestinal Endoscopy reported 860,000 OGDs were performed across the UK in a calendar year. of these, only 26,685 were trans-nasal despite having a similarly low risk profile and being preferred by patients. We compared comfort score, sedation, and safety to show trans-nasal OGD is a feasible alternative to trans-oral OGD reducing nursing burden, avoiding endoscopy suites, and reducing procedure length. Methods A single centre retrospective analysis was performed comparing all OGDs performed by a single endoscopist at Whipps Cross and Mile End Hospitals between 01/06/2021 and 24/11/2021. Demographic data, route of entry, indication, comfort score (scale of 0-3), sedation agent and dose, and any complications were recorded for each procedure. The data sets were compared using paired t-test for statistical significance. Results There was 110 OGDs performed (table 1);73 transoral (66%) and 37 trans-nasal (34%). of those trans-nasal OGD 18 (49%) were completed seated. The trans-nasal route had mean comfort score of 0.29 compared with 0.85 for trans-oral route (p = 0.001). There was no statistical difference in xylocaine application with either route. The mean dose of both fentanyl and midazolam was statistically higher in the trans-oral route compared with trans-nasal (p = 0.0001). There were only two complications reported in the cases reviewed. Conclusions Trans-nasal OGD caused significantly less discomfort than trans-oral OGD and required significantly less sedation, and almost half of patients undergoing trans-nasal OGD were able to tolerate the procedure in a seated position. This has advantages for patient safety, as the risk of aspiration is greatly reduced, but is also much less resource intensive. Given the current pressure on endoscopy services nationwide, amplified by COVID-19, trans-nasal endoscopy is safe, less resource intensive, and can be performed outside of a dedicated endoscopy suite. This may be a useful tool in alleviating waiting list pressure and should be discussed with patients and service leads.

Abdominal pain is a key symptom of inflammatory bowel disease (IBD), particularly in active IBD, but also occurs in patients with quiescent disease suggesting that mechanisms other than active inflammation may be responsible. Putative hypothesis to explain chronic abdominal pain in patients with quiescent IBD includes crossover with irritable bowel syndrome where rectal hypersensitivity is common and has pathophysiological implications. In contrast, in IBD, the role of rectal hypersensitivity has not been established. We aimed to determine if rectal hypersensitivity was more common in IBD compared to a healthy control population. We searched MEDLINE and EMBASE databases (1970-2018). Prospective studies that measured pain/discomfort thresholds to mechanical rectal stimuli in IBD and healthy controls were included. Data were pooled for meta-analysis and effect sizes were calculated with 95% confidence intervals (CIs). Our search strategy identified 222 citations of which 8 met the inclusion criteria, covering 133 individuals with IBD (67 men), aged between 10 and 77 compared to 99 healthy controls (55 men), aged between 10 and 67. The prevalence of rectal hypersensitivity in IBD compared to healthy controls was similar with an effect size of 0.59 (95% CIs: -0.27 to 1.44, P = .16, I-2 = 87.3%). Subgroup analysis did show a significant effect size for patients compared to healthy controls with active disease (1.32) but not for quiescent disease (-0.02). These results suggest that reduced rectal pain thresholds to experimental stimulation are not seen in IBD populations except during active flares of the disease. Further research is required to understand the pathophysiology of chronic abdominal pain in quiescent IBD populations with and without chronic abdominal pain to identify appropriate management strategies. Lay Summary Chronic abdominal pain is common in IBD, a possible cause of this is the bowel being extra sensitive. This study looks to see whether people with IBD are more sensitive than healthy people. Results show that generally, this is not the case.

Introduction Hepatitis D virus (HDV) only infects patients with pre-existing hepatitis B. It is commonly found in Eastern Europe, Middle East, Africa and South America. Barts Health NHS Trust is one of the largest NHS trust in the UK and consists mainly of The Royal London, St Bartholomew’s, Whipps Cross, Newham and Mile End hospital. It serves 2.6 million population in a large part of cosmopolitan East London area where HDV could be more prevalent due to its mobile population. We conducted a retrospective study to evaluate the burden of hepatitis D in our trust with an aim to improve our service delivery and care. Methods All patients who had positive hepatitis B surface antigen (HBsAg) and those who were tested for anti HDV serology (total IgG and IgM) were identified from Virology department database. Newly diagnosed hepatitis B patients were screened from the above data and matched with HDV results. Data were then collected from electronic health records. Results Two thousand and one hundred eight cases were identified in the one-year period from 1st October 2017–30th September 2018. After removing duplicates, previous diagnosis and incomplete data, there are confirmed 927 new diagnosis of hepatitis B. Of them, only 328 (35%) had anti HDV serology performed. Of them, 20 (6.1%) are anti HDV serology positive. Out of these 20 cases, 5 (25%) have HDV DNA >640 copies/ml, i.e. PCR positive. Overall, only 5 of 328 (1.5%) who were tested for HDV serology had acute HDV co infection. Conclusion In our hepatitis B population, we estimate that there is a 6.1% seroprevalence rate of hepatitis D and 1.5% acute hepatitis D co-infection. There is also a room for improvement in hepaitis D screening within our trust and more study is needed to identify barriers in screening and robust public health measures may be needed to follow up this population.

The vagus nerve exerts an anti‐nociceptive effect on the viscera.

Objectives: A frequent, although not universal, feature of irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), is heightened sensitivity to mechanical stimulation of the rectum, termed rectal hypersensitivity (RH). Differences in RH based on gender, IBS/IBD subtype, presence of inflammation and adult compared to paediatric populations are incompletely understood. We aimed to determine the magnitude of RH in IBS/IBD compared to healthy controls. Design: We searched MEDLINE and EMBASE databases (1970-2018). Prospective studies that compared pain/ discomfort thresholds to mechanical rectal stimuli in IBS/IBD and healthy controls were included. Data was pooled for meta-analyses and Hedges’ g effect sizes were calculated with 95% confidence interval (CIs). Results: Our search strategy identified 684 studies of which 31 studies met the IBS inclusion criteria. RH was more common in IBS patients effect size 0.97 95% CI (0.77-1.17), p < 0.0001, I2 = 77.2%. Paediatric IBS populations were more likely to be hypersensitive than adult populations (p = 0.04) but there were no differences based on diagnostic criteria, subtype or gender. In 8 studies met the IBD inclusion criteria, RH was not more common in IBD patients effect size 0.46 95% CI (-0.21-1.12), p = 0.18, I2 = 87.6% except during disease flares (p = 0.02). RH is more common in IBS than IBD populations (p = 0.0001). Conclusions: The results suggest that reduced rectal pain threshold to experimental stimulation is a marker of IBS. RH is not normally present in IBD except during active inflammation. Further research is required to understand the pathophysiological and therapeutic implications of rectal sensitivity in IBS compared to IBD.Funding Statement: AA was funded by the People Programme of the European Union’s Seventh Framework Programme under REA grant agreement no.607652 (NeuroGu). ADF was supported by the West Midlands Clinical Research Network Scholarship.Declaration of Interests: None of the authors have any conflict of interests to declare.

BACKGROUND/AIMSThe Internet offers a lot of non-filtered medical information which may interfere with the patient-doctor relationship. The aim of the present study was to assess the influence of the Internet on the classical doctor-patient relationship in gastroenterological outpatient settings.MATERIALS AND METHODSA multicenter study was conducted, including a representative sample selected from five major regional medical centers throughout Romania. We designed a questionnaire which had two parts. One had to be filled out by adult patients on their first visit to a gastroenterology clinic and the other by physicians, stating the diagnosis and giving a doctor-patient collaboration score.RESULTSFrom a total of 485 patients (49.9% females, mean age 50.42 years), 64.9% had Internet access, 75% out of whom searched for their symptoms online. University graduates searched for their symptoms online more often than secondary school graduates (80% vs. 31.1%, p<0.05). Most patients stated that they used the Internet to identify the most appropriate medical specialist for their condition. Internet users were less likely to visit a general practitioner (GP) before coming to a specialist (85.3% vs. 92.2%, odds ratio (OR) 0.491, 95% confidence interval (CI) 0.24-0.98, p<0.05). Patients who had searched for their symptoms online were less likely to follow the treatment prescribed by the GP (53.6% vs. 67.5%, p=0.004), but they received a better collaboration score (OR 1.12, 95% CI 1.05-1.36, p<0.05).CONCLUSIONThe Internet exerts a positive influence on specialist doctor-patient relationship, but it might burden the health system with the incorrect tendency to replace the role of the GP.

The array of end organ innervations of the vagus nerve, coupled with increased basic science evidence, has led to vagus nerve stimulation (VNS) being explored as a management option in a number of clinical disorders, such as heart failure, migraine and inflammatory bowel disease. Both invasive (surgically implanted) and non-invasive (transcutaneous) techniques of VNS exist. Transcutaneous VNS (tVNS) delivery systems rely on the cutaneous distribution of vagal afferents, either at the external ear (auricular branch of the vagus nerve) or at the neck (cervical branch of the vagus nerve), thus obviating the need for surgical implantation of a VNS delivery device and facilitating further investigations across a wide range of uses. The concept of electrically stimulating the auricular branch of the vagus nerve (ABVN), which provides somatosensory innervation to several aspects of the external ear, is relatively more recent compared with cervical VNS; thus, there is a relative paucity of literature surrounding its operation and functionality. Despite the increasing body of research exploring the therapeutic uses of auricular transcutaneous VNS (tVNS), a comprehensive review of the cutaneous, intracranial and central distribution of ABVN fibres has not been conducted to date. A review of the literature exploring the neuroanatomical basis of this neuromodulatory therapy is therefore timely. Our review article explores the neuroanatomy of the ABVN with reference to (1) clinical surveys examining Arnold's reflex, (2) cadaveric studies, (3) fMRI studies, (4) electrophysiological studies, (5) acupuncture studies, (6) retrograde tracing studies and (7) studies measuring changes in autonomic (cardiovascular) parameters in response to auricular tVNS. We also provide an overview of the fibre composition of the ABVN and the effects of auricular tVNS on the central nervous system. Cadaveric studies, of which a limited number exist in the literature, would be the 'gold-standard' approach to studying the cutaneous map of the ABVN; thus, there is a need for more such studies to be conducted. Functional magnetic resonance imaging (fMRI) represents a useful surrogate modality for discerning the auricular sites most likely innervated by the ABVN and the most promising locations for auricular tVNS. However, given the heterogeneity in the results of such investigations and the various limitations of using fMRI, the current literature lacks a clear consensus on the auricular sites that are most densely innervated by the ABVN and whether the brain regions secondarily activated by electrical auricular tVNS depend on specific parameters. At present, it is reasonable to surmise that the concha and inner tragus are suitable locations for vagal modulation. Given the therapeutic potential of auricular tVNS, there remains a need for the cutaneous map of the ABVN to be further refined and the effects of various stimulation parameters and stimulation sites to be determined.

BACKGROUND:Supragastric belching (SGB) has a significant behavioural component. We recently used cognitive behavioural therapy (CBT) to treat SGB. We demonstrated that CBT significantly reduces symptoms and improves quality of life in 50% of patients who had completed treatment.AIMS:To investigate factors associated with successful CBT for SGB and to assess symptoms 6-12 months after completion of CBT METHODS: Records of 39 patients who had completed the CBT protocol were analysed. Per cent pre- to post-treatment change in symptoms was assessed using a visual analogue scale (VAS) score. We evaluated the association between 'pre-treatment' factors and 'during-treatment' factors, and symptomatic outcomes. Symptoms were also assessed 6-12 months after treatment.RESULTS:From 'pre-treatment factors', a lower number of SGBs (P < .01) and lower hypervigilance score (P < .04) were significantly associated with a better outcome. From 'during-treatment factors' a higher CBT 'proficiency score' ([a] acceptance of the explanation that SGB is a behavioural phenomenon [b] detection of a warning signal before belching [c] adherence to the exercises treatment) was associated with a better outcome (P = .001). Multiple regression analysis found that number of SGBs, hypervigilance score and CBT proficiency score were independently associated with outcome (P < .01, P = .01, P < .01). VAS score before CBT (267 ± 79) decreased to 151 ± 88 soon after CBT (P < .001), and the effect persisted at 6-12 months follow-up (153 ± 82).CONCLUSIONS:Lower number of SGBs, lower hypervigilance score and higher proficiency during CBT were associated with better CBT outcome. CBT positive effect lasted for at least 6-12 months post-treatment.

We read with interest the article by Katja Kovacic and colleagues, 1 Kovacic K Hainsworth K Sood M et al. Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial. Lancet Gastroenterol Hepatol. 2017; 2: 727-737 Summary Full Text Full Text PDF PubMed Scopus (63) Google Scholar which showed the hypoalgesic effect of percutaneous electric nerve field stimulation on functional abdominal pain. The authors postulated that this effect might be driven via stimulation of brainstem nuclei involved in pain pathways, such as the nucleus of the solitary tract. This stimulation is likely to be anatomically mediated via vagus nerve stimulation. Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trialOur results show that PENFS with Neuro-Stim has sustained efficacy for abdominal pain-related functional gastrointestinal disorders in adolescents. This safe and effective approach expands treatment options and should be considered as a non-pharmacological alternative for these disorders. Full-Text PDF

Background Functional gastrointestinal disorders (FGID) are common and characterised by chronic unexplained visceral pain. Conditioned pain modulation (CPM), a bulbar reflex permitting ‘’pain to inhibit pain’’ by descending inhibition, is a validated measure that interrogates the brain-gut axis. Previous studies variably implicate diminished CPM in the pathophysiology of FGID. We aimed to clarify this relationship by meta-analysis. Methods Pubmed and Web of Science databases were searched until April 2017. Studies that were included comprised of randomised controlled studies investigating CPM in FGID patients with abdominal pain, defined according any iteration of the Rome criteria. We excluded studies if patients had a concomitant pain condition, other than FGIDs. The methodological quality of included studies was evaluated following an adapted scoring system for controlled trials. Results We identified 645 studies, of which 14 were relevant and met the inclusion criteria; 12 included patients with irritable bowel syndrome (IBS), 1 with functional dyspepsia and 1 with functional abdominal pain. CPM was reduced in FGID patients versus healthy controls, odds ratio 3.95 (95% confidence interval 2.06–7.58) (Figure 1). There was significant heterogeneity in effect sizes (Q-test χ2=59.4, p Conclusion CPM is significantly reduced in patients with FGID when compared to healthy controls. These data provide evidence that deficiencies in visceral pain bulbar-mediated descending inhibitory pathways is an important pathophysiological facet which could represent a novel treatment target.

Background and Aims Irritable bowel syndrome (IBS) is a common disorder worldwide, with a prevalence ranging from 10% to 15% in the US and Europe.The prevalence of IBS is lower in China than in Western countries, ranging from 5.7% to 10.7% in provincial studies.However, there are no nationwide prevalence data from adult gastroenterology outpatients in China.Therefore, the LINGO study (NCT02955316) was designed to estimate the overall prevalence and diagnosis rate of IBS in adult gastroenterology outpatients in China and to describe the distribution of IBS subtypes.Methods This was a non-interventional observational, multicentre, nationwide cross-sectional study in consecutive adult (age $18 years) outpatients of gastroenterology departments at tertiary and secondary hospitals across China.A multi-stage, stratified, cluster random sampling method was used to select a national representative sample of hospitals in six geographic regions (north, northeast, east, south central, southwest and northwest).IBS diagnoses were made based on Rome III and IV diagnostic criteria for every patient following completion of patient questionnaires during outpatient visits.Demographics, lifestyles, gastroenterology disease history and symptoms of IBS patients were collected.Descriptive analysis was conducted for the primary and secondary endpoints of overall IBS prevalence and subtype distribution.Results Overall, 3,000 patients were enrolled.The prevalence of IBS in Chinese adult gastroenterology outpatients was 16.6% (n=499; Table 1).Overall subtype distribution was 16% IBS-C, 54% IBS-D, 15% IBS-M, and 15% IBS-U.The median age of IBS patients was 48 years and 55.3% (276/499) of patients were female; there were no obvious differences in age and sex between IBS and non-IBS patients.The prevalence of IBS in East China was lower than that of other regions and higher in South Central and Southwest China (Figure 1).Among 499 IBS patients, 498 patients met Rome III criteria, 187 met Rome IV criteria and 186 met both Rome III and IV criteria.Only 5.8% IBS patients (n=29) had a previous IBS diagnosis.Conclusions The prevalence of IBS among adult gastroenterology outpatients in China is 16.6% (95%CI: 15.3%-18.0%)and the prevalence using Rome IV diagnostic criteria is much lower than that based on Rome III criteria.Despite sampling a patient population seeking care at secondary and tertiary hospitals, only 5.8% of patients who self-report IBS actually received a prior IBS diagnosis, suggesting a need for enhanced IBS medical education in China.Table 1.Prevalence of IBS and IBS subtypes among adult gastroenterology outpatients in China

BACKGROUND:Irritable bowel syndrome (IBS) is common and is characterised by recurrent abdominal pain, which is a major contributor to healthcare seeking. The neurobiological basis of this pain is incompletely understood. Conditioned pain modulation is a neuromodulatory mechanism through which the brain inhibits the nociceptive afferent barrage through the descending pathways. Reduced conditioned pain modulation has been implicated in the pathophysiology of IBS, although to date only in studies with relatively small sample sizes.AIM:To clarify the relationship between conditioned pain modulation and IBS by undertaking a systemic review and meta-analysis METHODS: A systematic review of MEDLINE and Web of Science databases was searched (up to 10 May 2018). We included studies examining conditioned pain modulation in adults with IBS and healthy subjects. Data were pooled for meta-analysis to calculate the odds ratio and effect size of abnormal conditioned pain modulation in IBS, with 95% confidence intervals (CI).RESULTS:The search strategy identified 645 studies, of which 13 were relevant and 12 met the inclusion criteria. Conditioned pain modulation in IBS patients vs healthy subjects was significantly reduced, odds ratio 4.84 (95% CI: 2.19-10.71, P < 0.0001), Hedges' g effect size of 0.85 (95% CI: 0.42-1.28, P < 0.001). There was significant heterogeneity in effect sizes (Q-test χ2 = 52, P < 0.001, I2 = 78.8%) in the absence of publication bias.CONCLUSION:Conditioned pain modulation is significantly diminished in patients with IBS vs healthy controls. These data suggest that abnormal descending pathways may play an important pathophysiological role in IBS, which could represent an investigation and a therapeutic target in IBS.

The diverse array of end organ innervations of the vagus nerve, coupled with increased basic science evidence, has led to vagus nerve stimulation becoming a management option in a number of clinical disorders. This review discusses methods of electrically stimulating the vagus nerve and its current and potential clinical uses.

Biliary hamartoma or von Mayenburg complex (VMCs) is a rare benign congenital malformation of the biliary duct. Patients are usually asymptomatic. Hepatic lesions are incidentally discovered on ultrasonography (US) and subsequent radiological methods are necessary for confirmation. A correct diagnosis is established when typical imaging findings are present, otherwise histological confirmation might be needed.