Background/Aims:: Food is thought to play a central role in the pathophysiology of disorders of gut-brain interaction (DGBI). Data on these associations come largely from Western countries. We evaluated associations between diet and common bowel DGBI using the database of the Rome Foundation Global Epidemiology Study (RFGES). Methods:: The RFGES database contains data collected via the Internet, personal interviews, or both from 33 countries, providing prevalence rates for common DGBI. Logistic regressions were used to analyze associations between DGBI and vegan, vegetarian, lactose-free and bread-, pasta-, and rice-predominant diets. Results:: 54 127 internet and 20 973 household survey subjects were included. Rates of adherence to a vegan or vegetarian diet were low in both surveys (0.4% to 9.8%) and differences in dietary preference were also noted between surveys with lactose-free and rice-predominant diets being more common among household survey respondents. While discrepancies between results from the 2 surveys limited the interpretation of the data, some trends were evident with a lactose-free diet linked to an increased prevalence and bread- and rice-predominant diets to lower prevalence rates of several bowel DGBI. Conclusions:: Though complicated by variations in results between the 2 survey populations, this global survey has revealed dietary factors that may impact, in the general population, on reported prevalence rates for DGBI.

Background: Patients with coronavirus disease 2019 (COVID-19)-associated respiratory failure undergoing lung transplantation is an emerging subset of transplant patients in which gastroesophageal reflux disease (GERD) pre- or post-transplant is not well characterized. Methods: We retrospectively evaluated patients undergoing lung transplant for COVID-19, with attention to pre- and post-operative physiological testing for GERD. Results: Seventeen patients were identified who had undergone lung transplant for COVID-19. No patient underwent pre-transplant GERD testing. Post-transplant, 70.5% (12/17) patients reported reflux symptoms confirmed with additional testing. Three patients underwent anti-reflux surgery (ARS) based on results of testing, and none had complications or symptom-based recurrence of reflux. Conclusion: Our study depicts a unique cohort of patients who were unable to undergo pre-transplant testing for GERD in the setting of a global pandemic, and who were routinely assessed and managed post-transplant. J Curr Surg. 2023;13(1):12-16 doi: https://doi.org/10.14740/jcs467

The concept of small intestinal bacterial overgrowth (SIBO) arose in the context of maldigestion and malabsorption among patients with obvious risk factors that permitted the small bowel to be colonized by potentially injurious colonic microbiota. Such colonization resulted in clinical signs, symptoms, and laboratory abnormalities that were explicable within a coherent pathophysiological framework. Coincident with advances in medical science, diagnostic testing evolved from small bowel culture to breath tests and on to next-generation, culture-independent microbial analytics. The advent and ready availability of breath tests generated a dramatic expansion in both the rate of diagnosis of SIBO and the range of associated gastrointestinal and nongastrointestinal clinical scenarios. However, issues with the specificity of these same breath tests have clouded their interpretation and aroused some skepticism regarding the role of SIBO in this expanded clinical repertoire. Furthermore, the pathophysiological plausibility that underpins SIBO as a cause of maldigestion/malabsorption is lacking in regard to its purported role in irritable bowel syndrome, for example. One hopes that the application of an ever-expanding armamentarium of modern molecular microbiology to the human small intestinal microbiome in both health and disease will ultimately resolve this impasse and provide an objective basis for the diagnosis of SIBO.

Introduction: This case describes an under-recognized adverse effect of sevelamer on the gastrointestinal tract. Case Description/Methods: A 57-year-old woman with type 2 diabetes and ESRD on peritoneal dialysis (PD) was admitted to the hospital for right foot cellulitis treated with intravenous clindamycin. She developed right lower quadrant abdominal pain with non-bloody diarrhea on hospital day 6. CT of the abdomen and pelvis revealed cecal and ascending colon wall thickening. Peritoneal fluid drawn from the PD catheter was cloudy with 5046 WBC/cm3. 2 days later, she developed nausea and vomiting at which time repeat imaging showed partial small bowel obstruction with a transition point in the mid-ileum. Her symptoms improved with nasogastric tube decompression. The colon wall thickening and bowel obstruction were initially attributed to peritoneal fluid infection related to the PD catheter and further peritoneal effluent culture showed decreasing WBC count with antibiotics. Her symptoms did not improve and one week later she developed hematochezia. The physical examination was remarkable for right lower quadrant tenderness. Stool studies were negative for infection. Colonoscopy was performed and showed erythematous and edematous mucosa at the ileocecal valve and an area of ulcerated circumferential mucosa in the proximal ascending colon. Biopsy showed mucosal ulceration associated with sevelamer crystals with a characteristic pink and yellow fish-scale appearance. Sevelamer had been initiated during this hospitalization 4 days prior to development of symptoms. The patient’s symptoms resolved within 48 hours of stopping this medication (Figure 1). Discussion: This case attempts to increase physician awareness of sevelamer-induced gastrointestinal injury. Our patient presented not only with colitis but also small bowel obstruction from enteritis and ileocecal valve inflammation. Swanson et al were the first to report a series of 15 patients with a spectrum of mucosal injury involving the esophagus, small bowel and colon. Multiple reports have described the effects with the most severe being colonic obstruction, ischemic necrosis and perforation. A review of 19 cases identified no association between the dose of sevelamer and severity of injury. The potential mechanism for injury is deposition of this insoluble polymer in gastrointestinal mucosa like its resin counterpart, kayexalate. Prompt discontinuation of the medication can potentially prevent further injury and catastrophic complications such as perforation.Figure 1.: Sevelamer crystal in the center associated with mucosal ulceration and fibrinopurulent exudate. It is rectangular in shape and usually 2-toned in color on H&E-stained sections, with a pink center and yellow edges; exhibiting a fish-scale like appearance (H &E, ×100).

Background and Aims: Pancreatitis is a known complication of ERCP with an incidence as high as 7-16% in patients with risk factors such as pancreatic duct injection or previous post-ERCP pancreatitis (PEP).Both prophylactic pancreatic stents (PPS) and rectal indomethacin have been demonstrated to be effective for PEP prophylaxis, yet prior surveys of endoscopists in the US have suggested limited utilization of rectal indomethacin as prophylaxis.This study assessed the national trends in PEP prophylactic practices, among endoscopists at a variety of practice settings (community hospital based practices, tertiary academic centers, and private practice).Methods: An electronic questionnaire was sent in January 2021 to 372 endoscopists nationwide who perform ERCP.Inclusion criteria consisted of practicing physicians in the US who had performed ERCP within the last 12 months.The survey queried providers' ERCP experience, practice settings, and PEP prophylaxis practices.Results: The survey had a 22.0% response rate.Survey results revealed a 63.3% and 74.4% utilization of rectal indomethacin usage for patients at low and high-risk for PEP, respectively.PPS use continues to be greater in high-risk vs low-risk ERCP (47.6% vs 6.1%, p<0.0001), and rectal indomethacin was more likely to be used in combination with other prophylaxis measures in high-risk vs low-risk ERCP (52.5% vs 4.9%, p<0.0001).For low-risk ERCP patients, there was a significant difference in PEP prophylaxis measures among teaching endoscopists (n=64) compared to non-teaching endoscopists (n=18; p=0.03).Endoscopists who teach fellows employed rectal indomethacin monotherapy in 51.6% (n=33) and no therapy in 37.5% (n=24).Comparatively, among non-teaching endoscopists, 82.4% (n=14) reported rectal indomethacin monotherapy and 5.8% (n=1) reported using no prophylaxis.Of endoscopists who avoided rectal NSAIDs (n=8, 9.8%), the primary concern reported was insufficient data on NSAID efficacy (n=3, 3.6%), concern for NSAID-associated AKI (n=2, 2.4%), cost (n=2, 2.4%), and concern for bleeding risk (n=1, 1.2%).Conclusions: This survey shows increased utilization of rectal NSAIDs in high and low-risk ERCP procedures compared to prior surveys, but relative underutilization compared to Europe and Japan, especially in low-risk patients.PPS use alone or in combination with rectal indomethacin was more frequent in patients at high-risk compared to low-risk patients.Our respondents' trend in lower rectal NSAID use among teaching endoscopists may reflect limited advocacy for its use among low-risk patients in recent US clinical guidelines.Lack of awareness of the growing data on the efficacy of rectal indomethacin in both high and low-risk patients may also be contributing to lower use, suggesting a potential need for focused educational interventions from professional societies.

Article Title: Irritable Bowel Syndrome in Pregnancy.

1Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA. Correspondence: Daniel Bushyhead, MD. E-mail: [email protected].

Despite the current increase in interest in the role of the microbiota in health and disease and the recognition, for over 50 years, that an excess of colonic-type flora in the small intestine could lead to a malabsorption syndrome , small intestinal overgrowth remains poorly defined. This lack of clarity owes much to the difficulties that arise in attempting to arrive at consensus with regard to the diagnosis of this condition: there is currently no gold standard and the commonly available methodologies (the culture of jejunal aspirates and a variety of breath tests) suffer from considerable variations in their performance and interpretation, leading to variations in the prevalence of overgrowth in a variety of clinical contexts. Treatment is similarly supported by a scant evidence base and the most commonly used antibiotic regimens owe more to custom than clinical trials .

Gender-based differences in the use of professional titles during speaker introductions have been described in other medical specialties. Our primary aim was to assess gender-based differences in the formality of speaker introductions at the American College of Gastroenterology 2020 Virtual Annual Scientific Meeting. Our secondary aim was to assess gender-based differences in the formality of speaker self-introductions. Reviewed presentations from the American College of Gastroenterology Annual Meeting for gender-based differences in professional title use during speaker introductions and self-introductions. Speakers included 29 women (37.2%) and 49 men (62.8%). We found no significant gender differences in the use of professional titles by introducers (t(67) = −  0.775, p = 0.441) or in self-introductions (36.4% of women vs. 41.9% of men, t(63) = 0.422, p = 0.674). The lack of gender differences in professional title use may represent a novel advantage of virtual meeting formats or suggest increased attention to gender bias in introductions.

Objectives To analyze the proportion of gastroenterology society guidelines and technical reviews with female authors. Methods Retrospective study of the sex of authors of American Association for the Study of Liver Disease (AASLD), American College of Gastroenterology (ACG) and American Gastroenterological Association (AGA) guidelines and technical reviews. Results Between 2007 and 2019, 21% of authors of AASLD, ACG and AGA guidelines, and technical reviews were female. Eighteen percent of first authors were female. There was a statistically significant increase in female authorship over the past 10 years only for AASLD guidelines. Conclusions There were fewer female authors of AASLD, ACG and AGA guidelines, and technical reviews than males. This disparity decreased over time only in AASLD guidelines. Addressing disparities in guideline and technical review authorship may promote academic advancement for female gastroenterologists.

Successful bowel preparation for colonoscopy is an important factor in ensuring a high-quality examination. Inadequate preparations occur in up to 25% of all colonoscopies, which can compromise the detection and removal of colorectal neoplasia. Low volume bowel preparations have similar efficacy to large volume preparations but are higher cost. In an effort to improve bowel preparation quality, a Veterans Affairs hospital recently switched from a 4-liter polyethylene glycol-electrolyte lavage solution (PEG-ELS) to a 2-liter, low volume PEG-ELS with supplemental ascorbate and sodium sulfate (MoviPrep). As part of a quality improvement project, we sought to determine if this change was associated with an improvement in bowel preparation quality and patient tolerance. From September 2018 to August 2019, an optional survey was administered to all patients upon arrival for colonoscopy. This survey included preparation type, standardized measurements of how much preparation was completed, and standardized questions assessing patient tolerance and experience. All endoscopists were asked to watch a Boston Bowel Preparation Score (BBPS) training video as part of an effort to standardize bowel preparation quality reporting. The BBPS was abstracted from colonoscopy reports. Due to scheduling issues, there was a gradual shift from a high volume to a low volume PEG-ELS preparation in March 2019. Endoscopists were not specifically informed of which preparation was used. Chi-square test was used to determine statistical significance. Data were analyzed using Excel (Version 16.23). A total of 1,412 colonoscopies were included in our study. Seven hundred and sixty-five (54%) colonoscopies used large volume PEG-ELS, and 647 (46%) used low volume PEG-ELS. Adequate BBPS, defined as a score ≥2 in each colonic segment, was not significantly different between low and high volume preparations (90.1% v. 91.0%; p=0.58). Overall tolerability, defined as a rating of easy or very easy, was higher in low volume preparation (43.6% v. 34.4%; p<0.001). Willingness to take the bowel preparation again was higher in low volume preparation (83.7% v. 76.7%; p<0.001). Overall experience, defined as good or excellent, was also higher in low volume preparation (58.0% v. 51.2%; p=0.009). More subjects in the low volume preparation cohort completed >90% of the preparation (93.3% v. 90.0%; p=0.01). In a real-world comparison of low versus high volume bowel preparation as part of a quality improvement project, we found that utilization of low volume preparation was associated with comparable bowel cleaning, as defined by an adequate BBPS. Low volume preparation was also associated with increased tolerability, willingness to take the preparation again, better overall experience and completing >90% of the preparation.

The national incidence of colorectal cancer is increasing in people younger than 50 years old. Although diagnostic colonoscopy is detecting more sporadic adenomas in young adults, there are no guidelines for post-polypectomy surveillance. The aim of this review was to survey the medical literature on the prevalence of sporadic adenomas in young adults, subsequent risk of metachronous neoplasia, and lastly to provide several concluding recommendations for clinical practice. We found that the prevalence of sporadic adenomas in young adults is greater than initially estimated and dependent upon factors such as colonoscopy indication and age. The incidence of metachronous colorectal neoplasia following polypectomy is unclear but does not appear to be greater than that of older adults. Risk factors for metachronous neoplasia include findings on index colonoscopy, male gender, smoking status, and certain medical comorbidities. Upon finding a colorectal adenoma in a young person, we suggest that a detailed family history be obtained to confirm that it is truly sporadic. Testing adenomas for evidence of Lynch syndrome is low yield. Strategies to inform surveillance intervals may include an assessment of risk factors for metachronous neoplasia, although surveillance intervals shorter than those recommended in current guidelines are not warranted. Future research should focus on obtaining long-term, prospective data on the incidence of metachronous neoplasia in diverse patient populations.

Question: A 34-year-old woman with a history of asthma and peanut allergies was referred to gastroenterology clinic for the new onset of dysphagia. She had a history of anaphylaxis to peanuts beginning in childhood. One year prior to presentation she enrolled in a randomized, double-blind, placebo-controlled trial of oral immunotherapy with 300mg of peanut protein versus placebo. She tolerated the placebo well without adverse effects for six months, and then enrolled in the cross-over arm with the active drug. CME Exam 2: An Unexpected Consequence of a Clinical TrialGastroenterologyVol. 157Issue 4Preview Full-Text PDF

INTRODUCTION: Cannabinoids are compounds derived from the Cannabis sativa plant. These include the psychoactive delta-9-tetrahydrocannabinol (Δ9-THC), although non-psychoactive compounds such as cannabidiol also exist. Given the prevalence of cannabinoid receptors in the enteric nervous system, use of cannabinoids may contribute to the pathophysiology or treatment of gastrointestinal motility and functional disorders. However, little is known about the prevalence of cannabinoid use in patients referred to out-patient gastroenterologists. The aim of this study was to determine the prevalence of cannabinoid use, and its relation to specific gastrointestinal symptoms, in patients seen in gastroenterology clinic. METHODS: An optional survey was administered to patients attending gastroenterology clinic at a county hospital in a state where both recreational and medical cannabis use are legal. The study period was January to May of 2019. The survey queried subjects on type of cannabinoid product used, frequency of use, whether cannabinoids were used for treatment of gastrointestinal symptoms, and efficacy. Diagnosis was recorded following review of the electronic medical record. Patients who were unable to consent or those who did not demonstrate proficiency with written English were excluded. Data were analyzed with descriptive statistics using Excel (Version 16.23). Institutional Review Board approval was obtained. RESULTS: A total of 60 subjects completed the survey. Forty-nine (82%) respondents were female, and median age was 43-years-old. Twenty-nine (48%) subjects reported use of cannabinoids within the past year; the most common substances were marijuana (90%) or marijuana and cannabidiol (48%). The most common diagnosis for these subjects was chronic abdominal pain (see Figure 1). Thirty-one percent of patients reported using cannabinoids more than once daily. Twenty-eight percent of subjects reported use of cannabinoids to alleviate gastrointestinal symptoms, with a median improvement of 6 on a scale of 0-10 (0 representing no relief, 10 representing full relief). The most common reported symptom for this subset of patients was abdominal pain (see Figure 2). CONCLUSION: Use of cannabinoids, including both marijuana and cannabidiol products, was common in subjects with gastrointestinal symptoms referred to a gastroenterology clinic in a state where use is legal. More than half of subjects using cannabinoids did so for relief of a wide variety of gastrointestinal symptoms.

Question: A 73-year-old woman underwent surveillance colonoscopy for a history of colon adenomas. The colonoscopy was uncomplicated and remarkable for 3 small rectosigmoid polyps that were resected with cold biopsy forceps. The patient was discharged home, and approximately 12 hours later she had the acute onset of lower abdominal pain and obstipation. She presented to the emergency department and on physical examination there was mild abdominal distension with tympany and lower abdominal tenderness to deep palpation. Computed tomography (CT) scans of the abdomen and pelvis showed mildly dilated small bowel loops consistent with ileus. She was admitted to the surgery service and a nasogastric tube was placed to suction with bilious output. Later that night, she developed tachycardia and tachypnea. Physical examination showed worsening abdominal distension and tenderness. Blood tests revealed new leukocytosis, lactic acidemia, and hypoalbuminemia. Repeat CT scans of the abdomen and pelvis showed persistently dilated small bowel loops and new pneumatosis intestinalis with pneumoperitoneum (Figure A, B). She underwent emergent exploratory laparotomy that revealed small bowel necrosis (Figure C). What was the cause of her small bowel obstruction and necrosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Preoperative CT scans demonstrated evidence of small bowel obstruction and twisting of the mesentery in the left lower quadrant (Figure B, circle). Intraoperative findings demonstrated necrotic bowel internally herniated through an adhesion in the right lower quadrant from the epiploica of the sigmoid colon. There was no evidence of perforation. There was clear demarcation between healthy and necrotic bowel, and 160 cm of necrotic small bowel were resected with primary anastomosis. Her postoperative course was complicated by peritonitis requiring treatment with antimicrobials, and she was discharged 10 days later. Upon further questioning, she reported a several-month history of intermittent abdominal, right flank and right shoulder pain before colonoscopy that resolved after surgery. We hypothesize that she had a preexisting symptomatic chronic internal hernia; small bowel then became strangulated through an adhesion, which may have been caused by insufflation and manipulation of the colon during colonoscopy. She followed up in surgery clinic 5 days after discharge where she overall felt well and was maintaining adequate oral nutrition. Small bowel obstruction as a risk of colonoscopy is exceptionally uncommon. Small bowel obstruction after colonoscopy has previously been associated with both internal hernias1Patterson R. Klassen G. Small bowel obstruction from internal hernia as a complication of colonoscopy.Can J Gastroenterol. 2000; 14: 959-960Crossref PubMed Scopus (17) Google Scholar and adhesions.2Hunter I.A. Sarkar R. Smith A.M. Small bowel obstruction complicating colonoscopy: a case report.J Med Case Rep. 2008; 2: 179Crossref PubMed Scopus (9) Google Scholar There was a single case of mesenteric torsion comparable with our current patient found in the medical literature, in which the patient was managed conservatively without a need for surgical treatment.3Yarze J. Dimick R. Lieberth M. Mesenteric torsion causing small-bowel obstruction as a complication of colonoscopy.Gastrointest Endosc. 2006; 63: 723-725Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar However, our case demonstrates that intestinal necrosis requiring intestinal resection may also be encountered. Awareness of this rare but potentially life-threatening complication is critical in assessing any patient for postcolonoscopy complications.

INTRODUCTION: Complementary and alternative medicine are commonly used by patients with gastrointestinal symptoms often in conjunction with a naturopath or herbalist provider. It is unknown how often patients seen in gastroenterology clinic also consult with a naturopath or herbalist provider, what diagnoses patients are subsequently given, and how this affects management of their gastrointestinal symptoms. The purpose of this study was to determine the prevalence of naturopath and herbalist co-management, and details of this alternative medical care, in patients seen in gastroenterology clinic. METHODS: An optional survey was administered to patients attending gastroenterology clinic at a county hospital. The study period was January to May of 2019. The survey queried subjects on consultation with a naturopath or herbalist, which symptoms prompted this consultation, and what diagnoses and management recommendations were subsequently received. Patients unable to consent or those who did not demonstrate proficiency with written English language were excluded. Data were analyzed with descriptive statistics using Excel (Version 16.23). Institutional Review Board approval was obtained. RESULTS: A total of 60 subjects completed the survey. Forty-nine (82%) respondents were female, and median age was 43-years-old. Twelve (20%) subjects reported consultation with a naturopath or herbalist in the past year for gastrointestinal symptoms. The majority of these subjects were female (92%). The most common symptoms prompting referral were abdominal pain, nausea and constipation, but numerous other symptoms were also reported (see Figure 1). The most common diagnoses given to subjects were irritable bowel syndrome, food allergies, leaky gut and small intestinal bacterial overgrowth (25% for each diagnosis). Seven (58%) subjects reported receipt of herbal medications following consultation. CONCLUSION: One-fifth of subjects referred to gastroenterology clinic had also consulted with a naturopath or herbalist. A wide variety of gastrointestinal symptoms prompted these consultations, and more than half of subjects received treatment with herbal medications.