Integrated care refers to the coordinated delivery of health services across providers and settings, aimed at ensuring continuous, patient-centered care throughout the course of disease. Models of integrated care have demonstrated particular relevance in the management of gastrointestinal (GI) diseases, such as disorders of gut-brain interaction (DGBI) and inflammatory bowel disease (IBD), due to their multidimensional nature. Integrated care has the potential not only to alleviate symptom burden, but also to improve quality of life and mental health outcomes while reducing healthcare costs. Nevertheless, barriers to implementation persist, and despite growing recognition of its value, integrated care has not yet been systematically adopted for GI motility disorders. These disorders, thought to be multifactorial, exhibit considerable overlap with DGBI, rendering them clinically indistinguishable in some cases. Furthermore, while mental health problems are well recognized in DGBI, they are also commonly observed in individuals with GI motility disorders. In response, Maastricht University Medical Centre+ has developed a multidisciplinary, integrated, patient-centered care model for the diagnosis and management of neurogastroenterology and motility disorders. By presenting this approach, we aim to foster knowledge exchange and support the development of integrated care models adaptable to the specific needs of diverse healthcare settings.

INTRODUCTION:Visceral hypersensitivity (VHS) is considered a hallmark of irritable bowel syndrome (IBS) characterized by altered thresholds for rectal pain and discomfort during rectal distention. Rectal distention can also elicit the urge to defecate, a normal physical sensation that is, reported more often in IBS and may involve mechanisms distinct from pain and discomfort. This study investigates clinical, psychological, and physiological correlates of increased urge to defecate in IBS compared with healthy controls (HC), including sex-based differences. METHODS:Patients with IBS (Rome III criteria) and HC underwent rectal balloon-distension and completed questionnaires on demographics, lifestyle, gastrointestinal (GI) and psychological symptoms, and health-related quality of life (HrQoL). Latent clusters were identified using finite-mixture modeling, and associated determinants were evaluated using multivariable logistic regression analyses. RESULTS:Among 322 participants (220 IBS, 102 HC), the occurrence of the urge to defecate was more frequent in IBS than in HC (80.9% vs. 51.9%; p < 0.001) and often co-occurred with rectal pain and discomfort, particularly in patients with VHS. Latent class analysis identified three clusters, primarily distinguished by rectal symptom-distribution, with the most symptomatic cluster showing greater GI-symptom severity, higher psychological burden, and lower HrQoL (all p < 0.001). Regression analyses confirmed associations of urge with GI symptom severity, depressive symptom scores, and co-occurrence of pain/discomfort, but no association was found based on IBS subtype or sex. CONCLUSION:Increased urge to defecate is highly prevalent in IBS, strongly associated with rectal pain, rectal discomfort, psychological burden, and reduced HrQoL, but not in the IBS subtype, suggesting shared or overlapping mechanisms, particularly in the context of VHS. These findings underscore its clinical and pathophysiological relevance, supporting its value for patient-phenotyping and tailored management. TRIAL REGISTRATION:The Maastricht Irritable Bowel Syndrome (MIBS) cohort study was registered under the registration number NCT00775060.

BACKGROUND:Myotonic Dystrophy type 1 (DM1) is a multisystemic neuromuscular disorder. Gastrointestinal (GI) symptoms significantly impact quality of life, but remain under-assessed. Currently, no DM1 specific GI questionnaire is available. The Gastrointestinal Symptoms Rating Scale (GSRS) is widely used but lacks validation with modern clinimetric methods. OBJECTIVES:To evaluate the GSRS using Rasch analysis in DM1 patients and develop a disease-specific, interval-level GI symptom measure. METHODS:Rasch analysis evaluated item fit, threshold ordering, differential item functioning (DIF), local dependency, and unidimensionality. Model fit was evaluated using chi-square statistics, item and person fit residuals, and the Person Separation Index (PSI). RESULTS:Four hundred and three DM1 patients (206 women, mean age 48.3 years) completed the GSRS questionnaire. The GSRS initial data did not meet Rasch model expectations. Three items (hard stools, heartburn, diarrhea) were removed and the item nausea was split by age category. The item constipation had misfit exceeding the Bonferroni threshold, but was retained due to its clinical relevance. The final model did not fulfill Rasch requirements (item fit residuals: -0.23, SD 1.29; person fit residuals: mean -0.27, SD 1.15; item-trait Chi-square: p-value < 0.001; degrees of freedom: 60). Acceptable person separation index (0.76) was obtained. CONCLUSION:This study highlights the challenges of measuring GI symptoms in DM1. Although this research is an important first step, more research is needed for developing a questionnaire that reflects the patient experience whilst simultaneously considering measurement accuracy.

ABSTRACTHypermobility spectrum disorders (HSD) and hypermobility Ehlers–Danlos syndrome (hEDS) are frequently associated with gastrointestinal symptoms, although the underlying mechanisms remain unclear. This study aimed to compare antroduodenal motility in patients with and without HSD/hEDS. We included 239 patients (50 HSD/hEDS and 189 non‐HSD/hEDS) with gastrointestinal symptoms undergoing antroduodenal manometry (ADM). The prevalence of antroduodenal dysmotility was not different between both groups, but enteric dysmotility was less common in the HSD/hEDS group (13% vs. 34%, p = 0.006). Delayed gastric emptying rates were similar, suggesting that delayed gastric emptying is more relevant for patients with HSD/hEDS and gastrointestinal symptoms.

Disorders of gut–brain interaction (DGBI) affect up to 40

BACKGROUND AND AIMS: Gastrointestinal (GI) motility disorders are characterized by abnormalities in the motor functions of the GI tract. The diagnostic evaluation of these disorders frequently involves invasive and time-consuming examinations, for which access may be limited. Volatile organic compounds (VOCs) could serve as non-invasive alternative. Therefore, the aim of this study was to explore the potential of exhaled breath VOCs as biomarkers in patients with GI symptoms and potential GI motility disorders. METHODS: In this exploratory, prospective study, breath samples were obtained from patients undergoing ambulatory motility tests as part of routine clinical care. VOCs in exhaled breath were assessed using thermal desorption chromatography-mass spectrometry (TD-GC-MS). The resulting data were subsequently pre-processed and analyzed using machine learning approaches. RESULTS: Hundred participants were included in the analysis, of whom 67 were women (67%), with a median age of 56.5 years (IQR: 29.8). The diagnostic work-up comprised 55 gastric emptying tests, 55 high-resolution esophageal manometries, 3 antroduodenal manometries, and 1 colon manometry. These examinations resulted in 48 motility disorder diagnoses, while 51 patients showed no evidence of motility abnormalities. Fifteen VOCs were identified as most discriminative markers for the presence or absence of GI dysmotility, with a sensitivity of 75%, and specificity of 60%. CONCLUSIONS: VOCs in exhaled breath show promise to distinguish patients with GI motility disorders from those without, in a population of patients with GI symptoms. Future research is warranted to further refine and validate these results in a larger cohort and to explore the diagnostic performance of VOCs in specific subtypes of motility disorders.

BACKGROUND:Achieving competence in endoscopic retrograde cholangiopancreatography (ERCP) requires extensive training. Recognizing the potential of simulator-based education for safe and effective skill development, we aimed to assess whether initial training with the Boškoski-Costamagna ERCP Trainer (BCT) is beneficial compared with conventional training alone (i.e. predictive validity). METHODS:A prospective multicenter randomized trial involving 16 novice ERCP trainees, randomly assigned to intervention or control groups, was performed. Both underwent hands-on training, with the intervention group receiving additional simulation training during the first 3 months. Each trainee was required to complete a minimum of 60 ERCPs in up to 1 year. The TEESAT score evaluated rates of global overall competence (primary outcome), biliary cannulation, and adverse events (AEs; secondary outcomes). Mixed-effect logistic regression models assessed differences in between-group ERCP procedure competence and success. Learning curves were generated cumulatively over the training period. RESULTS:1106 ERCPs (562 simulator group; 544 control group) were included. Although no statistically significant difference in global overall competence was observed between the groups, possibly owing to data heterogeneity, simulation training demonstrated higher success for native biliary cannulation (52% vs. 42%; P<0.001) and faster median (interquartile range) biliary cannulation times (3 [6] vs. 5 [8] minutes; P<0.001). The simulator group also showed faster improvements in overall performance, native biliary cannulation, and sphincterotomy. No statistical difference was found in overall AEs between the groups. CONCLUSION:Early simulation training with the BCT improved technical competence in native biliary cannulation and accelerated overall ERCP learning. This approach has the potential to enhance ERCP training programs.

BACKGROUND:Gastric peroral endoscopic pyloromyotomy (G-POEM) is a promising therapeutic modality for refractory gastroparesis (GP). However, as characteristics of suitable patients for G-POEM remain unclear, antro-duodenal manometry (ADM) has been suggested to provide objective parameters for patient selection. The aim of the present study was to identify ADM parameters as predictors for treatment response after G-POEM in refractory GP. METHODS:Refractory GP patients who underwent a G-POEM between 2017 and 2022 were included. The following ADM parameters were mainly scored: antral hypomotility, pylorospasm, and the presence of neuropathic enteric patterns. Treatment response was defined as a GCSI-score decrease of ≥1 point 12 months after G-POEM. Explorative analyses were performed on potential predictors of response using logistic regression analysis. KEY RESULTS:Sixty patients (52 women, mean age 52 ± 14 years.) with refractory GP (33 idiopathic, 16 diabetic, 11 postsurgical) were included. Clinical response data were available for 52 patients. In 8 out of 60 patients, it was not feasible to advance the catheter beyond the pylorus. Abnormal ADM was found in 46/60 patients (77%). Antral hypomotility and pylorospasm were found in respectively 33% and 12% of patients. At least one neuropathic enteric dysmotility pattern was found in 58% of patients. No differences were found when comparing baseline ADM parameters between clinical response groups at 12 months follow-up. Following explorative analyses, no ADM parameters were identified to predict clinical response 12 months after G-POEM. CONCLUSIONS AND INFERENCES:No ADM parameters were identified as predictors of clinical response after G-POEM in refractory GP patients. Additionally, a high percentage of abnormal ADM tracings was found, in particular with relation to enteric dysmotility, while only a low percentage of patients showed antral hypomotility or pylorospasm.

Management of refractory gastroparesis is challenging after diet, prokinetics, and long-term nutritional support have failed. In this review, the efficacy and safety of surgical interventions (sleeve gastrectomy and Roux-en-Y gastric bypass surgery) are evaluated systematically in patients with refractory gastroparesis. The PubMed, Embase, and Scopus databases were searched to identify relevant studies published up to June 2021. Outcome of interest was symptom improvement and gastric emptying. Nineteen studies with 222 refractory gastroparesis patients (147 Roux-en-Y gastric bypass, 39 sleeve gastrectomy, and 36 subtotal gastrectomy) were included. All studies reported symptom improvement postoperatively, particularly vomiting and nausea. Gastric emptying improved postoperatively in 45% up to 67% for sleeve gastrectomy and 87% for Roux-en-Y gastric bypass. The findings of our systematic review suggest that sleeve gastrectomy and Roux-en-Y gastric bypass surgery improve symptoms and gastric emptying in patients with refractory gastroparesis. Surgery may be effective as treatment for a small group of patients when all other therapies have failed.

Gastroparesis (GP) is a gastrointestinal disorder associated with significant morbidity and healthcare costs. GP patients form a heterogeneous population with diverse etiology, and treatment is often challenging due to a poorly understood underlying pathophysiology. The aim of the present study was to assess antroduodenal motility patterns among the different GP etiologies.

Objective There is no evidence-based treatment for persistent dysphagia after laparoscopic fundoplication. The aim of this study was to evaluate the effect of pneumatic dilation on persistent dysphagia after laparoscopic fundoplication. Design We performed a multicentre, single-blind, randomised sham-controlled trial of patients with persistent dysphagia (>3 months) after laparoscopic fundoplication. Patients with an Eckardt symptom score ≥4 were randomly assigned to pneumatic dilation (PD) using a 35 mm balloon or sham dilation. Primary outcome was treatment success, defined as an Eckardt score <4 and a minimal reduction of 2 points in the Eckardt score after 30 days. Secondary outcomes included change in stasis on timed barium oesophagogram, change in high-resolution manometry parameters and questionnaires on quality of life, reflux and dysphagia symptoms. Results Forty-two patients were randomised. In the intention-to-treat analysis, the success rates of PD (7/21 patients (33%)) and sham dilation (8/21 patients (38%)) were similar after 30 days (risk difference −4.7% (95% CI (−33.7% to 24.2%) p=0.747). There was no significant difference in change of stasis on the timed barium oesophagogram after 2 min (PD vs sham: median 0.0 cm, p25–p75 range 0.0–4.3 cm vs median 0.0 cm, p25–p75 range 0.0–0.0; p=0.122) or change in lower oesophageal sphincter relaxation pressure (PD vs sham: 10.54±6.25 vs 14.60±6.17 mm Hg; p=0.052). Quality of life, reflux and dysphagia symptoms were not significantly different between the two groups. Conclusion Pneumatic dilation with a 35 mm balloon is not superior to sham dilation for the treatment of persistent dysphagia after fundoplication.

INTRODUCTION: Esophageal pain is mediated by sensory nerves, most importantly by the activation of the transient receptor potential vanilloid 1 (TRPV1) capsaicin receptor. TRPV1 is activated and sensitized by a broad range of pungent compounds, as well as inflammatory mediators and tissue irritants. Luminal stressors are suggested to impair the barrier function, which results in consequent activation of these sensory nerve terminals and pain. In this study, we investigated the effect of the perfusion of capsaicin, a TRPV1 agonist, on mucosal impedance and pain in asymptomatic volunteers. METHODS: Thirteen asymptomatic volunteers completed a single-blind, saline-controlled, randomized crossover study. Capsaicin or saline was perfused for 30 minutes in the distal esophagus. Visual analog scale pain intensity scores and intraluminal impedance indicating mucosal integrity were determined. Distal and proximal biopsies were obtained 10 minutes later to measure TRPV1 messenger RNA and TRPV1 immunopositivity, as well as the intercellular space area. RESULTS: Capsaicin perfusion resulted in significantly greater pain intensity (P = 0.047) and impaired recovery of the mucosal impedance compared with saline-treated controls (P = 0.027). Pain response was significantly associated with decreased mucosal impedance. Similar dynamics were seen in the proximal esophagus, but mucosal impedance recovered entirely to the preinfusion values there. There was a significant association between mucosal impedance and intercellular space width in the distal esophagus. TRPV1 transcription and expression were not significantly altered within this observation period. DISCUSSION: Esophageal capsaicin perfusion results in pain, which is likely to be explained by impaired mucosal impedance and defective restoration capacity in the distal esophagus.