ABSTRACT:Irritable bowel syndrome (IBS) is a prevalent, chronic functional gastrointestinal disorder that significantly impairs patients' quality of life. To promote standardized and high-quality care, the Saudi Neurogastroenterology and Motility Group, under the auspices of Saudi Gastroenterology Association (SGA) and in collaboration with the European Society of Neurogastroenterology and Motility (ESNM), developed evidence based clinical practice guidelines for the diagnosis and management of IBS in Saudi Arabia. Using a modified Delphi methodology, consensus was reached when at least 80% of participants agreed with a statement as "completely accepted" or "accepted with minor reservations." This process resulted in 29 consensus statements and two clinical algorithms addressing diagnostic criteria, clinical assessment, investigations, lifestyle modifications, and therapeutic strategies. The resulting guidelines provide a comprehensive framework for IBS diagnosis and management, highlight emerging treatment options, and outline areas requiring further research to enhance patient outcomes and guide future clinical practice.

Myths and misconceptions about the evaluation and treatment of constipation persist. Many widely prevalent misconceptions about laxatives, specifically stimulant laxatives, interfere with the effective management of constipation. Although some of these myths and misconceptions have been dispelled in recent years, there is additional room for improving the awareness and understanding of the pathophysiology of constipation, the mechanisms of action and the efficacy and safety of available therapies. An evolution in our understanding of pathophysiology and the availability of new treatments requires that primary care practitioners be better positioned to treat this common disorder that reduces patients’ quality of life and negatively impacts the healthcare system. This review defines constipation and elucidates various factors that contribute to its aetiology, including lifestyle, dietary habits, medications and underlying medical conditions. This review addresses and refutes common myths and misconceptions about constipation, such as the belief that regular bowel movements must occur daily or the use of laxatives leads to dependence. This review also highlights the importance of distinguishing between normal and abnormal bowel habits and emphasises the need for individualised management approaches to address constipation effectively. Finally, the review discusses different classes of laxatives, dispelling misconceptions about their safety, efficacy and potential for misuse, with a specific focus on stimulant laxatives. In summary, this review enhances awareness and knowledge of this prevalent disorder, provides evidence-based insights into common myths and misconceptions surrounding constipation and promotes more informed decision-making regarding constipation and the use of laxatives.

BACKGROUND:Fecal microbiota transplantation (FMT) has gained popularity over the last years. So far, conflicting data regarding the effect on disorders of gut-brain interaction (DGBI) exist. In this study we aimed to access current knowledge and attitude towards potential FMT of DGBI patients. METHODS:A survey on attitudes toward FMT was conducted in DGBI patients. Patients answered questions anonymously before and after having read a brief information sheet on FMT. Data were collected prospectively in 2017-2018 and in 2022-2023. RESULTS:In total, 387 patients completed the survey. Forty percent of patients had heard about FMT prior to underlying survey. Prior to a brief information regarding FMT, 38% of patients would have agreed to FMT, while 50% were undecided and 12% would have declined. After a brief information sheet on FMT, decisions significantly changed to 63%, 26% and 11% respectively (P<0.001). The decision of patients to undergo FMT remained unchanged between 2017 and 2022. Type of DGBI and disease severity are significantly associated with treatment decisions (P=0.005). CONCLUSIONS:This survey demonstrates great interest of DGBI patients in potential FMT, especially after being informed on details of the procedure. Bearing in mind that in the future FMT may be a clearer option in the treatment of certain DGBIs, patient education will be an important factor.

The EndoFLIP system is currently the only available impedance planimetry system, providing real-time, detailed information on the diameter, luminal area, distensibility, and compliance of the esophagogastric junction (EGJ), along with its 2D representation. EndoFLIP can support diagnosis and provide physiological feedback to potentially guide interventions for structural and functional gastroesophageal disorders. However, the lack of standardized usage protocols complicates the interpretation and comparability of results. This paper aims to establish a consensus on protocols to standardize the use of the EndoFLIP system in both diagnostic and intraoperative settings, so as to ensure consistent application across varied clinical and scientific settings. A multidisciplinary European Advisory Board (AB) comprising eight gastroenterologists and surgeons with extensive experience in EndoFLIP use undertook a structured international expert consensus process. Following a systematic literature review and a face-to-face expert meeting, candidate statements were developed and independently rated using an electronic survey. Consensus was predefined as ≥ 75

Dysphagia is a prevalent symptom of the upper gastrointestinal tract causing health related consequences, impacting quality of life and is associated with global economic burden. Swallowing difficulties are classified into oropharyngeal dysphagia (OD) and esophageal dysphagia. Despite its clinical importance, dysphagia is associated with several uncertainties regarding its optimal diagnostic work-up and management, particularly, considering the progress with diagnostic modalities and technologies. A Delphi consensus was performed with experts from various disciplines who conducted a literature summary and voting process on 41 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus was reached for all the statements. The panel agreed with the definition and prevalence of esophageal and OD types. The role of endoscopy, high-resolution manometry, EndoFLIP, barium swallow and other imaging tests in evaluating esophageal dysphagia has reached overall strong agreement. Videofluoroscopic swallow study, alongside fiber-endoscopic evaluation of swallowing, as the methods of choice for the instrumental assessment of oropharyngeal dysfunction is a strong recommendation. Regarding treatment, a weak recommendation was achieved for the use of PPIs, calcium-channel blockers, nitrates, phosphodiesterase type 5 inhibitors, antidepressants or peppermint oil for the treatment of hypercontractile esophagus. A strong recommendation exists for endoscopic and surgical treatment of achalasia, while a weak recommendation is provided for other esophageal motility disorders. Regarding OD, a weak recommendation was achieved for swallow therapy, to improve swallowing mechanics, reduce symptoms, and enhance quality of life. Swallow therapy could be more effective when using validated assessment tools, consistent treatment parameters, and considering long-term follow-up. A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of dysphagia.

Visual or haptic assessments of the pylorus during endoscopy may result in the diagnosis of a pylorospasm. However, subjective assessments may be affected by inter-rater variability, the antro-duodenal motility phase and the distance to scope. We evaluated to what extent the visual impression, the endoscopic resistance to pyloric intubation and gastric contents correlate with objectively determined values using EndoFLIP measurements. Patients scheduled for FLIP panometry of the upper gastrointestinal tract due to esophageal or epigastric conditions from January 2021 until November 2022 were considered for the study. Inclusion criteria were an EndoFLIP measurement of the pylorus using a standardized protocol for distensibility assessment and documented subjective assessments during upper endoscopy. Statistical analyses including MANOVA and logistic regression were performed for group comparisons and to evaluate significance. A total of 184 patients (56

INTRODUCTION:Food intolerances are prevalent in Europe and can cause considerable physical discomfort, dietary restrictions and psychosocial challenges. Among the prominent causes of food intolerance are defects in the digestion and/or transport of short-chain fermentable carbohydrates, fermentable oligo-, di-, monosaccharides and polyols (FODMAPs). A common diagnostic tool for food intolerance is the hydrogen breath test, which monitors the production of H2 gas from the fermentation of ingested FODMAPs by colonic microbiota. However, this method is limited due to its relatively poor correlation with gastrointestinal (GI) symptoms experienced by patients. Diagnosis is complicated as food intolerance is often associated with functional GI disorders, while FODMAPs may exert their effects individually or in combination. Further research on the pathophysiology and the impact of intervention strategies for these conditions is required to improve the diagnosis of food intolerance. METHODS AND ANALYSES:The Lactobreath pilot study is a randomised, two-arm, double-blinded controlled study. 120 healthy, free-living adults will undergo 6-hour postprandial tests with lactose or glucose (control) to investigate the molecular composition of human exhaled breath (exhalome) as a potential source of biomarkers associated with clinical and metabolic traits of lactose malabsorption (Lactobreath profiles). This serves as a proof-of-concept for the future application of this technology in diagnosing food intolerance. We will use a sensitive, non-invasive, real-time measurement technique based on secondary electrospray ionisation coupled with high-resolution mass spectrometry to analyse the chemical profile of the postprandial exhalome after lactose ingestion. Symptoms of lactose intolerance will be assessed using a standardised questionnaire and mechanistically linked to specific key metabolites of the discriminating breath profile. In parallel, a solid-state sensor will measure postprandial hydrogen gas in breath samples, while GI gases (CH4, H2, O2) and intestinal transit time will be monitored using a novel ingestible gas sensor (Atmo Gas capsule). Metabolites in urine, including lactose-derived metabolites, will be investigated using gas chromatography coupled with mass spectrometry. Postprandial bowel sounds will be recorded by wearable sensors (DigeHealth AG). Baseline assessments will be completed before the dietary challenge to capture usual dietary intake (repeated 24-hour recall), faecal microbiota (shallow shotgun sequencing) and to evaluate genetic polymorphisms using saliva samples (PCR analysis of selected penetrant single-nucleotide polymorphisms). ETHICS AND DISSEMINATION:The Lactobreath study has been approved by the Ethics Committee of the Canton of Zurich, Switzerland (#2023-01639). The project results will be published in open-access journals, presented at national and international conferences and communicated to the public and other relevant stakeholders via the communication channels of all investigators and partners. All results derived from the study will be accessible, in line with the Swiss National Science Foundation open access policy. TRIAL REGISTRATION NUMBER:NCT06177938.

In disorders of gut–brain interaction including functional dyspepsia and irritable bowel syndrome, clinical focus has shifted from pathophysiological criteria to symptoms. A single-arm, low-intervention clinical trial into the effectiveness and tolerability of Menthacarin, a peppermint oil/caraway oil combination, was performed. A total of 126 patients with abdominal pain/cramps or a sensation of being bloated without organic cause received 1 capsule Menthacarin twice a day for 8 weeks. Assessments included abdominal symptoms, stool parameters, and quality of life. During treatment, all assessed abdominal symptoms showed significant (p < 0.001), clinically meaningful improvements, with standardized effect sizes of 0.83–1.05 for change from baseline. The number of days/week with symptom impact or incomplete spontaneous bowel movements almost halved, while days/week with normal stool consistency increased (all p < 0.001). Health-related quality of life significantly improved (p < 0.001) and Menthacarin was well tolerated. The study demonstrates patient-relevant improvement in gastrointestinal symptoms during treatment with Menthacarin while underlining its favorable tolerability profile.

INTRODUCTION:In disorders of gut-brain interaction including functional dyspepsia and irritable bowel syndrome, clinical focus has shifted from pathophysiological criteria to symptoms. METHODS:A single-arm, low-intervention clinical trial into the effectiveness and tolerability of Menthacarin, a peppermint oil/caraway oil combination, was performed. A total of 126 patients with abdominal pain/cramps or a sensation of being bloated without organic cause received 1 capsule Menthacarin twice a day for 8 weeks. Assessments included abdominal symptoms, stool parameters, and quality of life. RESULTS:During treatment, all assessed abdominal symptoms showed significant (p < 0.001), clinically meaningful improvements, with standardized effect sizes of 0.83-1.05 for change from baseline. The number of days/week with symptom impact or incomplete spontaneous bowel movements almost halved, while days/week with normal stool consistency increased (all p < 0.001). Health-related quality of life significantly improved (p < 0.001) and Menthacarin was well tolerated. CONCLUSION:The study demonstrates patient-relevant improvement in gastrointestinal symptoms during treatment with Menthacarin while underlining its favorable tolerability profile.

Background: Gastroesophageal reflux disease (GERD) is common. Management of reflux symptoms includes medical and nonmedical interventions. Proton pump inhibitors (PPIs) continue to be considered first-line agents. Standard investigations to diagnose GERD include upper endoscopy, impedance-pH measurement or capsule-based pH measurements and high-resolution manometry. However, diagnosis can sometimes be difficult in individual cases when measurements yield borderline results. Combination of the three mentioned techniques is considered the diagnostic gold standard now. Summary: Aside from the current measures considered gold standard, new measurement parameters, mostly focusing on impedance of the esophageal mucosa will help better diagnose GERD. Another promising new modality is the combination of wireless pH measurements and evaluation of esophageal motility and structural abnormalities using the endoscopic functional lumen imaging probe (FLIP). Artificial intelligence may play an increasingly supportive role. Key Messages: GERD needs to be better diagnosed to avoid unnecessary or potentially harmful long-term acid suppression therapy or reflux surgery. A number of tools is under investigation. However, as of now they only have supportive value.

OBJECTIVES: Colorectal carcinoma remains one of the most common malignancies worldwide. Colonoscopy screening is most effective for early detection and tumour prevention and is currently recommended in Europe for adults aged over 50 years. However, given that an increasing proportion of patients are diagnosed before the age of 50, we set out to determine the detection rate of colorectal carcinoma in patients younger than 50 years and to determine the best threshold for starting colonoscopy screening. METHODS: Single-centre, retrospective cohort study of all colonoscopies performed, regardless of indication, in our department at a tertiary Swiss university hospital in patients aged ≥18 and <60 years between 2016 and 2021. Colorectal cancer detection rate was calculated per 5-year age group and analysed separately by sex. RESULTS: The current analysis included 2846 colonoscopies performed for any indication. Colorectal carcinoma was found in 5/366 (1.4%) patients aged 45–49 years (3/210 or 1.4% of males and 2/156 or 1.3% of females) and in 9/819 (1.1%) patients aged 50–54 years (5/495 or 1.0% of males and 4/324 or 1.2% of females). Adenomas with high-grade dysplasia were found in 5/366 (1.4%) patients aged 45–49 years and in 11/819 (1.3%) aged 50–54 years; by sex, in 4/210 or 1.9% of males and 1/156 or 0.6% of females aged 45–49 years, and in 6/495 or 1.2% of males and 5/324 or 1.5% of females aged 50–54 years. Detection of adenoma with low-grade dysplasia increased from 14.6% (21/144) at age <30 years to 41% (150/366) at 45–49 years and 43.5% (356/819) at 50–54 years. A similar increasing trend was also seen if we analysed these groups by sex. CONCLUSIONS: The detection rate of colorectal carcinoma, but also adenomas, in our patients aged 45–49 years was similar to that in patients aged over 50, in both sexes. Thus our data are in line with the assumption that lowering the screening age to 45 years might be reasonable from a medical point of view for achieving a reduction in disease-specific mortality by improved screening strategies.

Zusammenfassung Das als „belching“ bezeichnete Aufstoßen von Luft aus dem Ösophagus oder Magen in den Mund- und Rachenbereich gilt als physiologischer Prozess. Es kann jedoch in einem vermehrten Maße auftreten und im Sinne einer „belching disorder“ für die betroffenen Patienten mit einem erheblichen Leidensdruck verbunden sein. Die Diagnosestellung gestaltet sich zum Teil schwierig, insbesondere in Hinblick auf die Abgrenzung zu verwandten Krankheitsbildern wie der Aerophagie, dem Ruminationssyndrom oder dem Singultus. Neben der Diagnosestellung stellt auch die Therapie dieser Störungsbilder für den Hals-Nasen-Ohren-Arzt eine Herausforderung dar. Ziel dieser Arbeit ist es, eine interdisziplinäre Übersicht zu diesen Krankheitsbildern zu schaffen und klinisch-praktische Gesichtspunkte zur Diagnosestellung und Therapie aufzuarbeiten.

Aims We previously reported 6 months results of a prospective randomized sham-controlled trial comparing endoscopic pyloromyotomy (G-POEM) with a sham procedure in patients with gastroparesis (GREG, 1). G-POEM was superior to sham in terms of symptoms improvement and gastric emptying rate. Moreover, cross-over G-POEM, which was performed after a sham procedure was effective in 75% of patients. All patients have been prospectively followed according to an original protocol. Here, we report the long-term results. Unblinding of patients occurred 6 months after the originally allocated procedure (G-POEM or sham).

Zusammenfassung In dieser Kurzübersicht wird das erstmalig 2019 durch den Laryngologen Dr. Bastian beschriebene Syndrom der retrograden krikopharyngealen Dysfunktion (R-CPD) anhand eines klassischen Falls vorgestellt. Die Diagnose erfolgt in der Regel klinisch durch die klassischen Symptome wie beispielsweise die Unfähigkeit, Luft aufzustoßen, abdominales Blähgefühl und retrosternale gurgelnde Geräusche. Des Weiteren werden neue Möglichkeiten der Diagnosesicherung mittels hochauflösender Ösophagusmanometrie und die therapeutischen Möglichkeiten mittels Injektion von Botulinumtoxin in den M. cricopharyngeus beschrieben sowie die dazu publizierten Daten diskutiert.

Zusammenfassung: Funktionelle Dyspepsie (FD) und Reizdarm-Syndrom (RDS), zwei häufige gastro-intestinale Entitäten mit überlappenden Symptomen, sollten nach den Rom-IV-Kriterien diagnostiziert werden. Dabei handelt es sich um eines oder mehrere der folgenden Symptome: bei FD um postprandiales Völlegefühl, frühes Sättigungsgefühl, Schmerzen oder Brennen epigastral; bei RDS um rezidivierende abdominale Schmerzen jeweils assoziiert mit Defäkation, Veränderungen der Stuhlfrequenz oder der Stuhlform. Zum Ausschluss struktureller Krankheiten ist auf Alarmsymptome zu achten. Für die Therapie bewährt sich bei beiden Krankheiten ein Stufenschema. Stufe 1: Arzt-Patienten-Gespräch mit Erläuterung von Diagnose und Prognose sowie Klärung der Therapieziele; Optimierung des Lebensstils; Einsatz von Phytotherapeutika; Stufe 2: Symptomorientierte Medikamente: bei FD Protonenpumpenhemmer bzw. Prokinetika; bei RDS Spasmolytika, Sekretagoga, Laxanzien, Gallensäurebinder, Antidiarrhoika, Antibiotika, Probiotika; Stufe. 3: viszerale Analgetika (Antidepressiva).

Constipation is a common gastrointestinal disorder that may occur as occasional (acute) episodes, but can also persist over longer periods of time. Patients usually self-diagnose and self-manage constipation with over-the-counter (OTC) medications, so in terms of medical advice/consultation, the pharmacist is often the first point of contact. Patients’ self-management of constipation helps to free up primary care resources to focus on more complex conditions. However, there is no clear guidance on the appropriate, practice-oriented approach to, and the limitations of, self-management of constipation. The objective of this article is to provide up-to-date clinical practice guidance for healthcare professionals, particularly community pharmacists, to assist in the day-to-day management of patients who present with constipation. Here, we discuss typical clinical factors (e.g. symptom duration, warning symptoms and treatment response) that help to distinguish whether constipation can be self-managed or if further medical assessment is required. We have also developed screening questions and a patient management algorithm to help pharmacists and pharmacy technicians make appropriate decisions when a patient presents with symptoms of constipation or requests advice after initiation of OTC medications.

Gastroparesis is a neuromuscular disorder of the upper gastrointestinal tract. Patients typically complain about early satiety, postprandial fullness, nausea and vomiting. Etiology is multifactorial. Treatment strategies include nutritional support, pharmacologic agents or surgery for refractory cases. Metoclopramide is the first and only FDA approved pharmacologic agent for (diabetic) Gastroparesis. A couple of compounds are currently in clinical testing. Some beacons of hope have failed recently, however. Here we present an update on possible future treatment options.