Diarrhea may be defined as a decrease in stool consistency (increased liquidity) or increase in stool frequency. Historically, it has been objectively defined as more than 3 daily bowel movements or the production of more than 200 g of stool in a 24-hour time period. Regardless of the criteria used, diarrhea is exceedingly common. The overwhelming majority of cases consist of acute diarrhea. They are typically self-limited, resolving over a period of several days and rarely requiring more than supportive care. However, the scenario changes significantly with chronic diarrhea due to the complexity of the potential causes, diagnostic evaluation, and treatment. It is therefore essential to recognize the difference between an acute diarrhea and that of a chronic diarrhea. Symptoms persisting for more than 4 weeks have been arbitrarily defined as chronic diarrhea.1 A presentation of chronic diarrhea always warrants further investigation. At a minimum, this should consist of a detailed history, physical examination, routine laboratory studies, and stool analysis. Further directed testing is then pursued based on findings from this initial evaluation.

Patients with SARS-CoV-2 infection carry an increased risk of cardiovascular disease encompassing various implications, including acute myocardial injury or infarction, myocarditis, heart failure, and arrhythmias. A growing volume of evidence correlates SARS-CoV-2 infection with myocardial injury, exposing patients to higher mortality risk. SARS-CoV-2 attacks the coronary arterial bed with various mechanisms including thrombosis/rupture of preexisting atherosclerotic plaque, de novo coronary thrombosis, endotheliitis, microvascular dysfunction, vasculitis, vasospasm, and ectasia/aneurysm formation. The angiotensin-converting enzyme 2 receptor plays pivotal role on the cardiovascular homeostasis and the unfolding of COVID-19. The activation of immune system, mediated by proinflammatory cytokines along with the dysregulation of the coagulation system, can pose an insult on the coronary artery, which usually manifests as an acute coronary syndrome (ACS). Electrocardiogram, echocardiography, cardiac biomarkers, and coronary angiography are essential tools to set the diagnosis. Revascularization is the first-line treatment in all patients with ACS and obstructed coronary arteries, whereas in type 2 myocardial infarction treatment of hypoxia, anemia and systemic inflammation are indicated. In patients presenting with coronary vasospasm, nitrates and calcium channel blockers are preferred, while treatment of coronary ectasia/aneurysm mandates the use of antiplatelets/anticoagulants, corticosteroids, immunoglobulin, and biologic agents. It is crucial to untangle the exact mechanisms of coronary involvement in COVID-19 in order to ensure timely diagnosis and appropriate treatment. We have reviewed the current literature and provide a detailed overview of the pathophysiology and clinical spectrum associated with coronary implications of SARS-COV-2 infection. Patients with SARS-CoV-2 infection carry an increased risk of cardiovascular disease encompassing various implications, including acute myocardial injury or infarction, myocarditis, heart failure, and arrhythmias. A growing volume of evidence correlates SARS-CoV-2 infection with myocardial injury, exposing patients to higher mortality risk. SARS-CoV-2 attacks the coronary arterial bed with various mechanisms including thrombosis/rupture of preexisting atherosclerotic plaque, de novo coronary thrombosis, endotheliitis, microvascular dysfunction, vasculitis, vasospasm, and ectasia/aneurysm formation. The angiotensin-converting enzyme 2 receptor plays pivotal role on the cardiovascular homeostasis and the unfolding of COVID-19. The activation of immune system, mediated by proinflammatory cytokines along with the dysregulation of the coagulation system, can pose an insult on the coronary artery, which usually manifests as an acute coronary syndrome (ACS). Electrocardiogram, echocardiography, cardiac biomarkers, and coronary angiography are essential tools to set the diagnosis. Revascularization is the first-line treatment in all patients with ACS and obstructed coronary arteries, whereas in type 2 myocardial infarction treatment of hypoxia, anemia and systemic inflammation are indicated. In patients presenting with coronary vasospasm, nitrates and calcium channel blockers are preferred, while treatment of coronary ectasia/aneurysm mandates the use of antiplatelets/anticoagulants, corticosteroids, immunoglobulin, and biologic agents. It is crucial to untangle the exact mechanisms of coronary involvement in COVID-19 in order to ensure timely diagnosis and appropriate treatment. We have reviewed the current literature and provide a detailed overview of the pathophysiology and clinical spectrum associated with coronary implications of SARS-COV-2 infection.

Collagenous colitis represents one of the two major forms of microscopic colitis. This is an idiopathic, chronic condition marked by nonbloody, watery diarrhea and characteristic histologic abnormalities on mucosal biopsy. Associated symptoms may include occasional fecal incontinence, abdominal cramping, nausea, weight loss, and abdominal distention. Endoscopy and radiographic studies are normal, and laboratory studies are generally unremarkable as well. The mucosal abnormalities of collagenous colitis include a thickened linear subepithelial collagen layer and frequently a mononuclear (lymphocytes, plasma cell, and/or macrophages) cellular infiltrate with epithelial cell damage. Collagenous colitis has an incidence of 4 to 6 per 100,000 people. It occurs more commonly in women and the elderly, with a median age at onset of 65 years, although it has been diagnosed in all ages, including children. There are no known long-term colonic complications of this condition. Although symptoms may wax and wane, the primary objective of treatment is the effective control of the diarrhea and any accompanying lower abdominal symptoms. A variety of treatments exist to include antidiarrheals, fiber supplementation, binding agents, 5-aminosalicylates, antibiotics, immunosuppressants, antisecretory agents, and surgery. There are limited controlled studies assessing these treatment strategies as their use is largely based on anecdotal evidence and that of small, poorly controlled trials. Thus, the choice of treatment is based on a careful balance of symptom severity with that of the risks of therapy.

Laxatives are the most widely used medications in both the short- and long-term treatment of constipation. They are available by prescription as well as over-the-counter, and their primary therapeutic goal is to increase the frequency and ease of bowel movements. Laxatives work in a variety of ways within the gastrointestinal tract and are therefore categorized based on their mode of action. They are assigned to the stimulant, osmotic, bulk-forming, surfactant, or alternative/other categories.

The effect of age and gender differences on anorectal function, symptoms severity, and quality of life (QoL) in patients with chronic constipation (CC) is not well studied. This study examines the impact of age and gender on anorectal function testing (AFT) characteristics, symptoms burden, and QoL in patients with CC. This is a retrospective analysis of prospectively collected data from 2550 adults with CC who completed AFT. Collected data include demographics, sphincter response to simulated defecation during anorectal manometry (ARM), balloon expulsion testing (BET), and validated surveys assessing constipation symptoms and QoL. DD was defined as both the inability to relax the anal sphincter during simulated defecation and an abnormal BET. 2550 subjects were included in the analysis (mean age = 48.6 years). Most patients were female (81.6

INTRODUCTION: The aim of the study was to compare the effectiveness of a low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol diet (LFD) vs psyllium on the frequency and severity of fecal incontinence (FI) episodes in patients with loose stools. METHODS: This was a single-center, randomized pilot trial of adult patients with FI (Rome III) with at least 1 weekly FI episode associated with loose stool. Eligible patients were randomized to 4 weeks of either a dietitian-led LFD or 6 g/d psyllium treatment. RESULTS: Forty-three subjects were randomized from October 2014 to May 2019. Thirty-seven patients completed the study (19 LFD and 18 psyllium). There was no statistically significant difference in the proportion of treatment responders (>50% reduction in FI episodes compared with baseline) for treatment weeks 1–4 (LFD 38.9%, psyllium 50%, P = .33). Compared with baseline, mean fecal incontinence severity index score significantly improved with LFD (39.4 vs 32.6, P = .02) but not with psyllium (35.4 vs 32.1, P = .29). Compared with baseline values, the LFD group reported improvements in fecal incontinence quality of life coping/behavior, depression/self-perception, and embarrassment subscales. The psyllium group reported improvement in incontinence quality of life coping/behavior. DISCUSSION: In this pilot study, there was no difference in the proportion of patients who reported a 50% reduction of FI episodes with the LFD or psyllium. Subjects in the psyllium group reported a greater reduction in overall FI episodes, whereas the LFD group reported consistent improvements in FI severity and quality of life. Further work to understand these apparently discrepant results are warranted but the LFD and psyllium seem to provide viable treatment options for patients with FI and loose stools.

This guideline applies to adult patients with suspected or confirmed small bowel obstruction. It does not apply to medical problems that mimic bowel obstruction (eg, scleroderma, Hirschsprung-type disease, opioid induced ileus, etc.). The objective is to create an evidence-based guideline for the diagnosis, triage, and management of small bowel obstruction to improve patient outcome.

Introduction: More than half the population of people with spinal cord injury (SCI) suffer chronic constipation (CC) causing symptoms which significantly reduces quality of life. Practical issues including discomfort, additional visits, and inconsistent insurance coverage create barriers to performing a detailed evaluation in SCI patients. To better understand the pathophysiology of these clinical complaints, we performed Wireless Motility Capsule (WMC) and anorectal function testing in a consecutive, cohort of patients with SCI. The objective was to determine the relative contributions of slow gut transit and/or anorectal function in the pathophysiology of CC in SCI patients. Methods: Eligible subjects with chronic SCI ( >1 year) above T12 AIS (American Spinal Injury Score) A-E with complaints of functional constipation by the Rome IV criteria were recruited. Patients underwent a standardized evaluation with WMC and balloon expulsion testing (BET). Gastric emptying time (GET, abnormal >5 hours), small bowel transit time (SBTT, abnormal >6 hours), colon transit time (CTT, abnormal >59 hours), and the presence of an evacuation disorder (BET >59 seconds) were determined. Regional transit times (RTT) were reviewed to assess distributional abnormalities. Bivariate analyses were conducted as cross-tabulations, using chi-square tests to assess significance of differences. Results: Forty-nine subjects completed the study, 31 with cervical SCI (A= 9, B=8, C=11, D/E =11), 18 with thoracic SCI (A=15, D/E =3). All 49 subjects fulfilled the Rome IV criteria for functional constipation. Overall, WMC showed delayed GET=32.7%, SBTT=34.7%, CTT=51%. BET was abnormal in 84%; of these, 13 % of subjects had only delayed CTT, 44% had only an abnormal BET, and 40% had both delayed CTT and an abnormal BET. No significant relationships were observed between RTTs and either level or completeness of injury. Conclusion: The majority of SCI patients suffer with CC. While half of patients have delayed CTT, more than 80% have evidence of an evacuation disorder. Almost half of SCI patients have both delayed CTT and an evacuation disorder. Roughly a third of patients also have delayed GET and SB transit. Constipation in patients with SCI will often be complicated by an evacuation disorder. This should be taken into consideration when developing a bowel regimen for patients with SCI.

INTRODUCTION:The North American Consensus guidelines for glucose breath testing (GBT) for small intestinal bacterial overgrowth (SIBO) incorporated changes in glucose dosing and diagnostic cutoffs. We compared GBT positivity based on hydrogen and methane excretion and quantified symptoms during performance of the North American vs older modified Rome Consensus protocols.METHODS:GBT was performed using the North American protocol (75 g glucose, cutoffs >20 parts per million [ppm] hydrogen increase after glucose and >10 ppm methane anytime) in 3,102 patients vs modified Rome protocol (50 g glucose, >12 ppm hydrogen and methane increases after glucose) in 3,193 patients with suspected SIBO.RESULTS:Positive GBT were more common with the North American vs modified Rome protocol (39.5% vs 29.7%, P < 0.001). Overall percentages with GBT positivity using methane criteria were greater and hydrogen criteria lower with the North American protocol (P < 0.001). Peak methane levels were higher for the North American protocol (P < 0.001). Times to peak hydrogen and methane production were not different between protocols. With the North American protocol, gastrointestinal and extraintestinal symptoms were more prevalent after glucose with both positive and negative GBT (P < 0.04) and greater numbers of symptoms (P < 0.001) were reported.DISCUSSION:GBT performed using the North American Consensus protocol was more often positive for SIBO vs the modified Rome protocol because of more prevalent positive methane excretion. Symptoms during testing were greater with the North American protocol. Implications of these observations on determining breath test positivity and antibiotic decisions for SIBO await future prospective testing.

Gyawali, C. Prakash MD1; Baker, Jason R. PhD2; Moshiree, Baha MD2; Rao, Satish MD3; Neshatian, Leila MD4; Nguyen, Linda MD4; Chey, William D. MD5; Saad, Richard MD5; Garza, Jose M. MD6; Waseem, Shamaila MD7; Khan, Abraham R. MD8; Pandolfino, John E. MD9 Author Information

BACKGROUND:Small intestinal bacterial overgrowth (SIBO) is defined by an increased number of bacteria measured via exhaled hydrogen and/or methane gas following the ingestion of glucose. This condition is prevalent following abdominal surgery, including Roux-en-Y gastric bypass (RYGB), and associated with a variety of non-specific abdominal symptoms, often requiring an extensive diagnostic work-up.AIM:To assess the frequency that individuals with RYGB anatomy are diagnosed with SIBO and if they are more likely to report specific gastrointestinal (GI) symptoms compared to individuals with native anatomy.METHODS:This large matched cohort study evaluated patients with GI symptoms who underwent a glucose breath test (GBT) for SIBO evaluation, utilizing 1:2 matching between RYGB and native anatomy. Patients with positive GBT were included in univariate and multivariate analyses to distinguish the presence of ten specific GI symptoms between RYGB and native anatomy.RESULTS:A total of 17,973 patients were included, where 271 patients with RYGB were matched to 573 patients with native anatomy that underwent GBT. Patients with RYGB anatomy and a positive GBT (199; 73.4%) as compared to those with native anatomy and a positive GBT (209; 36%) more often reported nausea, vomiting, bloating, and diarrhea. There were no differences between the two groups in the report of heartburn, regurgitation, chest pain, gas, or constipation.CONCLUSIONS:SIBO is common in patients with RYGB and more commonly report nausea, vomiting, bloating, and diarrhea. The results of this study suggest that the report of these symptoms in RYGB should prompt early evaluation for SIBO.

INTRODUCTION: Helicobacter pylori (H.pylori) is an important worldwide cause of peptic ulcer disease, gastric cancer and upper gastrointestinal symptoms. Triple therapy with a proton pump inhibitor, clarithromycin, and amoxicillin (PCA) or metronidazole (PCM) for 14 days remains the mainstay of first-line therapy for H. pylori infection in the US, however, there is evidence that antibiotic resistance, particularly to macrolides, is increasing in the United States (US). Aim: (i) Determine the effectiveness of PCA & PCM for eradicating H.pylori infection over the past 19 years (ii) Determine the impact of compliance on eradication rates with PCA & PCM. METHODS: A retrospective analysis was performed on all patients (pts) referred for a 13C urea breath test (UBT) following first line PCA or PCM therapy for H. pylori at a single US medical center between January 2001 – October 2019. Patients included in this analysis had H. pylori infection documented by gastric biopsy, UBT or fecal antigen test. All patients were treated with PCA or PCM for 10-14 days. Time frames for comparison included a cure rate over the entire 19-year study period and sub-divided into four 5-year blocks (2001-2005, 2006-2010, 2011-2015, and 2016-2019). Cure rates & 95% confidence intervals were calculated for PCA & PCM combined and each regimen separately. Logistic regression was conducted to determine if therapy compliance influenced H.pylori eradication. RESULTS: Data was analyzed on 1058 pts (mean age 51.1 (SD = 15.4; Range:18-90), 61.8% female, and 49.5% Caucasian). H.pylori eradications rates using PCA or PCM was 78.1%. PCA (79.1%) and PCM yielded similar eradication rates (79.1% vs. 77.8%, NS). Eradication rates for PCA & PCM divided into 5-year time blocks were similar [Table 1]. Therapy compliance did not significantly influence eradication rates. CONCLUSION: Real world eradication rates of PCA & PCM at a large midwestern US medical center have remained stable over almost 2 decades. The eradication rates of < 80% raise questions about whether these regimens deserve to be the preferred first-line therapies for H. pylori in the US.Table 1.: Cumulative Eradication Rates (2001-2019)Table 2.: Five Year Interval Eradication Rates

Small intestinal bacterial overgrowth (SIBO) is a condition with presentation that can vary from asymptomatic to steatorrhea and malnutrition. Small bowel aspiration and culture is the current gold standard of diagnosis; however, this is invasive and is not without risk to the patient. Breath testing is a noninvasive and less expensive alternative method; however, it lacks diagnostic sensitivity and specificity. Novel diagnostic methods being studied include gas-sensing capsules. The mainstay of treatment is antibiotics; alternative therapies include herbal medications, dietary modifications, and prokinetic agents. Further investigation into less invasive and less harmful diagnostic methods and treatment options is warranted.