Gastroparesis is a functional disorder with a variety of symptoms that is characterized by delayed gastric emptying in the absence of mechanical obstruction. A recent series of retrospective studies ...has demonstrated that peroral endoscopic pyloromyotomy (G-POEM) is a promising endoscopic procedure for treating patients with refractory gastroparesis. The aim of this prospective study was to evaluate the feasibility, safety, and efficacy of G-POEM.
20 patients with refractory gastroparesis (10 diabetic and 10 nondiabetic) were prospectively included in the trial. Patients were treated by G-POEM after evaluation of pyloric function using an endoscopic functional luminal imaging probe. Clinical responses were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and quality of life was assessed using the Patient Assessment of Upper Gastrointestinal Disorders - Quality of Life scale and the Gastrointestinal Quality of Life Index scores. Gastric emptying was measured using 4-hour scintigraphy before G-POEM and at 3 months.
Feasibility of the procedure was 100 %. Compared with baseline values, G-POEM significantly improved symptoms (GCSI: 1.3 vs. 3.5;
< 0.001), quality of life, and gastric emptying (T½: 100 vs. 345 minutes,
< 0.001; %H2: 56.0 % vs. 81.5 %,
< 0.001; %H4: 15.0 % vs. 57.5 %,
= 0.003) at 3 months. The clinical success of G-POEM using the functional imaging probe inflated to 50 mL had specificity of 100 % and sensitivity of 72.2 % (
= 0.04; 95 % confidence interval 0.51 - 0.94; area under the curve 0.72) at a distensibility threshold of 9.2 mm
/mmHg.
G-POEM was efficacious and safe for treating refractory gastroparesis, especially in patients with low pyloric distensibility.
AIM：To assess the effects and safety of Lactobacillus casei rhamnosus LCR35 complete freeze-dried culture（LCR35） in patients suffering from irritable bowel syndrome（IBS）.METHODS：A ...randomized,double-blind pilot study was performed in 50 patients complaining of IBS symptoms complying with RomeⅢcriteria.Patients were allocated to receive either LCR35（n = 25） at a minimum daily dose of 6 × 108 colony forming units or placebo（n = 25） for 4 wk.At inclusion,after treatment and 2 wk later,patients completed the IBS severity scale.Change from baseline in the IBS severity score at the end of treatment was the primary efficacy criterion.Changes were compared between groups in the whole population and in IBS subtypes（IBS with predominance of constipation,IBS with predominance of diarrhoea,mixed IBS,unsubtyped IBS）.The presence of lactobacillus casei rhamnosus in stools was investigated at inclusion and at the end of treatment.The gastrointestinal quality of life questionnaire and the hospital anxiety and depression（HAD） scale were also completed.RESULTS：Both groups were balanced for baseline characteristics.In 85% of patients,stool analyses showed that lactobacillus casei rhamnosus able to survive in the digestive tract.In the whole population,improvements in the IBS severity score did not differ significantly between treatments with a 25% decrease after 4-wk treatment,and a 15% decrease from baseline 2 wk later in both groups.In IBS subgroups,statistical analysis could not be performed due to small sample size,but a clinical response in favour of LCR35 was observed in IBS patients with predominance of diarrhoea：no change in the symptom severity score was seen with the placebo after 4 wk treatment,whereas a clinically relevant decrease occurred with LCR35（-37% vs-3%）.Furthermore,in spite of an increase in symptom intensity,the IBS severity score was maintained below the baseline value 2 wk later with LCR35（-19% from baseline）,whilst a slight 5% increase from baseline was observed with placebo.In the IBS subgroup with predominance of diarrhoea only,a clinically relevant decrease in abdominal pain severity score（-36%）was observed with LCR35,whereas no change occurred with placebo.In mixed IBS patients,the 20% and 30% decreases in the IBS severity score observed after treatment with LCR35 and placebo,respectively,were maintained 2 wk later in both groups.A clinical response slightly in favour of placebo was observed at the end of the treatment period in IBS patients with predominance of constipation（-41% vs-20%） and unsubtyped IBS patients（-47% vs-17%）,with the same value maintained 2 wk later.In both groups,no clinically relevant changes were observed either for the gastrointestinal quality of life index or HAD score.Thus,these results suggest that sub-grouping of IBS patients may be important for optimizing treatment responses by the physician.CONCLUSION：This pilot study suggests that LCR35 could have some efficacy in IBS patients complaining of diarrhoea.These preliminary results need to be conf irmed in larger studies.
Capsule enteroscopy (CE) is the best noninvasive tool to explore the entire small bowel of patients with obscure gastrointestinal bleeding (OGIB); it has a diagnostic yield of 40%-80%. However, ...little is known about the factors associated with a diagnosis of OGIB by CE.
We analyzed data from 911 consecutive patients who underwent CE for OGIB from January 2004 to January 2010. Results from upper and lower gastrointestinal endoscopy examinations were negative in all patients. CE findings were recorded. Features of patients that were associated with diagnosis of OGIB by CE were identified by using logistic regression.
Based on CE, 509 patients (56%) had a confirmed lesion responsible for the OGIB: 203 had disease of the small bowel (22%), 88 had ulcerations (10%), 70 had tumors (8%), 24 had varices (2%), 6 had diverticula (0.5%), and 118 had what appeared to be bleeding lesions of the esophagus or stomach (10.6%) or colon (2%). Factors independently associated with a diagnosis of OGIB by CE were age >60 years (odds ratio OR, 1.2), male sex, history of overt bleeding (OR, 3.8), and current hospitalization (OR, 1.4). Women were less likely to be diagnosed with OGIB by CE (OR, 0.7).
A history of overt bleeding is the factor most strongly associated with a diagnosis of OGIB by CE. Male sex, age >60 years, and inpatient status were also independent predictors of positive diagnosis by CE.
Objectives. The aims of this study were to: (i) determine the prevalence of small intestinal bacterial overgrowth (SIBO) in unselected patients with SSc; (ii) assess both clinical presentation and ...outcome of SIBO; and (iii) make predictions about which SSc patients are at risk for SIBO. Methods. Fifty-one consecutive patients with SSc underwent glucose hydrogen and methane (H2/CH4) breath test. All SSc patients also completed a questionnaire for intestinal symptoms, and a global symptomatic score (GSS) was calculated. SSc patients with SIBO were given rotating courses of antibiotics (norfloxacin/metronidazole) for 3 months; glucose H2/CH4 breath test was performed at 3-month follow-up. Results. The prevalence of SIBO was 43.1% in our SSc patients. After logistic regression, we identified the following risk factors for SIBO: presence of diarrhoea and constipation. Interestingly, we observed a marked correlation between values of GSS of digestive symptoms (⩾5) and the presence of SIBO (P = 10−6); indeed, both sensitivity and specificity of GSS ⩾5 to predict SIBO were as high as 0.909 and 0.862, respectively. Finally, eradication of SIBO was obtained in 52.4% of the SSc patients with a significant improvement of intestinal symptoms. Conclusion. Our study underscores that SIBO often occurs in SSc patients. We further suggest that GSS may be systematically performed in SSc patients; since we found a correlation between GSS of digestive symptoms ⩾5 and SIBO, we suggest that glucose H2/CH4 breath test may be performed in the subgroup of SSc patients exhibiting GSS ⩾5.
Obesity and irritable bowel syndrome (IBS) are two major public health issues. Interestingly previous data report a marked increase of IBS prevalence in morbid obese subjects compared with non-obese ...subjects but underlying mechanisms remain unknown. Obesity and IBS share common intestinal pathophysiological mechanisms such as gut dysbiosis, intestinal hyperpermeability and low-grade inflammatory response. We thus aimed to evaluate the link between obesity and IBS using different animal models. Male C57Bl/6 mice received high fat diet (HFD) for 12 weeks and were then submitted to water avoidance stress (WAS). In response to WAS, HFD mice exhibited higher intestinal permeability and plasma corticosterone concentration than non-obese mice. We were not able to reproduce a similar response both in ob/ob mice and in leptin-treated non-obese mice. In addition, metformin, a hypoglycemic agent, limited fasting glycaemia both in unstressed and WAS diet-induced obese mice but only partially restored colonic permeability in unstressed HFD mice. Metformin failed to improve intestinal permeability in WAS HFD mice. Finally, cecal microbiota transplantation from HFD mice in antibiotics-treated recipient mice did not reproduce the effects observed in stressed HFD mice. In conclusion, stress induced a more marked intestinal barrier dysfunction in diet-induced obese mice compared with non-obese mice that seems to be independent of leptin, glycaemia and gut microbiota. These data should be further confirmed and the role of the dietary composition should be studied.
To assess the impact of baseline nutritional status on treatment response and survival in nonmetastatic patients with a locally advanced esophageal cancer (LAEC) treated with definitive ...chemoradiotherapy (CRT).
One hundred five patients with LAEC treated by definitive CRT were retrospectively included. The CRT regimen was based on an external radiotherapy (RT) delivered concomitantly to a cisplatin-based chemotherapy (CT). Patients were considered to have a complete response (CR) to CRT when no residual tumor was detected on CT scan and esophagoscopy performed 2 months after the end of CRT. Multivariate analysis of predictive factors of response to CRT and survival were performed using a logistic regression and a Cox model, respectively.
Mean value of baseline nutritional parameters was significantly different between nonresponder (N = 42) and responder (N = 63) patients to CRT (weight loss 10%vs 5.8%, P= 0.0047; serum albumin level 35 g/L vs 38.7 g/L, P= 0.0004; BMI 22.8 kg/m2vs 25.2 kg/m2, P= 0.01). In multivariate analysis, serum albumin level > 35 g/L was the only independent predictive factor of CR to CRT (P= 0.009). Independent prognostic factors of survival were BMI > 18 kg/m2 (P= 0.003), dysphagia Atkinson score <2 (P= 0.008), dose of RT > 50 Grays (Gy) (P < 0.0001) and CR to CRT (P < 0.0001).
Survival was influenced by baseline nutritional status as well as dysphagia, dose of RT, and CR to CRT. Despite the retrospective design of the study, our results may provide the concept basis for performing a prospective nutritional intervention study in patients treated by definitive CRT for an esophageal cancer.
To assess the symptomatic efficacy of Lactobacillus plantarum 299v (L. plantarum 299v) (DSM 9843) for the relief of abdominal symptoms in a large subset of irritable bowel syndrome (IBS) patients ...fulfilling the Rome III criteria.
In this double blind, placebo-controlled, parallel-designed study, subjects were randomized to daily receive either one capsule of L. plantarum 299v (DSM 9843) or placebo for 4 wk. Frequency and intensity of abdominal pain, bloating and feeling of incomplete rectal emptying were assessed weekly on a visual analogue scale while stool frequency was calculated.
Two hundred and fourteen IBS patients were recruited. After 4 wk, both pain severity (0.68 + 0.53 vs 0.92 + 0.57, P < 0.05) and daily frequency (1.01 + 0.77 vs 1.71 + 0.93, P < 0.05) were lower with L. plantarum 299v (DSM 9843) than with placebo. Similar results were obtained for bloating. At week 4, 78.1 % of the patients scored the L. plantarum 299v (DSM 9843) symptomatic effect as excellent or good vs only 8.1 % for placebo (P < 0.01).
A 4-wk treatment with L. plantarum 299v (DSM 9843) provided effective symptom relief, particularly of abdominal pain and bloating, in IBS patients fulfilling the Rome III criteria.
Fructose malabsorption may trigger gastrointestinal symptoms in irritable bowel syndrome patients and a low fructose diet seems to improve digestive symptoms.
The aim of our study was to determine ...whether fructose malabsorption detected by a 25g fructose breath test could be a predictor of the efficacy of a low fructose diet.
88 patients (73 women, median age, 45.5 years, range 18–69) with irritable bowel syndrome according to Rome III criteria were included in this prospective, controlled study. All 88 patients had a 25 g fructose breath test; 37 had a positive test result defining fructose malabsorption. All 88 patients followed a low fructose diet for 2 weeks, blinded to their test results. Patients filled self validated-questionnaires before and at the end of the dietary period. The main outcome measurement was the Irritable Bowel Syndrome-Symptom Severity Score.
Irritable Bowel Syndrome-Symptom Severity Score significantly decreased in fructose absorbers and fructose malabsorbers after a low fructose diet (−68.0 −137; 0 versus −73.5 −173; −11.5) with no difference according to fructose breath test result (adjusted P = 0.984).
A positive 25 g fructose breath test is not a predictor of the efficacy of a low fructose diet in irritable bowel syndrome.
www.clinicaltrials.gov (NCT02188680).
Recent studies showed that patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had an increased intestinal permeability as well as a decreased expression of tight junctions. ...Glutamine, the major substrate of rapidly dividing cells, is able to modulate intestinal permeability and tight junction expression in other diseases. We aimed to evaluate, ex vivo, glutamine effects on tight junction proteins, claudin-1 and occludin, in the colonic mucosa of patients with IBS-D.
Twelve patients with IBS-D, diagnosed with the Rome III criteria, were included (8 women/4 men, aged 40.7 ± 6.9 years). Colonic biopsy specimens were collected and immediately incubated for 18 hours in culture media with increasing concentrations of glutamine from 0.6-10 mmol/L. Claudin-1 and occludin expression was then measured by immunoblot, and concentrations of cytokines were assessed by multiplex technology. Claudin-1 expression was affected by glutamine (P < .05, analysis of variance). In particularly, 10 mmol/L glutamine increased claudin-1 expression compared with 0.6 mmol/L glutamine (0.47 ± 0.04 vs 0.33 ± 0.03, P < .05). In contrast, occludin expression was not significantly modified by glutamine. Interestingly, glutamine effect was negatively correlated to claudin-1 (Pearson r = -0.83, P < .001) or occludin basal expression (Pearson r = -0.84, P < .001), suggesting that glutamine had more marked effects when tight junction protein expression was altered. Cytokine concentrations in culture media were not modified by glutamine treatment.
Glutamine increased claudin-1 expression in the colonic mucosa of patients with IBS-D. In addition, glutamine effect seems to be dependent on basal expression of tight junction proteins.
The deleterious effect of fructose, which is increasingly incorporated in many beverages, dairy products, and processed foods, has been described; fructose malabsorption has thus been reported in up ...to 2.4% of healthy subjects, leading to digestive clinical symptoms (eg, pain, distension, diarrhea). Because digestive involvement is frequent in patients with systemic sclerosis (SSc), we hypothesized that fructose malabsorption could be responsible for intestinal manifestations in these patients. The aims of this prospective study were to: determine the prevalence of fructose malabsorption, in SSc; predict which SSc patients are at risk of developing fructose malabsorption; and assess the outcome of digestive symptoms in SSc patients after initiation of standardized low-fructose diet. Eighty consecutive patients with SSc underwent fructose breath test. All SSc patients also completed a questionnaire on digestive symptoms, and a global symptom score (GSS) was calculated. The prevalence of fructose malabsorption was as high as 40% in SSc patients. We also observed a marked correlation between the presence of fructose malabsorption and: higher values of GSS score of digestive symptoms (P = 0.000004); and absence of delayed gastric emptying (P = 0.007). Furthermore, in SSc patients with fructose malabsorption, the median value of GSS score of digestive symptoms was lower after initiation of standardized low-fructose diet (4 before vs. 1 after; P = 0.0009). Our study underscores that fructose malabsorption often occurs in SSc patients. Our findings are thus relevant for clinical practice, highlighting that fructose breath test is a helpful, noninvasive method by: demonstrating fructose intolerance in patients with SSc; and identifying the group of SSc patients with fructose intolerance who may benefit from low-fructose diet. Interestingly, because the present series also shows that low-fructose diet resulted in a marked decrease of gastrointestinal clinical manifestations in SSc patients with fructose malabsorption, our findings underscore that fructose malabsorption may play a significant role in the onset of gastrointestinal symptoms in these patients. Finally, we suggest that fructose malabsorption may be due to reduced fructose absorption by enterocytes, impaired enteric microbiome, and decreased intestinal permeability.
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