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The majority of cases of Shiga toxin-producing Escherichia coli are self-limited; however, the infection can occasionally be complicated by more severe phenomena, such as thrombotic microangiopathy, with resultant end-organ damage to the kidneys, colon, nervous system, and various other tissues. Shiga toxin-induced hemolytic uremic syndrome (ST-HUS)-the constellation of thrombocytopenia, hemolysis, and renal failure resulting from thrombotic microangiopathy in a subset of infections producing the Shiga toxin-is classically observed in the pediatric population. Nevertheless, the diagnosis should be considered in adults with this presentation, and especially in those with colonic findings suggestive of ischemia. ST-HUS must also be distinguished from other thrombotic microangiopathies and related conditions, such as disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and complement-mediated HUS, as these diagnoses prompt alternate management strategies. Here, we present a case of ST-HUS in a gentleman following pericardiectomy who was infected with non-O157:H7 E. coli producing Shiga toxin 2.

Background Despite the common practice of involving in-patients in the teaching of medical students little is known about the experience for patients. This study investigated inpatients' willingness, motivations and experience with participation in medical student bedside teaching. Methods In-patients at a tertiary hospital who participated in medical student teaching answered a 22 question survey. The survey examined the motivations, impact and overall experience for these patients. Results During July and August of 2019, 111 patients aged 19–93 years completed the survey. Most patients who were approached by preceptors to participate in teaching agreed to participate (74%). Ninety-six percent of patients felt like they could have said no if they had not wanted to participate in medical student teaching. Ninety percent of patients valued the time they spent with students. Conclusions Most hospital inpatients are willing to participate in medical student teaching in order to be helpful, and most have a positive experience. Preceptors in undergraduate medical education should prioritize a quality informed consent process and understand that the teaching experience can be mutually productive for patients and students.

Background Rumination syndrome is a functional gastroduodenal disorder characterised by effortless regurgitation of recently ingested food. Emerging evidence reports duodenal eosinophilic inflammation in a subset, suggesting a shared pathophysiology with functional dyspepsia (FD). Aim To assess the clinical features of rumination syndrome and FD in a community-based study. Methods We mailed a survey assessing gastrointestinal symptoms, diet and psychological symptoms to 9835 residents of Olmsted County, MN, USA in 2017-2018; diagnostic codes were obtained from linked clinical records. The two disorders were assessed as mutually exclusive in 'pure' forms with a separate overlap group, all compared to a control group not meeting criteria for either. Prevalence of associations, and univariate and independent associations with predictors were assessed by logistic regression. Results Prevalence of rumination syndrome and FD were 5.8% and 7.1%, respectively; the overlap was 3.83-times more likely than expected by chance. Independent predictors for rumination (odds ratio (OR), 95% confidence interval (CI)) were female gender (1.79, 1.21-2.63), smoking (1.89, 1.28-2.78), gluten-free diet (1.58, 1.14-2.19), allergic rhinitis (1.45, 1.01-2.08) and depression (1.10, 1.05-1.16). FD was independently associated with female gender, depression, non-coeliac wheat sensitivity, migraine, irritable bowel syndrome and somatic symptoms. A similar reported efficacy (≥54%) of low fat or dairy-free diets was found with both disorders (P = 0.53 and P = 1.00, respectively). The strongest independent associations with overlapping FD and rumination syndrome were a history of rheumatoid arthritis (3.93, 1.28-12.06) and asthma (3.02, 1.44-6.34). Conclusion Rumination syndrome overlaps with FD with a shared risk factor profile, suggesting a common pathophysiology.

Neuroendocrine tumors (NETs) arise from enterochromaffin cells found in neuroendocrine tissues, with most occurring in the gastrointestinal tract. The global incidence of NETs has increased in the past 15 years, likely due to better diagnostic methods. Small-bowel NETs are frequently associated with carcinoid syndrome (CS). Carcinoid syndrome diarrhea occurs in 80% of CS patients and poses a substantial symptomatic and economic burden. Patients with CS diarrhea frequently suffer from diarrhea and flushing and report corresponding impairment in quality of life, requiring substantial changes in daily activities and lifestyle. Treatment paradigms range from surgical debulking to liver-directed therapies to treatment with somatostatin analogs, nonspecific anti-diarrheal agents, and a tryptophan hydroxylase inhibitor. Other causes of diarrhea, including steatorrhea, short bowel syndrome, and bile acid malabsorption, should be considered in NET patients with refractory diarrhea. More therapeutic options are needed for symptomatic management of patients with NETs, and better understanding of the pathophysiology can empower clinicians with improved patient care.

Infection with Helicobacter pylori is a global health issue, and rapid and accurate testing is a key to diagnosis. We aimed to assess the performance of two novel enzyme immunoassays (EIA), the H. PYLORI QUIK CHEK™ and the H. PYLORI CHEK™ assays, for the detection of H. pylori antigen in stool. Patients from five geographically diverse sites across the USA, Germany, and in Bangladesh were tested for infection with Helicobacter pylori with the two novel stool antigen tests and two commercially available stool antigen assays. All patients provided a stool sample and underwent esophagogastroduodenoscopy for biopsy. Results were compared to a clinical diagnosis using a composite reference method consisting of histological analysis and rapid urease testing of the biopsy. A total of 271 patients, 68.2% female and mean age of 46 years, were included. The overall prevalence of H. pylori infection was 24.1%. The sensitivity of the H. PYLORI QUIK CHEK™ and H. PYLORI CHEK™ was 92% and 91%, respectively. The specificity of H. PYLORI QUIK CHEK™ and H. PYLORI CHEK™ was 91% and 100%, respectively. No significant cross-reactivity against other gut pathogens was observed. The H. PYLORI QUIK CHEK™ and H. PYLORI CHEK™ assays demonstrate excellent clinical performance compared the composite reference method.

Esophageal motility disorders can cause chest pain, heartburn, or dysphagia. They are diagnosed based on specific patterns seen on esophageal manometry, ranging from the complete absence of contractility in patients with achalasia to unusually forceful or disordered contractions in those with hypercontractile motility disorders. Achalasia has objective diagnostic criteria, and effective treatments are available. Timely diagnosis results in better outcomes. Recent research suggests that hypercontractile motility disorders may be overdiagnosed, leading to unnecessary and irreversible interventions. Many symptoms ascribed to these disorders are actually due to unrecognized functional esophageal disorders. Hypercontractile motility disorders and functional esophageal disorders are generally self-limited, and there is considerable overlap among their clinical features. Endoscopy is warranted in all patients with dysphagia, but testing to evaluate for less common conditions should be deferred until common conditions have been optimally managed. Opioid-induced esophageal dysmotility is increasingly prevalent and can mimic symptoms of other motility disorders or even early achalasia. Dysphagia of liquids in a patient with normal esophagogastroduodenoscopy findings may suggest achalasia, but high-resolution esophageal manometry is required to confirm the diagnosis. Surgery and advanced endoscopic therapies have proven benefit in achalasia. However, invasive interventions are rarely indicated for hypercontractile motility disorders, which are typically benign and usually respond to lifestyle modifications, although pharmacotherapy may occasionally be needed.

INTRODUCTION Uncontrolled results suggest that diaphragmatic breathing (DB) is effective in gastroesophageal reflux disease (GERD) but the mechanism of action and rigor of proof is lacking. This study aimed to determine the effects of DB on reflux, lower esophageal sphincter (LES), and gastric pressures in patients with upright GERD and controls. METHODS Adult patients with pH proven upright GERD were studied. During a high-resolution impedance manometry, study patients received a standardized pH neutral refluxogenic meal followed by LES challenge maneuvers (Valsalva and abdominal hollowing) while randomized to DB or sham. After that, patients underwent 48 hours of pH-impedance monitoring, with 50% randomization to postprandial DB during the second day. RESULTS On examining 23 patients and 10 controls, postprandial gastric pressure was found to be significantly higher in patients compared with that in controls (12 vs 7 mm Hg, P = 0.018). Valsalva maneuver produced reflux in 65.2% of patients compared with 44.4% of controls (P = 0.035). LES increased during the inspiratory portion of DB (42.2 vs 23.1 mm Hg, P < 0.001) in patients and healthy persons. Postprandial DB reduced the number of postprandial reflux events in patients (0.36 vs 2.60, P < 0.001) and healthy subjects (0.00 vs 1.75, P < 0.001) compared with observation. During 48-hour ambulatory study, DB reduced the reflux episodes on day 2 compared with observation on day 1 in both the patient and control groups (P = 0.049). In patients, comparing DB with sham, total acid exposure on day 2 was not different (10.2 ± 7.9 vs 9.4 ± 6.2, P = 0.804). In patients randomized to DB, esophageal acid exposure in a 2-hour window after the standardized meal on day 1 vs day 2 reduced from 11.8% ±6.4 to 5.2% ± 5.1, P = 0.015. DISCUSSION In patients with upright GERD, DB reduces the number of postprandial reflux events pressure by increasing the difference between LES and gastric pressure. These data further encourage studying DB as therapy for GERD.

CONTEXT: Delayed gastric emptying (GE) is common but often asymptomatic in diabetes. The relationship between symptoms, glycemia, and neurohormonal functions, including glucagonlike peptide 1 (GLP-1), are unclear. OBJECTIVES: To assess whether GE disturbances, symptoms during a GE study, and symptoms during enteral lipid infusion explain daily symptoms and whether GLP-1 mediates symptoms during enteral lipid infusion. DESIGN: In this randomized controlled trial, GE, enteral lipid infusion, gastrointestinal (GI) symptoms during these assessments, autonomic functions, glycosylated hemoglobin (HbA1c), and daily GI symptoms (2-week Gastroparesis Cardinal Symptom Index diary) were evaluated. During enteral lipid infusion, participants received the GLP-1 antagonist exendin 9-39 or placebo. SETTING: Single tertiary referral center. PARTICIPANTS: 24 healthy controls and 40 patients with diabetic gastroenteropathy. MAIN OUTCOME MEASURES: GE, symptoms during enteral lipid infusion, and the effect of exendin 9-39 on the latter. RESULTS: In patients, GE was normal (55%), delayed (33%), or rapid (12%). During lipid infusion, GI symptoms tended to be greater (P = 0.06) in patients with diabetes mellitus (DM) than controls; exendin 9-39 did not affect symptoms. The HbA1c was inversely correlated with the mean symptom score during the GE study (r = −0.46, P = 0.003) and lipid infusion (r = −0.47, P < 0.01). GE and symptoms during GE study accounted for 40% and 32%, respectively, of the variance in daily symptom severity and quality of life. CONCLUSIONS: In DM gastroenteropathy, GE and symptoms during a GE study explain daily symptoms. Symptoms during enteral lipid infusion were borderline increased but not reduced by a GLP-1 antagonist.

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless postprandial regurgitation. The disorder appears uncommon, although only limited epidemiologic data are available. Awareness of the characteristic symptoms is essential for recognizing the disorder, and thus avoiding the long delay in diagnosis, that many patients experience. Although objective testing by postprandial esophageal high-resolution impedance manometry is available in select referral centers, a clinical diagnosis can be made in most patients. The main therapy for rumination syndrome is behavioral modification with postprandial diaphragmatic breathing. This clinical practice update reviews the pathophysiology, diagnosis, and treatment of rumination syndrome. Best Practice Advice 1: Clinicians strongly should consider rumination syndrome in patients who report consistent postprandial regurgitation. Such patients often are labeled as having refractory gastroesophageal reflux or vomiting. Best Practice Advice 2: Presence of nocturnal regurgitation, dysphagia, nausea, or symptoms occurring in the absence of meals does not exclude rumination syndrome, but makes the presence of it less likely. Best Practice Advice 3: Clinicians should diagnose rumination syndrome primarily on the basis of Rome IV criteria after an appropriate medical work-up. Best Practice Advice 4: Diaphragmatic breathing with or without biofeedback is the first-line therapy in all cases of rumination syndrome. Best Practice Advice 5: Instructions for effective diaphragmatic breathing can be given by speech therapists, psychologists, gastroenterologists, and other health practitioners familiar with the technique. Best Practice Advice 6: Objective testing for rumination syndrome with postprandial high-resolution esophageal impedance manometry can be used to support the diagnosis, but expertise and lack of standardized protocols are current limitations. Best Practice Advice 7: Baclofen, at a dose of 10 mg 3 times daily, is a reasonable next step in refractory patients.

SummaryBackground Oesophageal lichen planus is an idiopathic inflammatory disorder characterized by significant oesophageal stricturing. Oesophageal lichen planus is a rare, difficult to diagnose, and likely an under recognized disease. As a result, there is no standardized approach to therapy and treatment strategies vary. Aim To examine the utility of topical steroid therapy (fluticasone or budesonide) in the management of oesophageal lichen planus. Methods A retrospective chart review was conducted of patients diagnosed with oesophageal lichen planus who underwent baseline and follow up endoscopy pre and post topical steroid therapy between 1995 and 2016 at Mayo Clinic, Rochester MN. Average time between upper GI endoscopy was 3.2 months (0.7–11.7). Swallowed steroid preparations included fluticasone 880 μg twice daily or budesonide 3 mg twice daily. Patients were reviewed for symptomatic response to therapy using the Dakkak-Bennett dysphagia score (0–4, no dysphagia to total aphagia). Pre- and post-endoscopic findings were assessed. Additional baseline demographic, endoscopic, and histologic data were also obtained. Results We identified 40 patients who met the inclusion criteria. A significant reduction in median dysphagia score from 1 (0–4) to 0 (0–3) after steroid therapy (P < 0.001) was noted. 62% of patients reported resolution of their dysphagia after receiving topical corticosteroids. 72.5% had an endoscopic response to steroid therapy. Conclusion Topical swallowed budesonide or fluticasone appear to effective treatment for oesophageal lichen planus.

Rumination syndrome is a gastrointestinal disorder characterized by effortless regurgitation of recently ingested food. The disorder is rare, but likely under-recognized and leads to impaired quality of life among those affected. This review discusses recent studies which examined the pathophysiology, diagnoses and therapy of rumination syndrome.The pathogenesis of rumination syndrome remains incompletely understood. Therapeutic options, which appear effective, include behavioral therapy with diaphragmatic breathing and pharmacotherapy with baclofen. A randomized trial of behavioral therapy, biofeedback therapy led to a 74% + /- 6% reduction in rumination activity (from 29 + /- 6 before to 7 + /- 2 daily events after intervention) vs. 1% + /- 14% during sham (from 21 + /- 2 before to 21 + /- 4 daily events after intervention) (P = .001). A recent randomized trial of baclofen at a dose of 10 mg three times daily led to symptomatic improvement in 63% of patients with rumination syndrome.This review summarizes a clinical approach to diagnosing and treating rumination syndrome. Behavioral therapy consisting of diaphragmatic breathing, with or without biofeedback, remains the most effective treatment strategy for patients with rumination syndrome.

BACKGROUND Non-ulcer dyspepsia (NUD) is a heterogeneous disorder, which is characterized by upper gastrointestinal symptoms and sensorimotor disturbances, including abnormal gastric emptying (GE) and increased intestinal chemosensitivity, and associated with greater plasma glucagon-like peptide-1 (GLP-1) levels during duodenal lipid infusion. However, the relationship(s) between these disturbances and daily symptoms in NUD is variable. We hypothesize that abnormal GE and symptoms during a GE study and during duodenal lipid infusion are associated with the severity of daily symptoms and that GLP-1 mediates symptoms during duodenal lipid infusion in NUD. METHODS Gastric emptying of solids, symptoms during the GE study and duodenal lipid infusion, and daily gastrointestinal symptoms (2 week diary) were measured in 24 healthy controls and 40 NUD patients. During duodenal lipid infusion, participants received the GLP-1 antagonist exendin 9-39 or placebo. KEY RESULTS In controls and patients, GE of solids was normal in 75% and 75%, delayed in 8% and 12.5%, or rapid in 17% and 12.5%, respectively. No controls but 26 patients (65%) had severe symptoms during the GE study. During lipid infusion, gastrointestinal symptoms were greater (P = .001) in patients and not affected by exendin. Symptoms during GE study and lipid infusion accounted for respectively 62% and 37% of variance in daily symptom severity. CONCLUSIONS In NUD, symptoms during a GE study and to a lesser extent during lipid infusion explain the variance in daily symptoms. Intestinal chemosensitivity is not reduced by GLP-1 antagonist. Assessment of symptoms during a GE study may provide a useful biomarker for NUD in research and clinical practice.

Baseline impedance measured during high-resolution impedance manometry (HRIM) can distinguish patients with gastroesophageal reflux disease (GERD) from controls, presumably due to differences in esophageal acid exposure. The characteristics of regurgitation and reflux in rumination syndrome and GERD are very different, and thus we investigated whether baseline esophageal impedance would differ in these 2 patient groups compared with controls.We compared 20 patients with rumination syndrome with 20 patients who had GERD and 40 controls. Baseline impedance was measured over 15 seconds during the landmark period of HRIM in all 18 impedance sensors on a HRIM catheter.The mean distal baseline impedance measured in ohms during HRIM was 1336 Ω [95% confidence interval (CI)=799, 1873) in patients with GERD, 1536 Ω in rumination syndrome (95% CI=1012, 2061), and 3379 Ω in controls (95% CI=2999, 3759) (P0.0001). Proximal impedance was significantly lower in the GERD and rumination groups compared with controls; rumination syndrome (2026; 95% CI=1493, 2559 Ω), GERD (2572; 95% CI=2027, 3118 Ω), and controls (3412; 95% CI=3026, 3798 Ω) (P0.001).Baseline impedance measured during HRIM in patients with rumination syndrome is significantly lower than controls and appears similar to patients with GERD both in the proximal and distal esophagus. These findings suggest that the postprandial regurgitation in rumination syndrome alters both the distal and proximal esophageal mucosal barrier.

Background Neostigmine, an acetyl cholinesterase inhibitor, stimulates colonic motor activity and may induce vagally mediated cardiovascular effects. Our aim was to evaluate effects of i.v. neostigmine on colonic compliance and its safety in patients with chronic constipation. Methods We retrospectively reviewed medical records of a selected group of 144 outpatients with chronic constipation who were refractory to treatment. These patients had undergone intracolonic motility and compliance measurements with an infinitely compliant balloon linked to a barostat. Data abstracted included barostat balloon mean volumes with increases in pressure (4 mmHg steps from 0 to 44 mmHg) before and after i.v. neostigmine. Vital signs and oxygen saturation before and after neostigmine were recorded. Key Results Of the 144 patients, 133 were female, mean age was 41.0 ± 15.4 years (SD), and duration of constipation was 12.9 ± 13.8 years. Among patients who had undergone colonic transit measurement by scintigraphy, the overall colonic transit at 24 h (geometric center, GC24 [n = 115]) was 1.5 ± 0.7 (normal >1.3), and at 48 h (GC48 [n = 75]) it was 2.3 ± 0.9 (normal >1.9). Neostigmine decreased colonic compliance at lower distension pressures (e.g., 12 and 20 mmHg [both p < 0.001]), but not at 40 mmHg. There were expected minor changes in vital signs in response to neostigmine in 144 patients; however, one patient developed unresponsiveness, significant bradycardia, hypotension, and muscular rigidity that responded to 400 mcg i.v. atropine. Conclusions & Inferences Neostigmine significantly decreases colonic compliance in patients with refractory chronic constipation. Symptomatic bradycardia in response to neostigmine should be promptly reversed with atropine.

Rumination syndrome is a functional gastrointestinal disorder characterized by effortless, postprandial regurgitation. Duodenal eosinophilia has been described in patients with functional dyspepsia. Because of the significant symptomatic overlap between functional dyspepsia and rumination syndrome, we hypothesized that histological changes might exist among patients with rumination syndrome. We included patients with rumination syndrome in whom we had obtained duodenal biopsies and compared these with controls. Digital images of biopsy specimens were analyzed for routine pathology and eosinophil counts by a pathologist blinded to the case–control status. The 22 patients with rumination syndrome had a mean age of 39.2 years (range 21–71) and 77% were female. The 10 controls had a mean age of 34.3 (range 27–69) and 80% were female. There was a significant increase in the mean eosinophil count among the patients with rumination syndrome compared to controls, 26 per mm2 (range 16–42) versus 18 per mm2 (range 10–28), p = 0.006. Intraepithelial lymphocyte counts were significantly higher in rumination patients (mean 15/100 enterocytes, range 8–29) versus controls (mean 11/100 enterocytes, range 11–18), p = 0.02. Patients with rumination syndrome have subtle duodenal pathology with eosinophilia and increased intraepithelial lymphocyte counts compared to controls.

BACKGROUND Current management of refractory benign oesophageal strictures with endoscopic dilations and stenting leads to resolution of dysphagia in only 30% of patients. Oesophageal self-dilation may be an alternative. AIM To evaluate the efficacy and safety of oesophageal self-dilation at a tertiary referral centre. METHODS We conducted a retrospective review of patients with refractory benign oesophageal strictures who participated in oesophageal self-dilation at Mayo Clinic (Rochester, MN, USA) between 2003 and 2017. Clinical data including stricture characteristics, Dakkak and Bennett Dysphagia Score, number and dates of endoscopies, and complications were collected. A two-tailed paired Student's t test was used to compare the measures of efficacy, with differences considered significant at a 5% probability level. RESULTS We identified 52 patients with refractory strictures treated with self-dilation. The median number of endoscopic interventions was reduced from 9.5 (range 5-30) to 0 (range 0-3) within 12 months before and after self-dilation, respectively (P

Smaller studies have suggested seasonal variation of the diagnosis of eosinophilic esophagitis with more patients being diagnosed in the aeroallergen season. We evaluated a large group of adult patients for a seasonal variation of the diagnosis of symptomatic eosinophilic esophageal infiltration. We performed a retrospective review of adult patients from a large Eosinophilic esophagitis database at the Mayo Clinic Rochester. We only included patients from three states in the upper Midwest, who had 15 or more eosinophils per high-power field on esophageal biopsy, symptomatic dysphagia, and were seen, in our Gastroenterology Clinic between 2000 and 2008. Clinical data were abstracted and the month of diagnosis was determined. The Rayleigh circular test and the Chi-square goodness-of-fit test were used to detect seasonality of symptomatic esophageal eosinophilia diagnosis and seasonality corrected for esophagogastroduodenoscopy monthly volume. The diagnosis of symptomatic eosinophilic esophageal infiltration was made in 372 patients. The mean number of eosinophils was 39.6 per high-power field. The December/January and May/June periods seem to have an increased presentation rate (p = 0.014). Of those tested, reactions to any aeroallergen was present in 69 % (48/70), reactions to >4 aeroallergens in 47 % (33/70) and reactions to any food allergen in 63 % (50/80) of patients. There was no evidence of monthly concentration of symptomatic esophageal eosinophilia diagnosis in the subgroups of patients with any positive aeroallergen, >4 positive aeroallergens, or history of atopy. The diagnosis of symptomatic esophageal eosinophilia is not made more frequently in the summer months.

Background The etiology of irritable bowel syndrome (IBS) is not been fully elucidated, but childhood trauma may disturb the brain–gut axis and therefore be important. Thus, we conducted a family based case–control study of IBS cases and their relatives with the aims to (i) determine the frequency of childhood trauma among IBS cases and controls as well as their relatives, and (ii) assess childhood trauma among IBS cases with affected relatives (familial IBS). Methods Outpatients with IBS, matched controls, and their first-degree relatives completed a self-report version of Bremner' Early Trauma Inventory. Percent of cases and controls with a family history were compared and odds ratios were computed using chi-squared test; recurrence risks to relatives were computed using logistic regression and generalized estimating equations. Key Results Data were collected from 409 cases, 415 controls, 825 case relatives, and 921 control relatives. IBS cases had a median age of 50 and 83% were women. Of IBS cases, 74% had experienced any general trauma compared to 59% among controls, yielding an odds ratio of 1.56 (95% CI: 1.13–2.15, p

BACKGROUND & AIMS: Screening for Barrett's esophagus (BE) with conventional esophagogastroduodenoscopy (C-EGD) is expensive. We assessed the performance of a clinic-based, single use transnasal capsule endoscope (EG Scan II) for the detection of BE, compared to C-EGD as the reference standard. METHODS: We performed a prospective multicenter cohort study of patients with and without BE recruited from 3 referral centers (1 in the United States and 2 in the United Kingdom). Of 200 consenting participants, 178 (89%) completed both procedures (11% failed EG Scan due to the inability to intubate the nasopharynx). The mean age of participants was 57.9 years and 67% were male. The prevalence of BE was 53%. All subjects underwent the 2 procedures on the same day, performed by blinded endoscopists. Patients completed preference and validated tolerability (10-point visual analogue scale [VAS]) questionnaires within 14 days of the procedures. RESULTS: A higher proportion of patients preferred the EG Scan (54.2%) vs the C-EGD (16.7%) (P < .001) and the EG Scan had a higher VAS score (7.2) vs the C-EGD (6.4) (P = .0004). No serious adverse events occurred. The EG Scan identified any length BE with a sensitivity value of 0.90 (95% CI, 0.83-0.96) and a specificity value of 0.91 (95% CI, 0.82-0.96). The EG Scan identified long segment BE with a sensitivity value of 0.95 and short segment BE with a sensitivity values of 0.87. CONCLUSIONS: In a prospective study, we found the EG Scan to be safe and to detect BE with higher than 90% sensitivity and specificity. A higher proportion of patients preferred the EG Scan to C-EGD. This device might be used as a clinic-based tool to screen populations at risk for BE. ISRCTN registry identifier: 70595405; ClinicalTrials.gov no: NCT02066233.

IBS is a common disorder that affects approximately 5-20% of the populations of Western countries; the main symptoms are abdominal pain and erratic, altered bowel habits, often accompanied by bloating. Despite an array of available pharmacological and nonpharmacological treatments aimed at a wide variety of gastrointestinal and brain targets, many patients do not report adequate symptom relief. The effect of IBS on an individual can be enormous, and the societal and financial costs overall are high, which is indicative of an unmet need for effective IBS treatments. Intense research efforts are ongoing that range from the development of new molecules for pharmacological therapies to testing the utility of internet technology to facilitate widespread delivery of efficacious behavioural therapy. This Review discusses the latest treatments for IBS, including novel nonpharmacological and pharmacological approaches. We have included estimates of the number needed to treat and the number needed to harm for selected treatments. Emerging and potential future treatments are included, with the data supporting an optimistic view about the future of IBS therapeutics. The ability to optimize therapy by individualizing management whilst also avoiding harm remains the key to achieving the best possible outcomes with currently available therapeutics.

What you need to know Barrett’s oesophagus is a premalignant condition where the oesophageal squamous epithelium undergoes columnar change with metaplasia which predisposes to the development of oesophageal adenocarcinoma. In order for Barrett’s oesophagus to be diagnosed, a segment of the lower oesophagus has to be replaced by columnar tissue (fig 1⇓). In patients with oesophageal columnar tissue without intestinal metaplasia the cancer risk is thought to be low. Many patients with Barrett’s oesophagus have no symptoms. Development of oesophageal adenocarcinoma is understood to progress in a stepwise manner following the sequence of oesophagitis, metaplasia, dysplasia, and finally adenocarcinoma (fig 2⇓). This review describes how Barrett’s oesophagus is diagnosed and explores questions regarding current and future management strategies for Barrett’s oesophagus. Fig 1 Endoscopic view and diagram of Barrett’s oesophagus Fig 2 Diagram of progression of Barrett’s oesophagus from normal oesophageal epithelium to oesophageal adenocarcinoma #### Methods We searched PubMed, Medline, and the Cochrane database from inception to November 2015 using the primary search terms “Barrett’s oesophagus,” “Barrett’s management,” and “endoscopic therapy for Barrett’s.” Abstracts published in English were included. Priority was given to randomised controlled trials and meta-analyses; citations from case series and retrospective studies were included where appropriate. The prevalence of Barrett’s oesophagus ranges varies widely in the general population depending on the definition of diagnosis and …

Background & Aims Hyperglycemia is implicated as a major risk factor for delayed gastric emptying in diabetes mellitus and vice versa. However, the extent to which hyperglycemia can affect gastric emptying and vice versa and the implications for clinical practice are unclear. We systematically reviewed the evidence for this bidirectional relationship and the effects of pharmacotherapy for diabetes on gastric emptying. Methods Full-length articles investigating the relationship between diabetes mellitus and gastroparesis were reviewed primarily to quantify the relationship between blood glucose concentrations and gastrointestinal sensorimotor functions, particularly gastric emptying, and gastrointestinal symptoms. The effects of drugs and hormones that affect glycemia on gastrointestinal sensorimotor functions were also evaluated. Results Acute severe hyperglycemia delayed gastric emptying relative to euglycemia in type 1 diabetes; the corresponding effects in type 2 diabetes are unknown. Limited evidence suggests that even mild hyperglycemia (8 mmol/L) can delay gastric emptying in type 1 diabetes. Long-term hyperglycemia is an independent risk factor for delayed gastric emptying in type 1 diabetes. There is little evidence that delayed gastric emptying causes hypoglycemia in diabetes and no evidence that improved control of glycemia improves gastric emptying or vice versa. Glucagon-like peptide-1 agonists but not dipeptidylpeptidase-4 inhibitors given acutely delay gastric emptying, but tachyphylaxis may occur. Conclusions Although acute severe and chronic hyperglycemia can delay gastric emptying, there is limited evidence that delayed gastric emptying is an independent risk factor for impaired glycemic control or hypoglycemia in diabetes. The impact of improved glycemic control on gastric emptying and vice versa in diabetes is unknown.

While high resolution esophageal manometry combined with impedancometry has demonstrated that gastric pressurizations lead to rumination, the contribution of upper esophageal sphincter (UES) and esophagogastric junction (EGJ) function to rumination is unclear. Behavioral therapy with diaphragmatic breathing (DB) can reduce rumination. We aimed to evaluate the pressures in the stomach, EGJ and UES during rumination and the effects of DB augmented with biofeedback therapy.Sixteen patients with rumination were studied with manometry and impedancometry before and after a meal. The postprandial assessment comprised three periods: before, during, and after DB augmented with biofeedback therapy.All patients had postprandial rumination, which was associated (p0.001) with increased gastric pressure and reversal of the postprandial gastroesophageal pressure gradient from -4 (-43 to 18) before to 20 (7-79) mmHg during rumination. The EGJ pressure was lower (p0.001) during gastric pressurizations that were associated with rumination vs those that were not. The UES also relaxed, almost completely, during rumination. Patients had a median (range) of 5 (2-10) rumination episodes before, 1 (0-2) (p0.001) during, and 3 (1-5) after (p0.001 vs during) diaphragmatic breathing. During manometry and impedancometry, DB was well-tolerated and learned within 5 min. Diaphragmatic breathing increased EGJ pressure (p0.001) and restored a negative gastroesophageal pressure gradient (-20 mmHg [-80 to 7]).Diaphragmatic breathing aided with high resolution esophageal manometry is well-tolerated, effective and averts the gastroesophageal pressure disturbance that leads to rumination.

Enhanced characterization of esophageal peristaltic and sphincter function provided by esophageal pressure topography (EPT) offers a potential diagnostic advantage over conventional line tracings (CLT). However, high-resolution manometry (HRM) and EPT require increased equipment costs over conventional systems and evidence demonstrating a significant diagnostic advantage of EPT over CLT is limited. Our aim was to investigate whether the inter-rater agreement and/or accuracy of esophageal motility diagnosis differed between EPT and CLT. Forty previously completed patient HRM studies were selected for analysis using a customized software program developed to perform blinded independent interpretation in either EPT or CLT (six pressure sensors) format. Six experienced gastroenterologists with a clinical focus in esophageal disease (attendings) and six gastroenterology trainees with minimal manometry experience (fellows) from three academic centers interpreted each of the 40 studies using both EPT and CLT formats. Rater diagnoses were assessed for inter-rater agreement and diagnostic accuracy, both for exact diagnosis and for correct identification of a major esophageal motility disorder. The total group agreement was moderate (κ=0.57; 95% CI: 0.56-0.59) for EPT and fair (κ=0.32; 0.30-0.33) for CLT. Inter-rater agreement between attendings was good (κ=0.68; 0.65-0.71) for EPT and moderate (κ=0.46; 0.43-0.50) for CLT. Inter-rater agreement between fellows was moderate (κ=0.48; 0.45-0.50) for EPT and poor to fair (κ=0.20; 0.17-0.24) for CLT. Among all raters, the odds of an incorrect exact esophageal motility diagnosis were 3.3 times higher with CLT assessment than with EPT (OR: 3.3; 95% CI: 2.4-4.5; P

Irritable bowel syndrome is one of the most common gastrointestinal disorders in developed nations. It is characterized by abdominal pain, altered bowel habits, and bloating. Several non-pharmacological and pharmacological agents, which target the peripheral gastrointestinal system and central nervous system, are used to treat the syndrome. The individual and societal impact of investigating and managing the syndrome is substantial, and despite newer treatments, many patients have unmet needs. Intense research at many international sites has improved the understanding of pathophysiology of the syndrome, but developing treatments that are effective, safe, and that have tolerable side effects remains a challenge. This review briefly summarizes the currently available treatments for irritable bowel syndrome then focuses on newer non-pharmacological and pharmacological therapies and recent evidence for older treatments. Recent guidelines on the treatment of irritable bowel syndrome are also discussed.

Background Fundoplication surgery is a commonly performed procedure for gastro-esophageal reflux disease or hiatal hernia repair. Up to 10% of patients develop persistent postoperative dysphagia after surgery. Data on the effectiveness of pneumatic dilation for treatment are limited. The aim of this study was to evaluate clinical outcomes and identify clinical factors associated with successful response to pneumatic dilation among patients with persistent postfundoplication dysphagia (PPFD). Methods We retrospectively evaluated patients who had undergone pneumatic dilation for PPFD between 1999 and 2016. Patients with dysphagia or achalasia prior to fundoplication were excluded. Demographic information, surgical history, severity of dysphagia, and clinical outcomes were collected. Data pertaining to esophagram, manometry, endoscopy, and pneumatic dilation were also collected. Results We identified 38 patients (82% female, 95% Caucasian, and median age 59 years) with PPFD who completed pneumatic dilation. The median postfundoplication dysphagia score was 2. Eleven patients had abnormal peristalsis on manometry. Seventeen patients reported response (seven complete) with an average decrease of 1 in their dysphagia score. Fifteen patients underwent reoperation due to PPFD. Hiatal hernia repair was the only factor that predicts a higher response rate to pneumatic dilation. Only one patient in our study developed complication (pneumoperitoneum) from pneumatic dilation. Conclusion & inferences We found that pneumatic dilation to be a safe treatment option for PPFD with moderate efficacy. Patients who developed PPFD after a hiatal hernia repair may gain the greatest benefit after pneumatic dilation. We were not able to identify additional clinical, radiological, endoscopic, or manometric parameters that were predictive of response.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MinnesotaQuestion: A 78-year-old man presentedwith a 12-month his-tory of progressivesolid food dysphagiaand weight loss. Hedescribed a sensationof food lodging atthe level of the ster-nal notch early inthe meal withoutregurgitation, heart-burn, or nasopha-ryngeal regurgitation.His past health wasnotable for severechronic obstructivepulmonary disease(FEV

Fecal incontinence is a common problem that has been associated with anatomic, physiological, and medical conditions. There are very few data on the factors associated with fecal incontinence in elderly women.We aimed to determine the factors associated with fecal incontinence via a population-based survey in a large cohort of elderly Australian women.Data from a large longitudinal population-based study of elderly Australian women aged 82 to 87 years were analyzed.Participants were 5560 women (aged 82-87 years) who participated in the Australian Longitudinal Study on Women's Health; 4815 women responded to questions relating to fecal incontinence.Fecal incontinence was defined as leakage of liquid and/or solid stool at least once per month over the past 12 months. Self-reported medical conditions and lifestyle factors as well as demographic factors were recorded.The prevalence of fecal incontinence was 10.4% (95% CI, 9.6-11.3) (n = 510). The prevalence was significantly higher among institutional- versus community-dwelling women (14.1% vs 9.7%; p = 0.0002). Univariately, lifestyle factors including fruit intake and fluid intake, along with a range of comorbidities, were associated. However, independent factors for fecal incontinence among community-dwelling women included diabetes mellitus (OR, 1.51; 95% CI, 1.14-2.01; p = 0.004), depression (OR, 1.84; 95% CI, 1.30-2.62; p = 0.001), urinary incontinence (OR, 2.29; 95% CI, 1.83-2.86; p0.0001), and osteoarthritis (OR, 0.73; 95% CI, 0.57-0.94; p = 0.013). Among institutional-dwelling women, however, we found urinary incontinence (OR, 4.43; 95% CI, 2.83-6.93; p0.0001) and poorer general health (OR, 0.98; 95% CI, 0.97-0.99; p = 0.003) to be independently associated.This is a cross-sectional study, which prevents making conclusions about the cause and effect of observed correlations.The independent factors associated with fecal incontinence in this population do not appear readily modifiable, and many previously identified risk factors may not be important in the elderly women with fecal incontinence.

Question: An 88-year-old man presented witha 1-week history of leftupper quadrant abdom-inal pain and jaundice ona background of a 2-month history of backpain and malaise. Hisbackground medicalhistory was notable forhypertension, hypercho-lesterolemia, and mela-noma. On examination, his pulse rate was 76 bpm and blood pressure, 112/64 mmHg. He was febrile (101.8 F; 38.8 C). Peripherally,there was no palmar erythema or clubbing, but spider angiomas were noted (Figure A). He was not encephalopathic, but had diffuseabdominal tenderness, hepatomegaly with a firm liver edge, and ascites. Laboratory investigations revealed a bilirubin of 108 mmol/L,gamma-glutamyl transferase of 774 U/L, alkaline phosphatase of 418 U/L, alanine aminotransferase of 234 U/L, aspartate amino-transferase of 202 U/L, and a prothrombin time of 15 seconds. Ultrasonography demonstrated a dilated common bile duct to 13 mmand 2 hypoechoic lesions in the right lobe of the enlarged liver with a span of 20 cm. Magnetic resonance imaging of the liver showedseveral signal abnormalities (Figure B).What is the diagnosis?See the G

Background Rumination syndrome is a functional gastrointestinal disorder characterized by effortless and repetitive regurgitation of recently ingested food from the stomach to the oral cavity followed by either re-swallowing or spitting. Rumination is thought to occur due to a reversal of the esophagogastric pressure gradient. This is achieved by a coordinated abdominothoracic maneuver consisting of a thoracic suction, crural diaphragm relaxation and an increase in intragastric pressure. Careful history is important in the diagnosis of rumination syndrome; patients often report “vomiting” or “reflux” and the diagnosis can therefore be missed. Objective testing is available with high resolution manometry or gastroduodenal manometry. Increase in intra-gastric pressure followed by regurgitation is the most important characteristic to distinguish rumination from other disorders such as gastroesophageal reflux. The mainstay of the treatment of rumination syndrome is behavioral therapy via diaphragmatic breathing in addition to patient education and reassurance. Purpose The purpose of this review was to critically appraise recent key developments in the pathophysiology, diagnosis and therapy for rumination syndrome. A literature search using OVID (Wolters Kluwer Health, New York, NY, USA) to examine the MEDLINE database its inception until May 2016 was performed using the search terms “rumination syndrome,” “biofeedback therapy,” and “regurgitation.” References lists and personal libraries of the authors were used to identify supplemental information. Articles published in English were reviewed in full text. English abstracts were reviewed for all other languages. Priority was given to evidence obtained from randomized controlled trials when possible.

Fecal incontinence is a common condition, which leads to impaired quality of life and huge financial cost at an individual and societal level. Recent studies have identified novel and potentially modifiable risk factors. Newer diagnostic modalities are giving more detailed information about underlying disorders, helping to implement targeted treatment. Many therapeutic options exist, and newer treatments are changing outcomes. This article will review recent developments in mechanisms, diagnosis, and treatment of fecal incontinence.Potentially modifiable risk factors have recently been identified, and should translate to changes in clinical practice and hopefully patient outcomes. These include diarrhea, smoking, and dietary fiber. Advances have been made in anatomical and physiological testing of the anorectum and this may assist in clarifying the diagnosis and guiding management. The long-term benefit of biofeedback has been questioned but patient selection may be key. Novel pharmacological therapies (e.g., clonidine) and minimally invasive surgical procedures are changing outcomes in well selected patients. The development of a magnetic anal sphincter may add a new management alternative in patients who are refractory to conservative management.Fecal incontinence remains a clinical challenge. Only a minority of persons with fecal incontinence seek treatment, but for those who do, improved understanding of risk factors coupled with diagnostic techniques and treatments are improving outcomes.

Gastroen Question: A 59-yearold woman presented with a 12-month history of bothersome nausea and periumbilical pain occurring after most meals. The symptoms occurred within 30-60 minutes of eating and lasted 3 hours. She also reported early satiety, followed by vomiting after larger meals. Not every meal caused the symptoms, and occasionally she reports pain unrelated to meals. She denied overt sitophobia. She had lost 48 kg over the last 12 months. Her past medical history was notable for constipation, depression, and nicotine dependence. She receives regular surveillance for a 4-cm aortic abdominal aneurysm. On examination, her weight was 68 kg, and her body mass index was 25 kg/m. She had no carotid bruits and her heart sounds were normal. A widespread wheeze was noted throughout both lung fields. The abdomen was soft and nontender. Investigations revealed a hemoglobin of 14.3 g/dL, creatinine of 0.7 mg/dL, and thyroid-stimulating hormone of 4.4 mIU/L. The abdominal aortic aneurysm was palpable but no bruits were noted. Esophagogastroduodenoscopy was performed and showed marked mucosal abnormalities (Figure A, B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Upper gastrointestinal hemorrhage remains a problem in spite of improved diagnosis and management. There is sparse knowledge of recent epidemiology and outcomes. We wanted to evaluate the characteristics and outcomes of patients with upper gastrointestinal hemorrhage over a 4-year period in a tertiary referral hospital.We prospectively collected data on patients admitted with upper gastrointestinal hemorrhage to John Hunter Hospital between August 2004 and December 2008. Variables of interest included age, gender, co-morbidities, and time to endoscopy. Main outcomes included etiology, treatment, and survival. Variceal and non-variceal bleeds were analyzed separately.There were 792 admissions from 734 unique patients (61% male) with a mean age of 66 years. The most frequent causes of non-variceal bleeds (88%) included ulcers 265 (33%); Mallory Weiss tear 91 (11%); esophagitis 60 (8%), and malignancy 29 (4%). Most patients had one or more co-morbidity (74%). Transfusion was not employed in 41%. Overall mortality was 4.0% (5.4% in the variceal and 3.9% in the non-variceal group). Only 1.9% of patients had surgery.Patients presenting with upper gastrointestinal hemorrhage are overall elderly with significant co-morbidities. Our overall mortality and surgery rates are lower than in previously published international data.

The burden of illness from esophageal adenocarcinoma continues to rise in the Western world, and overall prognosis is poor. Given that Barrett’s esophagus (BE), a metaplastic change in the esophageal lining is a known cancer precursor, an opportunity to decrease disease development by screening and surveillance might exist. This review examines recent updates in the pathogenesis of BE and comprehensively discusses known risk factors. Diagnostic definitions and challenges are outlined, coupled with an in-depth review of management. Current challenges and potential solutions related to screening and surveillance are discussed. The effectiveness of currently available endoscopic treatment techniques, particularly with regards to recurrence following successful endotherapy and potential chemopreventative agents are also highlighted. The field of BE is rapidly evolving and improved understanding of pathophysiology, combined with emerging methods for screening and surveillance offer hope for future disease burden reduction.