There is a need for a simple and practical tool adapted for the diagnosis of chronic constipation (CC) in the Asian population. This study compared the Asian Neurogastroenterology and Motility Association (ANMA) CC tool and Rome III criteria for the diagnosis of CC in Asian subjects.This multicenter, cross-sectional study included subjects presenting at outpatient gastrointestinal clinics across Asia. Subjects with CC alert symptoms completed a combination Diagnosis Questionnaire to obtain a diagnosis based on 4 different diagnostic methods: self-defined, investigator's judgment, ANMA CC tool, and Rome III criteria. The primary endpoint was the level of agreement/disagreement between the ANMA CC diagnostic tool and Rome III criteria for the diagnosis of CC.The primary analysis comprised of 449 subjects, 414 of whom had a positive diagnosis according to the ANMA CC tool. Rome III positive/ANMA positive and Rome III negative/ANMA negative diagnoses were reported in 76.8% and 7.8% of subjects, respectively, resulting in an overall percentage agreement of 84.6% between the 2 diagnostic methods. The overall percentage disagreement between these 2 diagnostic methods was 15.4%. A higher level of agreement was seen between the ANMA CC tool and self-defined (374 subjects [90.3%]) or investigator's judgment criteria (388 subjects [93.7%]) compared with the Rome III criteria.This study demonstrates that the ANMA CC tool can be a useful for Asian patients with CC.
The paper by Ghoshal et al in this issue of the journal reminds us that we can still find new uses for old tests. In this study, patients with the irritable bowel syndrome (IBS) were reported to exhale higher basal breath hydrogen than asymptomatic controls. While previous studies had found that IBS patients demonstrated greater breath hydrogen excretion after fibre rich meals and lactulose, they had not reported higher basal levels.
In order to appreciate the significance of this observation, the basis of the hydrogen breath test should be reviewed. Calloway et al1 observed that intestinal hydrogen gas was released by the human intestinal microflora, and that the measurement of breath hydrogen could be used to monitor intestinal hydrogen production. At about the same time Levitt2,3 provided evidence that hydrogen gas in the intestine is generated almost exclusively from microbial fermentation of unabsorbed carbohydrates. From these observations, test protocols employing the monitoring of breath hydrogen levels were developed to detect malabsorption of various mono- and disaccharide sugars (eg, fructose, glucose and lactose) and to measure the oro-caecal transit time.4 The physico-chemical basis for the hydrogen breath test is that hydrogen being a small molecule diffuses rapidly across the colonic mucosa, where it enters the blood stream to be circulated to the lungs where it is excreted in the breath. Breath hydrogen level rises rapidly in response to intestinal hydrogen release as a measurable hydrogen response can be recorded within 2 minutes following introduction of lactulose, an unabsorbable disaccharide.5 Recent studies from John Hunter's laboratory in Cambridge demonstrated that when IBS patients were given treatments that resulted in a reduction of intestinal gas production, breath hydrogen excretion also reduced in parallel.6
What are the roles of the hydrogen breath test in the investigation of IBS? Lactose and fructose intolerance may contribute to the development of IBS symptoms, particularly, bloating, flatulence, cramps and diarrhoea. In IBS patients, diarrhoea symptoms are associated with rapid small intestinal transit, while constipation is associated with delayed transit. As breath hydrogen can be used as a surrogate measure of intestinal gas production, we can use this to study bloating and other gas related symptoms. Unfortunately while Ghoshal et al, had postulated that bloating may result from increased intestinal gas production, their study did not test for an association between bloating and basal breath hydrogen. More recently, small intestinal bacterial overgrowth (SIBO) and coeliac disease have been also been implicated in the pathogenesis of IBS, and both of these conditions could have contributed to the high basal breath hydrogen reported by Ghoshal et al in their cohort of IBS patients. While they recognised SIBO as a possible contributing factor, they appear to have overlooked the possibility of undetected coeliac disease as a confounding factor. Studies from the west suggest that patients with IBS criteria may have sub-clinical coeliac disease, and studies from India have reported a rising incidence of coeliac disease, particularly in the north.7,8 In fact, Nunes et al,9 had reported high basal breath hydrogen in coeliac disease.
The other noteworthy finding in Ghoshal's study was the correlation of breath hydrogen levels with the number of stools. If we look carefully at the symptom profile of their patients, we find that the majority had diarrhoea type symptoms; their mean number of stools at 25 a week works out to more than 3 a day, with 95% reporting loose stools and 84% more frequent stools at the onset of pain. This suggests a possible correlation between basal breath hydrogen level and rapid intestinal transit. Previous studies from India have documented relatively shorter intestinal transit times in the Indian population than those reported in the west.10 In a society like India, where many people adopt a largely vegetarian diet, especially given the prevailing belief in the benefits of a high fibre diet, one wonders how good the compliance was in Ghoshal's subjects. Thus, we can postulate that the residue of a high fibre diet, coupled with rapid transit through the small intestine, could have combined to push a large load of fermentable carbohydrates into the caecum at the start of breath hydrogen measurement. Previous studies from the UK had shown that hydrogen levels are barely detected in the breath if the subject is carefully prepared.11 One of the requirements is that the subject must not be on a high fibre diet.
One lesson to draw from this analysis of the possible factors contributing and confounding the findings in Ghoshal's study, is that future studies must take into account the need to determine the type of diet consumed, and in particular dietary fibre intake, and also impose stricter checks and controls in the pre-test preparation. However, even taking a possible confounding effect into account, the observations by Ghoshal et al, still provides us with food for thought. Is it possible after all, that a high level of fibre intake could be contributing to the pathogenesis of IBS symptoms in the Indian population? In this context, the hydrogen breath test may find new life as an important tool in epidemiological studies comparing different diets in different populations and how this contributes to the development of IBS.
Objective To evaluate the influence of sample collection time during esophagogastroduodenoscopy (EGD) on the accuracy of a newly approved point-of-care test (POCT)-based polymerase chain reaction kit for detecting Helicobacter pylori and clarithromycin susceptibility in gastric wash fluid. Methods Intragastric fluid was collected at three time points: Collection Time 1 (start of EGD), Collection Time 2 (during EGD), and Collection Time 3 (after indigo carmine spraying). POCT-based quantitative PCR (qPCR) targeting 23S rRNA domain V (2142/2143) was used to quantify H. pylori DNA in the collected fluid at all three time points and compared with qPCR targeting 16S rRNA. Patients Fifty patients with suspected H. pylori infection were consecutively enrolled in this study over a three-month period and underwent EGD. Results In 9 out of 50 EGD cases that were H. pylori-positive, no significant differences in H. pylori DNA content, quantified using POCT-based qPCR targeting 23S rRNA, were observed between the three collection times: 1 vs. 2, p=0.81; 2 vs. 3, p=0.59; 1 vs. 3. Collection Time 2 had the strongest inverse correlation with the urea breath test (r=-0.80, p=0.01) and was the only time-point at which POCT-based qPCR could detect H. pylori in case 15. Conclusion This study suggests that the optimal collection timing for the H. pylori detection POCT kit (within 60 min) using intragastric fluid (with no biopsy) may be during EGD (Collection Time 2). However, our study had a limited sample size, so the findings must be verified through large-scale, multicenter collaboration studies.
Abstract Background and Aims The efficacy of herbal medicines (HMs) for functional gastrointestinal disorders (FGIDs) including irritable bowel syndrome (IBS), functional dyspepsia (FD) and functional constipation (FC) is controversial. A systematic review with meta‐analysis was conducted to determine their effectiveness for FGIDs. Methods We searched the following electronic databases till July 2019 with English language restriction: The Cochrane Library, EMBASE and PUBMED. Randomized double‐blind controlled trials of HMs compared with placebo or conventional pharmacological drugs for adult FGIDs patients were included. Results In total, 49 trials involving 7396 participants with FGIDs were included. The risk of bias was low in 9, unclear in 36, and high in 4 trials. More than 33 different herbal formulae were tested. HMs demonstrated statistically significant benefits for symptom improvement compared with placebo in 46 trials (RR = 1.67, 95% CI 1.48–1.88). When compared with conventional pharmacological therapy in 5 trials, HMs were found to be non‐inferior (RR = 1.10, 95% CI 1.03–1.18). The number of trials with regards to FD, IBS and FC were 19, 23 and 7 respectively. Subgroup analysis found that HMs were better than placebo in alleviating symptoms for FD (RR = 1.50, 95% CI 1.32–1.69), IBS (RR = 1.62, 95% CI 1.32–1.97) and FC (RR = 3.83, 95% CI 2.26–6.50). HMs tended to have more patients with adverse events than placebo, but similar to conventional pharmacological drugs. Conclusions Our findings provide a positive signal for HMs as a potentially well‐tolerated and effective treatment for FGIDs, deserving further examination in high‐quality trials.
Sirs, We appreciate the interest of Drs Mahadeva and Goh1 in our article.2 We agreed that our conclusions were mostly based on the data from East Asia, as only two articles from Southeast Asia were included. As discussed in our article, the malignancy detection rates in Singapore3 and Malaysia4 were relatively low which implies that prompt endoscopy for uninvestigated dyspepsia patients in Southeast Asia might not be as crucial as in East Asia, especially in China and Korea. However, more studies from Southeast Asia are needed before a definite conclusion can be drawn. It has been shown that the prevalence of gastric cancer in Asia has decreased over the decades5 and our included studies ranged from 1990 to 2009.2 The bias due to the long-time span could not be ignored, but we performed subgroup analyses by publication year to address this bias. We found that the malignancy detection rate among dyspepsia patients after 2005 was lower than that before 2005.2 However, the pooled prevalence of gastric cancer in Asia in the past decade was still higher than that in Western countries.6 Drs Mahadeva and Goh mentioned that cancer patients with dyspepsia symptoms usually present at an advanced stage7 and prompt endoscopy may not alter their prognosis.1 However, this does not necessarily mean that dyspepsia patients do not develop early gastric carcinoma, for the following reasons. First, the populations in the study of Schmidt et al. were gastric cancer patients rather than dyspepsia patients. Second, some potential early gastric cancer patients might have ignored dyspepsia symptoms and were therefore only detected at an advanced stage of the disease, when they consulted a physician because the symptoms were long-lasting and unbearable. Third, this study also demonstrated that early gastric cancer patients usually presented without alarm features, which means that prompt endoscopy might be important to detect early gastric cancers. Therefore, it remains unknown whether dyspepsia patients with cancer usually have an advanced stage of the disease. Our included studies did not investigate the staging of detected carcinoma among dyspepsia patients, and this information should be a priority for future studies. In summary, prompt endoscopy should be considered as the initial strategy for dyspepsia in East Asia and more prospective, large-scale and multicentre studies are needed to confirm the findings. The authors' declarations of personal and financial interests are unchanged from those in the original article.2
Abstract Historically, the epidemiology of gastrointestinal diseases in Asia was different from that in Western countries. Early studies suggested a low prevalence of irritable bowel syndrome (IBS) in Asia. As the diagnosis of IBS is symptom‐based and as symptom perception, expression, and interpretation are influenced by sociocultural perspectives including language, the presentation of IBS is expected to vary in different communities. Furthermore, the pathogenesis is multifactorial with psychosocial (stress, illness, behavior, and diet) and biological (infection, gut microbiota, and immune activation) variables interacting, and so, the present study can anticipate that the development of IBS will vary in different environments. In recognition of this aspect of functional gastrointestinal disorders, the recently published Rome IV documents have provided greater focus on cross‐cultural factors. In this review, the present study seeks to highlight Asian perspectives by identifying historical trends and recent publications from the region and comparing these with the observations from Western societies.
Background Data on Asian patients who present to primary care physicians with dyspepsia are limited. Aim To determine predictors of response to a trial of proton pump inhibitor therapy. Method One hundred ninety patients presenting to their general practitioners with dyspeptic symptoms but without alarm symptoms, underwent endoscopy and were subsequently treated with 20 mg of esomeprazole twice a day for 2 weeks. Possible predictors of response were assessed before treatment. Dyspeptic symptoms were scored at baseline and at the end of treatment. Excellent response and poor response were defined as end of treatment score of ≤1 and failure to achieve ≥50% reduction in symptom scores. Results On bivariate analysis male sex and having ≤2 concurrent dyspeptic symptoms predicted excellent response, whereas bloating as most bothersome symptom, >2 dyspeptic symptoms, anxiety, and irritable bowel syndrome predicted poor response. On multivariate analysis, male sex and ≤2 dyspeptic symptoms, and bloating remained significant predictors of excellent and poor responses, respectively. Conclusions Predictors of response to proton pump inhibitor trial that could be easily assessed in a primary care clinic were identified. In our population the response was not as favorable as suggested by clinical trials. Frequent overlap with irritable bowel syndrome seems to be an important factor.
Abstract The Asia‐Pacific region is diverse, with regard to ethnicity, culture, and economic development incorporating some of the world's least and most developed nations. Gastrointestinal diseases are common in the Asia‐Pacific region, and their prevalence, presentation, and management vary considerably within the region. There is growing evidence for an important role for the human gut microbiota in gastrointestinal health. As a consequence, geographic variations in the composition of the gut microbiota may contribute to variations in both the prevalence and response to therapy of specific diseases. Probiotics have been proposed as a valuable option in the prevention and treatment of a number of gastrointestinal illnesses, but the quality of available evidence to support their efficacy is variable. A meeting of international experts in adult and pediatric gastroenterology was held at the Sorbonne University, Paris, France, on April 11 and 12, 2016, to discuss current evidence supporting the use of probiotics in gastrointestinal disorders in the Asia‐Pacific region. This article provides an overview of the discussions held at this meeting and recommends the formation of an Asia‐Pacific Consortium on Gut Microbiota similar to those established in Europe and North America.
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