Bloating and functional gastro-intestinal disorders: Where are we and where are we going?

Bloating is one of the most common and bothersome symptoms complained by a large proportion of patients. This symptom has been described with various definitions, such as sensation of a distended abdomen or an abdominal tension or even excessive gas in the abdomen, although bloating should probably be defined as the feeling (e.g. a subjective sensation) of increased pressure within the abdomen. It is usually associated with functional gastrointestinal disorders, like irritable bowel syndrome, but when bloating is not part of another functional bowel or gastrointestinal disorder it is included as an independent entity in Rome III criteria named functional bloating. In terms of diagnosis, major difficulties are due to the lack of measurable parameters to assess and grade this symptom. In addition, it is still unclear to what extent the individual patient complaint of subjective bloating correlates with the objective evidence of abdominal distension. In fact, despite its clinical, social and economic relevance, bloating lacks a clear pathophysiology explanation, and an effective management endorsement, turning this common symptom into a true challenge for both patients and clinicians. Different theories on bloating etiology call into questions an increased luminal contents (gas, stools, liquid or fat) and/or an impaired abdominal empting and/or an altered intra-abdominal volume displacement (abdomino-phrenic theory) and/or an increased perception of intestinal stimuli with a subsequent use of empirical treatments (diet modifications, antibiotics and/or probiotics, prokinetic drugs, antispasmodics, gas reducing agents and tricyclic antidepressants). In this review, our aim was to review the latest knowledge on bloating physiopathology and therapeutic options trying to shed lights on those processes where a clinician could intervene to modify disease course.

Assessment of in Situ Anthelminthic Activity of Ethanolic Extract of Bidens pilosa against Adult’s Gastro-Intestinal Strongyle of Small Ruminants

Infections caused by gastrointestinal nematodes are major threats to livestock industry in the developing countries. They cause direct effects in form of loss in production and indirect economic losses due to high cost of anthelmintic drugs. Various alternative strategies are in practice to control parasitism which includes the usage of medicinal plants. This study evaluates the in situ anthelminthic activity of Bidens pilosa ethanolic extract on gastro-intestinal strongyles of small ruminants. Twenty (20) naturally infested goats of both sexes were distributed into 5 groups (n = 4) corresponding to groups receiving Tween 80 at 2.8%, Albendazole at 5 mg/kg and the three doses of extract (125, 250 and 500 mg/kg). The doses of extract and 2.8% Tween 80 were administered twice daily for 3 consecutive days while Albendazole was administered in a single dose. Faecal eggs count reduction, body weight, packed cell volume (PCV) and total worm count reduction were determined. Results showed that the ethanolic extract of B. pilosa was not effective against adult worms while Albendozole inflicted a 100% reduction of eggs count and total worm count of digestive strongyle. Body weight and PCV remain almost constant. This study indicates that ethanolic extract of B. pilosa at tested doses has no anthelminthic activity. However, further optimization and standardization of the ethanolic extract of B. pilosa could enhance its anthelminthic activity.

Validity of Upper Gastro-Intestinal Endoscopic Screening in HCV Cirrhotic Patients Awaiting Antiviral Therapy

Background and Aim: The Egyptian Ministry of Health initiated a nationwide HCV treatment program with the newly developed oral antiviral therapies and formulated national guidelines for treatment allocation which gave favor for patients with advanced fibrosis and early cirrhosis. One of the recommendations for treatment was upper Gastro-intestinal (GIT) endoscopy. This study aimed at estimating the prevalence of varices among those patients and judging the validity of this national recommendation. Methods: This study was carried out at gastrointestinal endoscopy units, Zagazig University Hospitals through the year 2014. The epidemiologic, clinical features and endoscopic findings of patients undergoing preparation for HCV therapy were analyzed. Endoscopic classifications of esophageal and gastric varices were carried out after the Italian liver cirrhosis project and Sarin’s classification respectively. Results: Totally 1143 patients performed upper GIT endoscopy as preparation for HCV treatment. This comprised 22% of all patients undergoing upper GIT endoscopy over that year. There was a fourfold rise in percentage of patients undergoing endoscopy for sofosbuvir-based therapy in this year (22%) when compared to assessment for Interferon/Ribavirin combination therapy (5%) in the previous year. A total of 361 patients had no esophageal or gastric varices. Small sized (grade I), medium sized (grade II) and large sized (grade III) varices were reported in 301, 188 and 293 patients respectively. Thirty patients (2.6%) had gastric varices. The prevalence of varices was higher in Child B in comparison to Child A (statistically not significant, p = 0.243). Conclusion: Screening endoscopy for early cirrhotic patients awaiting oral anti-HCV therapy is valid.

Common Gastro-Intestinal Parasites of Goats (<i>Capra aegagrus hircus</i>) from Mogadishu, Somalia

This study was conducted in two districts in Mogadishu, particularly smallholders to determine the Common gastrointestinal (GIT) parasites of Somali Goats. During the last two years, researchers meet many cases of goats having diarrhea, anemia and loss of body weight. That is the reason to conduct this study. The methodology of this study is explanation research with using lab technician for studied current prevalence cases of gastro-intestinal parasite of goat in Mogadishu Somalia. Study areas were two districts (Dayniile and Wadajir) located in Mogadishu Benadir region, Somali. Researcher has collected sample of feces from Somali goats in smallholders and transported the fecal containing box to the laboratory Room at University campus. Researchers made examination of fecal using Direct Smear Fecal Exam and then used Light microscope for identification of parasite eggs and oocytes, with 10× or 40× objective magnification. Data analysis was percentage and P value ≤ 0.005. Result: The result of this study revealed an overall prevalence of Gastro-intestinal parasites of Somali goats in the investigated area was 72.1% that means 62 samples were positive, and 24 samples were negative of gastro-intestinal parasites. Haemonchus spp (Nematodes) and Coccidia (Eimeria spp) were the most prevalent parasites recorded in all the 62 positive samples, having Haemonchus 23 (26.74%) and Eimeria spp 38 (44.19%);the second highest groups were all nematode with percentage Strongyloides 22 (25.58%), and Trichostrongylus 17 (19.77%). This study revealed statistically significant difference (P 0.05 that equals to P = 0.235. Recommendation: Researcher recommends making seasonal deworming to Somali goats in small holders which will reduce the prevalence and incidence of gastro-intestinal parasites in Somali goats.

Gastro-Intestinal Parasites of Camels (Camelus dromedarius) from Mogadishu, Somalia

Somalia has the largest dromedary (Camelus dromedarius) population in the world. However, scientific research and camel diseases investigation in the country were lacking since 1980s. A total of 167 camels (131 semi-intensive dairy camels system and 36 free grazing systems) were sampled from three districts in Mogadishu citybetween December 2015 and March 2016 to investigate the prevalence rate of gastro-intestinal parasites in camels from Mogadishu city using different coprological techniques. The overall prevalence of camel gastro-intestinal parasites was 50.3%. The prevalence rate were significantly varies between the extensive and semi-intensive production systems (p = 0.000) and between the different districts (p = 0.000). Nematodes revealed higher prevalence rate (47.9%) than Cestodes (6.0%), Trematodes (4.2%) and Coccidia (0.65%). Eggs of eight genera of nematodes, two genera of trematodes and two genera of cestodes as well as Eimeria sp. Oocysts were identified in this study. Dictyocaulus sp. and Trichostrongylus sp. were the most prevalent followed by Parascaris equorum and Strongyloides sp. About 56.0% of the infected camels revealed mix-infection of up to five different parasite species. Moreover, 35.7% of these animals revealed heavy infection. The important role of the camel has inspired investigators and researchers to look for diseases that may threaten camel health and production. However, in Somalia in spite of having the largest counts of camels but in depth scientific data are not available. Therefore, the present paper was to be the first detailed data on camel gastro-intestinal parasites in Mogadishu area and may be in whole Somalia. We came to conclude that gastrointes-tinal parasites were highly prevalent in camels from Mogadishu particularly in nomadic herds of camels. Studies on the effect of gastro-intestinal parasites on camel production and productivity are recommended. Moreover, the intensive system of camel production should be encouraged.

A case study: acupuncture combined with oriental medicine for lower gastro-intestinal bleeding

Objective To report the clinical approach and effectiveness of traditional Chinese medicine in the complementary treatment and symptom management of lower gastro-intestinal bleeding （LGIB） due to neoplasms. Methods A single case report of a 54-year-old female with a chronic case of LGIB due to neoplasms was observed. Acupuncture, moxibustion, and Chinese herbal medicine were administered in the patient＇s treatment plan. Results After 16 treatments over the course of 26 weeks, the patient had a significant drop in the amount of hematochezia, positive outcomes in the patient＇s vitality and quality of life. Conclusion Acupuncture, oriental medicine and moxibustion （AOM） may provide new options for effective management and improvement for LGIB for the patient＇s quality of life with less invasive modalities that could help to reduce healthcare costs, patient morbidit as well as mortality rates.

Cronkhite-Canada Syndrome:an unusual finding of gastro-intestinal adenomatous polyps in a syndrome characterized by hamartomatous polyps

Cronkhite-Canada syndrome is a rare,hamartomatous polyposis syndrome of unknown etiology.Hamartomatous gastrointestinal polyps,alopecia,onychodystrophy,cutaneous hyperpigmentation,abdominal pain,diarrhea,and complications of weight loss are typical of the syndrome.In this report,we describe a pathological finding of colonic adenomatous polyposis as opposed to hamartomatous polyposis.We also describe our treatment,long-term therapeutic plan,and the need for further research.

Utility of urgent colonoscopy in acute lower gastro-intestinal bleeding:a single-center experience

Background.The role of urgent colonoscopy in lower gastro-intestinal bleeding(LGIB)remains controversial.Over the last two decades,a number of studies have indicated that urgent colonoscopy may facilitate the identification and treatment of bleeding lesions;however,studies comparing this approach to elective colonoscopy for LGIB are limited.Aims.To determine the utility and assess the outcome of urgent colonoscopy as the initial test for patients admitted to the intensive care unit(ICU)with acute LGIB.Methods.Consecutive patients who underwent colonoscopy at our institution for the initial evaluation of acute LGIB between January 2011 and January 2012 were analysed retrospectively.Patients were grouped into urgent vs.elective colonoscopy,depending on the timing of colonoscopy after admission to the ICU.Urgent colonoscopy was defined as being performed within 24 hours of admission and those performed later than 24 hours were considered elective.Outcomes included length of hospital stay,early re-bleeding rates,and the need for additional diagnostic or therapeutic interventions.Multivariable logistic regression analysis was performed to identify factors associated with increased transfusion requirements.Results.Fifty-seven patients underwent colonoscopy for the evaluation of suspected LGIB,24 of which were urgent.There was no significant difference in patient demographics,co-morbidities,or medications between the two groups.Patients who underwent urgent colonoscopy were more likely to present with hemodynamic instability(P=0.019)and require blood transfusions(P=0.003).No significant differences in length of hospital stay,re-bleeding rates,or the need for additional diagnostic or therapeutic interventions were found.Patients requiring blood transfusions(n=27)were more likely to be female(P=0.016)and diabetics(P=0.015).Fourteen patients re-bled at a median of 2 days after index colonoscopy.Those with hemodynamic instability were more likely to re-bleed[HR 3.8(CI 1.06–13.7)],undergo angiography[HR 9.8(CI 1.8–54.1)],require surgery[HR 13.5(CI 3.2–56.5)],and had an increased length of hospital stay[HR 1.1(1.05–1.2)].Conclusion:The use of urgent colonoscopy,as an initial approach to investigate acute LGIB,did not result in significant differences in length of ICU stay,re-bleeding rates,the need for additional diagnostic or therapeutic interventions,or 30-day mortality compared with elective colonoscopy.In a pre-specified subgroup analysis,patients with hemodynamic instability were more likely to re-bleed after index colonoscopy,to require additional interventions(angiography or surgery)and had increased length of hospital stay.

A rare cause of gastro-intestinal hemorrhage in a patient with a Roux-en-Y gastric bypass

This case illustrates a rare cause of gastro-intestinal bleeding following bariatric surgery.Though it is essential to rule out common causes of variceal formation accompanied by intermittent,profuse bleeding,there should be a high degree of suspicion of this rare etiology in patients who have previously undergone alteration of their anatomy,especially Roux-en-Y gastric bypass(RYGB).The case emphasizes the need for a multidisciplinary medical-surgical team in evaluating and treating patients who present with complex intra-abdominal pathology.

Paradoxical association between dyspepsia and autoimmune chronic atrophic gastritis:Insights into mechanisms,pathophysiology,and treatment options

BACKGROUND Autoimmune gastritis(AIG)is a progressive,chronic,immune-mediated inflammatory disease characterized by the destruction of gastric parietal cells leading to hypo/anacidity and loss of intrinsic factor.Gastrointestinal symptoms such as dyspepsia and early satiety are very common,being second in terms of frequency only to anemia,which is the most typical feature of AIG.AIM To address both well-established and more innovative information and knowledge about this challenging disorder.METHODS An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature(retrospective and prospective studies,systematic reviews,case series)published in the last 10 years.RESULTS A total of 125 records were reviewed and 80 were defined as fulfilling the criteria.CONCLUSION AIG can cause a range of clinical manifestations,including dyspepsia.The pathophysiology of dyspepsia in AIG is complex and involves changes in acid secretion,gastric motility,hormone signaling,and gut microbiota,among other factors.Managing dyspeptic symptoms of AIG is challenging and there are no specific therapies targeting dyspepsia in AIG.While proton pump inhibitors are commonly used to treat dyspepsia and gastroesophageal reflux disease,they may not be appropriate for AIG.Prokinetic agents,antidepressant drugs,and non-pharmacological treatments may be of help,even if not adequately evidence-based supported.A multidisciplinary approach for the management of dyspepsia in AIG is recommended,and further research is needed to develop and validate more effective therapies for dyspepsia.

Uncharted Territory: Frequent Relapsing, Steroid Sensitive Secondary Minimal Change Nephrotic Syndrome Cause by Solid Tumor of the Gastro-Esophageal Junction —(Case Presentation and Review of the Literature)

We reported a biopsy proved case of minimal change nephrotic syndrome in a 72-year-old patient. The minimal change nephrotic syndrome has been steroid sensitive, but the patient had 7 relapses over a span of 5 years. Each time the dose of steroid is tapered, a relapse of the nephrotic syndrome occurred. Eventually, the patient was complaining of dysphagia and difficulty swallowing. Hospital work-up with barium swallow, endoscopy, and CT of the chest, abdomen and pelvis, revealed a focal stenotic lesion with mild to moderate esophageal dysmotility 7/15/2022. A diagnosis of an ulcerating lesion with biopsy confirmed a neuro-endocrine carcinoma of the gastro-esophageal junction was entertained. The CT of the chest/abdomen/pelvis, 7/19/2022, has shown, an esophageal mass of 5.1 × 5.6 × 7 cm of the gastro-esophageal junction with ulceration. No evidence of spread beyond the esophagus and stomach. The histology revealed a poorly differentiated neuroendocrine tumor of the gastro-esophageal junction. The patient underwent several rounds of chemotherapy, radiation, and surgery culminating in tumor control. His nephrotic syndrome was resolved after the tumor has been controlled by surgery and chemotherapy.

Cholecystectomy and the risk of alimentary tract cancers:A systematic review

AIM: To investigate the association between cholecystectomy and gastro-intestinal tract(GIT) cancers.METHODS: We conducted a systematic review according to the PRISMA guidelines. A MEDLINE search was performed with predefined search criteria for English Language articles on the association between cholecystectomy and GIT cancers. Additional articles were retrieved by manual search of references. All relevant articles were accessed in full text. Data onstudy type; cases; controls; country; effect estimate; adjustments for confounders and quality of publication were extracted. The quality of the publications were scored by adherence to the STROBE checklist. The data for each part of the GIT were presented in separate tables.RESULTS: Seventy-five studies and 5 meta-analyses satisfied the predefined criteria for inclusion and were included in this review. There were inconsistent reports and no strong evidence of an association between cholecystectomy and cancers of the oesophagus(Adenocarcinoma), pancreas, small bowel and rightsided colon cancers. In squamous cancer of the oesophagus, cancers of the stomach, liver, bile ducts, small bowel and left sided colon cancers, good quality studies suggested a lack of association with cholecystectomy. Equally, distal colon and rectal cancers were found not to be associated with cholecystectomy. Several mechanisms for carcinogenesis/promotion of carcinogensis have been proposed. These have focused on a role for bile salts in carcinogenesis with several potential mutagenic molecular events and gut metabolic hormones signaling cell proliferation or initiation of carcinogenesis.CONCLUSION: This is a comprehensive review of the association between GIT cancers and cholecystectomy. This review found no clear association between cholecystectomy and GIT cancers.

A new breakthrough:ESD using a newly developed grasping type scissor forceps for early gastrointestinal tract neoplasms

Endoscopic submucosal dissection(ESD) has allowed the achievement of histologically curative en bloc resection of gastrointestinal neoplasms regardless of size,permitting the resection of previously non-resectable tumors.The ESD technique for treatment of early gastric cancer has spread rapidly in Japan and a few other Asian countries due to its excellent eradication rate compared to endoscopic mucosal resection.Although numerous electrosurgical knives have been developed for ESD,technical difficulties and high complication rates(bleeding and perforation) have limited their use worldwide.We developed the grasping type scissor forceps(GSF) to resolve such ESD-related problems.Our animal and preliminary clinical studies showed that ESD using GSF is a safe(no intraoperative complication) and technically efficient(curative en bloc resection rate 92%) method for dissection of early gastrointestinal tumors.The use of GSF is a promising option for performing ESD on early stage GI tract tumors both safely and effectively.

Capsule endoscopy

Capsule endoscopy(CE) is a simple,safe,non-invasive,reliable technique,well accepted and tolerated by the patients,which allows complete exploration of the small intestine.The advent of CE in 2000 has dramatically changed the diagnosis and management of many diseases of the small intestine,such as obscure gastrointestinal bleeding,Crohn's disease,small bowel tumors,polyposis syndromes,etc.CE has become the gold standard for the diagnosis of most diseases of the small bowel.Lately this technique has also been used for esophageal and colonic diseases.

Facing the challenge of venous thromboembolism prevention in patients undergoing major abdominal surgical procedures for gastrointestinal cancer

Venous thromboembolism(VTE)refers to a hypercoa-gulable state that remains an important and preven-table factor in the surgical treatment of malignancies.VTE includes two identical entities with regards to deep vein thrombosis and pulmonary embolism.The incidence of VTE after major abdominal interventions for gastro-intestinal,hepato-biliary and pancreatic neoplastic disor-ders is as high as 25%without prophylaxis.Prophylactic use of classic or low-molecular-weight heparin,anti-Xa factors,antithrombotic stocking,intermittent pneumatic compression devices and early mobilization have been described.Nevertheless,thromboprophylaxis is often dis-continued after discharge,although a serious risk may persist long after the initial triggering event,as the coagu-lation system remains active for at least 14 d post-opera-tively.The aim of this review is to evaluate the results of the current practice of VTE prevention in cancer patients undergoing major abdominal surgical operations,with special attention to adequately elucidated guidelinesand widely accepted protocols.In addition,the recent literature is presented in order to provide an update on the current concepts concerning the surgical manage-ment of the disease.

Endoscopic placement of enteral feeding tubes

Malnutrition is common in patients with acute and chronic illness.Nutritional management of these malnourished patients is an essential part of healthcare.Enteral feeding is one component of nutritional support.It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract(GIT).This method of nutritional support has undergone progression over recent times.The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology.Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT.This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.

Overlapping gastroesophageal reflux disease and irritable bowel syndrome:Increased dysfunctional symptoms

AIM:To investigate the association of gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS) in Iranian patients and examine the prevalence of functional symptoms of the gastrointestinal tract in patients presenting with either IBS, GERD or both.METHODS: Six thousand four hundred and seventy six patients presented to the Gastro-intestinal (GI) clinic with symptoms of functional dysfunction of GI tract, 1419 patients (62.0% women, 38.0% men; mean age: 37.4±11.5 years) met Rome or Rome criteria(depending on the year of diagnosis)for IBS.2658 patients were diagnosed with GERD based on clinical presentation and endoscopic findings.We assessed other functional symptoms(epigastric pain,nausea,vomiting,belching,constipation and diarrhea)in patients suffering from GERD,IBS or both.RESULTS: Among IBS subjects, 63.6% (69.0% women, 31.0% men; mean age: 36.4±10.3 years) also hadGERD, whereas 34.7% of the non-IBS patients had GERD [odds ratio (OR) =3.2, 95% confidence interval (CI): 2.9-3.7, P<0.0001]. Among patients with GERD, 33.9% of subjects met Rome criteria compared to 13.5% of non-GERD patients (OR=3.6, 95% CI: 3.1-4.3, P<0.0001). Prevalence of all functional symptoms was higher in overlapping GERD and IBS subjects, when compared with their prevalence in the IBS subjects without GERD or GERD only subjects (P<0.05).CONCLUSION: This finding shows that in overlapping GERD and IBS, other functional abnormalities of the GI tract are also highly prevalent, suggesting a common underlying dysfunction.

Lipoma induced jejunojejunal intussusception

Intussusception in adults is rare. The clinical picture of intussusception in adults is subtle and the diagnosis is,therefore,elusive. The presence of a structural abnor- mality in the great majority of the adult cases mandates high clinical suspicion. Gastrointestinal lipomas are rare benign tumors and intussusception due to a gastrointes- tinal lipoma constitutes an infrequent clinical entity. The present report describes a case of jejunojejunal intus- susception in an adult with a history of severe episodes of hematochezia and colicky upper abdominal pain. The diagnosis was suspected preoperatively but computed tomography scan could not rule out malignancy. Explor- atory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with segmental intestinal resection.

Human endogenous retroviruses and cancer:Causality and therapeutic possibilities

A substantial part of the human genome is derived from transposable elements;remnants of ancient retroviral infections.Conservative estimates set the percentage of human endogenous retroviruses(HERVs) in the genome at 8%.For the most part,the interplay between mutations,epigenetic mechanisms and posttranscriptional regulations silence HERVs in somatic cells.We first highlight mechanisms by which activation of members of several HERV families may be associated with tumor development before discussing the arising chances for both diagnosis and therapy.It has been shown that at least in some cases,tumor cells expressing HERV open reading frames(ORFs) thus gain tumor-promoting functions.However,since these proteins are not expressed in healthy tissues,they become prime target structures.Of potential pharmacological interest are the prevention of HERV transposition,the inhibition of HERV-encoded protein expression and the interference with these proteins' activities.Evidence from recent studies unequivocally proves that HERV ORFs represent a very interesting source of novel tumor-specific antigens with even the potential to surpass entity boundaries.The development of new tumor(immune-) therapies is a very active field and true tumor-specific targets are of outstanding interest since they minimize the risk of autoimmunity and could reduce side effects.Finally,we postulate on main future research streams in order to stimulate discussion on this hot topic.

Transjugular intrahepatic portosystemic shunt as bridge-to-surgery in refractory gastric antral vascular ectasia

Gastric antral vascular ectasia(GAVE) may cause gastrointestinal bleeding(GIB). The treatment of GAVE relies on endoscopic approaches such as electrocoagulation(argon plasma coagulation, laser therapy, heater probe therapy, radiofrequency ablation), cryotherapy, and band ligation. In refractory cases, antrectomy may be considered. In the event of an associated cirrhosis and portal hypertension, it has been suggested that antrectomy could be an option, provided the mortality risk isn't considered too great. We report the case of a 67-year-old cirrhotic patient who presented with GAVE related GIB, unresponsive to multiple endoscopic treatments. The patient had a good liver function(model for end-stage disease 10). After a multidisciplinary meeting, a transjugular intrahepatic portosystemic shunt(TIPS) procedure was performed, in order to treat the cirrhosis associated ascites. The outcome was successful. An antrectomy was then performed, with no recurrence of GIB and no transfusion need during three months of follow up. In this case, the TIPS procedure achieved a complete ascites regression, allowing a safer surgical treatment of the GAVE-related GIB.