IBD & Intestinal Disorders

Allowed Publications

Clinician Reviews

GI and Hepatology News

LayerRx Mapping ID

387

Slot System

Featured Buckets

Featured Buckets Admin

Reverse Chronological Sort

Allow Teaser Image

Medscape Lead Concept

3032545

May 2024 – ICYMI

Article Type

News

Changed

Fri, 05/03/2024 - 16:28

Gastroenterology

January 2024

Hirano I, et al; ASCENT WORKING GROUP. Ascending to New Heights for Novel Therapeutics for Eosinophilic Esophagitis. Gastroenterology. 2024 Jan;166(1):1-10. doi: 10.1053/j.gastro.2023.09.004. Epub 2023 Sep 9. PMID: 37690772; PMCID: PMC10872872.

Åkerström JH, et al. Antireflux Surgery Versus Antireflux Medication and Risk of Esophageal Adenocarcinoma in Patients With Barrett’s Esophagus. Gastroenterology. 2024 Jan;166(1):132-138.e3. doi: 10.1053/j.gastro.2023.08.050. Epub 2023 Sep 9. PMID: 37690771.

Barnes EL, et al; AGA Clinical Guidelines Committee. AGA Clinical Practice Guideline on the Management of Pouchitis and Inflammatory Pouch Disorders. Gastroenterology. 2024 Jan;166(1):59-85. doi: 10.1053/j.gastro.2023.10.015. PMID: 38128971.

February 2024

Yoo HW, et al. Helicobacter pylori Treatment and Gastric Cancer Risk After Endoscopic Resection of Dysplasia: A Nationwide Cohort Study. Gastroenterology. 2024 Feb;166(2):313-322.e3. doi: 10.1053/j.gastro.2023.10.013. Epub 2023 Oct 18. PMID: 37863270.

Yang J, et al. High Soluble Fiber Promotes Colorectal Tumorigenesis Through Modulating Gut Microbiota and Metabolites in Mice. Gastroenterology. 2024 Feb;166(2):323-337.e7. doi: 10.1053/j.gastro.2023.10.012. Epub 2023 Oct 18. PMID: 37858797.

Young E, et al. Texture and Color Enhancement Imaging Improves Colonic Adenoma Detection: A Multicenter Randomized Controlled Trial. Gastroenterology. 2024 Feb;166(2):338-340.e3. doi: 10.1053/j.gastro.2023.10.008. Epub 2023 Oct 14. PMID: 37839498.

Clinical Gastroenterology and Hepatology

January 2024

Overbeek KA, et al; Dutch Familial Pancreatic Cancer Surveillance Study work group. Intraductal Papillary Mucinous Neoplasms in High-Risk Individuals: Incidence, Growth Rate, and Malignancy Risk. Clin Gastroenterol Hepatol. 2024 Jan;22(1):62-71.e7. doi: 10.1016/j.cgh.2023.03.035. Epub 2023 Apr 7. PMID: 37031711.

Reddy CA, et al. Achalasia is Strongly Associated With Eosinophilic Esophagitis and Other Allergic Disorders. Clin Gastroenterol Hepatol. 2024 Jan;22(1):34-41.e2. doi: 10.1016/j.cgh.2023.06.013. Epub 2023 Jun 28. PMID: 37391057; PMCID: PMC10753026.

Thiruvengadam NR, et al. The Clinical Impact and Cost-Effectiveness of Surveillance of Incidentally Detected Gastric Intestinal Metaplasia: A Microsimulation Analysis. Clin Gastroenterol Hepatol. 2024 Jan;22(1):51-61. doi: 10.1016/j.cgh.2023.05.028. Epub 2023 Jun 9. Erratum in: Clin Gastroenterol Hepatol. 2024 Jan 19;: PMID: 37302442.

February 2024

Goodoory VC, et al. Systematic Review and Meta-analysis: Efficacy of Mesalamine in Irritable Bowel Syndrome. Clin Gastroenterol Hepatol. 2024 Feb;22(2):243-251.e5. doi: 10.1016/j.cgh.2023.02.014. Epub 2023 Feb 27. PMID: 36858143.

Brenner DM, et al. Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome. Clin Gastroenterol Hepatol. 2024 Feb;22(2):222-234. doi: 10.1016/j.cgh.2023.09.013. Epub 2023 Sep 22. PMID: 37743035.

Techniques and Innovations in Gastrointestinal Endoscopy

January 2024

Ramirez PR, et al. Gaps and Improvement Opportunities in Post-Colonoscopy Communication. Tech Innov Gastrointest Endosc. 2024 Jan;26(1):90-92. doi: 10.1016/j.tige.2023.10.001. Epub 2023 Oct 22.

Gonzaga ER, et al. Gastric Peroral Endoscopic Myotomy (G-POEM) for the Management of Gastroparesis. Tech Innov Gastrointest Endosc. 2024 Jan; 26(1): 46-55. doi: 10.1016/j.tige.2023.09.002. Epub 2023 Oct 13.

Wang D, et al. Sphincterotomy vs Sham Procedure for Pain Relief in Sphincter of Oddi Dysfunction: Systematic Review and Meta-analysis. Tech Innov Gastrointest Endosc. 2024 Jan;26(1): 30-37. doi: 10.1016/j.tige.2023.10.003. Epub 2023 Nov 8.

Gastro Hep Advances

January 2024

Adeniran E, et al. Intense and Sustained Alcohol Consumption Associated With Acute Pancreatitis Warrants Early Intervention. Gastro Hep Advances. 2024 Jan;3(1):61-63. doi: 10.1016/j.gastha.2023.08.017. Epub 2023 Sep 2.

Alkhouri N, et al. A Novel Prescription Digital Therapeutic Option for the Treatment of Metabolic Dysfunction-Associated Steatotic Liver Disease. Gastro Hep Advances. 2024 Jan;3(1): 9-16. doi: 10.1016/j.gastha.2023.08.019. Epub 2023 Oct 1.

Publications

GI and Hepatology News

Topics

Upper GI Tract

GI Oncology

IBD & Intestinal Disorders

Pancreas and Biliary Tract

Endoscopy

Endoscopy, Pancreas, & Biliary Tract

Liver Disease

Read more about May 2024 – ICYMI

Sections

The New Gastroenterologist

Gastroenterology

January 2024

Clinical Gastroenterology and Hepatology

Techniques and Innovations in Gastrointestinal Endoscopy

Gastro Hep Advances

Gastroenterology

January 2024

Clinical Gastroenterology and Hepatology

Techniques and Innovations in Gastrointestinal Endoscopy

Gastro Hep Advances

Publications

GI and Hepatology News

Publications

GI and Hepatology News

Topics

Upper GI Tract

GI Oncology

IBD & Intestinal Disorders

Pancreas and Biliary Tract

Endoscopy

Endoscopy, Pancreas, & Biliary Tract

Liver Disease

Article Type

News

Sections

The New Gastroenterologist

A Simplified Approach to Pelvic Floor Dysfunction

Article Type

News

Changed

Fri, 05/03/2024 - 15:48

Author(s)

Ayesha Khan, DO

Raakhi Menon, DO

Lindsay Allen, PT, DPT, MBA

And Brooke Corning, MD

Pelvic floor dysfunction (PFD) represents a spectrum of symptoms involving sensory and emptying abnormalities of the bowel and bladder and pelvic organ prolapse. The pelvic floor refers to a group of muscles that spans the pelvic outlet, providing support to the pelvic organs and coordinating constrictor mechanisms to control urination and defecation. Symptoms reported by patients experiencing PFD include involuntary loss of stool or urine, incomplete emptying of the bowel and bladder, a sensation of fullness, bulging in the vagina, and sexual dysfunction.¹

As such, symptoms related to PFD are very common concerns raised by patients to their gastroenterologists. Data from the National Health and Nutrition Examination Survey show that 23.7% of women over the age of 20 had at least one symptom of PFD.² Unfortunately, patients experiencing pelvic floor dysfunction often are hesitant to seek care because of embarrassment or perception that limited treatment options exist for their symptoms.

Pelvic Floor Anatomy

Regions of the pelvis are often referred to by anatomic compartment: anterior (bladder and urethra), middle (vagina and uterus or prostate), and posterior (colon, rectum, and anal canal). Supporting these compartments is the levator ani, a muscle group that is used synonymously with the term “pelvic diaphragm.”

Continence of stool is provided by the anal sphincter muscles and the puborectalis muscle, which wraps around the posterior aspect of the anorectal canal. Damage to the musculature or sensory perception to this area may result in fecal incontinence. Defecation is a coordinated process during which the abdominal and rectal muscles contract, while the anal sphincter muscles and puborectalis simultaneously relax. A disturbance in neuromuscular coordination (dyssynergic defecation) or structural pathology such as pelvic organ prolapse may lead to obstructed defecation.

PFD is thought to be a result of one or more insults to the pelvic floor such as chronic straining, childbirth, iatrogenic injury, or systemic disease such as diabetes.³

Evaluation of PFD Symptoms

Patients presenting with suspected PFD necessitate a comprehensive interdisciplinary assessment. In addition to obtaining a medical, surgical, and obstetric history, details about symptoms and lifestyle should include toileting habits, diet, and physical activity. The Pelvic Floor Distress Inventory (PFDI-20) is a commonly used tool that can be employed in the clinical setting.⁴

A pelvic exam can reveal pelvic organ prolapse and other mucosal pathology. The Pelvic Organ Prolapse Quantification System (POP-Q) is a widely used classification system for describing pelvic organ prolapse.⁵ Protrusion of the rectal wall into the vagina is referred to as a rectocele, while prolapse of small bowel into the upper posterior wall of the vagina is called an enterocele. While the finding of a rectocele on exam is common in parous women and may not cause any symptoms, a larger rectocele may cause a sensation of incomplete evacuation of stool.

A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.

Initial Management

A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention. For patients reporting liquid stool consistency, the evaluation should pivot toward the workup and management of diarrhea, which can easily overwhelm continence mechanisms and cause fecal incontinence. Fiber supplementation to normalize stool consistency is considered first-line therapy for patients presenting with both fecal incontinence and obstructed defecation. Other tools for fecal incontinence include avoiding foods that trigger diarrhea and use of loperamide.⁶ For patients with obstructed defecation, a trial of laxatives can be followed by a prescription agent if needed, such as a secretagogue or prokinetic.⁷

Vaginal splinting is a technique that can be used in patients with rectocele, whereby a finger is inserted into the vagina and pressure is applied on the posterior vaginal wall toward the rectum. Reducing the rectocele can facilitate emptying stool from the rectum and prevent leakage of retained stool.⁸ Similarly, use of rectal irrigation enemas can also help clear retained stool.

Pelvic floor physical therapists examine the strength, coordination, and tone of the pelvic floor muscles. When hypertonic musculature is present, manual interventions may be performed including trigger point release, myofascial release, and dry needling.⁹ When hypotonic musculature or dyssynergia is present, strengthening and neuromuscular re-education are recommended. Biofeedback can be administered via surface electromyography and/or balloon training to improve rectal sensitivity. Proper defecation techniques, including positioning, breathing, and behavioral modifications, improve clinical outcomes.

Diagnostic Testing

For patients who do not improve with conservative management, further testing is recommended to characterize the underlying pathology. Typically, anorectal manometry (ARM) is performed in conjunction with the balloon expulsion test and imaging. Each modality has its strengths and limitations (see Table 1).

167838 Table_web.jpg

ARM allows for the assessment of rectal sensation and recto-anal pressures and coordination.¹⁰

Dynamic imaging, by barium defecography under fluoroscopy or MRI, captures anatomy at rest and with simulated defecation to identify pelvic organ prolapse, compartmental defects, and organ mobility.¹¹ Endoanal ultrasonography is considered in patients experiencing fecal incontinence to evaluate the integrity of the anal sphincter muscles.

Minimally Invasive Procedures and Surgical Options for PFD

Functional abnormalities such as dyssynergia often coexist with structural abnormalities. Because structural abnormalities are commonly found in asymptomatic patients, noninvasive functional therapy, such as pelvic floor physical therapy and anorectal biofeedback, are preferred prior to surgical repair of a structural finding. For patients with fecal incontinence, sacral nerve stimulation (SNS) has emerged as a preferred therapy due to demonstrated efficacy in symptom improvement.¹² Sphincteroplasty is reserved for those with acute sphincter injury or failure of SNS.

In patients with findings of intussusception, prolapse, or rectocele that have not responded to conservative therapy, referral for surgical repair may be considered. While the specific surgical approach will depend on many factors, the goal is typically excision and/or suspension of rectal tissue and reinforcement of the rectovaginal septum.

Pelvic floor disorders and related gastrointestinal complaints are very common, and likely to increase with increasing longevity and an aging population. It is critical that we are equipped with the available knowledge and tools to provide these patients with optimal care.

Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.

References

1. Grimes WR and Stratton M. Pelvic floor dysfunction. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2024 Jan. PMID: 32644672.

2. Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. doi: 10.1001/jama.300.11.1311.

3. Lawrence JM et al. Pelvic floor disorders, diabetes, and obesity in women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct. doi: 10.2337/dc07-0262.

4. Barber MD et al. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul. doi: 10.1016/j.ajog.2004.12.025.

5. Persu C et al. Pelvic Organ Prolapse Quantification System (POP-Q) — A new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar. PMID: 21505577.

6. Wald A et al. ACG Clinical Guidelines: Management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. doi: 10.14309/ajg.0000000000001507.

7. Bharucha AE and Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020 Apr. doi: 10.1053/j.gastro.2019.12.034.

8. Menees S and Chey WD. Fecal incontinence: Pathogenesis, diagnosis, and updated treatment strategies. Gastroenterol Clin North Am. 2022 Mar. doi: 10.1016/j.gtc.2021.10.005.

9. Wallace SL et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec. doi: 10.1097/GCO.0000000000000584.

10. Carrington EV et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan. doi: 10.1111/nmo.13679.

11. El Sayed RF et al. Magnetic resonance imaging of pelvic floor dysfunction — Joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017 May. doi: 10.1007/s00330-016-4471-7.

12. Thaha MA et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24. doi: 10.1002/14651858.CD004464.pub3.

13. Chiarioni G et al. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005 Jul. doi: 10.1053/j.gastro.2005.05.015.

14. Grossi U et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016 Mar. doi: 10.1136/gutjnl-2014-308835.

15. Albuquerque A. Endoanal ultrasonography in fecal incontinence: Current and future perspectives. World J Gastrointest Endosc. 2015 Jun 10. doi: 10.4253/wjge.v7.i6.575.

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Mixed Topics

Read more about A Simplified Approach to Pelvic Floor Dysfunction

Sections

The New Gastroenterologist

Short Clinical Reviews

Author(s)

Ayesha Khan, DO

Raakhi Menon, DO

Lindsay Allen, PT, DPT, MBA

And Brooke Corning, MD

Author(s)

Ayesha Khan, DO

Raakhi Menon, DO

Lindsay Allen, PT, DPT, MBA

And Brooke Corning, MD

Pelvic Floor Anatomy

Evaluation of PFD Symptoms

A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.

Initial Management

Diagnostic Testing

167838 Table_web.jpg

Minimally Invasive Procedures and Surgical Options for PFD

Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.

References

Pelvic Floor Anatomy

Evaluation of PFD Symptoms

A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities.

Initial Management

Diagnostic Testing

167838 Table_web.jpg

Minimally Invasive Procedures and Surgical Options for PFD

Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest.

References

Publications

GI and Hepatology News

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Mixed Topics

Article Type

News

Sections

The New Gastroenterologist

Short Clinical Reviews

Teambase XML

<?xml version="1.0" encoding="UTF-8"?>


<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>167838</fileName> <TBEID>0C04FC8C.SIG</TBEID> <TBUniqueIdentifier>MD_0C04FC8C</TBUniqueIdentifier> <newsOrJournal>News</newsOrJournal> <publisherName>Frontline Medical Communications</publisherName> <storyname>TNG Short Clinical Review</storyname> <articleType>2</articleType> <TBLocation>QC Done-All Pubs</TBLocation> <QCDate>20240430T161729</QCDate> <firstPublished>20240503T093623</firstPublished> <LastPublished>20240503T124227</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240503T093623</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline>Other Writer</byline> <bylineText>AYESHA KHAN, DO; RAAKHI MENON, DO; LINDSAY ALLEN, PT, DPT, MBA; AND BROOKE CORNING, MD</bylineText> <bylineFull>AYESHA KHAN, DO; RAAKHI MENON, DO; LINDSAY ALLEN, PT, DPT, MBA; AND BROOKE CORNING, MD</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType>Feature</newsDocType> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Pelvic floor disorders and related gastrointestinal complaints are very common, and likely to increase with increasing longevity and an aging population.</metaDescription> <articlePDF/> <teaserImage>301217</teaserImage> <teaser>A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention.</teaser> <title>A Simplified Approach to Pelvic Floor Dysfunction</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>2</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>gih</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> </publications_g> <publications> <term canonical="true">17</term> </publications> <sections> <term>68609</term> <term canonical="true">46646</term> </sections> <topics> <term canonical="true">345</term> <term>27442</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/2401289b.jpg</altRep> <description role="drol:caption">Dr. Ayesha Khan</description> <description role="drol:credit">University of Texas Medical Branch</description> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/2401289c.jpg</altRep> <description role="drol:caption">Dr. Raakhi Menon</description> <description role="drol:credit">University of Texas Medical Branch</description> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/2401289e.jpg</altRep> <description role="drol:caption">Dr. Lindsay Allen</description> <description role="drol:credit">University of Texas Medical Branch</description> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240128a2.jpg</altRep> <description role="drol:caption"/> <description role="drol:credit"/> </link> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/2401289d.jpg</altRep> <description role="drol:caption">Dr. Brooke Corning</description> <description role="drol:credit">University of Texas Medical Branch</description> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>A Simplified Approach to Pelvic Floor Dysfunction</title> <deck/> </itemMeta> <itemContent> Pelvic floor dysfunction (PFD) represents a spectrum of symptoms involving sensory and emptying abnormalities of the bowel and bladder and pelvic organ prolapse. The pelvic floor refers to a group of muscles that spans the pelvic outlet, providing support to the pelvic organs and coordinating constrictor mechanisms to control urination and defecation. Symptoms reported by patients experiencing PFD include involuntary loss of stool or urine, incomplete emptying of the bowel and bladder, a sensation of fullness, bulging in the vagina, and sexual dysfunction.1 As such, symptoms related to PFD are very common concerns raised by patients to their gastroenterologists. Data from the National Health and Nutrition Examination Survey show that 23.7% of women over the age of 20 had at least one symptom of PFD.2 Unfortunately, patients experiencing pelvic floor dysfunction often are hesitant to seek care because of embarrassment or perception that limited treatment options exist for their symptoms. <h2>Pelvic Floor Anatomy</h2> Regions of the pelvis are often referred to by anatomic compartment: anterior (bladder and urethra), middle (vagina and uterus or prostate), and posterior (colon, rectum, and anal canal). Supporting these compartments is the levator ani, a muscle group that is used synonymously with the term “pelvic diaphragm.” [[{"fid":"301217","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Ayesha Khan, University of Texas Medical Branch, Galveston","field_file_image_credit[und][0][value]":"University of Texas Medical Branch","field_file_image_caption[und][0][value]":"Dr. Ayesha Khan"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]] Continence of stool is provided by the anal sphincter muscles and the puborectalis muscle, which wraps around the posterior aspect of the anorectal canal. Damage to the musculature or sensory perception to this area may result in fecal incontinence. Defecation is a coordinated process during which the abdominal and rectal muscles contract, while the anal sphincter muscles and puborectalis simultaneously relax. A disturbance in neuromuscular coordination (dyssynergic defecation) or structural pathology such as pelvic organ prolapse may lead to obstructed defecation. PFD is thought to be a result of one or more insults to the pelvic floor such as chronic straining, childbirth, iatrogenic injury, or systemic disease such as diabetes.3 <h2>Evaluation of PFD Symptoms </h2> Patients presenting with suspected PFD necessitate a comprehensive interdisciplinary assessment. In addition to obtaining a medical, surgical, and obstetric history, details about symptoms and lifestyle should include toileting habits, diet, and physical activity. The <a href="https://cdn-links.lww.com/permalink/sap/a/sap_00_00_2019_05_06_manrique_spa51154_sdc2.pdf">Pelvic Floor Distress Inventory (PFDI-20)</a> is a commonly used tool that can be employed in the clinical setting.4 A pelvic exam can reveal pelvic organ prolapse and other mucosal pathology. The <a href="https://pop-q.netlify.app/">Pelvic Organ Prolapse Quantification System (POP-Q)</a> is a widely used classification system for describing pelvic organ prolapse.5 Protrusion of the rectal wall into the vagina is referred to as a rectocele, while prolapse of small bowel into the upper posterior wall of the vagina is called an enterocele. While the finding of a rectocele on exam is common in parous women and may not cause any symptoms, a larger rectocele may cause a sensation of incomplete evacuation of stool.[[{"fid":"301218","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Raakhi Menon, University of Texas Medical Branch, Galveston","field_file_image_credit[und][0][value]":"University of Texas Medical Branch","field_file_image_caption[und][0][value]":"Dr. Raakhi Menon"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]] A digital rectal exam (DRE) should be performed to assess pelvic floor function and help identify structural abnormalities. <h2>Initial Management</h2> A stepwise approach to the management of PFD can allow many patients to be effectively treated without the need for surgical intervention. For patients reporting liquid stool consistency, the evaluation should pivot toward the workup and management of diarrhea, which can easily overwhelm continence mechanisms and cause fecal incontinence. Fiber supplementation to normalize stool consistency is considered first-line therapy for patients presenting with both fecal incontinence and obstructed defecation. Other tools for fecal incontinence include avoiding foods that trigger diarrhea and use of loperamide.6 For patients with obstructed defecation, a trial of laxatives can be followed by a prescription agent if needed, such as a secretagogue or prokinetic.7 Vaginal splinting is a technique that can be used in patients with rectocele, whereby a finger is inserted into the vagina and pressure is applied on the posterior vaginal wall toward the rectum. Reducing the rectocele can facilitate emptying stool from the rectum and prevent leakage of retained stool.8 Similarly, use of rectal irrigation enemas can also help clear retained stool. Pelvic floor physical therapists examine the strength, coordination, and tone of the pelvic floor muscles. When hypertonic musculature is present, manual interventions may be performed including trigger point release, myofascial release, and dry needling.9 When hypotonic musculature or dyssynergia is present, strengthening and neuromuscular re-education are recommended. Biofeedback can be administered via surface electromyography and/or balloon training to improve rectal sensitivity. Proper defecation techniques, including positioning, breathing, and behavioral modifications, improve clinical outcomes.[[{"fid":"301220","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Lindsay Allen, University of Texas Medical Branch, Galveston","field_file_image_credit[und][0][value]":"University of Texas Medical Branch","field_file_image_caption[und][0][value]":"Dr. Lindsay Allen"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]] <h2>Diagnostic Testing</h2> For patients who do not improve with conservative management, further testing is recommended to characterize the underlying pathology. Typically, anorectal manometry (ARM) is performed in conjunction with the balloon expulsion test and imaging. Each modality has its strengths and limitations (see Table 1). [[{"fid":"301229","view_mode":"medstat_image_full_text","fields":{"format":"medstat_image_full_text","field_file_image_alt_text[und][0][value]":"Table 1. Balloon expulsion test (BET) and imaging","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":""},"type":"media","attributes":{"class":"media-element file-medstat_image_full_text"}}]] ARM allows for the assessment of rectal sensation and recto-anal pressures and coordination.10 Dynamic imaging, by barium defecography under fluoroscopy or MRI, captures anatomy at rest and with simulated defecation to identify pelvic organ prolapse, compartmental defects, and organ mobility.11 Endoanal ultrasonography is considered in patients experiencing fecal incontinence to evaluate the integrity of the anal sphincter muscles. <h2>Minimally Invasive Procedures and Surgical Options for PFD</h2> Functional abnormalities such as dyssynergia often coexist with structural abnormalities. Because structural abnormalities are commonly found in asymptomatic patients, noninvasive functional therapy, such as pelvic floor physical therapy and anorectal biofeedback, are preferred prior to surgical repair of a structural finding. For patients with fecal incontinence, sacral nerve stimulation (SNS) has emerged as a preferred therapy due to demonstrated efficacy in symptom improvement.12 Sphincteroplasty is reserved for those with acute sphincter injury or failure of SNS. [[{"fid":"301219","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Brooke Corning, University of Texas Medical Branch, Galveston","field_file_image_credit[und][0][value]":"University of Texas Medical Branch","field_file_image_caption[und][0][value]":"Dr. Brooke Corning"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_right"}}]] In patients with findings of intussusception, prolapse, or rectocele that have not responded to conservative therapy, referral for surgical repair may be considered. While the specific surgical approach will depend on many factors, the goal is typically excision and/or suspension of rectal tissue and reinforcement of the rectovaginal septum. Pelvic floor disorders and related gastrointestinal complaints are very common, and likely to increase with increasing longevity and an aging population. It is critical that we are equipped with the available knowledge and tools to provide these patients with optimal care. Dr. Khan, Dr. Menon, Dr. Allen, and Dr. Corning are based at the University of Texas Medical Branch in Galveston, Texas. They report no conflicts of interest. <h2>References</h2> 1. Grimes WR and Stratton M. Pelvic floor dysfunction. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (Fla.): StatPearls Publishing; 2024 Jan. <a href="https://www.ncbi.nlm.nih.gov/books/NBK559246/">PMID: 32644672</a>. 2. Nygaard I et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008 Sep 17. doi: <a href="https://jamanetwork.com/journals/jama/fullarticle/182572">10.1001/jama.300.11.1311</a>. 3. Lawrence JM et al. Pelvic floor disorders, diabetes, and obesity in women: Findings from the Kaiser Permanente Continence Associated Risk Epidemiology Study. Diabetes Care. 2007 Oct. doi: <a href="https://diabetesjournals.org/care/article/30/10/2536/30258/Pelvic-Floor-Disorders-Diabetes-and-Obesity-in">10.2337/dc07-0262</a>. 4. Barber MD et al. Short forms of two condition-specific quality-of-life questionnaires for women with pelvic floor disorders (PFDI-20 and PFIQ-7). Am J Obstet Gynecol. 2005 Jul. doi: <a href="https://www.ajog.org/article/S0002-9378(04)02108-8/abstract">10.1016/j.ajog.2004.12.025</a>. 5. Persu C et al. Pelvic Organ Prolapse Quantification System (POP-Q) — A new era in pelvic prolapse staging. J Med Life. 2011 Jan-Mar. PMID: <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3056425/">21505577</a>. 6. Wald A et al. ACG Clinical Guidelines: Management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. doi: <a href="https://journals.lww.com/ajg/fulltext/2021/10000/acg_clinical_guidelines__management_of_benign.13.aspx">10.14309/ajg.0000000000001507</a>. 7. Bharucha AE and Lacy BE. Mechanisms, evaluation, and management of chronic constipation. Gastroenterology. 2020 Apr. doi: <a href="https://doi.org/10.1053/j.gastro.2019.12.034">10.1053/j.gastro.2019.12.034</a>. 8. Menees S and Chey WD. Fecal incontinence: Pathogenesis, diagnosis, and updated treatment strategies. Gastroenterol Clin North Am. 2022 Mar. doi: <a href="https://doi.org/10.1016/j.gtc.2021.10.005">10.1016/j.gtc.2021.10.005</a>. 9. Wallace SL et al. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec. doi: <a href="https://journals.lww.com/co-obgyn/abstract/2019/12000/pelvic_floor_physical_therapy_in_the_treatment_of.19.aspx">10.1097/GCO.0000000000000584</a>. 10. Carrington EV et al. The international anorectal physiology working group (IAPWG) recommendations: Standardized testing protocol and the London classification for disorders of anorectal function. Neurogastroenterol Motil. 2020 Jan. <a href="https://onlinelibrary.wiley.com/doi/10.1111/nmo.13679">doi: 10.1111/nmo.13679</a>. 11. El Sayed RF et al. Magnetic resonance imaging of pelvic floor dysfunction — Joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol. 2017 May. <a href="https://link.springer.com/article/10.1007/s00330-016-4471-7">doi: 10.1007/s00330-016-4471-7</a>. 12. Thaha MA et al. Sacral nerve stimulation for faecal incontinence and constipation in adults. Cochrane Database Syst Rev. 2015 Aug 24. doi: <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD004464.pub3/full">10.1002/14651858.CD004464.pub3</a>. 13. Chiarioni G et al. Biofeedback benefits only patients with outlet dysfunction, not patients with isolated slow transit constipation. Gastroenterology. 2005 Jul. doi: <a href="https://doi.org/10.1053/j.gastro.2005.05.015">10.1053/j.gastro.2005.05.015</a>. 14. Grossi U et al. Diagnostic accuracy study of anorectal manometry for diagnosis of dyssynergic defecation. Gut. 2016 Mar. doi: <a href="https://gut.bmj.com/content/65/3/447">10.1136/gutjnl-2014-308835</a>. 15. Albuquerque A. Endoanal ultrasonography in fecal incontinence: Current and future perspectives. World J Gastrointest Endosc. 2015 Jun 10. doi: <a href="https://www.wjgnet.com/1948-5190/full/v7/i6/575.htm">10.4253/wjge.v7.i6.575</a>. </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Disable zoom

Off

Are Direct-to-Consumer Microbiome Tests Clinically Useful?

Article Type

News

Changed

Fri, 04/26/2024 - 09:55

Author(s)

Marilynn Larkin

Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.

“We analyze the trillions of microbes in your gut microflora and craft a unique formula for your unique gut needs,” one says. “Get actionable dietary, supplement, and lifestyle recommendations from our microbiome experts based on your results, tailored to mom and baby’s biomarkers. ... Any family member like dads or siblings are welcome too,” says another.

The companies assert that they can improve gut health by offering individuals personalized treatments based on their gut microbiome test results. The trouble is, no provider, company, or technology can reliably do that yet.

Clinical Implications, Not Applications

The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.

Although knowledge is increasing on the oral, cutaneous, and vaginal microbiomes, the gut microbiome is arguably the most studied. However, while research is increasingly demonstrating that the gut microbiome has clinical implications, much work needs to be done before reliable applications based on that research are available.

But lack of scientific evidence and validity hasn’t stopped a growing number of companies across the globe from offering direct-to-consumer (DTC) microbiome tests, Erik C. von Rosenvinge, MD, AGAF, a professor at the University of Maryland School of Medicine and chief of gastroenterology at the VA Maryland Health Care System, Baltimore, said in an interview.

“If you go to their websites, even if it’s not stated overtly, these companies at least give the impression that they’re providing actionable, useful information,” he said. “The sites recommend microbiome testing, and often supplements, probiotics, or other products that they sell. And consumers are told they need to be tested again once they start taking any of these products to see if they’re receiving any benefit.”

Dr. von Rosenvinge and colleagues authored a recent article in Science arguing that DTC microbiome tests “lack analytical and clinical validity” — and yet regulation of the industry has been “generally ignored.” They identified 31 companies globally, 17 of which are based in the United States, claiming to have products and/or services aimed at changing the intestinal microbiome.

Unreliable, Unregulated

The lack of reliability has been shown by experts who have tested the tests.

“People have taken the same stool sample, sent it to multiple companies, and gotten different results back,” Dr. von Rosenvinge said. “People also have taken a stool sample and sent it to the same company under two different names and received two different results. If the test is unreliable at its foundational level, it’s hard to use it in any clinical way.”

Test users’ methods and the companies’ procedures can affect the results, Dina Kao, MD, a professor at the University of Alberta, Edmonton, Alberta, Canada, said in an interview.

“So many biases can be introduced at every single step of the way, starting from how the stool sample was collected and how it’s preserved or not being preserved, because that can introduce a lot of noise that would change the analyses. Which primer they’re using to amplify the signals and which bioinformatic pipeline they use are also important,” said Dr. Kao, who presented at the recent Gut Microbiota for Health World Summit, organized by the American Gastroenterological Association (AGA) and the European Society of Neurogastroenterology and Motility (ESNM).

Different investigators and companies use different technologies, so it’s very difficult to compare them and to create a standard, said Mahmoud Ghannoum, PhD, a professor in the dermatology and pathology departments at Case Western Reserve University School of Medicine and director of the Center for Medical Mycology at University Hospitals in Cleveland.

The complexity of the gut microbiome makes test standardization more difficult than it is when just one organism is involved, Dr. Ghannoum, who chaired the antifungal subcommittee at the Clinical and Laboratory Standards Institute, said in an interview.

“Even though many researchers are focusing on bacteria, we also have fungi and viruses. We need standardization of methods for testing these organisms if we want to have regulations,” said Dr. Ghannoum, a cofounder of BIOHM, a microbiome company that offers nondiagnostic tests and markets a variety of probiotics, prebiotics, and immunity supplements. BIOHM is one of the 31 companies identified by Dr. von Rosenvinge and colleagues, as noted above.

Dr. Ghannoum believes that taking a systematic approach could facilitate standardization and, ultimately, regulation of the DTC microbiome testing products. He and his colleagues described such an approach by outlining the stages for designing probiotics capable of modulating the microbiome in chronic diseases, using Crohn’s disease as a model. Their strategy involved the following steps:

Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
Gaining insight into the interactions among the identified pathogens.
Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
Creating a prototype formulation for testing.
Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
Conducting clinical testing.

Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”

Potential Pitfalls

Whether test results from commercial companies are positioned as wellness aids or diagnostic tools, providing advice based on the results “is where the danger can really come in,” Dr. Kao said. “There is still so much we don’t know about which microbial signatures are associated with each condition.”

“Even when we have a solution, like the Crohn’s exclusion diet, a physician doesn’t know enough of the nuances to give advice to a patient,” she said. “That really should be done under the guidance of an expert dietitian. And if a company is selling probiotics, I personally feel that’s not ethical. I’m pretty sure there’s always going to be some kind of conflict of interest.”

Supplements and probiotics are generally safe, but negative consequences can occur, Dr. von Rosenvinge noted.

“We occasionally see people who end up with liver problems as a result of certain supplements, and rarely, probiotics have been associated with infections from those organisms, usually in those with a compromised immune system,” he said.

Other risks include people taking supplements or probiotics when they actually have a medically treatable condition or delays in diagnosis of a potentially serious underlying condition, such as colon cancer, he said. Some patients may stop taking their traditional medication in favor of taking supplements or may experience a drug-supplement interaction if they take both.

What to Tell Patients

“Doctors should be advising against this testing for their patients,” gastroenterologist Colleen R. Kelly, MD, AGAF, Brigham and Women’s Hospital, Boston, said in an interview. “I explain to patients that these tests are not validated and are clinically meaningless data and not worth the money. There is a reason they are not covered by insurance.

“Recommendations to purchase probiotics or supplements manufactured by the testing company to ‘restore a balanced or healthy microbiome’ clearly seem like a scam,” she added. “I believe some of these companies are capitalizing on patients who are desperate for answers to explain chronic symptoms, such as bloating in irritable bowel syndrome.”

Dr. von Rosenvinge said that the message to patients “is that the science isn’t there yet to support using the results of these tests in a meaningful way. We believe the microbiome is very important in health and disease, but the tests themselves in their current state are not as reliable and reproducible as we would like.”

When patients come in with test results, the first question a clinician should ask is what led them to seek out this type of information in the first place, Dr. von Rosenvinge said.

“Our patient focus groups suggested that many have not gotten clear, satisfactory answers from traditional medicine,” he said. “We don’t have a single test that says, yes, you have irritable bowel syndrome, or no, you don’t. We might suggest things that are helpful for some people and are less helpful for others.”

Dr. Kelly said she worries that “there are snake oil salesmen and cons out there who will gladly take your money. These may be smart people, capable of doing very high-level testing, and even producing very detailed and accurate results, but that doesn’t mean we know what to do with them.”

She hopes to see a microbiome-based diagnostic test in the future, particularly if the ability to therapeutically manipulate the gut microbiome in various diseases becomes a reality.

Educate Clinicians, Companies

More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.

“The microbiome never came up when I was going through my medical education,” she said. But we, and the next generation of physicians, “need to at least be able to understand the basics.

“Hopefully, one day, we will be in a position where we can have meaningful interpretations of the test results and make some kind of meaningful dietary interventions,” Dr. Kao added.

As for clinicians who are currently ordering these tests and products directly from the DTC companies, Dr. Kao said, “I roll my eyes.”

Dr. Ghannoum reiterated that companies offering microbiome tests and products also need to be educated and encouraged to use systematic approaches to product development and interpretation.

“Companies should be open to calls from clinicians and be ready to explain findings on a report, as well as the basis for any recommendations,” he said.

Dr. von Rosenvinge, Dr. Kao, and Dr. Kelly had no relevant conflicts of interest. Dr. Ghannoum is a cofounder of BIOHM.

A version of this article appeared on Medscape.com.

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

Rheumatology News

MDedge Family Medicine

MDedge Rheumatology

GI and Hepatology News

Topics

Gastroenterology

Digestive Health

Business of Medicine

IBD & Intestinal Disorders

Mixed Topics

Read more about Are Direct-to-Consumer Microbiome Tests Clinically Useful?

Sections

Author(s)

Author(s)

Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.

Clinical Implications, Not Applications

The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.

Unreliable, Unregulated

The lack of reliability has been shown by experts who have tested the tests.

Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
Gaining insight into the interactions among the identified pathogens.
Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
Creating a prototype formulation for testing.
Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
Conducting clinical testing.

Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”

Potential Pitfalls

What to Tell Patients

Educate Clinicians, Companies

More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.

A version of this article appeared on Medscape.com.

Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products.

Clinical Implications, Not Applications

The microbiome is the “constellation of microorganisms that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some 39 trillion cells.

Unreliable, Unregulated

The lack of reliability has been shown by experts who have tested the tests.

Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.
Gaining insight into the interactions among the identified pathogens.
Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.
Creating a prototype formulation for testing.
Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.
Conducting clinical testing.

Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.”

Potential Pitfalls

What to Tell Patients

Educate Clinicians, Companies

More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said.

A version of this article appeared on Medscape.com.

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

Rheumatology News

MDedge Family Medicine

MDedge Rheumatology

GI and Hepatology News

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

Rheumatology News

MDedge Family Medicine

MDedge Rheumatology

GI and Hepatology News

Topics

Gastroenterology

Digestive Health

Business of Medicine

IBD & Intestinal Disorders

Article Type

Sections

Teambase XML

<?xml version="1.0" encoding="UTF-8"?>


<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>167843</fileName> <TBEID>0C04FCA0.SIG</TBEID> <TBUniqueIdentifier>MD_0C04FCA0</TBUniqueIdentifier> <newsOrJournal>News</newsOrJournal> <publisherName>Frontline Medical Communications</publisherName> <storyname/> <articleType>2</articleType> <TBLocation>QC Done-All Pubs</TBLocation> <QCDate>20240425T140211</QCDate> <firstPublished>20240425T140221</firstPublished> <LastPublished>20240425T140221</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240425T140221</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline>M Larkin</byline> <bylineText>MARILYNN LARKIN</bylineText> <bylineFull>MARILYNN LARKIN</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType>Feature</newsDocType> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>lack of scientific evidence and validity hasn’t stopped a growing number of companies across the globe from offering direct-to-consumer (DTC) microbiome tests</metaDescription> <articlePDF/> <teaserImage>170850</teaserImage> <teaser>The lack of reliability has been shown by experts who have tested the tests.</teaser> <title>Are Direct-to-Consumer Microbiome Tests Clinically Useful?</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>rn</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>GIHOLD</publicationCode> <pubIssueName>January 2014</pubIssueName> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term canonical="true">21</term> <term>15</term> <term>26</term> </publications> <sections> <term canonical="true">27980</term> <term>39313</term> </sections> <topics> <term canonical="true">213</term> <term>49620</term> <term>38029</term> </topics> <links> <link> <itemClass qcode="ninat:picture"/> <altRep contenttype="image/jpeg">images/240060cc.jpg</altRep> <description role="drol:caption">Dr. Colleen R. Kelly</description> <description role="drol:credit"/> </link> </links> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Are Direct-to-Consumer Microbiome Tests Clinically Useful?</title> <deck/> </itemMeta> <itemContent> Companies selling gut microbiome tests directly to consumers offer up a variety of claims to promote their products. “We analyze the trillions of microbes in your gut microflora and craft a unique formula for your unique gut needs,” one says. “Get actionable dietary, supplement, and lifestyle recommendations from our microbiome experts based on your results, tailored to mom and baby’s biomarkers. ... Any family member like dads or siblings are welcome too,” says another. The companies assert that they can improve gut health by offering individuals personalized treatments based on their gut microbiome test results. The trouble is, no provider, company, or technology can reliably do that yet. <h2>Clinical Implications, Not Applications</h2> The microbiome is the “<a href="http://constellation of microorganisms">constellation of microorganisms</a> that call the human body home,” including many strains of bacteria, fungi, and viruses. That constellation comprises some <a href="https://www.sciencefocus.com/the-human-body/human-microbiome">39 trillion cells</a>. Although knowledge is increasing on the oral, cutaneous, and vaginal microbiomes, the gut microbiome is arguably the <a href="https://www.nature.com/articles/s41598-023-30625-9">most studied</a>. However, while research is increasingly demonstrating that the gut microbiome has <a href="https://doi.org/10.3390/biomedicines12010194">clinical implications</a>, much work needs to be done before reliable applications based on that research are available. But lack of scientific evidence and validity hasn’t stopped a growing number of companies across the globe from offering direct-to-consumer (DTC) microbiome tests, Erik C. von Rosenvinge, MD, AGAF, a professor at the University of Maryland School of Medicine and chief of gastroenterology at the VA Maryland Health Care System, Baltimore, said in an interview. “If you go to their websites, even if it’s not stated overtly, these companies at least give the impression that they’re providing actionable, useful information,” he said. “The sites recommend microbiome testing, and often supplements, probiotics, or other products that they sell. And consumers are told they need to be tested again once they start taking any of these products to see if they’re receiving any benefit.” Dr. von Rosenvinge and colleagues authored a <a href="https://doi.org/10.1126/science.adk4271">recent article</a> in Science arguing that DTC microbiome tests “lack analytical and clinical validity” — and yet regulation of the industry has been “generally ignored.” They identified <a href="https://www.law.umaryland.edu/media/sol/sol-2022-images-and-files/academics/programs-and-centers/health-law-program/pdfs-docs-and-files/DTC-Microbiome-Testing-Companies---Tables-Updated-2-26-24.pdf">31 companies</a> globally, 17 of which are based in the United States, claiming to have products and/or services aimed at changing the intestinal microbiome. <h2>Unreliable, Unregulated</h2> The lack of reliability has been shown by experts who have tested the tests. “People have taken the same stool sample, sent it to multiple companies, and gotten different results back,” Dr. von Rosenvinge said. “People also have taken a stool sample and sent it to the same company under two different names and received two different results. If the test is unreliable at its foundational level, it’s hard to use it in any clinical way.” Test users’ methods and the companies’ procedures can affect the results, Dina Kao, MD, a professor at the University of Alberta, Edmonton, Alberta, Canada, said in an interview. “So many biases can be introduced at every single step of the way, starting from how the stool sample was collected and how it’s preserved or not being preserved, because that can introduce a lot of noise that would change the analyses. Which primer they’re using to amplify the signals and which bioinformatic pipeline they use are also important,” said Dr. Kao, who presented at the recent <a href="https://www.gutmicrobiotaforhealth.com/washington-2024/">Gut Microbiota for Health World Summit</a>. Different investigators and companies use different technologies, so it’s very difficult to compare them and to create a standard, said Mahmoud Ghannoum, PhD, a professor in the dermatology and pathology departments at Case Western Reserve University School of Medicine and director of the Center for Medical Mycology at University Hospitals in Cleveland. The complexity of the gut microbiome makes test standardization more difficult than it is when just one organism is involved, Dr. Ghannoum, who chaired the antifungal subcommittee at the Clinical and Laboratory Standards Institute, said in an interview. “Even though many researchers are focusing on bacteria, we also have fungi and viruses. We need standardization of methods for testing these organisms if we want to have regulations,” said Dr. Ghannoum, a cofounder of <a href="https://www.biohmhealth.com/">BIOHM</a>, a microbiome company that offers nondiagnostic tests and markets a variety of probiotics, prebiotics, and immunity supplements. BIOHM is <a href="https://www.law.umaryland.edu/media/sol/sol-2022-images-and-files/academics/programs-and-centers/health-law-program/pdfs-docs-and-files/DTC-Microbiome-Testing-Companies---Tables-Updated-2-26-24.pdf">one of the 31 companies</a> identified by Dr. von Rosenvinge and colleagues, as noted above. Dr. Ghannoum believes that taking a systematic approach could facilitate standardization and, ultimately, regulation of the DTC microbiome testing products. He and his colleagues <a href="https://www.gastrojournal.org/article/S0016-5085(23)00049-5/fulltext">described such an approach</a> by outlining the stages for designing probiotics capable of modulating the microbiome in chronic diseases, using Crohn’s disease as a model. Their strategy involved the following steps: <ul class="body"> <li>Using primary microbiome data to identify, by abundance, the microorganisms underlying dysbiosis.</li> <li>Gaining insight into the interactions among the identified pathogens.</li> <li>Conducting a correlation analysis to identify potential lead probiotic strains that antagonize these pathogens and discovering metabolites that can interrupt their interactions.</li> <li>Creating a prototype formulation for testing.</li> <li>Validating the efficacy of the candidate formulation via preclinical in vitro and in vivo testing.</li> <li>Conducting clinical testing.</li> </ul> Dr. Ghannoum recommends that companies use a similar process “to provide evidence that what they are doing will be helpful, not only for them but also for the reputation of the whole industry.” <h2>Potential Pitfalls</h2> Whether test results from commercial companies are positioned as wellness aids or diagnostic tools, providing advice based on the results “is where the danger can really come in,” Dr. Kao said. “There is still so much we don’t know about which microbial signatures are associated with each condition.” “Even when we have a solution, like the Crohn’s exclusion diet, a physician doesn’t know enough of the nuances to give advice to a patient,” she said. “That really should be done under the guidance of an expert dietitian. And if a company is selling probiotics, I personally feel that’s not ethical. I’m pretty sure there’s always going to be some kind of conflict of interest.” Supplements and probiotics are generally safe, but negative consequences can occur, Dr. von Rosenvinge noted. “We occasionally see people who end up with liver problems as a result of certain supplements, and rarely, probiotics have been associated with infections from those organisms, usually in those with a compromised immune system,” he said. Other risks include people taking supplements or probiotics when they actually have a medically treatable condition or delays in diagnosis of a potentially serious underlying condition, such as colon cancer, he said. Some patients may stop taking their traditional medication in favor of taking supplements or may experience a drug-supplement interaction if they take both. <h2>What to Tell Patients</h2> “Doctors should be advising against this testing for their patients,” gastroenterologist Colleen R. Kelly, MD, AGAF, Brigham and Women’s Hospital, Boston, said in an interview. “I explain to patients that these tests are not validated and are clinically meaningless data and not worth the money. There is a reason they are not covered by insurance.[[{"fid":"170850","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Colleen R. Kelly, Brigham and Women’s Hospital, Boston","field_file_image_credit[und][0][value]":"","field_file_image_caption[und][0][value]":"Dr. Colleen R. Kelly"},"type":"media","attributes":{"class":"media-element file-medstat_image_flush_left"}}]] “Recommendations to purchase probiotics or supplements manufactured by the testing company to ‘restore a balanced or healthy microbiome’ clearly seem like a scam,” she added. “I believe some of these companies are capitalizing on patients who are desperate for answers to explain chronic symptoms, such as bloating in irritable bowel syndrome.” Dr. von Rosenvinge said that the message to patients “is that the science isn’t there yet to support using the results of these tests in a meaningful way. We believe the microbiome is very important in health and disease, but the tests themselves in their current state are not as reliable and reproducible as we would like.” When patients come in with test results, the first question a clinician should ask is what led them to seek out this type of information in the first place, Dr. von Rosenvinge said. “Our <a href="https://www.law.umaryland.edu/media/sol/sol-2022-images-and-files/academics/programs-and-centers/health-law-program/pdfs-docs-and-files/Microbiome-Tested-and-Untested-Consumers-Focus-Group-Report.pdf">patient focus groups</a> suggested that many have not gotten clear, satisfactory answers from traditional medicine,” he said. “We don’t have a single test that says, yes, you have irritable bowel syndrome, or no, you don’t. We might suggest things that are helpful for some people and are less helpful for others.” Dr. Kelly said she worries that “there are snake oil salesmen and cons out there who will gladly take your money. These may be smart people, capable of doing very high-level testing, and even producing very detailed and accurate results, but that doesn’t mean we know what to do with them.” She hopes to see a microbiome-based diagnostic test in the future, particularly if the ability to therapeutically manipulate the gut microbiome in various diseases becomes a reality. <h2>Educate Clinicians, Companies</h2> More education is needed on the subject, so we can become “microbial clinicians,” Dr. Kao said. “The microbiome never came up when I was going through my medical education,” she said. But we, and the next generation of physicians, “need to at least be able to understand the basics. “Hopefully, one day, we will be in a position where we can have meaningful interpretations of the test results and make some kind of meaningful dietary interventions,” Dr. Kao added. As for clinicians who are currently ordering these tests and products directly from the DTC companies, Dr. Kao said, “I roll my eyes.” Dr. Ghannoum reiterated that companies offering microbiome tests and products also need to be educated and encouraged to use systematic approaches to product development and interpretation. “Companies should be open to calls from clinicians and be ready to explain findings on a report, as well as the basis for any recommendations,” he said. Dr. von Rosenvinge, Dr. Kao, and Dr. Kelly had no relevant conflicts of interest. Dr. Ghannoum is a cofounder of BIOHM. A version of this article appeared on <a href="https://www.medscape.com/viewarticle/are-direct-consumer-microbiome-tests-clinically-useful-2024a10007yy">Medscape.com</a>. </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

240060CC.SIG

Disable zoom

Off

FDA OKs Subcutaneous Vedolizumab for Crohn’s Maintenance Therapy

Article Type

News

Changed

Tue, 04/23/2024 - 16:34

Author(s)

Megan Brooks

The US Food and Drug Administration (FDA) has approved the subcutaneous administration of vedolizumab (Entyvio) for maintenance therapy in adults with moderately to severely active Crohn’s disease (CD) after induction therapy with intravenous (IV) vedolizumab.

The move follows the FDA’s approval last year of subcutaneous vedolizumab for maintenance treatment of adults with moderately to severely active ulcerative colitis (UC).

The humanized immunoglobulin G1 monoclonal antibody is available as a single-dose prefilled pen (Entyvio Pen).

The FDA first approved the IV formulation of the biologic in 2014 for patients with moderate to severe UC and CD who cannot tolerate other therapies or in whom such therapies have failed.

The approval of subcutaneous vedolizumab for maintenance treatment of CD is based on the phase 3, randomized, double-blind, placebo-controlled VISIBLE 2 trial.

The trial enrolled 409 adult patients with moderately to severely active CD who had clinical response at week 6 following two doses of open-label IV vedolizumab at weeks 0 and 2.

At week 6, they were randomly allocated in a 2:1 ratio to receive vedolizumab 108 mg administered by subcutaneous injection or placebo every 2 weeks. The primary endpoint was clinical remission at week 52, which was defined as a total Crohn’s Disease Activity Index score ≤ 150.

The results showed that significantly more patients receiving subcutaneous vedolizumab than placebo achieved long-term clinical remission (48% vs 34%; P < .01), the company said in a news release.

The safety profile of subcutaneous vedolizumab is generally consistent with the known safety profile of IV vedolizumab, with the addition of injection-site reactions (including injection-site erythema, rash, pruritus, swelling, bruising, hematoma, pain, urticaria, and edema).

“Crohn’s disease is a complex and usually progressive disease for which an appropriate management plan is critical. My primary goal as a clinician is always to get patients to achieve remission,” Timothy Ritter, MD, senior medical director, GI Alliance Research, and assistant professor of medicine, Burnett School of Medicine at TCU, Fort Worth, Texas, said in the news release.

“In VISIBLE 2, about half of patients treated with Entyvio SC achieved long-term clinical remission. The data from VISIBLE 2 reaffirm the well-established efficacy profile of Entyvio, regardless of route of administration,” Dr. Ritter added.

A version of this article appeared on Medscape.com.

Publications

GI and Hepatology News

Internal Medicine News

Family Practice News

MDedge Internal Medicine

MDedge Family Medicine

Topics

IBD & Intestinal Disorders

Gastroenterology

Digestive Health

Read more about FDA OKs Subcutaneous Vedolizumab for Crohn’s Maintenance Therapy

Sections

News from the FDA/CDC

Latest News

Author(s)

Megan Brooks

Author(s)

Megan Brooks

A version of this article appeared on Medscape.com.

Publications

GI and Hepatology News

Internal Medicine News

Family Practice News

MDedge Internal Medicine

MDedge Family Medicine

Publications

GI and Hepatology News

Internal Medicine News

Family Practice News

MDedge Internal Medicine

MDedge Family Medicine

Topics

IBD & Intestinal Disorders

Gastroenterology

Digestive Health

Article Type

News

Sections

News from the FDA/CDC

Latest News

Teambase XML

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Disable zoom

Off

Which Probiotics Are Effective in Irritable Bowel Syndrome?

Article Type

News

Changed

Tue, 04/23/2024 - 16:35

Author(s)

Nathalie Raffier

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

The role of the microbiota in IBS is now well established, and patients frequently take probiotics on their own initiative or on the advice of a physician or pharmacist. However, not all probiotics have equal efficacy, so which ones should be recommended?

Jean-Marc Sabaté, MD, PhD, a gastroenterologist at Avicenne Hospital in Bobigny, France, shared insights about probiotics at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology.

IBS, according to the Rome IV symptom-based classification, is a “disorder of brain-gut axis interactions” with a prevalence of about 4% in the adult population. In France, during an average care pathway of about 8 years, patients try an average of five therapeutic strategies (and as many as 11), including antispasmodics (85%), diets (78%), and probiotics. In addition, 66.4% of patients had either taken or were taking probiotics at the time of a recent survey.

While the 2022 recommendations from the American College of Gastroenterology on the diagnosis and management of IBS do not support the use of probiotics for overall symptom relief — a recommendation for which they cite a low level of evidence — “there is nevertheless a rationale for prescribing probiotics in IBS due to the significant role of the microbiota (or dysbiosis) in this condition,” said Dr. Sabaté.

Microbiota in IBS

Evidence indicating that antibiotics exacerbate IBS symptoms and revealing chronic bacterial overgrowth in the small intestine of patients with IBS supports the role of the microbiota. Studies using a molecular approach (16s rRNA) have settled the debate, confirming differences in the intestinal flora between patients with IBS and healthy subjects. Data also indicate differences in flora between patient subtypes, such as an increased Firmicutes to Bacteroidetes ratio. However, one subgroup, which can represent as much as a third of patients, seems to harbor a “normal” microbiota.

Nonetheless, the microbiota plays a significant role in IBS. A Swedish study highlighted the influence of bacterial enterotypes on transit type associated with IBS and symptom severity, independent of diet composition or medication use.

This dysbiosis could play a significant role as it interacts with other mechanisms involved in IBS, including changes in intestinal motility related to diet (related to fermentable carbohydrates, for example). Moreover, the microbiota seems to induce a low level of immune activation in patients with IBS, leading to microinflammation and increased intestinal permeability, especially after an infection.

Furthermore, alterations in the regulation of bile acid deconjugation by the microbiota partly explain the frequency and consistency of stools in diarrhea-predominant IBS patients.

In addition, colonic gas production is higher in these patients. Those complaining of flatulence have poor tolerance to intestinal gases after a flatulent meal, associated with microbiota instability.

Data regarding the interaction between the microbiota and central mechanisms mainly come from animal studies. In rodents, microbiota constituents seem to affect brain development, function, and morphology. Emotional and physical traumas during childhood appear to be risk factors. Moreover, even brief exposure to broad-spectrum antibiotics in neonates could cause subsequent visceral hypersensitivity.

Lastly, the role of the microbiota in changes in medullary pain control after visceral stimulation (eg, rectal distension) has still not been demonstrated in humans.

Recent Guideline

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Three strains, as well as a combination of several strains, were supported by level 2 evidence, meaning at least two randomized studies with converging results. These are Bifidobacterium bifidum MIMBb75, which improves overall symptoms and quality of life; Lactobacillus plantarum 299v (DSM 9843), which acts on the severity of abdominal pain and bloating; and B infantis 35624 (new name: B longum 35624), which improves the overall assessment of IBS symptoms, as does the multistrain product containing L rhamnosus GG, L rhamnosus LC705, Propionibacterium freudenreichii ssp shermanii JS DSM 7067, and B animalis ssp lactis B012 DSM 15954.

Efficacy and Availability

Probiotics belonging to the category of dietary supplements or medical devices are not required to provide evidence for a mechanism of action or even efficacy to be marketed. Thus, for most probiotics sold, there are no human or even animal studies available.

Dr. Sabaté proposed a choice of probiotics based on the literature and the presence of at least one randomized placebo-controlled trial conducted in patients with IBS showing positive results.

“Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in randomized placebo-controlled trials should be recommended,” he emphasized. The parameters that can be improved include symptom severity, quality of life, abdominal pain, and bloating.

Effective Probiotics

B longum 35624, which was developed with researchers from University College Cork in Ireland, is probably the most studied in animals and humans. Research has encompassed the mechanistic, clinical, and safety aspects of the probiotic. It has shown good results on the IBS-Symptom Severity Score (SSS), quality of life, abdominal pain, bowel disturbances, and bloating. The treatment duration in studies is 4-8 weeks.

L plantarum 299v (DSM 9843) affects the frequency of abdominal pain and pain score. The treatment duration in studies is 4 weeks.

The multistrain product that includes L plantarum CECT 7484/L plantarum CECT 7485/ Pediococcus acidilactici CECT 7483 allows for an improvement in quality of life and anxiety related to digestive symptoms. No positive effect has been described on digestive symptoms, especially diarrhea. The treatment duration is 6 weeks.

B bifidum MIMBb75 (both normal and heat-inactivated forms) is beneficial for pain, the composite IBS-SSS score, and quality of life. The treatment duration is 4-8 weeks.

“Except for the multistrain combination, which is more suited to patients with diarrhea-predominant IBS, the other three probiotics can be prescribed regardless of the IBS subtype,” said Dr. Sabaté. “Treatment durations are typically 4 weeks, but it is possible to continue up to 8 weeks, which is the maximum duration of these studies. In practice, there are no tolerance issues with probiotics prescribed for IBS based on the literature. These should be tested under the conditions and for the duration of the published studies and should only be continued if there is individual benefit on symptoms or quality of life.”

Note that microbiota analyses conducted for individual purposes are of no help in choosing probiotics.

Mechanisms of Action

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

Only in animals to date, L farciminis and B lactis CNCM I-2494 have shown prevention of induced hypersensitivity (ie, inhibition of the cytoskeleton contraction of colon epithelial cells and subsequent opening of tight junctions).

B infantis 35624 has an anti-inflammatory action by modifying the IL-10 and IL-12 cytokine ratio in animals and humans. It has an immunomodulatory action by increasing dendritic cells in the mucosa and decreasing Th1 and Th7 helper T cells.

B infantis 35624 and L farciminis are two strains that decrease visceral sensitivity in mice.

Escherichia coli Nissle 1917 acts on lipopeptide production with an antinociceptive effect, as observed in mice, by decreasing visceral sensitivity through calcium nociceptor flux blockade (action on GABA type B receptor).

Acting on dysbiosis by modifying fecal microbiota during probiotic intake is possible but depends on the probiotics, like B infantis 35624. In humans, B longum NCC 3001 could modify brain activations.

Dr. Sabaté disclosed financial relationships with Mayoly Spindler, Kyowa Kirin, Tillotts, Servier, Norgine, Biocodex, Merck, Viatris, Abivax, and Inventiva.

This story was translated from the Medscape French edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

MDedge Family Medicine

Clinician Reviews

Federal Practitioner

GI and Hepatology News

Topics

Gastroenterology

IBD & Intestinal Disorders

Read more about Which Probiotics Are Effective in Irritable Bowel Syndrome?

Sections

Author(s)

Author(s)

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

Microbiota in IBS

Recent Guideline

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Efficacy and Availability

Effective Probiotics

Mechanisms of Action

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments.

Microbiota in IBS

Recent Guideline

In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics.

Efficacy and Availability

Effective Probiotics

Mechanisms of Action

In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors.

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

MDedge Family Medicine

Clinician Reviews

Federal Practitioner

GI and Hepatology News

Publications

MDedge Internal Medicine

Internal Medicine News

Family Practice News

MDedge Family Medicine

Clinician Reviews

Federal Practitioner

GI and Hepatology News

Topics

Gastroenterology

IBD & Intestinal Disorders

Article Type

Sections

Teambase XML

<?xml version="1.0" encoding="UTF-8"?>


<root generator="drupal.xsl" gversion="1.7"> <header> <fileName>167805</fileName> <TBEID>0C04FBBB.SIG</TBEID> <TBUniqueIdentifier>MD_0C04FBBB</TBUniqueIdentifier> <newsOrJournal>News</newsOrJournal> <publisherName>Frontline Medical Communications</publisherName> <storyname/> <articleType>2</articleType> <TBLocation>QC Done-All Pubs</TBLocation> <QCDate>20240422T135259</QCDate> <firstPublished>20240422T140120</firstPublished> <LastPublished>20240422T140120</LastPublished> <pubStatus qcode="stat:"/> <embargoDate/> <killDate/> <CMSDate>20240422T140119</CMSDate> <articleSource/> <facebookInfo/> <meetingNumber/> <byline>Nathalie Raffier</byline> <bylineText>NATHALIE RAFFIER</bylineText> <bylineFull>NATHALIE RAFFIER</bylineFull> <bylineTitleText/> <USOrGlobal/> <wireDocType/> <newsDocType>News</newsDocType> <journalDocType/> <linkLabel/> <pageRange/> <citation/> <quizID/> <indexIssueDate/> <itemClass qcode="ninat:text"/> <provider qcode="provider:imng"> <name>IMNG Medical Media</name> <rightsInfo> <copyrightHolder> <name>Frontline Medical News</name> </copyrightHolder> <copyrightNotice>Copyright (c) 2015 Frontline Medical News, a Frontline Medical Communications Inc. company. All rights reserved. This material may not be published, broadcast, copied, or otherwise reproduced or distributed without the prior written permission of Frontline Medical Communications Inc.</copyrightNotice> </rightsInfo> </provider> <abstract/> <metaDescription>Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in rand</metaDescription> <articlePDF/> <teaserImage/> <teaser>For most probiotics sold, there are no human or even animal studies available.</teaser> <title>Which Probiotics Are Effective in Irritable Bowel Syndrome?</title> <deck/> <disclaimer/> <AuthorList/> <articleURL/> <doi/> <pubMedID/> <publishXMLStatus/> <publishXMLVersion>1</publishXMLVersion> <useEISSN>0</useEISSN> <urgency/> <pubPubdateYear/> <pubPubdateMonth/> <pubPubdateDay/> <pubVolume/> <pubNumber/> <wireChannels/> <primaryCMSID/> <CMSIDs/> <keywords/> <seeAlsos/> <publications_g> <publicationData> <publicationCode>im</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>fp</publicationCode> <pubIssueName/> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> </publicationData> <publicationData> <publicationCode>GIHOLD</publicationCode> <pubIssueName>January 2014</pubIssueName> <pubArticleType/> <pubTopics/> <pubCategories/> <pubSections/> <journalTitle/> <journalFullTitle/> <copyrightStatement/> </publicationData> </publications_g> <publications> <term canonical="true">21</term> <term>15</term> </publications> <sections> <term>39313</term> <term canonical="true">53</term> </sections> <topics> <term canonical="true">213</term> </topics> <links/> </header> <itemSet> <newsItem> <itemMeta> <itemRole>Main</itemRole> <itemClass>text</itemClass> <title>Which Probiotics Are Effective in Irritable Bowel Syndrome?</title> <deck/> </itemMeta> <itemContent> PARIS — Irritable bowel syndrome (IBS) is a common brain-gut axis disorder, and patients are often dissatisfied with conventional treatments. The role of the microbiota in IBS is now well established, and patients frequently take probiotics on their own initiative or on the advice of a physician or pharmacist. However, not all probiotics have equal efficacy, so which ones should be recommended? Jean-Marc Sabaté, MD, PhD, a gastroenterologist at Avicenne Hospital in Bobigny, France, shared insights about probiotics at the Francophone Days of Hepatology, Gastroenterology, and Digestive Oncology. IBS, according to the Rome IV symptom-based classification, is a “disorder of brain-gut axis interactions” with a prevalence of about 4% in the adult population. In France, during an average care pathway of about 8 years, patients try an average of <a href="https://www.sciencedirect.com/science/article/abs/pii/S2210740120300474?via%3Dihub">five therapeutic strategies</a> (and as many as 11), including antispasmodics (85%), diets (78%), and probiotics. In addition, 66.4% of patients had either taken or were taking probiotics at the time of a recent survey. While the 2022 recommendations from the American College of Gastroenterology on the diagnosis and management of IBS do not support the use of probiotics for overall symptom relief — a recommendation for which they cite a low level of evidence — “there is nevertheless a rationale for prescribing probiotics in IBS due to the significant role of the microbiota (or dysbiosis) in this condition,” said Dr. Sabaté. <h2>Microbiota in IBS </h2> Evidence indicating that <a href="https://pubmed.ncbi.nlm.nih.gov/11808932/">antibiotics exacerbate IBS symptoms</a> and revealing <a href="https://pubmed.ncbi.nlm.nih.gov/12591062/">chronic bacterial overgrowth</a> in the small intestine of patients with IBS supports the role of the microbiota. Studies using a molecular approach (16s rRNA) have settled the debate, confirming differences in <a href="https://www.gastrojournal.org/article/S0016-5085(07)00734-2/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F">the intestinal flora</a> between patients with IBS and healthy subjects. Data also indicate differences in flora between <a href="https://gut.bmj.com/content/61/7/997">patient subtypes</a>, such as an increased Firmicutes to Bacteroidetes ratio. However, one subgroup, which can represent as much as a third of patients, seems to harbor a “normal” microbiota. Nonetheless, the microbiota plays a significant role in IBS. A <a href="https://www.gastrojournal.org/article/S0016-5085(16)35174-5/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F">Swedish study</a> highlighted the influence of bacterial enterotypes on transit type associated with IBS and symptom severity, independent of diet composition or medication use. This dysbiosis could play a significant role as it interacts with other mechanisms involved in IBS, including changes in intestinal motility related to diet (related to fermentable carbohydrates, for example). Moreover, the microbiota seems to induce a low level of immune activation in patients with IBS, leading to microinflammation and increased intestinal permeability, especially after an infection. Furthermore, alterations in the regulation of bile acid deconjugation by the microbiota partly explain the frequency and consistency of stools in diarrhea-predominant IBS patients. In addition, colonic gas production is higher in these patients. Those complaining of flatulence have poor tolerance to intestinal gases after a flatulent meal, associated with microbiota instability. Data regarding the interaction between the microbiota and central mechanisms mainly come from animal studies. In rodents, microbiota constituents seem to affect brain development, function, and morphology. Emotional and physical traumas during childhood appear to be risk factors. Moreover, even brief exposure to broad-spectrum antibiotics in neonates could cause subsequent visceral hypersensitivity. Lastly, the role of the microbiota in changes in medullary pain control after visceral stimulation (eg, rectal distension) has still not been demonstrated in humans. <h2>Recent Guideline </h2> In its February 2023 Global Guideline “Probiotics and Prebiotics” for IBS, the World Gastroenterology Organization looked at the level of evidence for probiotics. Three strains, as well as a combination of several strains, were supported by level 2 evidence, meaning at least two randomized studies with converging results. These are <a href="https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30056-X/abstract">Bifidobacterium bifidum MIMBb75,</a> which improves overall symptoms and quality of life; <a href="https://www.wjgnet.com/1007-9327/full/v18/i30/4012.htm">Lactobacillus plantarum 299v</a> (DSM 9843), which acts on the severity of abdominal pain and bloating; and B infantis 35624 (new name: B longum 35624), which improves the overall assessment of IBS symptoms, as does the multistrain product containing L rhamnosus GG, L rhamnosus LC705, Propionibacterium freudenreichii ssp shermanii JS DSM 7067, and B animalis ssp lactis B012 DSM 15954. <h2>Efficacy and Availability </h2> Probiotics belonging to the category of dietary supplements or medical devices are not required to provide evidence for a mechanism of action or even efficacy to be marketed. Thus, for most probiotics sold, there are no human or even animal studies available. Dr. Sabaté proposed a choice of probiotics based on the literature and the presence of at least one randomized placebo-controlled trial conducted in patients with IBS showing positive results. “Probiotic efficacy largely depends on the bacterial species, strain, and clinical situation treated. Only probiotics with demonstrated clinical efficacy in randomized placebo-controlled trials should be recommended,” he emphasized. The parameters that can be improved include symptom severity, quality of life, abdominal pain, and bloating. <h2>Effective Probiotics </h2> B longum 35624, which was developed with researchers from University College Cork in Ireland, is probably the most studied in animals and humans. Research has encompassed the mechanistic, clinical, and safety aspects of the probiotic. It has shown good results on the IBS-Symptom Severity Score (SSS), quality of life, abdominal pain, bowel disturbances, and bloating. The treatment duration in studies is 4-8 weeks. L plantarum 299v (DSM 9843) affects the frequency of abdominal pain and pain score. The treatment duration in studies is 4 weeks. The multistrain product that includes L plantarum CECT 7484/L plantarum CECT 7485/ Pediococcus acidilactici CECT 7483 allows for an improvement in quality of life and anxiety related to digestive symptoms. No positive effect has been described on digestive symptoms, especially diarrhea. The treatment duration is 6 weeks. B bifidum MIMBb75 (both normal and heat-inactivated forms) is beneficial for pain, the composite IBS-SSS score, and quality of life. The treatment duration is 4-8 weeks. “Except for the multistrain combination, which is more suited to patients with diarrhea-predominant IBS, the other three probiotics can be prescribed regardless of the IBS subtype,” said Dr. Sabaté. “Treatment durations are typically 4 weeks, but it is possible to continue up to 8 weeks, which is the maximum duration of these studies. In practice, there are no tolerance issues with probiotics prescribed for IBS based on the literature. These should be tested under the conditions and for the duration of the published studies and should only be continued if there is individual benefit on symptoms or quality of life.” Note that microbiota analyses conducted for individual purposes are of no help in choosing probiotics. <h2>Mechanisms of Action </h2> In a murine model, but not in humans, some strains, especially L acidophilus NCFM, have shown an antinociceptive effect by inducing opioid and cannabinoid receptors. Only in animals to date, L farciminis and B lactis CNCM I-2494 have shown prevention of induced hypersensitivity (ie, inhibition of the cytoskeleton contraction of colon epithelial cells and subsequent opening of tight junctions). B infantis 35624 has an anti-inflammatory action by modifying the IL-10 and IL-12 cytokine ratio in animals and humans. It has an immunomodulatory action by increasing dendritic cells in the mucosa and decreasing Th1 and Th7 helper T cells. B infantis 35624 and L farciminis are two strains that decrease visceral sensitivity in mice. Escherichia coli Nissle 1917 acts on lipopeptide production with an antinociceptive effect, as observed in mice, by decreasing visceral sensitivity through calcium nociceptor flux blockade (action on GABA type B receptor). Acting on dysbiosis by modifying fecal microbiota during probiotic intake is possible but depends on the probiotics, like B infantis 35624. In humans, B longum NCC 3001 could modify brain activations. Dr. Sabaté disclosed financial relationships with Mayoly Spindler, Kyowa Kirin, Tillotts, Servier, Norgine, Biocodex, Merck, Viatris, Abivax, and Inventiva. This story was translated from the <a href="https://francais.medscape.com/voirarticle/3611285?src=">Medscape French edition</a> using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on <a href="https://www.medscape.com/viewarticle/which-probiotics-are-effective-irritable-bowel-syndrome-2024a10007o4">Medscape.com</a>. </itemContent> </newsItem> <newsItem> <itemMeta> <itemRole>teaser</itemRole> <itemClass>text</itemClass> <title/> <deck/> </itemMeta> <itemContent> </itemContent> </newsItem> </itemSet></root>

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

IBD: Histologic Inflammation Linked With Lower Female Fertility

More Aggressive Treatment of Inflammation Is Appropriate

Article Type

News

Changed

Thu, 04/11/2024 - 12:34

Author(s)

Will Pass

Histologic inflammation in women with inflammatory bowel disease (IBD) may lead to reduced fertility, according to a Swedish nationwide cohort study.

Reduced fertility was linked with histologic inflammation even in the absence of clinical disease activity, highlighting the importance of achieving deep remission in women planning pregnancy, reported lead author Karl Mårild, MD, PhD, of Sahlgrenska Academy, Gothenburg, Sweden, and colleagues.

“Reduced female fertility (ie, number of live births) is believed to be primarily confined to women with clinically active IBD, especially in Crohn’s disease (CD), where symptoms may inhibit sexual activity, and inflammation may affect the fallopian tubes and ovaries,” the investigators wrote in Gastroenterology. “Despite the increasing appreciation of histologic activity in IBD, its association with female fertility has not been clarified, including whether histologic activity in the absence of clinical disease activity impairs fertility.”

Dr. Mårild and colleagues aimed to address this knowledge gap by analyzing fertility rates and histologic inflammation or IBD activity in two cohorts of women with IBD aged 15-44 years. The first group included approximately 21,000 women with and without histologic inflammation from 1990 to 2016. The second group included approximately 25,000 women with or without IBD clinical activity from 2006 to 2020. In each group, the relationship between fertility and IBD was compared with fertility in matched general population comparator individuals.

This approach showed that clinical IBD activity was associated with an adjusted fertility rate ratio (aFRR) of 0.76 (95% CI, 0.72-0.79), which equates to one fewer child per six women with 10 years of clinical activity. Impacts on fertility were similar for UC (aFRR, 0.75) and CD (aFRR, 0.76).

“Fertility rates were notably reduced during periods of clinical IBD activity and, contrary to a generally accepted belief, equally reduced in clinically active UC and CD,” the investigators wrote. “Besides inflammation, clinically active IBD may reduce fertility through psychological mechanisms (eg, depression), dyspareunia (especially in perianal CD), bowel pain, urgency, and other symptoms that hinder sexual activity.”

Compared with histologic remission, histologic inflammation was also associated with reduced fertility (aFRR, 0.90). This means that in periods of histologic inflammation, 6.35 live births occurred per 100 person-years of follow-up, compared with 7.09 lives births for periods of histologic remission. This amounts to one fewer child per 14 women with 10 years of histologic inflammation.

Finally, the study revealed that, in women with clinically quiescent IBD, those with histologic inflammation had significantly reduced fertility, compared with those in histologic remission (aFRR, 0.85). This association persisted after controlling for contraceptive use.

“Even if histologic inflammation was associated with an overall modest fertility reduction … its impact on the individual might be substantial, with potential ramifications beyond reproductive health, given that reduced female fertility is linked to poor quality of life and mental health,” Dr. Mårild and colleagues wrote. “At a societal level, involuntary childlessness causes high and increasing costs, highlighting the need to focus on preventable causes of reduced fertility.”

The investigators suggested that inflammation may be driving infertility by reducing ovulation and fertilization, or by reducing endometrial receptivity, which increases risk of pregnancy loss.

“This is the first study, to our knowledge, to show reduced fertility during histologic inflammation in IBD compared to histologic remission,” the investigators wrote. “Our findings suggest that achieving histologic remission may improve the fertility of women with IBD, even in the absence of clinically defined disease activity.”

The investigators disclosed relationships with AbbVie, Pfizer, Janssen, and others.

Body

The importance of controlling inflammation to ensure a healthy pregnancy cannot be overstated. With regard to fertility, the literature has emphasized that surgery has been the major risk factor for decreasing fertility in both ulcerative colitis and Crohn’s disease. Disease activity has been more influential on Crohn’s disease versus ulcerative colitis. Other factors such as voluntary childlessness, premature ovarian failure, and malnutrition can also play a role. There have been data to show that anti–tumor necrosis factor use increases the chances of successful implantation for women with sub-fertility who do not have concomitant IBD, perhaps by decreasing inflammation in the pelvis.

[[{"fid":"301082","view_mode":"medstat_image_flush_right","fields":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Sunanda Kane, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota","field_file_image_credit[und][0][value]":"CourtesyMayo Clinic","field_file_image_caption[und][0][value]":"Dr. Sunanda Kane"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_right","field_file_image_alt_text[und][0][value]":"Dr. Sunanda Kane, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota","field_file_image_credit[und][0][value]":"CourtesyMayo Clinic","field_file_image_caption[und][0][value]":"Dr. Sunanda Kane"}},"attributes":{"alt":"Dr. Sunanda Kane, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota","class":"media-element file-medstat-image-flush-right","data-delta":"2"}}]]Histologic activity has recently become the ultimate therapeutic goal. Up until now this has not been studied in the context of fertility. We know that clinical disease indices do not necessarily correlate with endoscopic appearance, and when trying to optimize pregnancy outcomes it might behoove us to know what our goal is — absence of clinical, endoscopic, or histologic inflammation. However, perfection might be the enemy of good: One fewer child per 14 women with 10 years of histologic inflammation is hard to put into clinical context. I think these results are important to again emphasize that we should not stop therapy in the preconception period, with a goal of controlling as much inflammation as possible. Perhaps the best way to use these data are to counsel women with unsuccessful attempts at pregnancy and, in the absence of any other factors, that more aggressive treatment of inflammation is appropriate.

Sunanda Kane, MD, MSPH, AGAF, is based in the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota. She reports serving as a consultant to Boehringer Ingelheim, Bristol Myers Squibb, Fresenius Kabi, Gilead, Janssen, and Takeda. She is also Section Editor for IBD for UptoDate.

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Read more about IBD: Histologic Inflammation Linked With Lower Female Fertility

Sections

From the AGA Journals

Author(s)

Author(s)

Body

Title

More Aggressive Treatment of Inflammation Is Appropriate

Histologic inflammation in women with inflammatory bowel disease (IBD) may lead to reduced fertility, according to a Swedish nationwide cohort study.

Publications

GI and Hepatology News

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Article Type

News

Sections

From the AGA Journals

From the Journals

Latest News

Teambase XML

Article Source

FROM GASTROENTEROLOGY

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

240127FA.SIG

Disable zoom

Off

Computer-Aided Colonoscopy Falls Short in Real-World Practice

Jury is still out on CADe

Article Type

News

Changed

Mon, 04/15/2024 - 11:30

Author(s)

Will Pass

Colonoscopy with computer-aided detection (CADe) fails to improve adenoma detection rate (ADR) in real-world, nonrandomized trials, according to investigators.

Although CADe did not increase burden of colonoscopy in the real-world, these real-world detection rates casts doubt on the generalizability of positive findings from randomized trials, reported lead author Harsh K. Patel, MD, of the University of Kansas Medical Center, Kansas City, Missouri, and colleagues.

CADe-assisted colonoscopy has gained increasing attention for its potential to improve ADR, particularly with the recent publication of a meta-analysis involving 20 randomized controlled trials (RCTs), Dr. Patel and colleagues wrote in Clinical Gastroenterology and Hepatology. “However, results of RCTs are not necessarily reproducible in clinical practice.”

RCTs evaluating this technology are susceptible to various issues with validity, they noted, such as psychological bias stemming from lack of blinding to the possibility that CADe could reduce operator attention, paradoxically “deskilling” endoscopists.

The present meta-analysis aimed to overcome these potential shortfalls by analyzing nonrandomized data from eight studies involving 9,782 patients.

“The lack of a highly controlled setting reduces the psychological pressure of the endoscopists to demonstrate a possible beneﬁt of CADe (i.e., the operator bias) and allows endoscopists to use CADe according to their preferences and attitudes which we usually experience in a real-world clinical practice,” the investigators wrote. “On the other hand, noncontrolled factors may affect the outcome of the study, especially when considering that an equivalent distribution of prevalence of disease is required for a fair assessment of the effectiveness of the intervention.”

This approach revealed less favorable outcomes than those reported by RCTs.

CADe-assisted ADR was not significantly different from ADR for standard colonoscopy (44% vs 38%; risk ratio, 1.11; 95% CI, 0.97-1.28), nor was mean number of adenomas detected per colonoscopy (0.93 vs 0.79; mean difference, 0.14; 95% CI, -0.04-0.32).

“Our study provides a contrasting perspective to those results previously known from the randomized studies,” the investigators wrote.

While detection benefits were not identified, burden of CADe-assisted colonoscopy was not elevated either.

Mean nonneoplastic lesions per colonoscopy was similar between modalities (0.52 vs 0.47; mean difference, 0.14; 95% CI, -0.07-0.34), as was withdrawal time (14.3 vs 13.4 minutes; mean difference, 0.8 minutes; 95% CI, -0.18-1.90).

Dr. Patel and colleagues described “a high level of heterogeneity that was qualitatively and quantitatively distinct from the heterogeneity discovered in the prior meta-analysis of RCTs.” Unlike the RCT meta-analysis, which had no studies with an ADR outcome favoring the control arm, the present meta-analysis found that one third of the included studies favored the control arm.

“This qualitative difference generates a much higher degree of ambiguity, as it does not apply only to the magnitude of the effect of CADe, but it puts in question the actual existence of any CADe-related beneﬁt,” they wrote. “An important point to make is that the analysis of adenoma and serrated lesions per colonoscopy supported the qualitative heterogeneity, favoring the control arm over the CADe arm, in the direction of the effect.”

Dr. Patel and colleagues suggested that the concurrent lack of benefit and lack of harm associated with CADe in the present meta-analysis is “interesting,” and may point to underutilization or a lack of effect of CADe.

“To address the uncertainties in the current literature, we recommend conducting additional randomized studies in a more pragmatic setting,” they concluded.

This meta-analysis was supported by the European Commission and AIRC. The investigators disclosed relationships with NEC, Satisfy, Odin, and others.

Body

The advent of AI in colonoscopy through computer-aided detection (CADe) systems has been promising, with over 20 randomized controlled trials (RCTs) affirming its benefits. However, this enthusiasm has been tempered by several recent nonrandomized studies indicating no real-world advantage, as discussed in Patel et al.’s systematic review and meta-analysis in Clinical Gastroenterology and Hepatology.

[[{"fid":"300209","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Nabil M. Mansour, McNair General GI Clinic at Baylor College of Medicine in Houston","field_file_image_credit[und][0][value]":"Baylor College of Medicine","field_file_image_caption[und][0][value]":"Dr. Nabil M. Mansour"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Nabil M. Mansour, McNair General GI Clinic at Baylor College of Medicine in Houston","field_file_image_credit[und][0][value]":"Baylor College of Medicine","field_file_image_caption[und][0][value]":"Dr. Nabil M. Mansour"}},"attributes":{"alt":"Dr. Nabil M. Mansour, McNair General GI Clinic at Baylor College of Medicine in Houston","class":"media-element file-medstat-image-flush-left","data-delta":"2"}}]]The stark differences in the results of RCTs and nonrandomized studies with CADe are interesting and thought-provoking, highlighting issues like potential RCT bias (due to lack of blinding) and the critical role of the human-AI interaction. It may be that some endoscopists derive a benefit from CADe while others do not, and further studies looking into the performance of individual endoscopists with and without CADe may be helpful. The meta-analysis also reveals varying outcomes based on study design — prospective or retrospective — and the nature of the control arm, be it concurrent or historical.

In addition, a critical consideration with evaluating any AI/CADe system is they often undergo frequent updates, each promising improved accuracy, sensitivity, and specificity. This is an interesting dilemma and raises questions about the enduring relevance of studies conducted using outdated versions of CADe.

In my opinion, the jury is still out on the effectiveness of CADe for colonoscopy in a real-world setting. The definitive assessment of CADe’s real-world value necessitates larger, well-structured trials that mirror actual clinical environments and span extended periods of time, taking care to minimize biases that may have influenced the results of current published studies.

Nabil M. Mansour, MD, is assistant professor of medicine in the Section of Gastroenterology, Baylor College of Medicine, Houston. He has served as a consultant for Iterative Health.

Publications

GI and Hepatology News

Federal Practitioner

Topics

Endoscopy

IBD & Intestinal Disorders

GI Oncology

Colon and Rectal

Read more about Computer-Aided Colonoscopy Falls Short in Real-World Practice

Sections

From the AGA Journals

Author(s)

Author(s)

Body

Nabil M. Mansour, MD, is assistant professor of medicine in the Section of Gastroenterology, Baylor College of Medicine, Houston. He has served as a consultant for Iterative Health.

Body

Nabil M. Mansour, MD, is assistant professor of medicine in the Section of Gastroenterology, Baylor College of Medicine, Houston. He has served as a consultant for Iterative Health.

Title

Jury is still out on CADe

Colonoscopy with computer-aided detection (CADe) fails to improve adenoma detection rate (ADR) in real-world, nonrandomized trials, according to investigators.

Publications

GI and Hepatology News

Federal Practitioner

Publications

GI and Hepatology News

Federal Practitioner

Topics

Endoscopy

IBD & Intestinal Disorders

GI Oncology

Colon and Rectal

Article Type

News

Sections

From the AGA Journals

From the Journals

Latest News

News

Teambase XML

Article Source

FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

240127BE.SIG

Disable zoom

Off

Linaclotide Succeeds for Functional Constipation in Children

Article Type

News

Changed

Thu, 03/28/2024 - 16:51

Author(s)

Heidi Splete

Children and adolescents with functional constipation showed significantly greater increases in spontaneous bowel movements with linaclotide compared with placebo, according to data from 330 individuals.

“Functional constipation is prevalent in pediatrics and is associated with chronic burdensome symptoms and impaired quality of life with an unmet need for treatment options for this age group,” corresponding study author Julie Khlevner, MD, AGAF, a pediatric gastroenterologist at Columbia University Vagelos College of Physicians and Surgeons, New York, said in an interview.

“Linaclotide has been approved for adults with chronic idiopathic constipation and irritable bowel syndrome with constipation, but its efficacy and safety in pediatric patients were unknown. Therefore, evaluating its use in this population was crucial to provide evidence-based treatment option,” she said.

In a study published in The Lancet Gastroenterology & Hepatology, the researchers randomized 166 pediatric patients with functional constipation to 72 micrograms of linaclotide once daily for 12 weeks and 164 to a placebo. The study was conducted at 64 clinic or hospital sites across 7 countries between October 1, 2019, and March 21, 2022. Approximately half (55%) of the patients were female.

The primary outcome was a change from baseline to 12 weeks in the frequency of spontaneous bowel movements (SBMs) per week, with no rescue medication on the day of or before the bowel movement. The secondary endpoint was change in stool consistency from baseline to 12 weeks. The mean frequency for SBMs at baseline was 1.16 per week in patients randomized to linaclotide and 1.28 for those randomized to placebo; these rates increased to 3.41 and 2.29, respectively, over the study period. The linaclotide patients showed a significantly greater improvement over placebo patients based on least-squares mean change from baseline (2.22 vs. 1.05, P = .0001).

In a subgroup analysis by age, the response was stronger in younger patients aged 6-11 years than in those aged 12-17 years, the researchers noted. This difference might stem from different pathophysiological mechanisms between older and younger ages, such as withholding behavior, they added.

Linaclotide was well tolerated overall; the most frequently reported treatment-emergent events were diarrhea (seven linaclotide patients and three placebo patients). In addition, five linaclotide patients and four placebo patients developed COVID-19 during treatment. No deaths occurred during the study, but one serious adverse event involving severe diarrhea, dehydration, and hospitalization, occurred in a 17-year-old female patient, but resolved after administration of intravenous fluids, the researchers noted.

Clinical Implications and Next Steps

The study findings reflect previous research on linaclotide in adults, Dr. Khlevner said. “The significant improvement in spontaneous bowel movements frequency and stool consistency with linaclotide compared to placebo is consistent with its mechanism of action as a guanylate cyclase C agonist,” she noted.

In clinical practice, barriers to the use of linaclotide may include lack of awareness of linaclotide’s safety and efficacy profile, and of its Food and Drug Administration approval for use in children aged 6-17 years with functional constipation, said Dr. Khlevner. “Additionally, access to the medication and insurance coverage may be potential barriers for some patients.” However, “some of these barriers can be overcome through education and training of healthcare providers regarding the appropriate use of linaclotide in pediatric patients with functional constipation,” she added.

The findings were limited by several factors including potential measurement bias and selection bias, lack of assessment of lifestyle modifications as confounding factors, and lack of quality-of-life assessment, the researchers noted. Other limitations included the relatively short 12-week treatment duration, which may not fully capture long-term safety and efficacy, and the focus on patients aged 6-17 years, Dr. Khlevner told this news organization.

“Future research could address these limitations through longer-term studies with broader age ranges and incorporating patient-reported outcomes in real world situations to assess the overall impact of linaclotide treatment on pediatric patients with functional constipation,” she said.

Study Supports Noninvasive Treatment Option

An alternative medication for children with functional constipation who do not respond to current therapies could prevent the use of more invasive interventions such as frequent enemas or antegrade enemas, Stephen M. Borowitz, MD, professor of pediatrics at the University of Virginia, Charlottesville, said in an interview.

Dr. Borowitz said he was not surprised by study findings. “Given the mechanism of action of the drug, I would expect the majority of children with functional constipation to respond in the sense of having more frequent and softer stools,” he said. “The bigger question, which wasn’t answered, is whether children who fail more conservative therapies respond to linaclotide,” said Dr. Borowitz, who was not involved in the study. “This was a phase 3 trial of otherwise healthy children with functional constipation and we know the majority of these children will respond to aggressive management with osmotic stool softeners, plus or minus a stimulant like senna coupled with lifestyle modifications (such as drinking more fluid, regular toileting, and appropriate toileting behaviors),” he said.

The greatest short-term barrier to the expanded use of linaclotide in clinical practice will likely be cost, and whether insurance will cover the drug, Dr. Borowitz told this news organization. Insurance coverage may not be an option until the child has failed more conservative, less expensive therapies, he said.

Also, the current study was a placebo-controlled trial, and not a comparison between linaclotide and polyethylene glycol, plus or minus senna, with other routine interventions, he said.

Looking ahead, “now that we know linaclotide is better than placebo, we need to know if it is as good, better, or worse than other proven interventions, and perhaps even more importantly, is it effective among children who have failed more conservative management,” Dr. Borowitz said. “We also need to know long-term risks, and given that the majority of childhood constipation develops before age 6 years, whether the drug can be used in younger children,” he emphasized. If so, studies need to examine whether linaclotide alters the natural history of the problem, he added. Previous studies suggest that the longer the symptom goes on, the harder it is to undo the secondary behaviors that result, such as withholding, pelvic floor dysfunction, and toileting refusal, he noted.

The study was supported by AbbVie and Ironwood Pharmaceuticals. The lead author, Carlo Di Lorenzo, MD, disclosed consulting fees from AbbVie, Ironwood Pharmaceuticals, Mallinckrodt, NeurAxis, QOL Medical, and Takeda. Dr. Khlevner disclosed honoraria from Abbott Pediatric Nutrition and participation on a data safety monitoring board and advisory board for AbbVie. Dr. Borowitz had no financial conflicts to disclose.

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Pediatric News

MDedge Family Medicine

MDedge Internal Medicine

MDedge Pediatrics

Topics

IBD & Intestinal Disorders

Gastroenterology

Pediatrics

Read more about Linaclotide Succeeds for Functional Constipation in Children

Sections

Author(s)

Author(s)

Clinical Implications and Next Steps

Study Supports Noninvasive Treatment Option

Clinical Implications and Next Steps

Study Supports Noninvasive Treatment Option

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Pediatric News

MDedge Family Medicine

MDedge Internal Medicine

MDedge Pediatrics

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Pediatric News

MDedge Family Medicine

MDedge Internal Medicine

MDedge Pediatrics

Topics

IBD & Intestinal Disorders

Article Type

Sections

Teambase XML

Article Source

FROM THE LANCET GASTROENTEROLOGY & HEPATOLOGY

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

240127B2.SIG

Disable zoom

Off

Liquid Biopsy for Colorectal Cancer Appears Promising But Still Lacks Robust Efficacy

Article Type

News

Changed

Wed, 03/27/2024 - 10:04

Author(s)

Carolyn Crist

Blood-based screening for colorectal cancer (CRC), also known as a “liquid biopsy,” may be better than nothing among patients who skip established screening tests, but it can’t replace colonoscopy as the gold standard, according to two new modeling studies and an expert consensus commentary.

Although some patients find blood-based tests more convenient, the higher numbers of false positives and false negatives could lead to more CRC cases and deaths.

“Based on their current characteristics, blood tests should not be recommended to replace established colorectal cancer screening tests, since blood tests are neither as effective nor cost-effective and would worsen outcomes,” David Lieberman, MD, AGAF, chair of the American Gastroenterological Association’s CRC Workshop Panel, and lead author of the expert commentary, said in a statement.

The blood tests detect circulating nucleotides, such as cell-free DNA or metabolic products associated with CRC and its precursors. Current tests are in development by Guardant Health and Freenome.

The two modeling studies, published in Gastroenterology on March 26, analyzed the effectiveness and cost-effectiveness of blood-based CRC screening that meets Centers for Medicare & Medicaid Services (CMS) coverage criteria, as well as the comparative effectiveness and cost-effectiveness of CRC screening with blood-based biomarkers versus fecal tests or colonoscopy.

Also published on March 26 in Clinical Gastroenterology and Hepatology, the expert commentary included key conclusions from the AGA CRC Workshop, which analyzed the two modeling studies.

Comparing CRC Screening Methods

In the first modeling study, an international team of researchers ran three microsimulation models for CRC to estimate the effectiveness and cost-effectiveness of triennial blood-based screening for ages 45-75, compared with no screening, annual fecal immunochemical testing (FIT), triennial stool DNA testing combined with a FIT assay, and colonoscopy screening every 10 years. The researchers used CMS coverage criteria for blood tests, with a sensitivity of at least 74% for detection of CRC and specificity of at least 90%.

Without screening, the models predicted between 77 and 88 CRC cases and between 32 and 36 deaths per 1,000 individuals, costing between $5.3 million to $5.8 million. Compared with no screening, blood-based screening was considered cost-effective, with an additional cost of $25,600 to $43,700 per quality-adjusted life-year gained (QALYG).

However, compared with the FIT, stool, and colonoscopy options, blood-based screening was not cost-effective, with both a decrease in QALYG and an increase in costs. FIT was more effective and less costly, with 5-24 QALYG and nearly $3.5 million cheaper than blood-based screening, even when blood-based uptake was 20 percentage points higher than FIT uptake.

In the second modeling study, US researchers compared triennial blood-based screening with established alternatives at the CMS thresholds of 74% sensitivity and 90% specificity.

Overall, a blood-based test at the CMS minimum reduced CRC incidence by 40% and CRC mortality by 52% versus no screening. However, a blood-based test was significantly less effective than triennial stool DNA testing, annual FIT, and colonoscopy every 10 years, which reduced CRC incidence by 68%-79% and CRC mortality by 73%-81%.

Assuming a blood-based test would cost the same as a multi-target stool test, the blood-based test would cost $28,500 per QALYG versus no screening. At the same time, FIT, colonoscopy, and stool DNA testing were less costly and more effective. In general, the blood-based test would match FIT’s clinical outcomes if it achieved 1.4- to 1.8-fold the participation rate for FIT.

Even still, the sensitivity for advanced precancerous lesion (APL) was a key determinant. A paradigm-changing blood-based test would need to have higher than 90% sensitivity for CRC and 80% for APL, 90% specificity, and cost less than $120 to $140, the study authors wrote.

“High APL sensitivity, which can result in CRC prevention, should be a top priority for screening test developers,” the authors wrote. “APL detection should not be penalized by a definition of test specificity that focuses on CRC only.”

Additional Considerations

The AGA CRC Workshop Panel met in September 2023 to review the two modeling studies and other data on blood-based tests for CRC. Overall, the group concluded that a triennial blood test that meets minimal CMS criteria would likely result in better outcomes than no screening and provide a simple process to encourage more people to participate in screening.

However, patients who may have declined colonoscopy should understand the need for a colonoscopy if blood-based tests show abnormal results, the commentary authors wrote.

In addition, because blood-based tests for CRC appear to be less effective and more costly than current screening options, they shouldn’t be recommended to replace established screening methods. Although these blood-based tests may improve screening rates and outcomes in unscreened people, substituting blood tests for other effective tests would increase costs and worsen patient outcomes.

Beyond that, they wrote, the industry should consider other potential benchmarks for an effective blood test, such as a sensitivity for stage I-III CRC of greater than 90% and sensitivity for advanced adenomas of 40%-50% or higher.

“Unless we have the expectation of high sensitivity and specificity, blood-based colorectal cancer tests could lead to false positive and false negative results, which are both bad for patient outcomes,” John M. Carethers, MD, AGAF, vice chancellor for health sciences at UC San Diego, AGA past president, and a member of the AGA CRC Workshop panel, said in a statement.

Several authors reported consultant roles and funding support from numerous companies, including Guardant Health and Freenome.

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Oncology Practice

MDedge Family Medicine

MDedge Internal Medicine

MDedge Hematology and Oncology

Federal Practitioner

AVAHO

Topics

GI Oncology

IBD & Intestinal Disorders

Gastroenterology

Oncology

Gastrointestinal Cancer

Colon and Rectal

Read more about Liquid Biopsy for Colorectal Cancer Appears Promising But Still Lacks Robust Efficacy

Sections

From the AGA Journals

Author(s)

Author(s)

Comparing CRC Screening Methods

Additional Considerations

Comparing CRC Screening Methods

Additional Considerations

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Oncology Practice

MDedge Family Medicine

MDedge Internal Medicine

MDedge Hematology and Oncology

Federal Practitioner

AVAHO

Publications

GI and Hepatology News

Family Practice News

Internal Medicine News

Oncology Practice

MDedge Family Medicine

MDedge Internal Medicine

MDedge Hematology and Oncology

Federal Practitioner

AVAHO

Topics

GI Oncology

IBD & Intestinal Disorders

Gastroenterology

Oncology

Gastrointestinal Cancer

Colon and Rectal

Article Type

News

Sections

From the AGA Journals

From the Journals

Latest News

News

Teambase XML

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

2400CDA7.SIG

Disable zoom

Off

IBS Placebo Responses Predicted By Patient Beliefs, Relationship with Provider

‘Cognitive Reappraisal’ May Aid IBS Treatment

Article Type

News

Changed

Mon, 03/11/2024 - 16:36

Author(s)

Will Pass

Placebo responses in patients with irritable bowel syndrome (IBS) may be altered by baseline beliefs and the patient-provider relationship, according to investigators.

These findings may improve prediction of placebo responses in IBS, and may help avoid patient-provider “mismatch,” both of which can alter treatment outcomes and confound clinical trial findings, reported lead author Jeffrey M. Lackner, PsyD, chief of the division of behavioral medicine at the University of Buffalo, New York, and colleagues.

“A relatively large (40%) placebo response in IBS trials obscures potentially useful, mechanistic, and pharmacodynamically induced symptom changes among agents that do reach market,” the investigators wrote in Gastro Hep Advances. “This begs the question of what individual difference factors distinguish placebo responders.”

While previous studies have explored placebo patient predictors in IBS, most focused on study design and baseline personal characteristics such as age and sex, with none yielding prognostically reliable findings, according to Dr. Lackner and colleagues. Mid-treatment factors such as patient-provider dynamics have not been featured in published meta-analyses, they noted, despite their potential importance.

“This limitation partly reﬂects the demands of efﬁcacy trials that prioritize pre- and posttreatment data over that collected during acute phase, when the putative mechanisms underpinning placebo effects play out,” the investigators wrote. “The expectation that one can beneﬁt from a treatment, for example, is optimally assessed after its rationale is delivered but before a clinically thorough regimen is provided, meaning that it cannot be fruitfully assessed at baseline along with other personal characteristics when treatment rationale is not fully disclosed. The same applies to relational factors such as patient-physician interactions that define the context where treatment is delivered, and placebo response presumably incubates.”

To explore the above factors, Dr. Lackner and colleagues conducted a secondary analysis of 145 patients with Rome III-diagnosed IBS from the Irritable Bowel Syndrome Outcome Study.

During the study, patients were randomized to receive either 10 sessions of clinic-based cognitive behavioral therapy (CBT), 4 sessions of minimal-contact CBT, or 4 sessions of supportive counseling and education without any prescribed behavior changes. Responses were measured by the IBS version of the Clinical Global Improvement Scale, with evaluations conducted at the treatment midpoint and 2 weeks after treatment.

Candidate predictors at baseline included pain catastrophizing, somatization, emotion regulation, neuroticism, stress, and others, while clinical factors included treatment expectancy/credibility and patient-provider relationship.

Responses during treatment were significantly associated with lower somatization and stress level at baseline, as well as greater patient-provider agreement on treatment tasks (P less than .001).

Posttreatment responses were significantly associated with baseline gastroenterologist-rated IBS severity, anxiety, agreement that the patient and the provider shared goals from a provider perspective, and ability to reframe stressful events in a positive light (P less than .001). That ability to reconsider emotions was also associated with a faster placebo response (P = .011).

“The strength of placebo responsiveness is subject to the influence of patient factors that precede treatment delivery (rethinking or reinterpreting stressful situations in everyday life in a way that reduces their subsequent impact) and speciﬁc elements of provider-patient interactions that occur while treatment is delivered, particularly practitioners’ estimation that patients agree on their goals and tasks to achieve them,” Dr. Lackner and colleagues concluded. “We believe this line of research can help identify factors that drive placebo response and narrow the patient-provider ‘mismatch’ that undermines the quality, satisfaction, and efﬁciency of IBS care regardless of what treatment is delivered.”

The study was supported by the NIH. The investigators disclosed no conflicts of interest.

Body

Irritable bowel syndrome (IBS) is associated with impaired functioning and work or school absenteeism. Current treatments are suboptimal and there is a need for improved management strategies. A challenge in designing trials can be placebo response. Placebo can also be a treatment modality with approximately 40% response in adults and children with IBS. The study by Lackner et al. provides predictors of the magnitude, and timing of placebo response. Accordingly, certain behaviors and strategies adopted by patients and clinicians in addition to pharmacotherapy can harness greater clinical improvements.

While patient factors such as stress levels, somatization, and anxiety played a role in predicting rapid and delayed placebo response, an interesting domain was “cognitive reappraisal,” the ability to alter the impact of stressful events by reframing unpleasantness toward them. This was associated with greater global improvement post treatment and differed between rapid and delayed responders. Cognitive reappraisal has shown changes in the limbic system such as activation of the prefrontal cortex like placebo analgesia. Thus, optimal introduction of treatments to patients may be important to maximize the cognitive appraisal abilities, enhance expectation effects, and improve treatment outcomes. Similarly, minimizing nocebo effects may be equally important to decrease side effects.[[{"fid":"300657","view_mode":"medstat_image_flush_left","fields":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Neha Santucci, director of the Disorders of Gut-Brain Interaction Program at the Neurogastroenterology and Motility Center, Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center","field_file_image_credit[und][0][value]":"Cincinnati Children’s Hospital","field_file_image_caption[und][0][value]":"Dr. Neha Santucci"},"type":"media","field_deltas":{"2":{"format":"medstat_image_flush_left","field_file_image_alt_text[und][0][value]":"Dr. Neha Santucci, director of the Disorders of Gut-Brain Interaction Program at the Neurogastroenterology and Motility Center, Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center","field_file_image_credit[und][0][value]":"Cincinnati Children’s Hospital","field_file_image_caption[und][0][value]":"Dr. Neha Santucci"}},"attributes":{"alt":"Dr. Neha Santucci, director of the Disorders of Gut-Brain Interaction Program at the Neurogastroenterology and Motility Center, Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center","class":"media-element file-medstat-image-flush-left","data-delta":"2"}}]]

The agreement between patients and clinicians on treatment goals and tasks also predicted response. Thus, developing thorough treatment goals beforehand could be crucial to sustain treatment responses. For example, improved functioning may be a goal to agree upon rather than symptom reduction alone before commencement of treatment. Similarly, shared decision-making during treatment may have a tremendous influence on favorable outcomes.

Neha Santucci, MD, MBBS, is director of the Disorders of Gut-Brain Interaction Program at the Neurogastroenterology and Motility Center, Pediatric Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, and associate professor of pediatrics, University of Cincinnati College of Medicine.

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Read more about IBS Placebo Responses Predicted By Patient Beliefs, Relationship with Provider

Sections

From the AGA Journals

Latest News

Author(s)

Will Pass

Author(s)

Will Pass

Body

Title

‘Cognitive Reappraisal’ May Aid IBS Treatment

Placebo responses in patients with irritable bowel syndrome (IBS) may be altered by baseline beliefs and the patient-provider relationship, according to investigators.

Publications

GI and Hepatology News

Publications

GI and Hepatology News

Topics

IBD & Intestinal Disorders

Article Type

News

Sections

From the AGA Journals

Latest News

Teambase XML

Article Source

FROM GASTRO HEP ADVANCES

Disallow All Ads

Content Gating

No Gating (article Unlocked/Free)

Alternative CME

Disqus Comments

Default

Consolidated Pubs: Do Not Show Source Publication Logo

Use ProPublica

Conference Recap Checkbox

Not Conference Recap

Clinical Edge

Display the Slideshow in this Article

Medscape Article

Display survey writer

Reuters content

Disable Inline Native ads

WebMD Article

Teaser Media

Teambase ID

24012717.SIG

Disable zoom

Off

Subscribe to IBD & Intestinal Disorders

User login

Gastroenterology

Clinical Gastroenterology and Hepatology

Techniques and Innovations in Gastrointestinal Endoscopy

Gastro Hep Advances

Gastroenterology

Clinical Gastroenterology and Hepatology

Techniques and Innovations in Gastrointestinal Endoscopy

Gastro Hep Advances

Gastroenterology

Clinical Gastroenterology and Hepatology

Techniques and Innovations in Gastrointestinal Endoscopy

Gastro Hep Advances

Pelvic Floor Anatomy

Evaluation of PFD Symptoms

Initial Management

Diagnostic Testing

Minimally Invasive Procedures and Surgical Options for PFD

References

Pelvic Floor Anatomy

Evaluation of PFD Symptoms

Initial Management

Diagnostic Testing

Minimally Invasive Procedures and Surgical Options for PFD

References

Pelvic Floor Anatomy

Evaluation of PFD Symptoms

Initial Management

Diagnostic Testing

Minimally Invasive Procedures and Surgical Options for PFD

References

Clinical Implications, Not Applications

Unreliable, Unregulated

Potential Pitfalls

What to Tell Patients

Educate Clinicians, Companies

Clinical Implications, Not Applications

Unreliable, Unregulated

Potential Pitfalls

What to Tell Patients

Educate Clinicians, Companies

Clinical Implications, Not Applications

Unreliable, Unregulated

Potential Pitfalls

What to Tell Patients

Educate Clinicians, Companies

Microbiota in IBS

Recent Guideline

Efficacy and Availability

Effective Probiotics

Mechanisms of Action

Microbiota in IBS

Recent Guideline

Efficacy and Availability

Effective Probiotics

Mechanisms of Action

Microbiota in IBS

Recent Guideline

Efficacy and Availability

Effective Probiotics

Mechanisms of Action

Clinical Implications and Next Steps

Study Supports Noninvasive Treatment Option

Clinical Implications and Next Steps

Study Supports Noninvasive Treatment Option

Clinical Implications and Next Steps

Study Supports Noninvasive Treatment Option

Comparing CRC Screening Methods

Additional Considerations

Comparing CRC Screening Methods

Additional Considerations

Comparing CRC Screening Methods

Additional Considerations