Functional Gastrointestinal Disorders Research Articles

General practitioners’ experiences with chronic abdominal symptoms and a faecal calprotectin guided referral strategy in children: A Dutch qualitative study

Background General practitioners (GPs) often struggle to distinguish functional gastrointestinal disorders (FGID) from organic disorders in children with chronic abdominal symptoms. A referral strategy guided by faecal calprotectin (FCal) testing may help. Objective This study explores GPs’ experiences with these children and the strategy. Methods GPs were sampled purposively to data saturation. Ultimately, we conducted one focus group session and 13 semi-structured interviews with 17 Dutch GPs who had been involved in a randomised controlled trial evaluating an FCal-testing strategy. The online focus group and interviews were recorded, transcribed verbatim, and subject to thematic content analysis. Results Four themes arose: diagnostic confidence, fear of missing something severe, reassurance and managing FGID in primary care. Although GPs typically felt confident during the diagnostic process, they did fear missing somatic or psychosocial conditions. They felt more diagnostically confident due to FCals clear indications, high diagnostic accuracy, and non-invasiveness. Reassurance was considered crucial in children with FGID, either by labelling symptoms, providing explanatory models, or offering medical interventions (e.g. FCal testing). When helping children with FGID proved too difficult, GPs referred to specialist care. Besides the integration of FCal during reassurance, the testing strategy did not help GPs manage children with FGID. Conclusion While the FCal-strategy improved diagnosis according to GPs, they found the primary challenge to be managing children with FGID. Nevertheless, they found the FCal-strategy beneficial, likely due to its integration into reassurance strategies. Further research focusing on enhancing communication and interventions for paediatric FGID in primary care is warranted.

Epidemiology of Rome IV Fecal Incontinence in Japan: An Internet Survey of 9995 Individuals.

Fecal incontinence (FI) is a debilitating condition defined as recurrent uncontrolled passage of fecal material according to Rome IV. Although FI greatly impacts patients' health-related quality of life (HRQOL), there have been few studies about the prevalence of FI in the Japanese general population. The aim of this study was to investigate the epidemiology of FI using Rome IV criteria in Japan. This was a cross-sectional internet survey for Japanese individuals aged 18 to 79 years using a questionnaire about demographics, comorbidities, lifestyle, abdominal symptoms, bowel habits, HRQOL, and disorders of gut-brain interaction according to Rome IV diagnostic criteria. Multivariate linear regression analysis identified factors associated with FI fulfilling Rome IV criteria (Rome IV FI). Overall, 9995 subjects were analyzed. Of which, 9.5% of the participants had at least one episode of FI in the last 3 months, and the prevalence of Rome IV FI was 1.2%. HRQOL was significantly impaired in patients with Rome IV FI compared to continent individuals. Major functional bowel disorders overlapped with 39.5% of Rome IV FI where functional diarrhea (25.8%) was the most predominant. The overlap further impaired HRQOL in Rome IV FI patients. Alcohol consumption (odds ratio 1.82, 95% CI 1.24-2.66, p = 0.002) was independently related to Rome IV FI apart from gastroesophageal reflux disease, irritable bowel syndrome, functional abdominal bloating/distension, and functional diarrhea. The prevalence of Rome IV FI was 1.2% in Japan. Further study is warranted to investigate the effect of lifestyle modification on the management of FI.

Lateral periaqueductal gray participate in the regulation of irritable bowel syndrome induced by chronic restraint stress

Irritable bowel syndrome (IBS) is a functional bowel disorder defined by recurrent abdominal pain, coupled with irregular bowel habits and alterations in the frequency as well as the consistency of stool. At present, IBS is considered as a disease of gut-brain interaction, and an increasing number of studies are focusing on the brain-gut axis. However, the brain regions associated with IBS have not been fully studied yet. In this study, we utilized the chronic restraint stress (CRS) model to evoke IBS-like symptoms in mice, which were accompanied by anxiety-like behaviors and hyperalgesia. Through cFOS staining, we observed the activation of the lateral periaqueductal gray (LPAG) in the mice after CRS. By inhibiting the activity of the LPAG through tetanus toxin or chemogenetics, we found that IBS-like symptoms could be relieved, whereas chemogenetic activation of the LPAG induced IBS-like symptoms. Finally, we utilized the classic analgesic drug sufentanil and found that it could alleviate CRS-induced IBS-like symptoms.

Current state of the non-pharmacological management of irritable bowel syndrome: an up-to-date review of the literature.

Irritable bowel syndrome (IBS) is a complex disorder of gut-brain interaction (DGBI) that is thought to affect a significant proportion of the population. As a result of the nature of IBS, it is hard to predict treatment efficacy as all individuals respond differently, and thus multidisciplinary treatment has become increasingly of interest as it targets multiple aspects of IBS at the same time. Here, we aim to review the literature of both multidisciplinary and single-discipline therapy for IBS. Ovid MEDLINE was utilised with a systematic search to find relevant randomised controlled trials. The population included adults with a Rome diagnosis of IBS and an intervention that was either multidisciplinary care, diet, psychotherapy, gut-directed hypnotherapy (GDH) or physiotherapy. Multidisciplinary care studies found an overall significant improvement, while dietary treatment was varied. A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet was the only one to improve symptoms, while gluten-free and fibre diets had mixed evidence for their efficacy. Novel diets, including a tritordeum-based diet and low tryptophan diet, significantly improved symptoms. Cognitive behavioural therapy was found to be efficacious when compared to controls, as was psychoeducation. GDH was also found to be efficacious, but 83.3% of studies examined a refractory IBS population. There is a lack of literature looking at how multidisciplinary care and different combinations of disciplines work to treat those with IBS in secondary care. Further studies are required for a greater understanding of how multidisciplinary care may be utilised to better manage IBS.

Disorders of gut-brain interaction, eating disorders and gastroparesis: a call for coordinated care and guidelines on nutrition support.

Disorders of gut-brain interaction, eating disorders and gastroparesis: a call for coordinated care and guidelines on nutrition support.

Prevalence and etiologies of non-responsive celiac disease: A systematic review and meta-analysis.

Non-responsive celiac disease (NRCD) is defined as ongoing symptoms despite 6-12months of gluten-free diet (GFD), the only known treatment for celiac disease (CeD). There is inconsistency in studies describing the proportion of patients having NRCD and its various causes among patients with CeD. We therefore conducted a systematic review and meta-analysis to determine the prevalence and causes of NRCD. The PubMed, Embase, Cochrane Library, Scopus, and Web of Science databases were searched for original studies reporting the proportion of patients with persistent symptoms after ≥6months of GFD. Studies reporting the etiologies of NRCD were also identified. The systematic review was conducted as per the Meta-analysis of Observational Studies in Epidemiology guidelines. Statistical analysis was performed in STATA. Of 2965 search results, nine studies met the inclusion and exclusion criteria. Five studies (n=4414) reported data on prevalence, and seven studies (n=790) reported the causes of NRCD. The pooled prevalence of NRCD was 22% (95% confidence interval, 11-35%). Among patients with NRCD, inadvertent exposure to gluten was the most common cause (33%), followed by functional gastrointestinal disorders including irritable bowel syndrome in 16%. Refractory CeD type II along with its premalignant and malignant sequelae was observed in 7% of patients with NRCD. One in five patients with CeD may not respond to GFD and would likely be classified as NRCD. Inadvertent gluten exposure was the cause of ongoing symptoms in one-third of patients with NRCD. Improving adherence to GFD along with developing novel therapeutics to mitigate symptoms due to ongoing gluten exposure is critical.

Aberrant intrinsic brain activities in functional gastrointestinal disorders revealed by seed-based d mapping with permutation of subject images.

Functional gastrointestinal disorders (FGIDs) are characterized by complex interactions between the gut and brain, leading to altered brain function and symptom manifestation. We used neuroimaging meta-analytic techniques in order to analyze the correlation between FGIDs and aberrant brain activity. A systematic review was performed to ascertain resting-state functional magnetic resonance imaging (rs-fMRI) studies examining brain function in FGIDs. Pooled meta-analyses by seed-based d mapping with permutation of subject images (SDM-PSI) were performed to assess variations in regional brain activity, and sensitivity analyses were applied to evaluate the robustness of findings. Meta-regression analyses were then carried out to examine possible links between demographic factors and neuroimaging changes. Our meta-analysis revealed significant changes in regional brain activities among FGIDs patients compared to healthy controls (HC). Increased brain activation was observed in several regions including the postcentral gyrus, calcarine fissure/surrounding cortex, superior frontal gyrus, and insula, while decreased activity was noted in the left posterior cingulate gyrus, right median cingulate/paracingulate gyri, and the left caudate nucleus. Furthermore, meta-regression analyses indicated negative associations between disease duration and alterations in specific brain regions. These findings underscored the intricate interplay between gut dysfunction and aberrant brain activity in FGIDs. Early intervention and multidisciplinary approaches addressing both gastrointestinal symptoms and associated emotional distress are crucial for improving the quality of life of the patients.

Scalable balloon catheter assisted contact enhancement of 3D electrode array for colon electrophysiological recording

The clinical diagnosis of functional gastrointestinal disorders primarily relies on symptom assessment and physical examination, methods that are inherently limited due to undetermined specific biomarkers and susceptibility to subjective judgment. Electrophysiological techniques offer a clinically practical approach by precisely recording the electrical activities of the intestines, providing deeper biophysical insights. However, in vivo electrophysiological investigation of the intestines remains challenging, such as the stability of the electrode-tissue interface, high-frequency signal transmission, motion artifact, and signal interpretation. This study developed an endoscopic-based high spatiotemporal electrophysiological recording device, by integrating balloon catheters and flexible three-dimensional electrode arrays with a mapping function. We integrated the 3D electrode array on a scalable balloon catheter and deployed this device in rabbits, achieving a stable collection of multiphasic electrophysiological signals from the intestinal mucosa. In vivo electrophysiological recordings identified observable spike bursts associated with intestinal motility, as well as coordinated periodic pulses potentially related to intestinal pacemaker activities, revealing their activation modulation patterns. Further, longer-duration non-periodic spike bursts were also observed to link to spontaneous non-periodic peristaltic contractions. This technique realized through minimally invasive procedures, achieves a high spatiotemporal resolution in electrophysiological recording, providing a powerful tool for the diagnosis and research of functional bowel diseases.

A machine learning approach to stratify patients with hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders according to disorders of gut brain interaction, comorbidities and quality of life.

A high prevalence of disorders of gut-brain interaction (DGBI) exist in patients with hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorders (HSD). However, it is unknown if clusters of hEDS/HSD patients exist which overlap with different DGBIs and whether this overlap influences presence of comorbidities and quality of life. We aimed to study these knowledge gaps. A prospectively collected hEDS/HSD cohort of 1044 individuals were studied. We undertook Uniform Manifold Approximation and Projection-enabled (UMAP) dimension reduction to create a representation of nonlinear interactions between hEDS/HSD and DGBIs, from which individuals were stratified into clusters. Somatization, Postural Tachycardia Syndrome (PoTS), autonomic symptoms, psychological factors and quality of life were statistically compared between clusters. The mean age of patients was 40 ± 13.2 years; 87.8% were female. Patients segregated into three clusters: Cluster 0 (n = 466): hEDS/HSD+ functional foregut disorders (FFD) + irritable bowel syndrome (IBS); Cluster 1 (n = 180): hEDS/HSD+ IBS and Cluster 2 (n = 337): hEDS/HSD alone. In cluster 0, we demonstrated increased somatization (p <0.0001), anxiety (p <0.0001), depression (p <0.0001), PoTS prevalence (p = 0.003), autonomic symptoms (p <0.0001) and reduced quality of life (p <0.0001) compared to cluster 2. Cluster 0 had greater comorbidity burden than cluster 1. Within hEDS/HSD, subgroups exist with a high prevalence of FFD and IBS. These subgroups have a higher prevalence of psychological disorders, dysautonomia and poorer quality of life compared with hEDS/HSD alone. Further research should focus on healthcare utilization, management and prognosis in hEDS/HSD and DGBI overlap.

Practical Concepts and strategies for early diagnosis and management of eosinophilic gastrointestinal disorders in East-Asian children.

Eosinophilic gastrointestinal disorders (EGIDs) are emerging as significant concerns in the Korean pediatric population and transitioning from rare to more commonly diagnosed conditions. This review discusses the increasing prevalence of EGID among children and adolescents and highlights the complexities involved in its diagnosis and management. This review begins with a thorough examination of the diverse clinical presentations of EGIDs in Korean children, with a special focus on common gastrointestinal symptoms such as abdominal pain, diarrhea, and bloody stool. Additionally, we explored extraintestinal manifestations, including growth failure, malnutrition, and associated allergic comorbidities, highlighting their importance in the clinical landscape of EGIDs. Because of its subtle and overlapping symptoms with those of other gastrointestinal disorders, EGID is frequently underdiagnosed. Addressing this challenge requires maintaining a high index of suspicion and employing a comprehensive diagnostic approach to differentiating EGID from functional gastrointestinal disorders (FGIDs) and other inflammatory or systemic diseases such as inflammatory bowel disease. The optimal management of EGID requires a collaborative multidisciplinary strategy that includes dietary management, regular monitoring, and tailored medical interventions. This review emphasizes the importance of proactive patient and caregiver education and regular follow-ups to improve long-term outcomes in affected children. Enhanced awareness among healthcare providers and better educational resources for families are critical for the early identification and effective management of EGID among pediatric patients.

Pomegranate Peel Extract Mitigates Diarrhea-Predominant Irritable Bowel Syndromes via MAPK and NF-κB Pathway Modulation in Rats.

Diarrhea-predominant irritable bowel syndrome (IBS-D) is a common chronic functional gastrointestinal disorder that causes diarrheal and intestinal barrier disruptions. Although pomegranate peel extract (PPE) has been reported for the treatment of diarrheal and intestinal inflammation, its effectiveness and mechanisms specifically for the treatment of IBS-D remain unknown. This study aimed to explore the therapeutic effect of PPE on IBS-D and elucidate its underlying mechanisms. A high-fat diet, restraint stress, and senna gavage were combined to establish a rat model mimicking IBS-D, to evaluate the therapeutic effects of PPE. Network pharmacology analysis, serum medicinal chemistry, and transcriptomics were employed to investigate potential downstream signaling pathways. Findings were further validated through molecular docking and Western blot analysis. The findings revealed that PPE significantly improved the symptoms of IBS-D, ameliorated intestinal inflammation, and promoted intestinal barrier function. The target genes in the MAPK and NF-κB signaling pathways were significantly enriched and down-regulated. Molecular docking and Western blot assays were performed to verify that PPE had a high affinity for the protein candidates in these pathways, and significantly down-regulated the expression of p-IκB, p-p65, p-JNK, p-p38, and p-ERK1/2. The present study is the first to demonstrate that PPE alleviates diarrheal and intestinal damage in IBS-D, potentially by inhibiting MAPK and NF-κB signaling pathways. These findings suggest that PPE may provide a novel therapeutic option for IBS-D.

Effects of an anti-inflammatory diet (AID) on maternal and neonatal health outcomes in pregnant Chinese patients with inflammatory bowel disease treated with infliximab (IFX)

Objective This study aimed to evaluate the effects of an anti-inflammatory diet (AID) combined with Infliximab (IFX) therapy on maternal and neonatal health outcomes in pregnant Chinese patients with inflammatory bowel disease (IBD). Methods IBD patients treated with steady IFX maintenance therapy at the time of conception were randomly assigned to either the IBD-AID group (n = 49), which received an anti-inflammatory diet intervention during the third trimester, or the habitual diet group (n = 49). Primary outcomes included assessments of disease activity, inflammatory markers, and neonatal health. Secondary outcomes included health-related quality of life (HRQoL) in patients and functional gastrointestinal disorders (FGIDs) in infants. Results The IBD-AID intervention significantly reduced disease activity scores in IBD patients at 4 weeks post-intervention and 1 month postpartum compared to the habitual diet group, and also improved HRQoL. Serum C-reactive protein (CRP) and fecal calprotectin (FC) levels were significantly lower in the IBD-AID group at these times, with a trend towards lower levels at 6 months postpartum. Birth weight and Apgar scores were higher in the IBD-AID group but did not reach statistical significance. The incidence of at least one FGID in infants was significantly lower in the IBD-AID group (24.5%) compared to the habitual diet group (46.9%, p = 0.034). Conclusion The IBD-AID intervention combined with IFX therapy significantly improved disease activity, inflammatory markers, and QoL in maternal IBD patients, and was associated with a lower incidence of FGIDs in infants, indicating benefits for both maternal and neonatal health.

Clinical Comparison of OC-Sensor Pledia and Phadia 250 for Fecal Calprotectin Testing.

Background: The fecal calprotectin (f-Cal) test is a convenient method used for differentiating inflammatory bowel disease (IBD) from functional bowel disorders. The OC-Sensor Pledia (OC-FCa; Eiken Chemical Co., Tokyo, Japan) is a latex agglutination turbidimetric immunoassay used for f-Cal measurements. We evaluated the clinical performance of OC-FCa and compared the f-Cal levels between OC-FCa and Phadia 250 (Thermo Fisher Scientific, Freiburg, Germany). Methods: We collected 278 stool samples; of these, 158 were taken from patients with suspected IBD, and 120 were taken from healthy individuals. We analyzed the f-Cal distribution in each group and compared the clinical performance and agreement between OC-FCa and Phadia 250. Results: The f-Cal of patients with IBD was significantly different from that of patients without IBD for both OC-FCa and Phadia 250 (p < 0.0001 and p < 0.001, respectively). The concordance between OC-FCa and Phadia 250 was 82.3%, with moderate agreement (kappa = 0.644, 95% confidence interval = 0.525-0.763). OC-FCa and Phadia 250 showed a high correlation (r = 0.90); their diagnostic performance showed moderate accuracy (AUC = 0.873 and 0.866, respectively) and had no significant difference (p = 0.616). Conclusions: Both OC-FCa and Phadia 250 showed a high correlation and good clinical performance. F-Cal measured using OC-FCa was reliable for initial differentiation between patients with IBD and without IBD. Therefore, OC-FCa and Phadia 250 could be alternative devices for measuring f-Cal depending on the laboratory situation.

StepFit-18K: Improving Irritable Bowel Syndrome (IBS) Symptoms with a Simple, Structured Walking Intervention.

Background: Irritable Bowel Syndrome (IBS) is a chronic functional gastrointestinal (GI) disorder characterized by abdominal pain, altered bowel habits, and bloating, affecting approximately 10.1% of the global population. While current treatments emphasize dietary modifications and symptom management, emerging evidence suggests that physical activity (PA) may help alleviate IBS symptoms. This study evaluated the effects of a structured walking program, "StepFit-18K", on IBS symptom relief. Methods: A total of 106 participants (68 females and 38 males) completed the 12-week intervention, which consisted of 18,000 additional steps per week (6000 extra steps on three days per week) tracked via fitness devices. The program emphasized step count, ease of adoption, and social support through walking groups. Results: As assessed by validated questionnaires, significant reductions in GI symptoms were observed. The IBS Symptom Severity Score (IBS-SSS) decreased from 118.30 ± 98.73 to 74.46 ± 74.93, with a delta score of -43.84%, highlighting bloating as the most improved symptom. No clinically significant changes were observed in anthropometric or biochemical markers. Conclusions: StepFit-18K is a simple, accessible, and effective form of physical activity that has demonstrated therapeutic benefits for IBS symptoms. This offers an additional application beyond its well-established role in preventing cardiovascular diseases.

Gut-Brain Nexus: Mapping Multi-Modal Links to Neurodegeneration at Biobank Scale.

Co-occurring disorders of the gut-brain axis combined with genetic and proteomic data can better predict neurodegenerative risk.

Abnormal Autonomic Nervous Regulation in Patients with Globus Pharyngeus.

Globus pharyngeus could be described as a benign sensation of lump or foreign object in the throat. The etiology of the globus as a solitary syndrome is still unknown, but it is proposed that stress could have an important role in symptom emergence. To evaluate the autonomic nervous regulation in patients with globus compared to healthy controls in reaction to stress. Patients included in the study were diagnosed based on ROME IV criteria for Disorders of Gut Brain Interaction. Besides globus, the patients did not suffer any other substantial medical condition. As a control group, measurement of healthy volunteers was performed. Both groups underwent the same stress protocol assessment in the same laboratory settings. The protocol consist of two types of stressors: cold pressor test and mental arithmetic test to test different types of autonomic reactivity. Baroreflex sensitivity was significantly decreased in patients compared to controls in all phases of the protocol. Low-frequency band of systolic blood pressure variability was significantly increasedduring both stress phases in patients compared to controls. High-frequency band of heart rate variability was significantly decreased in patients compared to controls during the both of the stress phases. The results of this study shows discrete abnormalities in complex autonomic reflex control which are predominantly manifested in response to stressful stimuli indicating altered neurocardiac regulation as a reaction to stress associated with globus pharynegus. This fact could have an important role in the personalized management of globus patients such as biofeedback.

Effects of a Revision to the Standard Admission Order Set on Laxative Prescribing for Opioid-Induced Constipation

Purpose: Opioid-induced constipation (OIC) is highly prevalent in patients with cancer-related pain on opioid analgesics and has negative consequences on physical and psychological well-being and quality of life. Oncology clinical practice guidelines recommend the use of osmotic and stimulant laxatives for the prevention and management of opioid-induced constipation, not stool softeners such as docusate sodium. Prescribing practices continue to fall behind these recommendations. Methods: This quality improvement project revised the laxative options available in the standard admission order set in the electronic medical record. Specifically, docusate sodium was removed and replaced with senna and polyethylene glycol 3350. Results: A total of 2,742 patient admissions preintervention were compared to 2,752 admissions postintervention. The number of orders for docusate (p &lt; .001) and docusate-senna (p = .002) orders decreased significantly after the intervention, in addition to the number of OIC diagnoses (p &lt; .001). However, the number of orders for polyethylene glycol (p = .559), senna (p = .582), other laxatives (p = .245), or functional bowel disorder medications (p = .533) did not change significantly. No significant differences were observed in the frequency of laxative orders placed within 24 hours of an opioid order, number of laxatives prescribed at discharge, admissions related to bowel-related complications, or length of stay. Conclusions: Interventions utilizing the electronic medical record can facilitate evidence-based management of OIC. Development of clinical practice guidelines and tailoring these interventions further is needed to adapt this approach at other institutions and sustain practice change.

Effects of Limosilactobacillus reuteri DSM 17938 in neonates exposed to antibiotics: a randomised controlled trial.

Perinatal antibiotic exposure potentially leads to gut microbiota dysbiosis, which is associated with functional gastrointestinal disorders (FGIDs). We aimed to investigate the effects of Limosilactobacillus reuteri DSM 17938 supplementation on the development of FGIDs, crying and sleep duration, and the gut microbial composition in infants exposed to antibiotics during the neonatal period. In this randomised, double-blind, placebo-controlled study, we included 89 term neonates treated with antibiotics. Neonates received the study product for six weeks. FGIDs, assessed by the Infant Gastrointestinal Symptom Questionnaire, crying and sleep duration were assessed at four and eight weeks, and six months after enrolment. Faecal samples were collected six weeks and twelve months after enrolment. The gut microbial community composition was analysed using 16S amplicon sequencing and qPCR. The proportion of infants with FGIDs was greater in the control group, although the difference between the groups was significant only six months after enrolment. At all time points, the probiotic group presented a longer sleep duration and shorter crying time than the control group, but the difference was not statistically significant. Probiotic consumption had no significant effect on the gut microbiota composition except for increased L. reuteri DSM 17938 abundance in the probiotic group at six weeks after enrolment. At specific time points after supplementation with L. reuteri DSM 17938, a reduction in the prevalence of FGIDs was observed in the probiotic group. However, no observable effect on the gut microbiota was detected during the intervention. We believe that probiotic supplementation in neonates during and after antibiotic treatment to minimise the negative effects of antibiotics on gut function during this vulnerable period of human development warrants further investigation. The trial is registered at ClinicalTrials.gov (NCT02865564).

Clinicians' Knowledge, Attitudes, and Practices Regarding the Management of Functional Gastrointestinal Disorders With Neuromodulators and Psychological Treatment.

Little is known about the practical clinical application of neuromodulators and psychiatric treatments in patients with functional gastrointestinal disorders (FGIDs). We investigate the knowledge, attitudes, and practices of Korean clinicians regarding the use of neuromodulators and psychiatric treatments for FGIDs. This prospective, online, cross-sectional study was conducted between May and August 2022. A questionnaire regarding the knowledge, attitude, and practice of neuromodulators and psychiatric treatments for FGIDs was developed and administered to primary care clinicians and gastroenterologists in university hospitals in Korea. Overall, 451 clinicians from primary (n = 179, 39.7%), secondary (n = 113, 25.1%), and tertiary (n = 159, 35.3%) hospitals participated in the survey. Most of them considered that neuromodulators (98.7%) and psychiatric treatment (86.5%) were required for patients with FGIDs. However, approximately one-third of them did not prescribe neuromodulators, mainly due to unfamiliarity with the drugs, and only one-quarter considered psychiatric referral. Compared to gastroenterologists at university hospitals, primary care clinicians' prescriptions had a lower rate (87.2% vs 64.2%, P < 0.001) and shorter duration of neuromodulator. The psychiatric referral rate was lower for primary care clinicians than for gastroenterologists at university hospitals (19.0% vs 34.2%, P < 0.001). Knowledge, attitude, and practice levels regarding neuromodulators and psychiatric treatment among clinicians are inhomogeneous, and a knowledge gap exists between primary care clinicians and gastroenterologists at university hospitals. Encouraging ongoing education for Korean clinicians regarding the appropriate use of neuromodulators and psychiatric treatments in patients with FGIDs is suggested.

OPTIMIZING GUT HEALTH: THE ROLE OF NABHI MARMA (NAVEL VITAL POINT) STIMULATION IN CONTEMPORARY MEDICINE

The human gut, often referred to as the “second brain,” plays a crucial role in a person's overall well-being. There is a growing interest in integrating ancient Indian sciences with modern pharmaceutical systems, such as Marma Chikitsa (Marma Therapy), which includes Nabhi Marma (the vital point at the navel). This review paper aims to discuss key aspects of Nabhi Marma (the crucial point at the navel) and its relevance to modern medicine. The research involved the use of published articles from PubMed and Google Scholar to establish the effectiveness of Nabhi Marma stimulation, its mechanisms, and its compatibility with modern medical practices. The paper considered the historical and anatomical perspectives of Nabhi Marma, as well as recent research findings, which indicated that stimulation of Nabhi Marma may affect gut motility, enzyme secretion, gut-brain axis, and bacterial flora composition. Proposed mechanisms include the modulation of the autonomic nervous system, activation of the enteric nervous system, neuroendocrine activity, and psychological factors. The results suggest potential benefits of incorporating Marma (vital points) therapy into integrative medical models, promoting interprofessional collaboration, and considering individualized medical treatment concepts. Nabhi Marma stimulation may be used as a complementary approach for treating functional gastrointestinal disorders and post-treatment care. Further extensive studies should be conducted in the future to evaluate the therapeutic benefits of ozone auto-probing and to understand their underlying effects on the gut and microbiome.