Small Intestinal Malabsorption Research Articles

Recurrent calcium oxalate calculi: the culprit in disguise.

Congenital sucrase isomaltase deficiency (CSID) is a rare autosomal recessive monogenic disorder of small intestinal malabsorption and manifests typically in early childhood with chronic osmotic diarrhoea. Though there have been case reports in adults presenting with hypercalcemia and renal calculi in CSID, this is quite rare in children. We hereby report a 6-year-old boy who presented with recurrent episodes of calcium oxalate calculi without any gastrointestinal symptoms and was confirmed as having sucrase isomaltase deficiency by genetic analysis.

590. RESOLUTION OF SYMPTOMS AFTER OESOPHAGO-GASTRIC CANCER RESECTION (RESTORED)–STANDARDISING GASTROINTESTINAL SYMPTOMS AND CONDITIONS AFTER SURGERY: A MULTI-DISCIPLINARY EXPERT DELPHI STUDY

Abstract Background Oesophago-gastric cancer surgery negatively affects quality of life with a high post-operative symptom burden. Several conditions that may be diagnosed and treated after surgery are recognised. However, consensus regarding their definition and management is lacking. We aimed to develop consensus regarding the definition, investigation and management of the common symptoms and conditions, and triggers to consider disease recurrence, as a foundation for improving management and quality of life in these patients. Design Modified 2-round Delphi consensus study of a multidisciplinary expert panel. Results 86/127(67.7%) and 77/100(77.0%) responses were received in rounds 1 and 2. Consensus was achieved in defining 26 symptoms. For 10 conditions (anastomotic stricture, acid reflux, non-acid reflux, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption), definitions, diagnostic criteria, first and second-line investigation and first-line treatments were agreed. Consensus was not reached for third line investigation of some conditions, nor for second, third or fourth-line treatments for others. 12 of 14(85.7%) symptoms were agreed as triggers to consider cancer recurrence, during the early (< 1 year) and late (> 1 year) post-operative periods. Conclusion Expert consensus regarding symptoms, conditions and triggers to consider investigation for recurrence after oesophago-gastric cancer surgery was achieved. This will allow standardisation and timely diagnosis and treatment of post-operative conditions, reducing variation in care. It will facilitate comparative, prospective research to establish the incidence and response to treatment of these conditions, helping develop robust evidence to optimise patients’ quality of life.

OGC P28 Gastrointestinal symptoms and disorders after oesophago-gastric cancer surgery: The RESTORE modified Delphi survey

Abstract Background Oesophago-gastric (OG) cancer surgery is life-changing with a significant impact on quality of life (QOL). OG cancer surgery reconfigures the upper gastrointestinal (GI) tract altering its physiological function. Certain disorders such as anastomotic stricture are well recognised whereas others, such as small intestinal bacterial overgrowth, are increasingly being diagnosed. As multimodality treatment improves survival, more poly-symptomatic patients are living with these disorders as a consequence of surgery. We aimed to establish consensus on the definitions of relevant symptoms and disorders, as well as appropriate investigation and treatment. Standardisation will form a foundation for optimising QOL in this growing patient group. Methods This on-line modified Delphi study focused on patients after oesophagectomy, gastrectomy or subtotal gastrectomy for cancer (OG cancer surgery). The survey covered symptoms, common conditions, and symptoms triggering investigation for recurrence. The survey was designed using non-systematic reviews and expert opinion. Items were rated from 1 (completely disagree) to 9 (absolutely agree). Multi-disciplinary experts were identified through word of mouth and expressions of interest at previous conferences. Two rounds were completed, with some revisions after first round review. Median ratings were determined. Consensus agreement was judged as 70% or more respondents in agreement (7-9) and less than 15% disagreement (1-3). Results 86 and 77 complete surveys were received in rounds 1 and 2. Respondents were multidisciplinary, including OG surgeons, oncologists, gastroenterologists, radiologists, dietitians and nurse specialists. 7 upper GI, 13 non-specific and 6 lower GI symptom definitions were agreed. Clinical definitions, diagnostic criteria, first line investigations and treatments were agreed for 10 conditions: anastomotic stricture, acid reflux, non-acid reflux oesophagitis, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption. Agreement was also reached across many second-line investigations and treatments, and 12 of 14 (86%) symptom triggers to investigate for recurrence. Conclusions The RESTORE multidisciplinary consensus study has established a foundation for assessing and treating 10 conditions negatively affecting QOL after OG cancer surgery. Standardised symptom definitions will guide diagnostic assessments. Agreed condition definitions and diagnostic criteria will allow robust measurement of their incidence, and evaluation of treatment effects. Future work will aim to develop algorithms for managing these conditions. This work will raise standards of diagnosis and treatment of conditions that affect patients after OG cancer surgery, allowing collection of robust data to evaluate improvements in symptoms and QOL.

Evaluation of Interleukin -1β, GOT, and GPT in Patients with Giardiasis in Thi-Qar Province

Giardiasis is a well-known gastroenteritis that causes small intestine malabsorption and fatty diarrhea. The current study was performed from the start of September 2021 to the end of March 2022. Fifty blood samples were collected from suspected infected patients with G. lamblia when they returned to the laboratory to receive the result of microscopic analysis and were proved to be infected with the parasite, and (40) blood samples were collected from healthy people as a control group. This study reveals a significant increase in the level of interleukin-1B, being (2.807) in the infected patients. Higher than in the control group (0.454). The study of biochemical parameters of patients infected with parasites showed an increase in the concentration of liver enzymes (GOT and GPT) in patients and compared to the healthy group

29: INCIDENCE, DIAGNOSIS AND MANAGEMENT OF MALABSORPTION FOLLOWING OESOPHAGECTOMY: A SYSTEMATIC REVIEW

Abstract Background and aim Survival following oesophagectomy for oesophageal cancer is increasing. This has resulted in increased focus on quality-of-life and improved survivorship. Weight loss and malnutrition occurs in 25–46% of patients after three years, with associated adverse gastrointestinal symptoms. Malabsorption syndrome is multifactorial and includes exocrine pancreatic insufficiency (EPI), small intestinal bacterial overgrowth (SIBO) and bile acid malabsorption (BAM), however there is little literature available in patients following oesophagectomy. The aim of this study was to evaluate the reported incidence and management of malabsorption syndromes post-oesophagectomy. Methods A systematic search of PubMed, EMBASE, MEDLINE, Scopus and the Cochrane Library evaluating incidence, diagnosis and management of malabsorption was performed for studies published until March 2021. Results Of 461 identified studies, seven studies (6/7 non-randomised observational studies) were included, with a combined population of 344 (range 7–87). Incidence of malabsorption syndromes including EPI, SIBO and BAM were 10.2–100%, 37.8–100% and 3.33–100% respectively. There was no consensus definition for EPI, SIBO or BAM; and there was variation in diagnostic methods. Diagnostic criteria varied from clinical (gastrointestinal symptoms or weight loss), or biochemical (faecal elastase, hydrogen breath test and Selenium-75-labelled synthetic bile acid measurements). Treatment modalities using pancreatic enzyme replacement, rifaximin and colesevelam showed improvement in symptoms and weight in all studies. Conclusion Malabsorption syndromes following oesophagectomy are likely to be severely underestimated. The resultant gastrointestinal symptoms have a negative effect on post-operative quality of life. Current literature suggests benefit with outlined therapies, however greater understanding of these conditions, their diagnosis, and management is required to further understand which patients will benefit from treatment.

Performance and Interpretation of Hydrogen and Methane Breath Testing Impact of North American Consensus Guidelines

BackgroundHydrogen and methane breath tests (HMBT) are widely used clinical investigations but lack standardization. To address this, the North American Consensus (NAC) group published evidence-based recommendations for HMBT.AimsTo evaluate results obtained using NAC recommendations for HMBT, compared to retrospective data that utilized guidelines previously recommended.MethodsHMBT data from 725 patients referred for small intestinal bacterial overgrowth (SIBO) and/or carbohydrate malabsorption (CM) testing were analyzed. Data were compared regarding dose of substrate for SIBO testing (16 vs. 10 g lactulose, and 50 vs. 75 g glucose) and the effect of post-ingestion sampling period for malabsorption testing. The effect of different recommended cut-off values for SIBO were examined.ResultsSubstrate dose did not affect methane production. 10 g lactulose significantly reduced positive SIBO results compared to 16 g lactulose (42 vs. 53%, p = 0.04). 75 g glucose significantly increased positive results compared to 50 g glucose (36 vs. 22%, p = 0.04). Provoked symptoms were significantly more prevalent in patients testing positive by both North American Consensus and Ledochowski cut-off values.34.5% of patients tested positive for CM at 180-min compared to 28% at 120-min (not significant, p = 0.19).Conclusions and Inferences10 g lactulose substrate produces fewer positive SIBO results than 16 g lactulose, while 75 g glucose dose produces more positive SIBO results than 50 g. Performing CM breath tests for 180 min increases number of positive results when compared to 120 min. SIBO cut-off timings require further investigation, but our findings broadly support the NAC recommendations for SIBO and CM testing.

P-OGC33 Incidence, diagnosis and management of malabsorption following oesophagectomy: a systematic review

Abstract Background Survival following oesophagectomy for oesophageal cancer is increasing. This has resulted in increased focus on quality-of-life and improved survivorship. Weight loss and malnutrition occurs in 25-46% of patients after three years, with associated adverse gastrointestinal symptoms. Malabsorption syndrome is multifactorial and includes exocrine pancreatic insufficiency (EPI), small intestinal bacterial overgrowth (SIBO) and bile acid malabsorption (BAM), however there is little literature available in patients following oesophagectomy. The aim of this study was to evaluate the reported incidence and management of malabsorption syndromes post-oesophagectomy. Methods A systematic search of PubMed, EMBASE, MEDLINE, Scopus and the Cochrane Library evaluating incidence, diagnosis and management of malabsorption was performed for studies published until March 2021. Results Of 461 identified studies, seven studies (6/7 non-randomised observational studies) were included, with a combined population of 344 (range 7-87). Incidence of malabsorption syndromes including EPI, SIBO and BAM were 10.2-100%, 37.8-100% and 3.33-100% respectively. There was no consensus definition for EPI, SIBO or BAM; and there was variation in diagnostic methods. Diagnostic criteria varied from clinical (gastrointestinal symptoms or weight loss), or biochemical (faecal elastase, hydrogen breath test and Selenium-75-labelled synthetic bile acid measurements). Treatment modalities using pancreatic enzyme replacement, rifaximin and colesevelam showed improvement in symptoms and weight in all studies. Conclusions Malabsorption syndromes following oesophagectomy are likely to be severely underestimated. The resultant gastrointestinal symptoms have a negative effect on post-operative quality of life. Current literature suggests benefit with outlined therapies, however greater understanding of these conditions, their diagnosis, and management is required to further understand which patients will benefit from treatment.

Uncovering the pathophysiology of irritable bowel syndrome by exploring the gut-brain axis: a narrative review.

ObjectiveTo improve the pathophysiological understanding of irritable bowel syndrome (IBS) by exploring the gut-brain axis.BackgroundDisorders of gut-brain interaction (DGBIs) are gastrointestinal (GI) disorders in which alterations in bowel functions occur. IBS, which is one of the most studied DGBIs, is linked with abdominal distress or pain without obvious structural or biochemical anomalies.MethodsThe etiology of IBS has not been clearly described but is known to be multifactorial, involving GI motility changes, post-infectious reactivity, visceral hypersensitivity, gut-brain interactions, microbiota dysbiosis, small intestinal bacterial overgrowth, food sensitivity, carbohydrate malabsorption, and intestinal inflammation.ConclusionsOne of the main features of IBS is the occurrence of structural and functional disruptions in the gut-brain axis, which alter reflective and perceptual nervous system reactions. Herein, we provide a brief summary of this topic. Furthermore, we discuss animal models, which are important in the study of IBS, especially as it is linked with stressors. These animal models cannot fully represent the human disease but serve as important tools for understanding this complicated disorder. In the future, technologies, such as organ-on-a-chip models and metabolomics, will provide novel information regarding the pathophysiology of IBS, which will play an important role in treatment development. Finally, we take a brief glance at how acupuncture treatments may hold potential for patients with IBS.

Mast Cell Mediated Regulation of Small Intestinal Chloride Malabsorption in SAMP1/YitFc Mouse Model of Spontaneous Chronic Ileitis.

In Inflammatory Bowel Disease (IBD), malabsorption of electrolytes (NaCl) results in diarrhea. Inhibition of coupled NaCl absorption, mediated by the dual operation of Na:H and Cl:HCO3 exchangers on the brush border membrane (BBM) of the intestinal villus cells has been reported in IBD. In the SAMP1/YitFcs (SAMP1) mice model of spontaneous ileitis, representing Crohn’s disease, DRA (Downregulated in Adenoma) mediated Cl:HCO3 exchange was shown to be inhibited secondary to diminished affinity of the exchanger for Cl. However, NHE3 mediated Na:H exchange remained unaffected. Mast cells and their secreted mediators are known to be increased in the IBD mucosa and can affect intestinal electrolyte absorption. However, how mast cell mediators may regulate Cl:HCO3 exchange in SAMP1 mice is unknown. Therefore, the aim of this study was to determine the effect of mast cell mediators on the downregulation of DRA in SAMP1 mice. Mast cell numbers and their degranulation marker enzyme (β-hexosaminidase) levels were significantly increased in SAMP1 mice compared to control AKR mice. However, treatment of SAMP1 mice with a mast cell stabilizer, ketotifen, restored the β-hexosaminidase enzyme levels to normal in the intestine, demonstrating stabilization of mast cells by ketotifen. Moreover, downregulation of Cl:HCO3 exchange activity was restored in ketotifen treated SAMP1 mice. Kinetic studies showed that ketotifen restored the altered affinity of Cl:HCO3 exchange in SAMP1 mice villus cells thus reinstating its activity to normal. Further, RT-qPCR, Western blot and immunofluorescence studies showed that the expression levels of DRA mRNA and BBM protein, respectively remained unaltered in all experimental conditions, supporting the kinetic data. Thus, inhibition of Cl:HCO3 exchange resulting in chloride malabsorption leading to diarrhea in IBD is likely mediated by mast cell mediators.

Serological Tests Assessment in Patients Suspected to have Celiac Disease Attending the Gastroenterology and Hepatology Teaching Hospital in Baghdad

Background: Celiac disease is characterized by small intestinal malabsorption of nutrients after the ingestionof wheat gluten or related proteins from rye and barley, villus atrophy of the small intestinal mucosa, promptclinical and histologic improvement following strict adherence to a gluten-free diet, and relapse when glutenis retaken.Aim of the Study: Evaluation of patients seeking gastroenterology and hepatology teaching hospital/medicalcity/Baghdad with suspected celiac disease regarding serological investigation, histological findings andgenetic testing, to determine sensitivity, specificity, positive predictive value and negative predictive valuefor every test.Patients and Method: The study is a cross sectional descriptive analytic study conducted at the teachinghospital of gastroenterology and hepatology/Baghdad/Iraq during a period from the 1st of February 2018 tothe 1st of April 2019. After thorough history and Clinical examination patients with suspected celiac diseasewere sent for serological investigation (TTG IgA and IgG), (antigliadin IgA and IgG), all patients were sentfor endoscopic examination for duodenal biopsies with subsequent histological assessment. Patients whofailed to be confirmed (positive serology and negative histology or vice versa) were sent either for HLAgenotyping or for IgG Deaminated gliadin peptide. Sensitivity & specificity were measured for each test.Results: A total of 140 suspected celiac disease patients involved in this study. Mean age was 18.9 yearsand ranged from 2 years to 60 years. Male represented 36.4% of the cases while female represented 63.6%.Only 19 patients show positive family history of celiac disease (13.6 %). Regarding associated autoimmunediseases, the majority (111 patients) have no associated diseases (79.3%) while the other patients who haveassociations most of them show positive association with type 1 DM (16.4%).Fifty patients (35.7%) presented with short stature, (25.7%) came with diarrhea. The other symptoms varybetween bloating and distention, unexplained anemia and weight loss. Constipation was seen in one patient.tTG IgA and tTG IgG showed high sensitivity, specificity, positive predictive value and negative predictivevalue while antigliadin antibody failed to show these significant results.Conclusion: The use of serologic markers inceliac is easy, direct, noninvasive and reliableand could be benefit in the diagnosis andmonitoring of the disease. More specifically,both the tTG-IgA/IgG are very good markersin the diagnostis of CD. This study confirmedthe high specificity and sensitivity of tTG, and the low results of AGA, but celiac serology does not replace the biopsy in the diagnosis but is useful as anassistant for diagnosis.

Senescence-accelerated mouse prone 8 mice exhibit specific morphological changes in the small intestine during senescence and after pectin supplemented diet.

Impairment of gastrointestinal function and reduction of nutrient absorption associated with aging contribute to increased risk of malnutrition in the elderly population, resulting in physical weakness and vulnerability to disease. The present study was performed to examine the relationships between aging-associated morphological changes of the small intestine and nutrient malabsorption using senescence-accelerated mouse prone 8 (SAMP8) mice. Comparison of the morphology of the small intestine of young (22-week-old) and senescent (43-week-old) SAMP8 mice showed no significant changes in villus length, while the mRNA expression levels of secretory cell marker genes were significantly reduced in senescent mice. In addition, crypts recovered from the small intestine of senescent mice showed a good capacity to form intestinal organoids ex vivo, suggesting that the regenerative capacity of intestinal stem cells (ISCs) was unaffected by accelerated senescence. These results indicated that changes induced by accelerated senescence in the small intestine of SAMP8 mice are different from changes reported previously in normal aging mouse models. Biochemical analyses of serum before and during senescence also indicated that senescent SAMP8 mice are not in a malabsorption state. Furthermore, a diet supplemented with persimmon pectin had a mild effect on the small intestine of senescent SAMP8 mice. Intestinal villus length was slightly increased in the medial part of the small intestine of pectin-fed mice. In contrast, intestinal crypt formation capacity was enhanced by the pectin diet. Organoid culture derived from the small intestine of mice fed pectin exhibited a greater number of lobes per organoid compared with those from mice fed a control diet, and Lyz1 and Olfm4 mRNA levels were significantly increased. In conclusion, accelerated senescence induced exclusive changes in the small intestine, which were not related to nutrient malabsorption. Therefore, the SAMP8 strain may not be a suitable model to evaluate the effects of aging on intestinal homeostasis and nutrient absorption impairment.

Gluten hydrolyzing activity of Bacillus spp isolated from sourdough

BackgroundCeliac disease is an intestinal chronic disorder with multifactorial etiology resulting in small intestinal mucosal injuries and malabsorption. In genetically predisposed individuals with HLA DQ2/DQ8 molecules, the gluten domains rich in glutamine and proline present gluten domains to gluten reactive CD4+ T cells causing injury to the intestine. In the present experimental design, the indigenous bacteria from wheat samples were studied for their gluten hydrolyzing functionality.ResultsProteolytic activity of Bacillus spp. was confirmed spectrophotometrically and studied extensively on gliadin-derived synthetic enzymatic substrates, natural gliadin mixture, and synthetic highly immunogenic 33-mer peptide. The degradation of 33-mer peptide and the cleavage specificities of the selected isolates were analyzed by tandem mass spectrometry. The gluten content of the sourdough fermented by the chosen bacterial isolates was determined by R5 antibody based competitive ELISA. All the tested isolates efficiently hydrolyzed Z-YPQ-pNA, Z-QQP-pNA, Z-PPF-pNA, and Z-PFP-pNA and also cleaved 33-mer immunogenic peptide extensively. The gluten content of wheat sourdough was found to be below 110 mg/kg.ConclusionIt has been inferred that four Bacillus spp especially GS 188 could be useful in developing gluten-reduced wheat food product for celiac disease prone individuals.

Iron Absorption Disturbances in Patients with Enteropathy: Interim Analysis of a Single Centre Study

Abstract There are about 2 billion people in the world who suffer from anaemia, mostly iron deficiency anaemia (IDA), by WHO data. Iron deficiency without anaemia is three times more common than IDA. In such patients, the condition of the small intestine should be evaluated, and malabsorption excluded. The aim of the study was to evaluate potential correlation between different types of enteropathy and iron absorption disturbances. The study was performed at the Latvian Maritime Medical Center “Gastroklinika” between the years 2014 and 2018. Iron absorption tests with 50 mg of oral iron gluconate were performed for each patient. Patients had filled in a FACIT questionnaire and had underwent video capsule endoscopy (VCE). A total of 48 patients were enrolled for analysis — 41 (85.4%) female and 7 (14.6%) male. Enteropathy was diagnosed in 35 cases: erosive — 17, erythematous — 12 and congestive — 6. By the time of VCE, 24 patients were suffering from anaemia. A total of 33 (68.7%) patients had problems with iron absorption, of whom 8 had no signs of enteropathy and 25 were diagnosed with enteropathy during VCE. IDA did not show a statistically significant correlation with enteropathy. However, the obtained results suggest that this should be studied further in association with small intestine malabsorption, to determine the precise role of enteropathy in IDA patients.

MicroRNAs: Novel Markers in Diagnostics and Therapeutics of Celiac Disease.

microRNAs (miRNAs) are a novel class of single-stranded RNAs with a key role in the regulation of gene expression. miRNA main mechanism of action involves interaction with the mRNA transcribed from the genes, leading to the target mRNA silencing and degradation. Indeed, it is easy to conceive that a defective miRNA-based mRNA regulation may compromise normal cell function and cause genetic diseases. A wide spectrum of studies has focused on the identification and introduction of regulatory diseases-specific miRNAs for the past decade. Overexpression or downregulation of several miRNAs can potentially stimulate or inhibit pathways related to the pathogenesis of celiac disease (CD). CD is a chronic inflammatory disease characterized by small intestinal mucosal injury and nutrient malabsorption in genetically susceptible individuals after the dietary ingestion of gluten. The disease is characterized by villous atrophy, intraepithelial lymphocyte infiltration, and chronic inflammation and activation of lamina propria T cells. The common genetic background in CD is the presence of heterodimeric human leukocyte antigen class II molecules DQ2 or DQ8 that account for ∼40% of the genetic predisposition in this disease. In fact, by minute identification of these miRNAs and related targets and mechanisms, specific therapeutics can be developed to suppress these pathophysiological pathways through the enhancement or inhibition of miRNAs. This development can open a new prospect for personalized medicine.

The safety and sensitivity of a telemetric capsule to monitor gastrointestinal hydrogen production invivo in healthy subjects: a pilot trial comparison to concurrent breath analysis.

Intestinal gases are currently used for the diagnosis of disorders including small intestinal bacterial overgrowth and carbohydrate malabsorption. To compare the performance of measuring hydrogen production within the gut directly with the telemetric gas-sensing capsule with that of indirect measurement through breath testing. Using standard breath testing protocols, the capsules and breath tests were simultaneously evaluated in a single-blinded trial in 12 healthy subjects. Eight received a single dose of 1.25-40g inulin and four 20 or 40g glucose. Safety and reliability of the capsules were also assessed. There were no reported adverse events. All capsules were retrieved and operated without failure. Capsule measurements were in agreement with breath test measurements in magnitude but not in timing; minimal hydrogen production was observed after glucose ingestion and capsule measurements correlated with breath hydrogen after ingestion of 40g inulin. A dose-dependent increase in concentration of hydrogen was observed from the capsule following ingestion of inulin as low as 1.25g compared with >10g for breath measurements. Specifically, the capsule measured >3000 times higher concentrations of hydrogen compared to breath tests, resulting in a signal-to-noise ratio of 23.4 for the capsule compared to 4.2 for the breath test. The capsule showed high sensitivity and signal-to-noise ratio in measuring luminal hydrogen concentrations, provided information on the site of intestinal gas production, and demonstrated safety and reliability. The capsule has potential for improving diagnostic precision for disorders such as small intestinal bacterial overgrowth.

Intestinal Involvement in Systemic Sclerosis: A Clinical Review.

Systemic sclerosis (SSc) is a chronic systemic disease characterized by microvasculopathy, autoantibodies, and extensive fibrosis. Intestinal involvement is frequent in SSc and represents a significant cause of morbidity. The pathogenesis of intestinal involvement includes vascular damage, nerve dysfunction, smooth muscle atrophy, and fibrosis, causing hypomotility, which leads to small intestinal bacterial overgrowth (SIBO), malabsorption, malnutrition, diarrhea, pseudo-obstruction, constipation, pneumatosis intestinalis, and fecal incontinence. Manifestations are often troublesome and reduce quality of life and life expectancy. Assessment of intestinal involvement includes screening for small intestine hypomotility, malnutrition, SIBO, and anorectal dysfunction. Current management of intestinal manifestations is largely inadequate. Patients with diarrhea are managed with low-fat diet, medium-chain triglycerides, avoidance of lactulose and fructose, and control of bacterial overgrowth with antibiotics for SIBO. In diarrhea/malabsorption, bile acid sequestrant and pancreatic enzyme supplementation may help, and nutritional support is needed. General measures are applied for constipation, and intestine rest plus antibiotics for pseudo-obstruction. Fecal incontinence is managed with measures for associated SIBO, or constipation, and with behavioral therapies. Pneumatosis intestinalis is usually an incidental finding that does not require any specific treatment. Immunomoduation should be considered early in intestinal involvement. Multidisciplinary approach of intestinal manifestations in SSc by gastroenterologists and rheumatologists is required for optimum management.

An Unlikely Cause of Bowel Obstruction in a Woman With Scleroderma

Systemic sclerosis is a multisystem disease that is characterized by vasculitis of the small arteries and fibrosis of the skin and other organs. The gastrointestinal system is the most frequently affected organ system in patients with systemic sclerosis, affecting 70-90% of patients. Gastrointestinal manifestations most commonly involve the esophagus but can also affect the entire GI tract from mouth to anus in the form of GERD, gastroparesis, pseudoobstruction, secondary small intestinal bacterial overgrowth (SIBO) and malabsorption. This is a case of a 59 year old woman with scleroderma, gastroparesis, SIBO, pseudoosbtruction. Her symptoms worsened and required a hospitalization and was found to have a cecal volvulus. She was taken to the operating room and the volvulus was reduced and no bowel resection was performed. This volvulus reoccurred four months later but resolved with conservative management. Over the following months, she developed an iron-deficiency anemia and underwent EGD and colonoscopy. Colonoscopy revealed a twist in the ascending colon and could not be traversed to the cecum. Within the twist was a flat polyp diagnosed as being a tubulovillous adenoma with high-grade dysplasia. She was referred to surgery for partial colectomy. In the operating room, she was found to have colonic distension and was found to have a mesenteric defect through which the colon herniated. She underwent an extended right sided colon resection. Large bowel obstruction due to trans-mesenteric internal hernias are exceedingly rare and has a reported incidence between 0.2 - 0.9%. This is a difficult diagnosis to make even with imaging studies and many times is found during the operation. In this case, her first operation did not identify the mesenteric defect and was a presumed volvulus secondary to her scleroderma. Therefore, trans-mesenteric internal hernias are a difficult diagnosis to make and often times require an exploratory laparotomy.

Systematic review: exercise‐induced gastrointestinal syndrome—implications for health and intestinal disease

"Exercise-induced gastrointestinal syndrome" refers to disturbances of gastrointestinal integrity and function that are common features of strenuous exercise. To systematically review the literature to establish the impact of acute exercise on markers of gastrointestinal integrity and function in healthy populations and those with chronic gastrointestinal conditions. Search literature using five databases (PubMed, EBSCO, Web of Science, SPORTSdiscus, and Ovid Medline) to review publications that focused on the impact of acute exercise on markers of gastrointestinal injury, permeability, endotoxaemia, motility and malabsorption in healthy populations and populations with gastrointestinal diseases/disorders. As exercise intensity and duration increases, there is considerable evidence for increases in indices of intestinal injury, permeability and endotoxaemia, together with impairment of gastric emptying, slowing of small intestinal transit and malabsorption. The addition of heat stress and running mode appears to exacerbate these markers of gastrointestinal disturbance. Exercise stress of ≥2hours at 60% VO2max appears to be the threshold whereby significant gastrointestinal perturbations manifest, irrespective of fitness status. Gastrointestinal symptoms, referable to upper- and lower-gastrointestinal tract, are common and a limiting factor in prolonged strenuous exercise. While there is evidence for health benefits of moderate exercise in patients with inflammatory bowel disease or functional gastrointestinal disorders, the safety of more strenuous exercise has not been established. Strenuous exercise has a major reversible impact on gastrointestinal integrity and function of healthy populations. The safety and health implications of prolonged strenuous exercise in patients with chronic gastrointestinal diseases/disorders, while hypothetically worrying, has not been elucidated and requires further investigation.

Gastrointestinal Dysfunction Following Intestinal or Multivisceral Transplantation

Introduction: The risk of rejection and infection following intestinal or multivisceral transplant is well documented[1] however there is little literature on the other causes of gastrointestinal symptoms, which can affect intestine containing grafts. Our aim was to review the incidence of other gastrointestinal conditions identified following transplantations. Methods: A retrospective search of patient notes and radiology reports was carried out in Addenbrookes hospital, in patients who had undergone either an isolated intestine or multivisceral transplant. Small intestinal bacterial overgrowth and bile salt malabsorption were investigated with a glucose hydrogen breath test and 23-seleno-25-homotaurocholic acid (SeHCAT) respectively. Other tests undertaken included whole gut scintigraphy and oesophageal physiology in selected cases. Results: There were 71 transplants in 65 patients between Jan 2006 and September 2016. 8 patients (11 transplants) in this cohort with gastrointestinal symptoms following transplant have undergone investigation for causes of these symptoms. Four patients were diagnosed as having small intestinal bacterial overgrowth (SIBO) as a result of positive breath tests with consistent symptoms. Two patients with otherwise unexplained diarrhoea had bile salt malabsorption (BSM) identified following positive SeHCAT scans. Both of these patients had a colon in continuity. One patient had both SIBO and BSM diagnosed one year apart. There were two cases of gastric dumping syndrome detected (one positive glucose tolerance test and one had rapid gastric emptying on scintigraphy). One of these patients had documented hypoglycaemia after meals, while the other patient presented with diarrhoea. One patient who underwent a full multivisceral transplant suffered recurrent aspiration pneumonia and had demonstrable oesophageal dysmotility. He is awaiting fundoplication. Conclusion: This review identified four different causes of gastrointestinal symptoms in intestine transplant patients. Before the diagnosis was made all patients were screened for rejection and infection. Patients are at risk of SIBO due to distorted intestinal anatomy. Those with an oeosophago-gastric anastomosis are vulnerable to gastro-oesophageal reflux and fundoplication may be considered concurrently with the transplant or at a later date. Five of the eight patients had full multivisceral transplants with denervation of the vagal supply to the entire gastrointestinal tract, which may explain the slighter higher incidence of gastrointestinal dysfunction in these patients. We should have a low threshold for suspecting these intestinal disorders following intestine containing grafts. This would allow prompt treatment of these conditions. Reference: 1. Middleton SJ, Pither C, Gao R, et al. Small intestinal and multivisceral transplantation: lessons through the “Retrospectoscope” at a single UK centre from 1991 to 2013. Transplant Proceedings 2014;46:2114–8.

Chronic alcohol overconsumption may alter gut microbial metabolism: a retrospective study of 719 13C-D-xylose breath test results.

ABSTRACT Objective: Alterations of gut microbiota composition or function may participate in the pathophysiology of several diseases. We aimed to explore the effect of chronic alcohol overconsumption on gut microbial metabolism, as assessed by evaluating 13C-D-xylose breath test results. Materials and methods: We investigated all 13C-D-xylose breath tests performed at Lovisenberg Diaconal Hospital during the years 2005 to 2011, using patient files for diagnosing the patients into one of three patient categories: alcohol overconsumption, coeliac disease and functional bowel disorder. In addition, a group of healthy controls was included. The time curves of 13CO2 excretion in breath samples were divided into two phases, evaluating small intestinal absorption (0–60 min) and colonic microbial metabolism (90–240 min), respectively. Results: A total of 719 patients underwent 13C-D-xylose breath testing during the inclusion period. Thirty-five had a history of alcohol overconsumption, 66 had coeliac disease, and 216 had a functional bowel disorder, while 44 healthy controls were included for comparison. The alcohol overconsumption group had similar small intestinal phase results as the group of patients with untreated coeliac disease. During the colonic phase, the group of patients with alcohol overconsumption differed from all the other groups in terms of 13C-xylose recovery, with significantly less 13CO2 excretion compared to the other groups. Conclusion: The results suggest that patients with a history of alcohol overconsumption suffer from both small intestinal malabsorption and impaired colonic microbial metabolism. The role of gut microbiota in chronic alcohol overconsumption should be investigated further.