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Daveson AJM, Popp A, Taavela J, Goldstein KE, Isola J, Truitt KE, Mäki M, Anderson RP, Adams A, Andrews J, Behrend C, Brown G, Chen Yi Mei S, Coates A, Daveson A, DiMarino A, Elliott D, Epstein R, Feyen B, Fogel R, Friedenberg K, Gearry R, Gerdis M, Goldstein M, Gupta V, Holmes R, Holtmann G, Idarraga S, James G, King T, Klein T, Kupfer S, Lebwohl B, Lowe J, Murray J, Newton E, Quinn D, Radin D, Ritter T, Stacey H, Strout C, Stubbs R, Thackwray S, Trivedi V, Tye‐Din J, Weber J, Wilson S. Baseline quantitative histology in therapeutics trials reveals villus atrophy in most patients with coeliac disease who appear well controlled on gluten‐free diet. ACTA ACUST UNITED AC 2020. [DOI: 10.1002/ygh2.380] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Alina Popp
- Tampere Centre for Child Health Research Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
- University of Medicine and Pharmacy "Carol Davila" and National Institute for Mother and Child Health "Alessandrescu‐Rusescu" Bucharest Romania
| | - Juha Taavela
- Tampere Centre for Child Health Research Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
- Department of Internal Medicine Central Finland Central Hospital Jyväskylä Finland
| | | | - Jorma Isola
- Laboratory of Cancer Biology Faculty of Medicine and Health Technology Tampere University Tampere Finland
- Jilab Inc. Tampere Finland
| | | | - Markku Mäki
- Tampere Centre for Child Health Research Faculty of Medicine and Health Technology Tampere University and Tampere University Hospital Tampere Finland
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Potter MDE, Jones MP, Walker MM, Koloski NA, Keely S, Holtmann G, Talley Ac NJ. Incidence and prevalence of self-reported non-coeliac wheat sensitivity and gluten avoidance in Australia. Med J Aust 2020; 212:126-131. [PMID: 31909482 DOI: 10.5694/mja2.50458] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To determine the incidence of self-reported non-coeliac wheat sensitivity (SR-NCWS) and factors associated with its onset and resolution; to describe the prevalence of factors associated with gluten avoidance. DESIGN Longitudinal cohort study; analysis of responses to self-administered validated questionnaires (Digestive Health and Wellbeing surveys, 2015 and 2018). SETTING, PARTICIPANTS Subset of an adult population sample randomly selected in 2015 from the electoral rolls for the Newcastle and Gosford regions of New South Wales. MAIN OUTCOME MEASURES Prevalence of SR-NCWS (2015, 2018) and incidence and resolution of SR-NCWS, each by demographic and medical factors; prevalence of gluten avoidance and reasons for gluten avoidance (2018). RESULTS 1322 of 2185 eligible participants completed the 2018 survey (response rate, 60.5%). The prevalence of SR-NCWS was similar in 2015 (13.8%; 95% CI, 12.0-15.8%) and 2018 (13.9%; 95% CI, 12.1-15.9%); 69 of 1301 respondents (5.3%) reported developing new onset (incident) SR-NCWS between 2015 and 2018 (incidence, 1.8% per year). Incident SR-NCWS was significantly associated with a diagnosis of functional dyspepsia, and negatively associated with being male or older. Gluten avoidance was reported in 2018 by 24.2% of respondents (20.5% partial, 3.8% complete avoidance); general health was the most frequent reason for avoidance (168 of 316 avoiders, 53%). All 13 participants with coeliac disease, 56 of 138 with irritable bowel syndrome (41%), and 69 of 237 with functional dyspepsia (29%) avoided dietary gluten. CONCLUSIONS The prevalence of SR-NCWS was similar in 2015 and 2018. Baseline (2015) and incident SR-NCWS (2018) were each associated with functional gastrointestinal disorders. The number of people avoiding dietary gluten exceeds that of people with coeliac disease or SR-NCWS, and general health considerations and abdominal symptoms are the most frequently reported reasons for avoidance.
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Affiliation(s)
- Michael DE Potter
- University of Newcastle, Newcastle, NSW.,John Hunter Hospital, Newcastle, NSW
| | | | | | - Natasha A Koloski
- University of Queensland, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
| | | | - Gerald Holtmann
- University of Queensland, Brisbane, QLD.,Princess Alexandra Hospital, Brisbane, QLD
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Burns G, Pryor J, Holtmann G, Walker MM, Talley NJ, Keely S. Immune Activation in Functional Gastrointestinal Disorders. Gastroenterol Hepatol (N Y) 2019; 15:539-548. [PMID: 31802978 PMCID: PMC6883739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
There is growing appreciation that functional gastrointestinal disorders (FGIDs) such as functional dyspepsia and irritable bowel syndrome are heterogeneous conditions linked by subtle inflammation within the gastrointestinal (GI) tract. The literature suggests that while the symptoms of these diseases may manifest with similar clinical presentations, there are significant differences in triggers and disease severity among patients classified into the same subtype. It is hypothesized that the subtle inflammation observed in these patients is related to an imbalance in GI homeostasis. Disruption of the delicate homeostatic balance within the GI tract can result from any number or combination of factors, including dysbiosis, loss of barrier integrity, genetic predisposition, or immune responses to dietary or luminal antigens. This article discusses the interplay between the immune system, microbiota, and luminal environment in FGIDs. In addition, the article proposes emerging immune pathways, including those involving T-helper type 17 response and innate lymphoid cells, as potential regulators of the subtle inflammation characteristic of FGIDs that warrant investigation in future studies.
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Affiliation(s)
- Grace Burns
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
| | - Jennifer Pryor
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
| | - Gerald Holtmann
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
| | - Marjorie M Walker
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
| | - Nicholas J Talley
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
| | - Simon Keely
- Ms Burns is a PhD graduate student, Ms Pryor is an undergraduate research student
- Dr Walker is a professor of anatomical pathology
- Dr Talley is a laureate professor
- Dr Keely is an associate professor in the Priority Research Centre for Digestive Health and Neurogastroenterology in the Faculty of Health and Medicine at the University of Newcastle in Callaghan, New South Wales, Australia, as well as in the Hunter Medical Research Institute in New Lambton Heights, New South Wales, Australia
- Dr Holtmann is director of gastroenterology and hepatology at the Princess Alexandra Hospital in Brisbane, Queensland, Australia and a professor in the Faculty of Medicine at the University of Queensland in Woolloongabba, Queensland, Australia
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Carter HE, Knowles D, Moroney T, Holtmann G, Rahman T, Appleyard M, Steele N, Zanco M, Graves N. The use of modelling studies to inform planning of health services: case study of rapidly increasing endoscopy services in Australia. BMC Health Serv Res 2019; 19:608. [PMID: 31464609 PMCID: PMC6716875 DOI: 10.1186/s12913-019-4438-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/19/2019] [Indexed: 11/20/2022] Open
Abstract
Background Demand for gastrointestinal endoscopy in Australia is increasing as a result of the expanding national bowel cancer screening program and a growing, ageing population. More services are required to meet demand and ensure patients are seen within clinically recommended timeframes. Methods A discrete event simulation model was developed to project endoscopy waiting list outcomes for two large metropolitan health services encompassing 8 public hospitals in Australia. The model applied routinely collected health service data to forecast the impacts of future endoscopic demand over 5 years and to identify the level of service activity required to address patient waiting times and meet key policy targets. The approach incorporated evidence from the literature to produce estimates of cost-effectiveness by showing longer term costs and Quality Adjusted Life Years (QALYs) associated with service expansion. Results The modelling revealed that doing nothing would lead to the number of patients waiting longer than clinically recommended doubling across each health service within 5 years. A 38% overall increase in the number of monthly procedures available was required to meet and maintain a target of 95–98% of patients being seen within clinically recommended timeframes to the year 2021. This was projected to cost the funder approximately $140 million in additional activity over a 5 year period. Due to improved patient outcomes associated with timely intervention, it was estimated that the increased activity would generate over 22,000 additional QALYs across the two health services. This translated to an incremental cost-effectiveness ratio of $6467 and $5974 per QALY for each health service respectively. Conclusions Discrete event simulation modelling provided a rational, data based approach that allowed decision makers to quantify the future demand for endoscopy services and identify cost-effective strategies to meet community needs. Electronic supplementary material The online version of this article (10.1186/s12913-019-4438-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia.
| | - Dylan Knowles
- Anthrodynamics Simulation Services Australia, Homebush, NSW, 2140, Australia
| | - Timothy Moroney
- Healthcare Purchasing and System Performance, Queensland Health, 33 Charlotte St, Brisbane, QLD, 4001, Australia
| | - Gerald Holtmann
- Faculty of Medicine & Faculty of Health & Behavioural Sciences, University of Queensland, 288 Herston Rd, Herston, QLD, 4006, Australia.,Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
| | - Tony Rahman
- The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia
| | - Mark Appleyard
- Royal Brisbane and Women's Hospital, Butterfield St, Herston, QLD, 4029, Australia
| | - Nick Steele
- Healthcare Purchasing and System Performance, Queensland Health, 33 Charlotte St, Brisbane, QLD, 4001, Australia
| | - Michael Zanco
- Health systems innovation branch, Queensland Health, 33 Charlotte St, Brisbane, QLD, 4001, Australia
| | - Nicholas Graves
- Australian Centre for Health Services Innovation, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
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Koloski N, Jones M, Walker MM, Veysey M, Zala A, Keely S, Holtmann G, Talley NJ. Population based study: atopy and autoimmune diseases are associated with functional dyspepsia and irritable bowel syndrome, independent of psychological distress. Aliment Pharmacol Ther 2019; 49:546-555. [PMID: 30687959 DOI: 10.1111/apt.15120] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 11/13/2018] [Accepted: 12/10/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The pathogenesis of functional GI disorders (FGIDs) is uncertain. However, underlying immune activation and psychological distress has been documented in irritable bowel syndrome (IBS) and functional dyspepsia (FD). Epidemiological data from the UK suggest that FGIDs are linked to atopy and certain autoimmune diseases but this has not been confirmed. AIM To test if allergic or autoimmune diseases are independently associated with FGIDs, irrespective of psychological distress in a large population based study. METHODS A total of 3542 people (mean age 57.9 years and 52.7% females) randomly selected from the Australian population, returned a mail survey (response rate = 43%). The survey asked about a physician diagnosis of autoimmune disease (scleroderma, psoriasis, rheumatoid arthritis and diabetes mellitus) or allergic conditions (asthma, food, pollen and/or animal allergy). The questionnaire assessed psychological distress and Rome III criteria for FD and IBS. RESULTS Asthma, food, pollen and animal allergies, psoriasis and rheumatoid arthritis were univariately significantly associated with IBS and FD. Food allergy (OR = 1.66; 95% CI = 1.15-2.40, P = 0.007), psoriasis (OR = 1.81; 95% CI = 1.19-2.74, P = 0.006) and rheumatoid arthritis (OR = 1.68; 95% CI = 1.15-2.4, P = 0.007) were independent risk factors for IBS, controlling for age, gender and psychological distress. In FD, asthma (OR = 1.32; 95% CI = 1.04-1.68, P = 0.025) and food allergy (OR = 1.78; 95% CI = 1.28-2.49, P = 0.001) were independent predictors, controlling for age, sex and psychological distress. CONCLUSIONS There is evidence that both atopic and autoimmune diseases are risk factors for FGIDs, independent of psychological distress, differing in IBS and FD. This provides evidence that different peripheral pathways may be involved in the pathogenesis of certain FGIDs.
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Affiliation(s)
- Natasha Koloski
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia.,Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,School of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Michael Jones
- Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia.,Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Marjorie M Walker
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia
| | - Martin Veysey
- Hull York Medical School & York Teaching Hospital NHS Foundation Trust, York, UK
| | - Alkesh Zala
- Department of Gastroenterology, John Hunter Hospital, New Lambton, NSW, Australia
| | - Simon Keely
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia
| | - Gerald Holtmann
- Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia.,Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,School of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia.,Australian Gastrointestinal Research Alliance (AGIRA), Newcastle, NSW, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton, NSW, Australia
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von Wulffen M, Talley NJ, Hammer J, McMaster J, Rich G, Shah A, Koloski N, Kendall BJ, Jones M, Holtmann G. Overlap of Irritable Bowel Syndrome and Functional Dyspepsia in the Clinical Setting: Prevalence and Risk Factors. Dig Dis Sci 2019; 64:480-486. [PMID: 30368683 DOI: 10.1007/s10620-018-5343-6] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 10/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND According to Rome IV criteria, functional dyspepsia (FD) and irritable bowel syndrome (IBS) are distinct functional gastrointestinal disorders (FGID); however, overlap of these conditions is common in population-based studies, but clinical data are lacking. AIMS To determine the overlap of FD and IBS in the clinical setting and define risk factors for the overlap of FD/IBS. METHODS A total of 1127 consecutive gastroenterology outpatients of a tertiary center were recruited and symptoms assessed with a standardized validated questionnaire. Patients without evidence for structural or biochemical abnormalities as a cause of symptoms were then categorized based upon the symptom pattern as having FD, IBS or FD/IBS overlap. Additionally, this categorization was compared with the clinical diagnosis documented in the integrated electronic medical records system. RESULTS A total of 120 patients had a clinical diagnosis of a FGID. Based upon standardized assessment with a questionnaire, 64% of patients had FD/IBS overlap as compared to 23% based upon the routine clinical documentation. In patients with severe IBS or FD symptoms (defined as symptoms affecting quality of life), the likelihood of FD/IBS overlap was substantially increased (OR = 3.1; 95%CI 1.9-5.0) and (OR = 9.0; 95%CI 3.5-22.7), respectively. Thus, symptom severity for IBS- or FD symptoms were significantly higher for patients with FD/IBS overlap as compared to patients with FD or IBS alone (p all < 0.01). Age, gender and IBS-subtype were not associated with overlap. CONCLUSION In the clinical setting, overlap of FD and IBS is the norm rather than the exception. FD/IBS overlap is associated with a more severe manifestation of a FGID.
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Affiliation(s)
- Moritz von Wulffen
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Johann Hammer
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
- Medical University of Vienna, Vienna, Austria
| | - Jessica McMaster
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Graeme Rich
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Ayesha Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Natasha Koloski
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Bradley J Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, Brisbane, QLD, Australia
| | - Mike Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, 199 Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Translational Research Institute, Brisbane, QLD, Australia.
- Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia.
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine, Translational Research Institute, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
| | - Mark Morrison
- Diamantina Institute, Translational Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Gerald Holtmann
- Faculty of Medicine, Translational Research Institute, Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia.
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Affiliation(s)
- Nicholas J Talley
- a University of Newcastle, Faculty of Health and Medicine , Newcastle , Australia.,b Australian GI Research Alliance (AGIRA) , Newcastle , Australia
| | - Gerald Holtmann
- b Australian GI Research Alliance (AGIRA) , Newcastle , Australia.,c Department of Gastroenterology , University of Queensland , Brisbane , Australia
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So D, Whelan K, Rossi M, Morrison M, Holtmann G, Kelly JT, Shanahan ER, Staudacher HM, Campbell KL. Dietary fiber intervention on gut microbiota composition in healthy adults: a systematic review and meta-analysis. Am J Clin Nutr 2018; 107:965-983. [PMID: 29757343 DOI: 10.1093/ajcn/nqy041] [Citation(s) in RCA: 345] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 02/14/2018] [Indexed: 12/17/2022] Open
Abstract
Background Dysfunction of the gut microbiota is frequently reported as a manifestation of chronic diseases, and therefore presents as a modifiable risk factor in their development. Diet is a major regulator of the gut microbiota, and certain types of dietary fiber may modify bacterial numbers and metabolism, including short-chain fatty acid (SCFA) generation. Objective A systematic review and meta-analysis were undertaken to assess the effect of dietary fiber interventions on gut microbiota composition in healthy adults. Design A systematic search was conducted across MEDLINE, EMBASE, CENTRAL, and CINAHL for randomized controlled trials using culture and/or molecular microbiological techniques evaluating the effect of fiber intervention on gut microbiota composition in healthy adults. Meta-analyses via a random-effects model were performed on alpha diversity, prespecified bacterial abundances including Bifidobacterium and Lactobacillus spp., and fecal SCFA concentrations comparing dietary fiber interventions with placebo/low-fiber comparators. Results A total of 64 studies involving 2099 participants were included. Dietary fiber intervention resulted in higher abundance of Bifidobacterium spp. (standardized mean difference (SMD): 0.64; 95% CI: 0.42, 0.86; P < 0.00001) and Lactobacillus spp. (SMD: 0.22; 0.03, 0.41; P = 0.02) as well as fecal butyrate concentration (SMD: 0.24; 0.00, 0.47; P = 0.05) compared with placebo/low-fiber comparators. Subgroup analysis revealed that fructans and galacto-oligosaccharides led to significantly greater abundance of both Bifidobacterium spp. and Lactobacillus spp. compared with comparators (P < 0.00001 and P = 0.002, respectively). No differences in effect were found between fiber intervention and comparators for α-diversity, abundances of other prespecified bacteria, or other SCFA concentrations. Conclusions Dietary fiber intervention, particularly involving fructans and galacto-oligosaccharides, leads to higher fecal abundance of Bifidobacterium and Lactobacillus spp. but does not affect α-diversity. Further research is required to better understand the role of individual fiber types on the growth of microbes and the overall gut microbial community. This review was registered at PROSPERO as CRD42016053101.
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Affiliation(s)
- Daniel So
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Kevin Whelan
- Department of Nutritional Sciences, King's College, London, United Kingdom
| | - Megan Rossi
- Department of Nutritional Sciences, King's College, London, United Kingdom
| | - Mark Morrison
- The University of Queensland Diamantina Institute, Translational Research Institute.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Gerald Holtmann
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Department of Gastroenterology & Hepatology
| | - Jaimon T Kelly
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Erin R Shanahan
- The University of Queensland Diamantina Institute, Translational Research Institute.,Department of Gastroenterology & Hepatology
| | | | - Katrina L Campbell
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia.,Department of Nutrition and Dietetics, Princess Alexandra Hospital, Brisbane, Australia
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Affiliation(s)
- Miriam Goebel-Stengel
- Department of Internal Medicine II: Gastroenterology, Helios Clinic Rottweil, Rottweil, Germany.,Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany
| | - Gerald Holtmann
- Princess Alexandra Hospital, Australian GI Research Alliance (AGIRA), University of Queensland, Brisbane, Australia
| | - Paul Enck
- Department of Internal Medicine VI: Psychosomatic Medicine and Psychotherapy, University Hospital Tübingen, Tübingen, Germany.
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Dear BF, Fogliati VJ, Fogliati R, Gandy M, McDonald S, Talley N, Holtmann G, Titov N, Jones M. Transdiagnostic internet-delivered cognitive-behaviour therapy (CBT) for adults with functional gastrointestinal disorders (FGID): A feasibility open trial. J Psychosom Res 2018; 108:61-69. [PMID: 29602327 DOI: 10.1016/j.jpsychores.2018.02.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/18/2022]
Abstract
Many people with functional gastrointestinal disorders (FGIDs) face significant barriers in accessing psychological treatments that are known to reduce symptoms and their psychological sequelae. This study examined the feasibility and initial outcomes of a transdiagnostic and internet-delivered cognitive behaviour therapy (iCBT) intervention, the Chronic Conditions Course, for adults with functional gastrointestinal disorders (FGIDs). A single-group feasibility open trial design was employed and administered to twenty seven participants. The course ran for 8 weeks and was provided with weekly contact from a Clinical Psychologist. Seventy percent of participants completed the course within the 8 weeks and 81.5% provided data at post-treatment. High levels of satisfaction were observed and relatively little clinician time (M = 42.70 min per participant; SD = 46.25 min) was required. Evidence of clinical improvements in FGID symptoms (ds ≥ 0.46; avg. improvement ≥21%), anxiety symptoms (ds ≥ 0.99; avg. improvement ≥42%), and depression symptoms (ds ≥ 0.75; avg. improvement ≥35%) were observed, which either maintained or continued to improve to 3-month follow-up. Evidence of improvement was also observed in pain catastrophising and mental-health related quality of life, but not physical-health related quality of life. These findings highlight the potential value of transdiagnostic internet-delivered programs for adults with FGIDs and support for the conduct of larger-scale controlled studies.
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Affiliation(s)
- B F Dear
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.
| | - V J Fogliati
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - R Fogliati
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - M Gandy
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - S McDonald
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - N Talley
- Faculty of Health & Medicine, University of Newcastle, Newcastle, Australia
| | - G Holtmann
- Princess Alexandra Hospital and Translational Research Institute, Brisbane, Australia
| | - N Titov
- eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia
| | - M Jones
- Faculty of Health & Medicine, University of Newcastle, Newcastle, Australia; Department of Psychology, Macquarie University, Sydney, Australia
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Burns G, Shanahan E, Do A, Bruce J, Minahan K, Horvat J, Foster P, Holtmann G, Morrison M, Walker MM, Talley NJ, Keely S. Seroreactivity to Microbial Antigens and Gut‐Homing Immune Responses in Functional Dyspepsia Patients with Postprandial Distress Syndrome. FASEB J 2018. [DOI: 10.1096/fasebj.2018.32.1_supplement.613.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Grace Burns
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
| | - Erin Shanahan
- Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaAustralia
- Translational Research InstituteUniversity of QueenslandWoolloongabbaAustralia
| | - Anh Do
- Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaAustralia
- Translational Research InstituteUniversity of QueenslandWoolloongabbaAustralia
| | - Jessica Bruce
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
| | - Kyra Minahan
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
| | - Jay Horvat
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
| | - Paul Foster
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
| | - Gerald Holtmann
- Gastroenterology and HepatologyPrincess Alexandra HospitalWoolloongabbaAustralia
- Translational Research InstituteUniversity of QueenslandWoolloongabbaAustralia
| | - Mark Morrison
- Translational Research InstituteUniversity of QueenslandWoolloongabbaAustralia
| | - Marjorie M. Walker
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
| | - Nicholas J. Talley
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
| | - Simon Keely
- Priority Research Centre for Digestive Health and NeurogastroenterologyUniversity of NewcastleNew Lambton HeightsAustralia
- School of Biomedical Sciences & PharmacyFaculty of Health & MedicineUniversity of NewcastleNew Lambton HeightsAustralia
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Gray MA, Chao CY, Staudacher HM, Kolosky NA, Talley NJ, Holtmann G. Anti-TNFα therapy in IBD alters brain activity reflecting visceral sensory function and cognitive-affective biases. PLoS One 2018. [PMID: 29518097 PMCID: PMC5843226 DOI: 10.1371/journal.pone.0193542] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background In inflammatory bowel disease (IBD), immune activation with increased circulating TNF-α is linked to the intensity of gastrointestinal symptoms and depression or anxiety. A central feature of depression is cognitive biases linked to negative attributions about self, the world and the future. We aimed to assess the effects of anti-TNFα therapy on the central processing of self-attribution biases and visceral afferent information in patients with Crohn’s disease. Methods We examined 9 patients with Crohn’s disease (age 26.1±10.6. yrs, 5 female, 5 ileocolonic, 2 colonic and 2 ileal disease) during chronic anti-TNFα therapy (5 adalimumab, 4 infliximab). Patients were studied twice in randomized order before and after anti-TNFα administration. On each occasion patients underwent functional magnetic resonance imaging (fMRI) of the brain during a test of implicit attribution biases regarding sickness/health and undertook a standardized nutrient challenge. Results Following anti-TNFα treatment, ratings of ‘fullness’ following nutrient challenge reduced compared to pre-treatment ratings (p<0.05). Reaction times revealed improved processing of self-related and positive health words, consistent with improved implicit sense of wellbeing that correlated with improvements in sensory function after treatment (r = 0.67, p<0.05). Treatment-associated improvements in implicit processing were mirrored by alterations of prefrontal, amygdala, posterior cingulate and visual regions. Between patients, the degree of functional amygdala change was additionally explained by individual differences in attention regulation and body awareness rankings. Conclusion In patients with Crohn’s disease, anti-TNFα administration reduces visceral sensitivity and improves implicit cognitive-affective biases linked to alterations in limbic (amygdala) function.
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Affiliation(s)
- Marcus A. Gray
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
- Faculty of Health and Behavioral Science, University of Queensland, St. Lucia, Brisbane, Queensland, Australia
- * E-mail:
| | - Che-yung Chao
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Queensland, Australia
| | - Heidi M. Staudacher
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
| | - Natasha A. Kolosky
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, St. Lucia, Brisbane, Queensland, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Nicholas J. Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
- Faculty of Health and Behavioral Science, University of Queensland, St. Lucia, Brisbane, Queensland, Australia
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Abstract
Background and Summary: Traditionally, functional gastrointestinal disorders (FGID), including functional dyspepsia or irritable bowel syndrome (IBS), are defined by more or less specific symptoms and the absence of structural or biochemical abnormalities that cause these symptoms. This concept is now considered to be outdated; if appropriate tests are applied, structural or biochemical abnormalities that explain or cause the symptoms may be found in many patients. Another feature of FGID are the highly prevalent psychiatric comorbidities, such as depression and anxiety. It is implied that mood disorders "cause" gastrointestinal symptoms. In fact, epidemiological data now provide strong evidence that in subsets of cases, gastrointestinal (GI) symptoms arise first and mood disorders occur later, while in other patients the reverse appears to happen. Possible mechanisms for gut-brain dysfunction have been identified, with systemic minimal inflammation as a causal factor in at least some subjects. Other mechanisms that play a role in FGID include chronic infections, intestinal microbiota, low-grade mucosal inflammation including the increase of eosinophils, systemic immune activation, altered intestinal permeability, in diarrhea predominant IBS altered bile salt metabolism, abnormalities in the serotonin metabolism and genetic factors. All these factors might be modulated by environmental factors such as diet. Key Messages: While a number of factors can be linked to specific symptoms (e.g., pain or diarrhea), it is evident that the symptom-based categorization of patients will not allow targeted treatments that specifically address the underlying pathophysiology.
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Affiliation(s)
- Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine and Falty of Health and Behavioural Sciences, University of Queensland, Queensland, Queensland, Australia
| | - Ayesha Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Mark Morrison
- Diamantina Institute, University of Queensland, Queensland, Queensland, Australia
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Ghoshal UC, Gwee KA, Holtmann G, Li Y, Park SJ, Simadibrata M, Sugano K, Wu K, Quigley EMM, Cohen H. The role of the microbiome and the use of probiotics in gastrointestinal disorders in adults in the Asia-Pacific region - background and recommendations of a regional consensus meeting. J Gastroenterol Hepatol 2018; 33:57-69. [PMID: 28589613 DOI: 10.1111/jgh.13840] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/28/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022]
Abstract
The Asia-Pacific region is diverse, with regard to ethnicity, culture, and economic development incorporating some of the world's least and most developed nations. Gastrointestinal diseases are common in the Asia-Pacific region, and their prevalence, presentation, and management vary considerably within the region. There is growing evidence for an important role for the human gut microbiota in gastrointestinal health. As a consequence, geographic variations in the composition of the gut microbiota may contribute to variations in both the prevalence and response to therapy of specific diseases. Probiotics have been proposed as a valuable option in the prevention and treatment of a number of gastrointestinal illnesses, but the quality of available evidence to support their efficacy is variable. A meeting of international experts in adult and pediatric gastroenterology was held at the Sorbonne University, Paris, France, on April 11 and 12, 2016, to discuss current evidence supporting the use of probiotics in gastrointestinal disorders in the Asia-Pacific region. This article provides an overview of the discussions held at this meeting and recommends the formation of an Asia-Pacific Consortium on Gut Microbiota similar to those established in Europe and North America.
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Affiliation(s)
- Uday C Ghoshal
- Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kok-Ann Gwee
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital Brisbane, University of Queensland, Brisbane, Queensland, Australia
| | - Yanmei Li
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing, China
| | - Soo Jung Park
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Marcellus Simadibrata
- Faculty of Medicine, University of Indonesia and Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.,RSUPN Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Kentaro Sugano
- Department of Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Kaichun Wu
- Fourth Military Medical University, Xi'an, China
| | - Eamonn M M Quigley
- Division of Gastroenterology and Hepatology, Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital, Houston, Texas, USA
| | - Henry Cohen
- Clínica de Gastroenterología, Facultad de Medicina, Montevideo, Uruguay
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Rich G, Shah A, Koloski N, Funk P, Stracke B, Köhler S, Holtmann G. A randomized placebo-controlled trial on the effects of Menthacarin, a proprietary peppermint- and caraway-oil-preparation, on symptoms and quality of life in patients with functional dyspepsia. Neurogastroenterol Motil 2017; 29. [PMID: 28695660 DOI: 10.1111/nmo.13132] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 05/18/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Functional dyspepsia (FD) is a very common condition affecting more than 10% of the population. While there is no cure, a few drugs have been found to be effective for the relief of symptoms, although most are only effective in a subgroup of patients. We assess and compare the efficacy of a fixed peppermint/caraway-oil-combination (Menthacarin) on symptoms and quality of life (QoL) in patients with FD symptoms consistent with epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS). METHODS In a prospective, double-blind, multicenter trial, 114 outpatients with chronic or recurrent FD were randomized and treated for 4 weeks with the proprietary peppermint- and caraway-oil-preparation Menthacarin or placebo (2×1 capsule/day). Improvement of abdominal pain and discomfort were used as co-primary efficacy measures (scores measured with the validated Nepean Dyspepsia Index). KEY RESULTS After 2 and 4 weeks, active treatment was superior to placebo in alleviating symptoms consistent with PDS and EPS (P all <.001). After 4 weeks of treatment, pain and discomfort scores improved by 7.6±4.8 and 3.6±2.5 points (full analysis set; mean±SD) for Menthacarin and by 3.4±4.3 and 1.3±2.1 points for placebo, respectively. All secondary efficacy measures showed advantages for Menthacarin. CONCLUSIONS & INFERENCES Menthacarin is an effective therapy for the relief of pain and discomfort and improvement of disease-specific QoL in patients with FD and significantly improves symptoms consistent with EPS and PDS.
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Affiliation(s)
- G Rich
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Faculty of Medicine & Faculty of Health & Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia
| | - A Shah
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Faculty of Medicine & Faculty of Health & Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia
| | - N Koloski
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Faculty of Medicine & Faculty of Health & Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - P Funk
- Clinical Research Department, Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany
| | - B Stracke
- Clinical Research Department, Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany
| | - S Köhler
- Clinical Research Department, Dr. Willmar Schwabe GmbH & Co. KG, Karlsruhe, Germany
| | - G Holtmann
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Faculty of Medicine & Faculty of Health & Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia
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Shah A, Shanahan E, Macdonald GA, Fletcher L, Ghasemi P, Morrison M, Jones M, Holtmann G. Systematic Review and Meta-Analysis: Prevalence of Small Intestinal Bacterial Overgrowth in Chronic Liver Disease. Semin Liver Dis 2017; 37:388-400. [PMID: 29272899 DOI: 10.1055/s-0037-1608832] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors conducted a meta-analysis of the prevalence of small intestinal bacterial overgrowth (SIBO) in patients with chronic liver disease (CLD) and controls. Using the search terms "small intestinal bacterial overgrowth (SIBO)" and "chronic liver disease (CLD)" or "cirrhosis," 19 case-control studies were identified. Utilizing breath tests, the prevalence of SIBO in CLD was 35.80% (95% CI, 32.60-39.10) compared with 8.0% (95% CI, 5.70-11.00) in controls. Using culture techniques, the prevalence was 68.31% (95% CI, 59.62-76.00) in CLD patients as compared with 7.94% (95% CI, 3.44-12.73) in controls. No difference between cirrhotic and noncirrhotic patients was found. SIBO is significantly more frequent in CLD patients as compared with controls. The association of SIBO and CLD was not confined to patients with advanced CLD, suggesting that SIBO is not a consequence of advanced liver disease but may play a role in the progression of CLD.
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Affiliation(s)
- Ayesha Shah
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Erin Shanahan
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Graeme A Macdonald
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Linda Fletcher
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Pegah Ghasemi
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Mark Morrison
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Diamantina Institute, Microbial Biology and Metagenomics, University of Queensland, Queensland, Australia
| | - Mike Jones
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Gerald Holtmann
- Faculty of Medicine, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Translational Research Institute, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Talley NJ, Holtmann G, Nguyen QN, Gibson P, Bampton P, Veysey M, Wong J, Philcox S, Koloski N, Bunby L, Jones M. Undiagnosed pancreatic exocrine insufficiency and chronic pancreatitis in functional GI disorder patients with diarrhea or abdominal pain. J Gastroenterol Hepatol 2017; 32:1813-1817. [PMID: 28332731 DOI: 10.1111/jgh.13791] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 02/19/2017] [Accepted: 03/20/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM A previous UK study showed that 6.1% of patients with diarrhea-predominant irritable bowel syndrome (IBS-D) had evidence of severe pancreatic exocrine insufficiency (PEI), but these findings need replication. We aimed to identify the prevalence of PEI based on fecal elastase stool testing in consecutive outpatients presenting with chronic unexplained abdominal pain and/or diarrhea and/or IBS-D. METHODS Patients aged over 40 years presenting to hospital outpatient clinics from six sites within Australia with unexplained abdominal pain and/or diarrhea for at least 3 months and/or IBS-D were studied. Patients completed validated questionnaires and donated a stool sample in which elastase concentration was measured by ELISA. A concentration of < 100 mcg/g stool represented severe and < 200 mcg/g mild to moderate PEI. Patients whose fecal elastase was < 200 mcg/g underwent testing for pancreatic pathology with an endoscopic ultrasound or abdominal CT. RESULTS Two hundred eighteen patients (mean age of 60 years, 29.4% male) were studied. PEI was found in 4.6% (95% CI 2.2-8.3%) (n = 10), with five patients (2.3% (95% CI 0.8-5.3%) having severe PEI. Only male sex and heavy alcohol use were significantly associated with abnormal versus normal pancreatic functioning. Of seven patients who underwent endoscopic ultrasound or CT, two had features indicative of chronic pancreatitis. CONCLUSION One in 50 patients with IBS-D or otherwise unexplained abdominal pain or diarrhea have an abnormal fecal elastase, but unexpected pancreatic insufficiency was detected in only a minority of these. This study failed to confirm the high prevalence of PEI among patients with unexplained GI symptoms previously reported.
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Affiliation(s)
- Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Quoc Nam Nguyen
- Department of Gastroenterology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter Gibson
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Victoria, Australia
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Martin Veysey
- Teaching & Research Unit, Gosford & Wyong Hospital, Gosford, New South Wales, Australia
| | - James Wong
- Mylan EPD, Macquarie, New South Wales, Australia
| | - Stephen Philcox
- Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia
| | - Natasha Koloski
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.,Department of Gastroenterology, John Hunter Hospital, New Lambton, New South Wales, Australia.,Department of Gastroenterology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Lisa Bunby
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Michael Jones
- Department of Psychology, Macquarie University, Ryde, New South Wales, Australia
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Koloski NA, Jones M, Hammer J, von Wulffen M, Shah A, Hoelz H, Kutyla M, Burger D, Martin N, Gurusamy SR, Talley NJ, Holtmann G. Erratum to: The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting. Dig Dis Sci 2017; 62:2607. [PMID: 28689252 DOI: 10.1007/s10620-017-4674-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- N A Koloski
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, 4072, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, 2308, Australia
| | - M Jones
- Department of Psychology, Macquarie University, North Ryde, NSW, 2109, Australia
| | - J Hammer
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, 4072, Australia
| | - M von Wulffen
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, 4072, Australia
| | - A Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, 4072, Australia
| | - H Hoelz
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - M Kutyla
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - D Burger
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - N Martin
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - S R Gurusamy
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - N J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, 2308, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital and Translational Research Institute (TRI), Ipswich Rd, Woolloongabba, Brisbane, QLD, 4102, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, 4072, Australia.
- Faculty of Health and Behavioural Sciences, University of Queensland, St Lucia, QLD, 4067, Australia.
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Shah A, Talley NJ, Walker M, Koloski N, Morrison M, Burger D, Andrews JM, McGuckin M, Jones M, Holtmann G. Is There a Link Between H. Pylori and the Epidemiology of Crohn's Disease? Dig Dis Sci 2017; 62:2472-2480. [PMID: 28281167 DOI: 10.1007/s10620-017-4496-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 02/08/2017] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Case control studies suggest an inverse association between Helicobacter pylori (H. pylori) and Crohn's disease (CD). It is possible this could be accounted for by confounders such as antibiotic therapy. Analyzing the geographic distribution of H. pylori and the links with the incidence and prevalence of CD would be an alternative approach to circumvent these confounders. METHODS The literature was searched for studies published between 1990 and 2016 that reported incidence or prevalence data for CD in random population samples in developed countries (GDP per capita >20,000 USD/year). Corresponding prevalence studies for H. pylori in these same regions were then sought matched to the same time period (±6 years). The association between the incidence and prevalence of CD and H. pylori prevalence rates were assessed before and after adjusting for GDP and life expectancy. RESULTS A total of 19 CD prevalence and 22 CD incidence studies from 10 European countries, Japan, USA, and Australia with date-matched H. pylori prevalence data were identified. The mean H. pylori prevalence rate was 43.4% (range 15.5-85%), and the mean rates for incidence and prevalence for CD were 6.9 and 91.0/100,000 respectively. The incidence (r = -0.469, p < 0.03) and prevalence (r = -0.527, p = 0.02) of CD was inversely and significantly associated with prevalence of H. pylori infection. CONCLUSIONS Our data demonstrate a significant inverse association between geographic distribution of H. pylori and CD. Thus, it is highly unlikely that the findings of previous case control studies were simply due to confounding factors such as concomitant antibiotic use in CD patients.
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Affiliation(s)
- Ayesha Shah
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Faculty of Medicine and Faculty of Health and Behavioural Sciences, Translational Research Institute, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Marjorie Walker
- Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Natasha Koloski
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Faculty of Medicine and Faculty of Health and Behavioural Sciences, Translational Research Institute, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Mark Morrison
- Microbial Biology and Metagenomics, Diamantina Institute, University of Queensland, Brisbane, QLD, Australia
| | - Daniel Burger
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Faculty of Medicine and Faculty of Health and Behavioural Sciences, Translational Research Institute, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia
| | - Jane M Andrews
- Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia
| | - Michael McGuckin
- Mater Medical Research Institute, Translational Research Institute, University of Queensland, Woolloongabba, QLD, Australia
| | - Mike Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Faculty of Medicine and Faculty of Health and Behavioural Sciences, Translational Research Institute, University of Queensland, Ipswich Road, Woolloongabba, Brisbane, QLD, Australia.
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Jones MP, Tack J, Van Oudenhove L, Walker MM, Holtmann G, Koloski NA, Talley NJ. Mood and Anxiety Disorders Precede Development of Functional Gastrointestinal Disorders in Patients but Not in the Population. Clin Gastroenterol Hepatol 2017; 15:1014-1020.e4. [PMID: 28087404 DOI: 10.1016/j.cgh.2016.12.032] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Understanding the interactions between brain and gastrointestinal disorders requires analysis of the order of disease onset. We analyzed data from 2 independent studies to determine the proportion of individuals with diagnoses of functional gastrointestinal disorders (FGIDs) before diagnoses of mood or anxiety disorders (gut to brain), and vice versa (brain to gut). METHODS We collected data from a retrospective study of 4966 patients diagnosed with a FGID (irritable bowel syndrome, dyspepsia, or constipation) and mood or anxiety disorder at general practices in the United Kingdom (health care seekers) over an average period of 13.1 years; we recorded which diagnosis appeared first and compared these with patients' sex and socioeconomic factors. We also collected data from a population study of 1002 randomly selected individuals in Australia (non-heath care seekers) followed from 1997 through 2009; we determined whether subjects were free of either FGID or an anxiety or mood disorder at baseline but developed either one after a 12-year follow-up period. RESULTS Among the 4966 health care seekers, 3279 patients were diagnosed with a mood or anxiety disorder before an FGID (ratio of 2:1). This ratio increased with socioeconomic disadvantage. The time period between diagnosis of mood or anxiety disorder and FGID was longer (median, 3.5 years) than time period between diagnosis of an FGID and a mood or anxiety disorder (median, 1.8 years). Among non-heath care seekers (population study), equal proportions were diagnosed with a mood or anxiety disorder before versus after an FGID. CONCLUSIONS In an analysis of data from a study of patients and a population-based study of individuals with these diagnoses, we found 2-fold more patients to receive a diagnosis of a mood or anxiety disorder before an FGID, but equal proportions of individuals in the population to be diagnosed with the mood or anxiety disorder before versus after an FGID. Among patients, the mood or anxiety disorder was on average diagnosed more than 3 years before the FGID, offering opportunity for prevention. Our findings support a role for adverse socioeconomic factors in development of FGIDs in patients with psychological disorders.
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Affiliation(s)
- Michael P Jones
- Psychology Department, Macquarie University, North Ryde, New South Wales, Australia.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Division of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, Division of Gastroenterology, University of Leuven, Leuven, Belgium; University Psychiatric Centre, Liaison Psychiatry, University Hospital Gasthuisberg, Leuven, Belgium
| | - Marjorie M Walker
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Natasha A Koloski
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia; Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
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72
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Zhong L, Shanahan ER, Raj A, Koloski NA, Fletcher L, Morrison M, Walker MM, Talley NJ, Holtmann G. Dyspepsia and the microbiome: time to focus on the small intestine. Gut 2017; 66:1168-1169. [PMID: 27489239 DOI: 10.1136/gutjnl-2016-312574] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 07/14/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Laurie Zhong
- School of Population Health, University of Queensland, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Erin R Shanahan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia.,Microbial Biology and Metagenomics Research Group, Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Ashok Raj
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Natasha A Koloski
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Linda Fletcher
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
| | - Mark Morrison
- Microbial Biology and Metagenomics Research Group, Diamantina Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Marjorie M Walker
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Translational Research Institute, Woolloongabba, Queensland, Australia.,School of Medicine, University of Queensland, Translational Research Institute, Woolloongabba, Queensland, Australia
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73
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Morrison M, Holtmann G. Translating our microbiome into medicine. Med J Aust 2017; 206:287-288. [PMID: 28403755 DOI: 10.5694/mja17.00087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/09/2017] [Indexed: 11/17/2022]
Affiliation(s)
- Mark Morrison
- University of Queensland Diamantina Institute, Translational Research Institute, Brisbane, QLD
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74
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Shanahan ER, Holtmann G, Morrison M. Life in the small intestine: the forgotten microbiome? Microbiol Aust 2017. [DOI: 10.1071/ma17045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The gastrointestinal (GI) microbiota is now widely accepted to be an important modulator of our health and well-being. The microbes colonising the GI tract aid in promoting gut and immune homeostasis, while alterations in the composition and/or density of these microbes, often referred to as dysbiosis, have been implicated in many intestinal and extra-intestinal disorders. As a result, the GI microbiota is of increasing interest as a therapeutic target. This is particularly the case in the context of GI disorders linked to chronic inflammation of the mucosa. In this article, we focus on the small intestinal microbiota, which in many senses can be considered the ‘forgotten' gut microbiome.
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75
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Abstract
PURPOSE OF REVIEW Functional dyspepsia affects 10% of the population. Emerging data are beginning to unravel the pathogenesis of this heterogeneous disorder, and new data on treatment are helping to guide evidence-based practice. In this review, the latest advances are summarized and discussed. RECENT FINDINGS The Rome IV criteria were published in 2016 and are similar to Rome III but further emphasize the subtypes (postprandial distress syndrome and epigastric pain syndrome) rather than focussing on the syndrome as a whole, and conclude that gastroesophageal reflux disease and irritable bowel syndrome are part of the functional dyspepsia spectrum. Environment is dominant in the pathogenesis. New data implicate herbivore pets and antibiotic exposure for a nongastrointestinal infection but require confirmation. Further experimental data suggest duodenal eosinophils and mast cells can alter enteric neuronal structure and function in functional dyspepsia. SUMMARY Advances in our understanding of functional dyspepsia are changing clinical practice.
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Affiliation(s)
- Nicholas J Talley
- aFaculty of Health and Medicine, University of Newcastle, New Lambton bFaculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales cDepartment of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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76
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Talley NJ, Holtmann G. Irritable bowel syndrome, dyspepsia and other chronic disorders of gastrointestinal function. Med J Aust 2016; 205:303-4. [PMID: 27681970 DOI: 10.5694/mja16.00874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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77
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von Wulffen M, Holtmann G. Editorial: the burden of chronic liver disease - an ecological method sees the wood for the trees. Authors' reply. Aliment Pharmacol Ther 2016; 44:532-3. [PMID: 27484934 DOI: 10.1111/apt.13713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- M von Wulffen
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia. .,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia. .,Translational Research Institute, Brisbane, Qld, Australia. .,Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Qld, Australia.
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78
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Fock KM, Talley N, Goh KL, Sugano K, Katelaris P, Holtmann G, Pandolfino JE, Sharma P, Ang TL, Hongo M, Wu J, Chen M, Choi MG, Law NM, Sheu BS, Zhang J, Ho KY, Sollano J, Rani AA, Kositchaiwat C, Bhatia S. Asia-Pacific consensus on the management of gastro-oesophageal reflux disease: an update focusing on refractory reflux disease and Barrett's oesophagus. Gut 2016; 65:1402-15. [PMID: 27261337 DOI: 10.1136/gutjnl-2016-311715] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/15/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Since the publication of the Asia-Pacific consensus on gastro-oesophageal reflux disease in 2008, there has been further scientific advancement in this field. This updated consensus focuses on proton pump inhibitor-refractory reflux disease and Barrett's oesophagus. METHODS A steering committee identified three areas to address: (1) burden of disease and diagnosis of reflux disease; (2) proton pump inhibitor-refractory reflux disease; (3) Barrett's oesophagus. Three working groups formulated draft statements with supporting evidence. Discussions were done via email before a final face-to-face discussion. We used a Delphi consensus process, with a 70% agreement threshold, using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria to categorise the quality of evidence and strength of recommendations. RESULTS A total of 32 statements were proposed and 31 were accepted by consensus. A rise in the prevalence rates of gastro-oesophageal reflux disease in Asia was noted, with the majority being non-erosive reflux disease. Overweight and obesity contributed to the rise. Proton pump inhibitor-refractory reflux disease was recognised to be common. A distinction was made between refractory symptoms and refractory reflux disease, with clarification of the roles of endoscopy and functional testing summarised in two algorithms. The definition of Barrett's oesophagus was revised such that a minimum length of 1 cm was required and the presence of intestinal metaplasia no longer necessary. We recommended the use of standardised endoscopic reporting and advocated endoscopic therapy for confirmed dysplasia and early cancer. CONCLUSIONS These guidelines standardise the management of patients with refractory gastro-oesophageal reflux disease and Barrett's oesophagus in the Asia-Pacific region.
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Affiliation(s)
- Kwong Ming Fock
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Nicholas Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Khean Lee Goh
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kentaro Sugano
- Department of Medicine, Jichi Medical University, Tochigi, Japan
| | - Peter Katelaris
- Gastroenterology Department, Concord Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Biomedical Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - John E Pandolfino
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Prateek Sharma
- University of Kansas and VA Medical Center, Kansas City, Kansas, USA
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Michio Hongo
- Department of Comprehensive Medicine, Tohoku University, Sendai, Japan
| | - Justin Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, China
| | - Minhu Chen
- Division of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Myung-Gyu Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ngai Moh Law
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Bor-Shyang Sheu
- Department of Internal Medicine, National Cheng Kung University Hospital, Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Jun Zhang
- The Second Affiliated Hospital, Xian Jiaotong University, Xian, China
| | - Khek Yu Ho
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
| | - Jose Sollano
- Department of Medicine, University of Sano Tomas, Manila, Philippines
| | - Abdul Aziz Rani
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Chomsri Kositchaiwat
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, India
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79
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Shanahan ER, Zhong L, Talley NJ, Morrison M, Holtmann G. Letter: investigating the intestinal mucosa-associated microbiota - relevance and potential pitfalls. Authors' reply. Aliment Pharmacol Ther 2016; 44:648-9. [PMID: 27511137 DOI: 10.1111/apt.13741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- E R Shanahan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia. .,Faculty of Medicine and Biomedical Sciences, Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia. .,Microbial Biology and Metagenomics, The University of Queensland Diamantina Institute, Brisbane, Qld, Australia. .,Translational Research Institute (TRI), Brisbane, Qld, Australia.
| | - L Zhong
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
| | - N J Talley
- Faculty of Health, The University of Newcastle, Callaghan, NSW, Australia
| | - M Morrison
- Microbial Biology and Metagenomics, The University of Queensland Diamantina Institute, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
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80
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von Wulffen M, Clark PJ, Macdonald GA, Raj AS, Kendall BJ, Powell EE, Jones MP, Holtmann G. Liver-related mortality in countries of the developed world: an ecological study approach to explain the variability. Aliment Pharmacol Ther 2016; 44:68-77. [PMID: 27189900 DOI: 10.1111/apt.13657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 02/24/2016] [Accepted: 04/08/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liver-related mortality varies across developed nations. AIM To assess the relative role of various risk factors in relation to liver-related mortality in an ecological study approach. METHODS Data for liver-related mortality, prevalence data for hepatitis B and C, human immunodeficiency virus (HIV), alcohol consumption per capita, Type 2 Diabetes mellitus (T2DM), overweight and obesity were extracted from peer-reviewed publications or WHO databases for different developed countries. As potential other risk-modifying factors, purchase power parity (PPP)-adjusted gross domestic product (GDP) per capita and health expenditure per capita were assessed. As an environmental 'hygiene factor', we also assessed the effect of the prevalence of Helicobacter pylori. Only countries with a PPP-adjusted GDP greater than $20 000 and valid information for at least 8 risk modifiers were included. Univariate and multivariate analyses were utilised to quantify the contribution to the variability in liver-related mortality. RESULTS The proportion of chronic liver diseases (CLD)-related mortality ranged from 0.73-2.40% [mean 1.56%, 95% CI (1.43-1.69)] of all deaths. Univariately, CLD-related mortality was significantly associated with Hepatitis B prevalence, alcohol consumption, PPP-adjusted GDP (all P < 0.05) and potentially H. pylori prevalence (P = 0.055). Other investigated factors, including hepatitis C, did not yield significance. Backward elimination suggested hepatitis B, alcohol consumption and PPP-adjusted GDP as risk factors (explaining 66.3% of the variability). CONCLUSION Hepatitis B infection, alcohol consumption and GDP, but not hepatitis C or other factors, explain most of the variance of liver-related mortality.
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Affiliation(s)
- M von Wulffen
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - P J Clark
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Cancer Control Unit, Berghofer-QIMR Medical Research Institute, Brisbane, Qld, Australia
| | - G A Macdonald
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - A S Raj
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia
| | - B J Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia
| | - E E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia
| | - M P Jones
- Faculty of Human Sciences, Macquire University, Sydney, NSW, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute, Brisbane, Qld, Australia.,Faculty of Health and Behavioral Sciences, University of Queensland, Brisbane, Qld, Australia
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81
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Shanahan ER, Zhong L, Talley NJ, Morrison M, Holtmann G. Characterisation of the gastrointestinal mucosa-associated microbiota: a novel technique to prevent cross-contamination during endoscopic procedures. Aliment Pharmacol Ther 2016; 43:1186-96. [PMID: 27086880 DOI: 10.1111/apt.13622] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 03/09/2016] [Accepted: 03/22/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The mucosa-associated microbiota appears to be highly relevant to host-microbe interactions in the gastrointestinal (GI) tract. Thus, precise characterisation of the mucosa-associated microbiota may provide important insights for diagnostic and therapeutic development. However, for technical reasons, mucosal biopsies taken during standard endoscopic procedures are potentially contaminated by GI luminal contents. AIM To develop and validate a biopsy device that minimises contamination during sampling of the mucosa-associated microbiota. METHODS A new, encased biopsy forceps was developed, the Brisbane Aseptic Biopsy Device (BABD). This comprises sterile forceps encased by a sheath with a plug at the tip, allowing targeted, aseptic sampling of the mucosa. Matched duodenal biopsies were obtained using the BABD, standard biopsy forceps, and a sterile brush, from patients undergoing upper GI endoscopy for iron deficiency (n = 6). Total genomic deoxyribonucleic acid (gDNA) was extracted from samples and bacterial 16S rRNA gene libraries sequenced to investigate the mucosa-associated microbiota. RESULTS Microbial DNA was recovered from biopsies obtained by the BABD, confirming the presence of a duodenal mucosa-associated microbiota. This microbiota was dominated by the genus Streptococcus, with lower levels of Prevotella, Veillonella and Neisseria. At the individual patient level, substantial differences were observed between matched samples obtained using the different devices. A greater degree of bacterial diversity was observed in samples collected using the standard forceps, indicating the BABD affords collection of samples more representative of the mucosa-associated microbiota, by precluding luminal cross-contamination. CONCLUSIONS Cross-contamination can occur when mucosal biopsies are taken during standard endoscopic procedures. Utilising the novel Brisbane Aseptic Biopsy Device can reduce cross-contamination, and it offers improved opportunities to more precisely examine host-mucosa-associated microbiota interactions.
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Affiliation(s)
- E R Shanahan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia.,Microbial Biology and Metagenomics, The University of Queensland Diamantina Institute, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
| | - L Zhong
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
| | - N J Talley
- Faculty of Health, The University of Newcastle, Callaghan, NSW, Australia
| | - M Morrison
- Microbial Biology and Metagenomics, The University of Queensland Diamantina Institute, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
| | - G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Qld, Australia.,Faculty of Medicine and Biomedical Sciences, and Faculty of Health and Behavioral Sciences, The University of Queensland, Brisbane, Qld, Australia.,Translational Research Institute (TRI), Brisbane, Qld, Australia
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82
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O’Connor SA, Hewett DG, Watson MO, Kendall BJ, Hourigan LF, Holtmann G. Accuracy of polyp localization at colonoscopy. Endosc Int Open 2016; 4:E642-6. [PMID: 27556071 PMCID: PMC4993896 DOI: 10.1055/s-0042-105864] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/07/2016] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Accurate documentation of lesion localization at the time of colonoscopic polypectomy is important for future surveillance, management of complications such as delayed bleeding, and for guiding surgical resection. We aimed to assess the accuracy of endoscopic localization of polyps during colonoscopy and examine variables that may influence this accuracy. PATIENTS AND METHODS We conducted a prospective observational study in consecutive patients presenting for elective, outpatient colonoscopy. All procedures were performed by Australian certified colonoscopists. The endoscopic location of each polyp was reported by the colonoscopist at the time of resection and prospectively recorded. Magnetic endoscope imaging was used to determine polyp location, and colonoscopists were blinded to this image. Three experienced colonoscopists, blinded to the endoscopist's assessment of polyp location, independently scored the magnetic endoscope images to obtain a reference standard for polyp location (Cronbach alpha 0.98). The accuracy of colonoscopist polyp localization using this reference standard was assessed, and colonoscopist, procedural and patient variables affecting accuracy were evaluated. RESULTS A total of 155 patients were enrolled and 282 polyps were resected in 95 patients by 14 colonoscopists. The overall accuracy of polyp localization was 85 % (95 % confidence interval, CI; 60 - 96 %). Accuracy varied significantly (P < 0.001) by colonic segment: caecum 100 %, ascending 77 % (CI;65 - 90), transverse 84 % (CI;75 - 92), descending 56 % (CI;32 - 81), sigmoid 88 % (CI;79 - 97), rectum 96 % (CI;90 - 101). There were significant differences in accuracy between colonoscopists (P < 0.001), and colonoscopist experience was a significant independent predictor of accuracy (OR 3.5, P = 0.028) after adjustment for patient and procedural variables. CONCLUSIONS Accuracy of localization of polyps is imprecise and affected by position within the colon and colonoscopist, including their level of experience. Magnetic endoscope imaging may improve the localization of lesions during colonoscopy.
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Affiliation(s)
- Sam A. O’Connor
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital;,School of Medicine, The University of Queensland;,Corresponding author Sam A O’Connor, MBBS (Hons), FRACP Department of GastroenterologyPrincess Alexandra Hospital199 Ipswich RdWoolloongabba, QueenslandAustralia+61-414-447-725+61 7-3176-2613+61-7-3176-5111
| | - David G. Hewett
- School of Medicine, The University of Queensland;,Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital;
| | - Marcus O. Watson
- School of Medicine, The University of Queensland;,Queensland Health Clinical Skills Development Service;
| | - Bradley J. Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital;,School of Medicine, The University of Queensland;
| | - Luke F. Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital;
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital;,Faculty of Medicine and Biomedical Sciences, & Faculty of Health and Behavioural Sciences, The University of Queensland; Brisbane, AUSTRALIA
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83
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Smith RC, Smith SF, Wilson J, Pearce C, Wray N, Vo R, Chen J, Ooi CY, Oliver M, Katz T, Turner R, Nikfarjam M, Rayner C, Horowitz M, Holtmann G, Talley N, Windsor J, Pirola R, Neale R. Summary and recommendations from the Australasian guidelines for the management of pancreatic exocrine insufficiency. Pancreatology 2016; 16:164-80. [PMID: 26775768 DOI: 10.1016/j.pan.2015.12.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 12/01/2015] [Accepted: 12/10/2015] [Indexed: 02/06/2023]
Abstract
AIM Because of increasing awareness of variations in the use of pancreatic exocrine replacement therapy, the Australasian Pancreatic Club decided it was timely to re-review the literature and create new Australasian guidelines for the management of pancreatic exocrine insufficiency (PEI). METHODS A working party of expert clinicians was convened and initially determined that by dividing the types of presentation into three categories for the likelihood of PEI (definite, possible and unlikely) they were able to consider the difficulties of diagnosing PEI and relate these to the value of treatment for each diagnostic category. RESULTS AND CONCLUSIONS Recent studies confirm that patients with chronic pancreatitis receive similar benefit from pancreatic exocrine replacement therapy (PERT) to that established in children with cystic fibrosis. Severe acute pancreatitis is frequently followed by PEI and PERT should be considered for these patients because of their nutritional requirements. Evidence is also becoming stronger for the benefits of PERT in patients with unresectable pancreatic cancer. However there is as yet no clear guide to help identify those patients in the 'unlikely' PEI group who would benefit from PERT. For example, patients with coeliac disease, diabetes mellitus, irritable bowel syndrome and weight loss in the elderly may occasionally be given a trial of PERT, but determining its effectiveness will be difficult. The starting dose of PERT should be from 25,000-40,000 IU lipase taken with food. This may need to be titrated up and there may be a need for proton pump inhibitors in some patients to improve efficacy.
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Affiliation(s)
| | - Ross C Smith
- Department of Surgery, University of Sydney, NSW, Australia; Australasian Pancreatic Club, Australia.
| | | | | | - Callum Pearce
- Institute for Immunology and Infectious Diseases, Murdoch University, WA, Australia; Fremantle Hospital, WA, Australia
| | - Nick Wray
- Nutrition & Dietetics, School of Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Ruth Vo
- Liverpool Hospital, University of NSW, Australia
| | - John Chen
- South Australian Liver Transplant & HPB Unit, RAH & Flinders Medical Centre, SA, Australia
| | - Chee Y Ooi
- School of Women's and Children's Health, Dept. of Medicine, University of NSW, Australia; Department of Gastroenterology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Mark Oliver
- Department of Gastroenterology and Clinical Nutrition, Royal Children's Hospital, Parkville, VIC, Australia
| | - Tamarah Katz
- Sydney Children's Hospital, Randwick, NSW, Australia
| | - Richard Turner
- Hobart Clinical School and Dept. Surgery, University of Tasmania, Australia
| | - Mehrdad Nikfarjam
- Dept. Surgery, University of Melbourne, VIC, Australia; Australasian Pancreatic Club, Australia
| | - Christopher Rayner
- School of Medicine, University of Adelaide, SA, Australia; Centre for Digestive Diseases, Royal Adelaide Hospital, SA, Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, University of Adelaide and Royal Adelaide Hospital, SA, Australia
| | - Gerald Holtmann
- Faculty of Medicine and Biomedical Sciences, University of Queensland, Australia; Translational Research Institute, Department of Gastroenterology & Hepatology, Princess Alexandra Hospital, Qld, Australia
| | - Nick Talley
- Faculty of Health and Medicine, University of Newcastle, NSW, Australia; Royal Australasian College of Physicians, Australia
| | - John Windsor
- Dept. of Surgery, University of Auckland, New Zealand
| | - Ron Pirola
- Faculty of Medicine, SW Sydney Clinical School, University of NSW, Australia
| | - Rachel Neale
- Cancer Control Laboratory, Queensland Institute of Medical Research, Qld, Australia
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Abstract
PURPOSE OF REVIEW Structural causes are absent in more than 50% of patients with symptoms referred to the gastroduodenal region when routine diagnostic tests are applied. New knowledge holds the prospect that targeted therapy may more optimally manage subsets of these patients with functional dyspepsia. RECENT FINDINGS An understanding of gut-to-brain and brain-to-gut pathways in functional dyspepsia is expanding. Minimal mucosal inflammation with eosinophils (and in some cases mast cells) characterized by ultrastructural changes in the duodenum appears to be present in a substantial subgroup of functional dyspepsia patients as identified now by investigators globally. Although antibiotic therapy targeting Helicobacter pylori appears to be effective in a small proportion of functional dyspepsia patients, eradication therapy may be more effective in functional dyspepsia patients with microscopic duodenal inflammation, a potentially important finding needing to be confirmed. This may suggest that the effects of antibiotics for functional dyspepsia are not simply mediated by the eradication of gastric H. pylori, but have other antibacterial effects (e.g., on the duodenal microbiome). Abnormal visceral sensory function plays a key role not only in the manifestations of functional dyspepsia but also in peptic ulcer disease. SUMMARY The pathophysiologic concepts underlying functional dyspepsia and related treatment approaches are shifting from a focus on H. pylori, acid suppression or modulation of motility toward new models. New evidence suggests that minimal duodenal inflammation plays a role in symptom generation in at least a proportion of patients with otherwise unexplained symptoms. This is a paradigm shift and ultimately may change the treatment of many patients with functional gastrointestinal disorders.
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Affiliation(s)
- Gerald Holtmann
- aFaculty of Medicine and Biomedical Sciences bFaculty of Health and Behavioural Sciences, Princess Alexandra Hospital Brisbane cTranslational Research Institute, University of Queensland, Brisbane, Queensland dFaculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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85
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Chao CY, Raj A, Saad N, Hourigan L, Holtmann G. Esophageal perforation, inflammatory mediastinitis and pseudoaneurysm of the thoracic aorta as potential complications of botulinum toxin injection for achalasia. Dig Endosc 2015; 27:618-21. [PMID: 25329507 DOI: 10.1111/den.12392] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 10/01/2014] [Indexed: 12/11/2022]
Abstract
Primary achalasia is a motility disorder of the esophagus involving impaired relaxation of the esophageal sphincter and, in later stages, dilatation and aperistalsis of the tubular esophagus. Endoscopic botulinum toxin injection to the lower esophageal sphincter is an effective and safe option in the treatment algorithm of achalasia, particularly in high-surgical-risk patients. In the present case report, we describe a rare complication of esophageal perforation following botulinum injection, resulting in associated inflammatory mediastinitis and formation of a pseudoaneurysm in the descending aorta. To the authors' knowledge, this is the first report in the literature of this rare complication of endoscopic botulinum injection. A contributing factor might have been the use of an injecting device with a significantly longer adjustable needle. Endoscopists should remain clinically vigilant to the potential complications associated with this common procedure.
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Affiliation(s)
- Che Yung Chao
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Ashok Raj
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Nivene Saad
- Department of Radiology, Princess Alexandra Hospital, Brisbane, Australia
| | - Luke Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | - Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia.,Faculty of Health Sciences, University of Queensland, Brisbane, Australia
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86
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Talley NJ, Holtmann G, Walker MM. Therapeutic strategies for functional dyspepsia and irritable bowel syndrome based on pathophysiology. J Gastroenterol 2015; 50:601-13. [PMID: 25917563 DOI: 10.1007/s00535-015-1076-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 02/06/2023]
Abstract
Functional gastrointestinal disorders (FGIDs) are common and distressing. They are so named because a defined pathophysiology in terms of structural or biochemical pathways is lacking. Traditionally FGIDs have been conceptualized as brain-gut disorders, with subgroups of patients demonstrating visceral hypersensitivity and motility abnormalities as well as psychological distress. However, it is becoming apparent that there are certain structural or biochemical gut alterations among subsets with the common FGIDs, most notably functional dyspepsia (FD) and irritable bowel syndrome (IBS). For example, a sodium channel mutation has been identified in IBS that may account for 2 % of cases, and subtle intestinal inflammation has been observed in both IBS and FD. Other research has implicated early life events and stress, autoimmune disorders and atopy and infections, the gut microbiome and disordered mucosal immune activation in patients with IBS or FD. Understanding the origin of symptoms in FGIDs will allow therapy to be targeted at the pathophysiological changes, not at merely alleviating symptoms, and holds hope for eventual cure in some cases. For example, there are promising developments in manipulating the microbiome through diet, prebiotics and antibiotics in IBS, and testing and treating patients for Helicobacter pylori infection remains a mainstay of therapy in patients with dyspepsia and this infection. Locally acting drugs such as linaclotide have been an advance in treating the symptoms of constipation-predominant IBS, but do not alter the natural history of the disease. A role for a holistic approach to patients with FGIDs is warranted, as brain-to-gut and gut-to-brain pathways appear to be activated.
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Affiliation(s)
- Nicholas J Talley
- Global Research, University of Newcastle, HMRI Building, Room 3419, Kookaburra Circuit, New Lambton, NSW, 2305, Australia,
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87
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Williamson KD, Steveling K, Holtmann G, Schoeman M, Andrews JM. Clinical triage for colonoscopy is useful in young women. Intern Med J 2015; 45:492-6. [DOI: 10.1111/imj.12703] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 01/28/2015] [Indexed: 12/19/2022]
Affiliation(s)
- K. D. Williamson
- Translational Gastroenterology Unit; John Radcliffe Hospital; Oxford UK
- Nuffield Department of Medicine; Oxford University; Oxford UK
- Discipline of Medicine; University of Adelaide; Adelaide Australia
| | - K. Steveling
- Department of Rheumatology; Knappschaftskrankenhaus; Püttlingen Germany
| | - G. Holtmann
- Department of Gastroenterology and Hepatology; Princess Alexandra Hospital; Brisbane Australia
- Faculty of Medicine and Biomedical Sciences; University of Queensland; Queensland Australia
| | - M. Schoeman
- Gastrointestinal Endoscopic Services; Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; South Australia Australia
| | - J. M. Andrews
- Discipline of Medicine; University of Adelaide; Adelaide Australia
- Inflammatory Bowel Disease Service and Education; Department of Gastroenterology and Hepatology; Royal Adelaide Hospital; South Australia Australia
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88
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Holtmann G, Talley NJ. Herbal medicines for the treatment of functional and inflammatory bowel disorders. Clin Gastroenterol Hepatol 2015; 13:422-32. [PMID: 24674944 DOI: 10.1016/j.cgh.2014.03.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Revised: 03/08/2014] [Accepted: 03/14/2014] [Indexed: 02/07/2023]
Abstract
In many parts of the world, there continues to be a long-standing tradition of prescribing herbal products for a range of gastrointestinal conditions. Scientific evidence supporting the use of all herbal preparations is imperfect, however, and available studies are plagued by methodological limitations. For functional gastrointestinal disorders, there is limited evidence supporting the use of some well-characterized preparations. A number of herbals have immunomodulatory activity, and in inflammatory bowel disease there are limited positive placebo-controlled trials; other studies used active controls with suboptimal doses of the comparators. Like all drugs, herbals can lead to serious adverse events (eg, hepatic failure). Quality control is a serious issue to consider when prescribing herbal medicines. Many herbal preparations are marketed without evidence for stringent adherence to good manufacturing practice guidelines. Unpredictable environmental conditions may affect the composition and the concentration of the active ingredients of plant extracts. Further, commercial herbal products usually combine a variable plethora of chemical families with possible medicinal utility. While some of these ingredients might be of benefit, the concentration and dose of these constituents needs to be closely monitored. Physicians and regulators need to remain very cautious about the use of herbal remedies. Appropriate scientific evidence for the claimed clinical benefits should become mandatory worldwide, and the standards for production and safety monitoring should comply with established standards for chemically defined products. If these principles were adopted, the full value of herbal remedies may come to light, particularly as the individually bioactive compounds present in these preparations become recognized.
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Affiliation(s)
- Gerald Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital Brisbane, Brisbane, Queensland, Australia; Faculty of Health Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia.
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89
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Abstract
The stomach has distinct functions in relation to the ingestion and handling of solids and liquids. These functions include storage of the food before it is gradually emptied into the duodenum, mechanical crushing of larger food particles to increase the surface area, secretion of an acidic enzyme rich gastric juice and mixing the ingested food with the gastric juice. In addition, the stomach 'senses' the composition of the gastric content and this information is passed via the vagal nerve to the lateral hypothalamus and the limbic system, most likely as palatability signals that influence eating behaviour. Other sensory qualities related to the stimulation of gastric tension receptors are satiety and fullness. Receptors that respond to macronutrient content or gastric wall tension influence appetite and meal related hormone responses. The ingestion of food - in contrast to an infusion of nutrients into the stomach - has distinct effects on the activation of specific brain regions. Brain areas such as thalamus, amygdala, putamen and praecuneus are activated by the ingestion of food. Gastric nutrient infusion evokes greater activation in the hippocampus and anterior cingulate. The brain integrates these interrelated neural and hormonal signals arising from the stomach as well as visual, olfactory and anticipatory stimuli that ultimately influence eating and other behavioural patterns. Furthermore, there is now good evidence from experimental studies that gastric afferents influence mood, and animal studies point towards the possibility that gastric dysfunction may be a risk factor for mood disorders such as anxiety and depression. The stomach is also not only colonised by Helicobacter pylori but a large array of bacteria. While there is sufficient evidence to suggest that H. pylori may alter caloric intake and mood, the role of other gastric microbiome for the brain function is unknown. To address this appropriate targeted gastric microbiome studies would be required instead of widely utilised opportunistic stool microbiome studies. In summary, it is now well established that there are important links between the brain and the stomach that have significant effects on gastric function. However, the stomach also influences the brain. Disturbances in the crosstalk between the stomach and the brain may manifest as functional GI disorders while disturbances in the stomach-brain communication may also result in an altered regulation of satiety and as a consequence may affect eating behaviour and mood. These observations may enable the identification of novel therapies targeted at the gastroduodenum that positively alter brain function and treat or prevent conditions such as obesity or functional gastrointestinal disorders.
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Affiliation(s)
- Gerald Holtmann
- Department of Gastroenterology & Hepatology, Princess Alexandra Hospital Brisbane, Translational Research Institute, Faculty for Medicine and Biomedical Sciences, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, QLD, Australia.
| | - Nicholas J Talley
- Faculty of Health & Medicine, University of Newcastle, Newcastle, NSW, Australia
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90
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Hughes PA, Moretta M, Lim A, Grasby DJ, Bird D, Brierley SM, Liebregts T, Adam B, Blackshaw LA, Holtmann G, Bampton P, Hoffmann P, Andrews JM, Zola H, Krumbiegel D. Immune derived opioidergic inhibition of viscerosensory afferents is decreased in Irritable Bowel Syndrome patients. Brain Behav Immun 2014; 42:191-203. [PMID: 25063707 DOI: 10.1016/j.bbi.2014.07.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 06/30/2014] [Accepted: 07/01/2014] [Indexed: 12/29/2022] Open
Abstract
Alterations in the neuro-immune axis contribute toward viscerosensory nerve sensitivity and symptoms in Irritable Bowel Syndrome (IBS). Inhibitory factors secreted from immune cells inhibit colo-rectal afferents in health, and loss of this inhibition may lead to hypersensitivity and symptoms. We aimed to determine the immune cell type(s) responsible for opioid secretion in humans and whether this is altered in patients with IBS. The β-endorphin content of specific immune cell lineages in peripheral blood and colonic mucosal biopsies were compared between healthy subjects (HS) and IBS patients. Peripheral blood mononuclear cell (PBMC) supernatants from HS and IBS patients were applied to colo-rectal sensory afferent endings in mice with post-inflammatory chronic visceral hypersensitivity (CVH). β-Endorphin was identified predominantly in monocyte/macrophages relative to T or B cells in human PBMC and colonic lamina propria. Monocyte derived β-endorphin levels and colonic macrophage numbers were lower in IBS patients than healthy subjects. PBMC supernatants from healthy subjects had greater inhibitory effects on colo-rectal afferent mechanosensitivity than those from IBS patients. The inhibitory effects of PBMC supernatants were more prominent in CVH mice compared to healthy mice due to an increase in μ-opioid receptor expression in dorsal root ganglia neurons in CVH mice. Monocyte/macrophages are the predominant immune cell type responsible for β-endorphin secretion in humans. IBS patients have lower monocyte derived β-endorphin levels than healthy subjects, causing less inhibition of colonic afferent endings. Consequently, altered immune function contributes toward visceral hypersensitivity in IBS.
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Affiliation(s)
- Patrick A Hughes
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia; Leukocyte Biology Laboratory, Women's and Children's Health Research Institute, North Adelaide, SA 5006, Australia.
| | - Melissa Moretta
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Amanda Lim
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Dallas J Grasby
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Daniel Bird
- Leukocyte Biology Laboratory, Women's and Children's Health Research Institute, North Adelaide, SA 5006, Australia
| | - Stuart M Brierley
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Tobias Liebregts
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Birgit Adam
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - L Ashley Blackshaw
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Gerald Holtmann
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Peter Bampton
- Department of Gastroenterology, Flinders Medical Centre, Flinders University, Bedford Park, SA 5042, Australia
| | - Peter Hoffmann
- Adelaide Proteomics Centre, School of Molecular Biomedical Science, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Jane M Andrews
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA 5000, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Heddy Zola
- Leukocyte Biology Laboratory, Women's and Children's Health Research Institute, North Adelaide, SA 5006, Australia; Discipline of Paediatrics, Faculty of Health Sciences, University of Adelaide, SA 5005, Australia
| | - Doreen Krumbiegel
- Leukocyte Biology Laboratory, Women's and Children's Health Research Institute, North Adelaide, SA 5006, Australia; Discipline of Paediatrics, Faculty of Health Sciences, University of Adelaide, SA 5005, Australia; SA Pathology, Adelaide, SA 5000, Australia
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91
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Whitty JA, Tallis C, Nguyen KH, Scuffham PA, Crosland P, Hewson K, Pai Mangalore R, Black M, Holtmann G. Cost and time savings from a rapid access model of care using transient elastography to screen and triage patients with chronic Hepatitis C infection. J Med Econ 2014; 17:159-65. [PMID: 24246063 DOI: 10.3111/13696998.2013.867271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Treatment uptake amongst patients with chronic Hepatitis C virus (HCV) in Australia is relatively low. New approaches to assessment have the potential to reduce public waiting lists, improve access to treatment, and to reduce healthcare costs. AIM To describe the costs to the public hospital system and waiting time associated with a novel integrated rapid access to assessment and treatment (RAAT) model of care that utilizes Transient Elastography (TE) as a specialist outpatient-based approach for a streamlined assessment of patients with chronic HCV, compared to conventional outpatient management with liver biopsy (LB). METHODS Time from first medical review to treatment plan and costs associated with detection of fibrosis were recorded for patients receiving RAAT during a 3-month period, and for a similar historical cohort managed conventionally with LB. Costs related to medical and multidisciplinary team reviews and the TE/LB test itself were included. RESULTS Patients receiving RAAT had lower costs (n = 27, median AU$2716) and shorter time to treatment (median = 194 days) than for conventional management (n = 13, median $5005, 420 days; p < 0.01). Differences related to the lower TE test costs and the lower cost of consults between first medical review and establishment of a treatment plan. CONCLUSIONS Based on real world audit data, this evaluation suggests TE, used as part of a new RAAT model of care, is cost saving to the health system in the short-term and reduces waiting times. The analysis reported here was intended to assess the costs related to detection of fibrosis, and is limited by the small sample size and potential selection bias. Future research should undertake a full economic evaluation at a whole of service level, to consider a more comprehensive and longer-term assessment of the costs and benefits associated with HCV management.
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Affiliation(s)
- Jennifer A Whitty
- Griffith Health Institute and Centre for Applied Health Economics, School of Medicine, Griffith University , Meadowbrook, Queensland , Australia
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92
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Adam B, Tsopelas C, Liebregts T, Bartholomeusz FD, Holtmann G. Host immune response determines visceral hyperalgesia in a rat model of post-inflammatory irritable bowel syndrome. J Gastroenterol 2013; 48:1119-27. [PMID: 23307099 DOI: 10.1007/s00535-012-0729-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 11/29/2012] [Indexed: 02/04/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is associated with visceral hyperalgesia and frequently occurs after a transient gastrointestinal infection. Only a proportion of patients with acute gastroenteritis develop post-infectious IBS suggesting differences in host response to inflammatory stimuli. We aimed to investigate this concept by characterizing visceral sensitivity in two rat strains, following a chemically induced colitis. METHODS Colorectal instillation of trinitrobenzenesulfonic acid (TNBS) in aqueous ethanol was used to induce a transient colitis in Lewis and F344 rats. The colitis was characterized semiquantitatively by histology, as well as by quantitative methods using (99m)Tc-leukocytes (radioactive organ assay) and plasma IL-2 and IL-6 levels. Visceromotor response to colorectal distensions was assessed after 2 h and, 5, 14, and 28 days. RESULTS The colitis peaked on day 5 and dissipated to no visible mucosal damage on day 14. Cytokines were significantly increased in TNBS-treated rats at 2 h and on day 5. On day 14 cytokines were still significantly enhanced in Lewis but not Fisher rats. Both strains had a highly inflamed to non-inflamed tissue ratio at 3 h after TNBS instillation with increased uptake in Lewis compared to F344 rats. No (99m)Tc-tin-colloid-leukocytes were detected in colon samples on day 28. Visceromotor response was significantly elevated in both strains during the acute colitis (day 5), whereas only Lewis rats developed a post-inflammatory (day 28) visceral hyperalgesia. CONCLUSION Genetically determined host factors account for prolonged immune activation in response to a standardized inflammatory stimulus and are linked to susceptibility for a post-inflammatory visceral hyperalgesia.
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Affiliation(s)
- Birgit Adam
- Department of Bone Marrow Transplantation, University Hospital Essen, University Duisburg-Essen, West German Cancer Center, Hufelandstr. 55, 45122, Essen, Germany,
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93
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Hughes PA, Harrington AM, Castro J, Liebregts T, Adam B, Grasby DJ, Isaacs NJ, Maldeniya L, Martin CM, Persson J, Andrews JM, Holtmann G, Blackshaw LA, Brierley SM. Sensory neuro-immune interactions differ between irritable bowel syndrome subtypes. Gut 2013; 62:1456-65. [PMID: 22767422 DOI: 10.1136/gutjnl-2011-301856] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The gut is a major site of contact between immune and sensory systems and evidence suggests that patients with irritable bowel syndrome (IBS) have immune dysfunction. Here we show how this dysfunction differs between major IBS subgroups and how immunocytes communicate with sensory nerves. DESIGN Peripheral blood mononuclear cell supernatants from 20 diarrhoea predominant IBS (D-IBS) patients, 15 constipation predominant IBS (C-IBS) patients and 36 healthy subjects were applied to mouse colonic sensory nerves and effects on mechanosensitivity assessed. Cytokine/chemokine concentration in the supernatants was assessed by proteomic analysis and correlated with abdominal symptoms, and expression of cytokine receptors evaluated in colonic dorsal root ganglia neurons. We then determined the effects of specific cytokines on colonic afferents. RESULTS D-IBS supernatants caused mechanical hypersensitivity of mouse colonic afferent endings, which was reduced by infliximab. C-IBS supernatants did not, but occasionally elevated basal discharge. Supernatants of healthy subjects inhibited afferent mechanosensitivity via an opioidergic mechanism. Several cytokines were elevated in IBS supernatants, and levels correlated with pain frequency and intensity in patients. Visceral afferents expressed receptors for four cytokines: IL-1β, IL-6, IL-10 and TNF-α. TNF-α most effectively caused mechanical hypersensitivity which was blocked by a transient receptor potential channel TRPA1 antagonist. IL-1β elevated basal firing, and this was lost after tetrodotoxin blockade of sodium channels. CONCLUSIONS Distinct patterns of immune dysfunction and interaction with sensory pathways occur in different patient groups and through different intracellular pathways. Our results indicate IBS patient subgroups would benefit from selective targeting of the immune system.
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Affiliation(s)
- Patrick A Hughes
- Nerve-Gut Research Laboratory, Discipline of Medicine, Faculty of Health Sciences, The University of Adelaide and Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, Adelaide, South Australia, Australia 5000
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Sun J, Yuan YZ, Holtmann G. Itopride in the treatment of functional dyspepsia in Chinese patients: a prospective, multicentre, post-marketing observational study. Clin Drug Investig 2012. [PMID: 22035464 DOI: 10.2165/11593290-000000000-00000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prokinetic agents are commonly used in the symptomatic treatment of functional dyspepsia (FD). Safety or efficacy issues associated with the use of available prokinetics, such as metoclopramide, domperidone, cisapride and mosapride, mean there is a need for an effective and well tolerated prokinetic agent. Itopride is a novel prokinetic agent with a dual mode of action, good safety profile and documented efficacy in placebo-controlled trials. OBJECTIVE The objective of this study was to assess the effectiveness and safety of itopride in the management of FD. METHODS This was a prospective, multicentre, post-marketing observational study carried out in private outpatient clinics throughout China. The study included patients with symptomatic FD aged ≥18 years. Patients were prescribed itopride 50 mg three times daily before meals for 4 weeks, after which there was a 2-week follow-up period during which they did not take itopride. Effectiveness and tolerability data obtained from patients who completed 4 weeks of therapy were analysed. The treatment response rate after 4 weeks was measured by patient global assessment; scores at the end of treatment were compared with baseline scores. Response rate based on symptom scoring was also measured after 4 weeks, with an effective treatment being defined as a symptom improvement of ≥50%. RESULTS In total, 587 patients with FD were enrolled. The mean ± SD difference in the total symptom score before and after the 4-week treatment period was -5.62 ± 3.27, corresponding to a 69.23 ± 26.53% reduction from baseline (p < 0.001). The treatment response rates in patients who fulfilled Rome I, II and III criteria for FD were 33.68%, 34.71% and 35.50%, respectively, after 1 week of treatment; 52.82%, 54.61% and 56.51%, respectively, after 2 weeks; 66.67%, 67.23% and 68.64%, respectively, after 3 weeks; and 72.82%, 73.54% and 75.15%, respectively, after 4 weeks. Response rates were significantly different at 1 week versus 4 weeks of treatment. Nine patients (1.54%) had adverse events: four were probably related to the study drug, three were possibly related and two were not related. Of the nine patients with adverse events, two discontinued the study drug, two suspended (i.e. temporarily discontinued the drug until the adverse event subsided) the study drug, and five continued the study drug. Seven of the nine patients with adverse events had adverse reactions (defined as adverse events considered causally related to the study drug): two improved, three recovered and two showed no change. No adverse reactions were serious enough to warrant discontinuation of therapy. CONCLUSION Itopride was an effective and well tolerated drug in the management of FD in this patient population.
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Affiliation(s)
- Jing Sun
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, China
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Mikocka-Walus AA, Turnbull D, Holtmann G, Andrews JM. An integrated model of care for inflammatory bowel disease sufferers in Australia: development and the effects of its implementation. Inflamm Bowel Dis 2012; 18:1573-81. [PMID: 22179943 DOI: 10.1002/ibd.22850] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 11/09/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Psychological comorbidities are associated with poor outcome and increased healthcare utilization in patients with inflammatory bowel disease (IBD). However, a model of care addressing the biopsychosocial dimension of disease is not routinely applied in IBD. This review describes the development of such a model and the effects of its implementation in a hospital-based cohort of patients with IBD. METHODS Three different approaches were used: 1) collecting baseline epidemiological data on mental health comorbidities; 2) raising awareness of and targeting mental health problems; 3) examining the effects of the model implementation. RESULTS High rates of anxiety and depressive symptoms (36% and 13%, respectively) that are maintained over time were identified in IBD patients presenting at a metropolitan teaching hospital. Patients with documented psychological comorbidities were more likely to be hospitalized than those without (odds ratio [OR] = 4.13, 95% confidence interval [CI]: 1.25, 13.61). Improvements in disease activity, anxiety, depression, quality of life, and coping have been noted when cognitive-behavioral therapy (CBT) was provided to patients. A drop in the use of opiates (P = 0.037) and hospitalization rates (from 48% to 30%) in IBD patients has been noted as a result of introduction of the changed model of care. In addition, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 [US$15,236.79] vs. US$ 30,467.78 [US$ 53,760.20], P = 0.005). CONCLUSION Our data to date suggest that an integrated model of care for patients with IBD may yield superior long-term outcomes in terms of medication use and hospitalization rates and reduce healthcare costs.
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Affiliation(s)
- Antonina A Mikocka-Walus
- School of Nursing and Midwifery and Sansom Institute for Health Research, University of South Australia, Adelaide, Australia.
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Holtmann G, van Rensburg C, Schwan T, Sander P, Siffert W. Improvement of non-steroidal anti-inflammatory drug-induced gastrointestinal symptoms during proton pump inhibitor treatment: are G-protein β3 subunit genotype, Helicobacter pylori status, and environmental factors response modifiers? Digestion 2012; 84:289-98. [PMID: 22041889 DOI: 10.1159/000331468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 08/03/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with significant upper and lower gastrointestinal (GI) morbidity. AIM To determine the efficacy and safety of pantoprazole versus placebo in controlling GI symptoms during treatment with NSAIDs and to evaluate the influence of potential response modifiers. METHODS 800 patients with GI complaints during NSAID treatment were randomized to pantoprazole 20 mg once daily or placebo for 4 weeks in this double-blind, multicenter trial. Assessments included the difference in cumulated overall symptom load of any GI complaint during treatment (primary endpoint), proportion of days without GI symptoms, and influence of risk factors such as gender, age, alcohol consumption, smoking, Helicobacter pylori status, and GNB3 genotype SNP rs5443 (825C>T) on symptom load. RESULTS At 4 weeks, cumulated overall symptom load was significantly lower in pantoprazole than placebo recipients [p < 0.0001; intent-to-treat (ITT)]; the effect was statistically significant after 7 days' treatment. Pantoprazole versus placebo recipients had 54 versus 29% of days without GI symptoms (p < 0.0001; ITT). Neither common risk factors nor GNB3 genotype were significantly associated with therapeutic response, while GNB3 825TT versus CT was associated with a significantly higher baseline symptom load (p < 0.05). CONCLUSION In the population studied, treatment with the proton pump inhibitor pantoprazole significantly improves GI symptoms during NSAID therapy, irrespective of the risk factors investigated or GNB3 genotype.
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Affiliation(s)
- G Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, University of Queensland, Woolloongabba, Qld., Australia.
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Sack C, Phan VA, Grafton R, Holtmann G, van Langenberg DR, Brett K, Clark M, Andrews JM. A chronic care model significantly decreases costs and healthcare utilisation in patients with inflammatory bowel disease. J Crohns Colitis 2012; 6:302-10. [PMID: 22405166 DOI: 10.1016/j.crohns.2011.08.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 08/15/2011] [Accepted: 08/31/2011] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Inflammatory bowel disease (IBD) is a chronic condition, yet the model of care is often reactive. We sought to examine whether a formal IBD service (IBDS) reduced inpatient healthcare utilisation or lowered costs for inpatient care. MATERIAL AND METHODS With protocols, routine nurse phone follow-up a help-line, more proactive care was delivered, with many symptoms and concerns dealt with prior to routine presentation. Over two five month periods before (2007/8) and after (2009/10) introducing a formal IBDS two discrete cohorts of admitted IBD patients were identified at a single centre. Each patient was assigned five contemporaneously admitted, age and gender matched controls. Inpatient healthcare utilisation was compared between patients and controls and disease-specific factors amongst the two IBD cohorts. RESULTS The initial audit captured 102 admitted IBD patients (510 controls, median age 44 years, 57% female); the second audit 95 patients (475 controls, median age 46 years, 45.3% female). In 2009/10, the number of admissions was lower in IBD patients than in controls (mean 1.53+/-1.03 vs. 2.54+/-2.35; p<0.0001). This contrasts with the first audit, where IBD patients had more admissions than controls. Following IBDS introduction, the mean total cost of inpatient care was lower for IBD patients than controls (US$12,857.48 (US$15,236.79) vs. US$ 30,467.78 (US$ 53,760.20), p=0.005). In addition, patients known to a specialist gastroenterologist (GE) and the IBD Service tended to have the lowest mean number of admissions (GE and IBDS 1.14 (+/-0.36) vs. no GE/IBDS 1.64 (+/-1.25)). CONCLUSIONS Healthcare utilisation and disease burden in IBD decreased significantly since introducing an IBDS. These data suggest that proactive management improved outcomes. Contact with a gastroenterologist and IBDS seemed to give best results.
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Affiliation(s)
- C Sack
- IBD Service, Department of Gastroenterology & Hepatology, Royal Adelaide Hospital, Australia
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Liebregts T, Adam B, Bertel A, Lackner C, Neumann J, Talley NJ, Gerken G, Holtmann G. Psychological stress and the severity of post-inflammatory visceral hyperalgesia. Eur J Pain 2012; 11:216-22. [PMID: 16545971 DOI: 10.1016/j.ejpain.2006.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 01/27/2006] [Accepted: 02/06/2006] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Lowered visceral sensory thresholds are a key finding in at least a subgroup of patients with functional bowel disorders. Stress and inflammation contribute to this altered visceral sensory function. We aimed to elucidate the role of repetitive stress and acute mucosal inflammation, alone and in combination, on sensory function. METHODS In randomized order, trinitrobenzenesulfonic acid (TNBS) plus the equal amount of ethanol or saline were instilled into the colorectum of female Lewis rats. Colorectal distensions (CRD) were performed with a barostat device (3 min/40 mmHg); to quantify the visceromotor response (VMR) to CRD, electromyographic activity (EMG) of the abdominal muscles was recorded. In randomized order, equal numbers of both treatment groups underwent either seven days (1 h/day) repetitive water avoidance stress (WAS) or sham WAS. CRD's were conducted 28 days later. Colonic tissue samples were obtained to characterize inflammation and blood samples were taken at day 28 to measure plasma IL-2 levels by enzyme-linked immunosorbent assay (ELISA). RESULTS Compared to controls (662+/-114 microV) TNBS (1081+/-227 microV), WAS (1366+/-125 microV) and the combination of both (1477+/-390 microV) significantly augmented the VMR to CRD. TNBS and/or WAS caused significant inflammatory changes at day 5, while only TNBS+WAS also showed signs of mucosal inflammation on day 14 and significantly elevated IL-2 levels on day 28. CONCLUSIONS Stress and inflammation cause long lasting alterations of visceral sensory function. Concomitant stress further increases post-inflammatory visceral hyperalgesia.
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Affiliation(s)
- Tobias Liebregts
- Royal Adelaide Hospital, Department of Gastroenterology, Hepatology and General Medicine, University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
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Liebregts T, Adam B, Bredack C, Gururatsakul M, Pilkington KR, Brierley SM, Blackshaw LA, Gerken G, Talley NJ, Holtmann G. Small bowel homing T cells are associated with symptoms and delayed gastric emptying in functional dyspepsia. Am J Gastroenterol 2011; 106:1089-98. [PMID: 21245834 DOI: 10.1038/ajg.2010.512] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Immune activation may have an important pathogenic role in the irritable bowel syndrome (IBS). While little is known about immunologic function in functional dyspepsia (FD), we have observed an association between cytokine secretion by peripheral blood mononuclear cells (PBMCs) and symptoms in IBS. Upper gastrointestinal inflammatory diseases are characterized by enhanced small bowel homing α4-, β7-integrin, chemokine receptor 9 (CCR9) positive T lymphocytes. We hypothesized that increased cytokine release and elevated circulating small bowel homing T cells are linked to the severity of symptoms in patients with FD. Thus, we aimed to (i) compare cytokine release in FD and healthy controls (HCs), (ii) quantify "gut homing" T cells in FD compared with HC and patients with IBS, and (iii) correlate the findings to symptom severity and gastric emptying. METHODS PBMC from 45 (Helicobacter pylori negative) patients with FD (Rome II) and 35 matched HC were isolated by density gradient centrifugation and cultured for 24 h. Cytokine production (tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-10) was measured by enzyme-linked immunosorbent assay. CD4+ α4β7+CCR9+ T cells were quantified by flow cytometry in FD, HC and 23 patients with IBS. Gastric emptying was measured by scintigraphy. Symptom severity was assessed utilizing the standardized Gastrointestinal Symptom Score. RESULTS FD patients had significantly higher TNF-α (107.2 ± 42.8 vs. 58.7 ± 7.4 pg/ml), IL-1β (204.8 ± 71.5 vs. 80.2 ± 17.4 pg/ml), and IL-10 (218 ± 63.3 vs. 110.9 ± 18.5 pg/ml) levels compared with HC, and enhanced gut homing lymphocytes compared with HC or IBS. Cytokine release and CD4+α4β7+CCR9+ lymphocytes were correlated with the symptom intensity of pain, cramps, nausea, and vomiting. Delayed gastric emptying was significantly associated (r = 0.78, P = 0.021) with CD4+α4β7+CCR9+ lymphocytes and IL-1β, TNF-α, and IL-10 secretion. CONCLUSIONS Cellular immune activation with increased small bowel homing T cells may be key factors in the clinical manifestations of H. pylori-negative FD.
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Affiliation(s)
- Tobias Liebregts
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
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