Findings in patients with chronic intestinal dysmotility investigated by capsule endoscopy

Quantitative Analysis of Small Intestinal Motility in 3D Cine-MRI Using Centerline-Aware Motion Estimation

BACKGROUND

Currently available tools for noninvasive motility quantification of the small intestine are limited to dynamic 2D MRI scans, which are limited in their ability to differentiate between types of intestinal motility.

PURPOSE

To develop a method for quantification and characterization of small intestinal motility in 3D, capable of differentiating motile, non-motile and peristaltic motion patterns.

STUDY TYPE

Prospective.

SUBJECTS

Fourteen healthy volunteers (127 small intestinal segments) and 10 patients with Crohn's disease (87 small intestinal segments).

FIELD STRENGTH/SEQUENCE

3.0 T, 3D balanced fast field echo sequence, 1 volume per second.

ASSESSMENT

Using deformable image registration between subsequent volumes, the local velocity within the intestinal lumen was quantified. Average velocity and average absolute velocity along intestinal segments were used with linear classifiers to differentiate motile from non-motile intestines, as well as erratic motility from peristalsis. The mean absolute velocity of small intestinal content was compared between healthy volunteers and Crohn's disease patients, and the discriminative power of the proposed motility metrics for detecting motility and peristalsis was determined. The consensus of two observers was used as referenced standard.

STATISTICAL TESTS

Student's t-test to assess differences between groups; area under the receiver operating characteristic curve (AUC) to assess discriminative ability. P < 0.001 was considered significant.

RESULTS

A significant difference in the absolute velocity of intestinal content between Crohn's patients and healthy volunteers was observed (median [IQR] 1.06 [0.61, 1.56] mm/s vs. 1.84 [1.37, 2.43] mm/s), which was consistent with manual reference annotations of motile activity. The proposed method had a strong discriminative performance for detecting non-motile intestines (AUC 0.97) and discernible peristalsis (AUC 0.81).

DATA CONCLUSION

Analysis of 3D cine-MRI using centerline-aware motion estimation has the potential to allow noninvasive characterization of small intestinal motility and peristaltic motion in 3D.

EVIDENCE LEVEL

3 TECHNICAL EFFICACY: Stage 2.

Quality indicators for capsule endoscopy and deep enteroscopy

BACKGROUND AND AIMS

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

CONCLUSIONS

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Quality Indicators for Capsule Endoscopy and Deep Enteroscopy

INTRODUCTION

Capsule endoscopy (CE) and deep enteroscopy (DE) can be useful for diagnosing and treating suspected small-bowel disease. Guidelines and detailed recommendations exist for the use of CE/DE, but comprehensive quality indicators are lacking. The goal of this task force was to develop quality indicators for appropriate use of CE/DE by using a modified RAND/UCLA Appropriateness Method.

METHODS

An expert panel of 7 gastroenterologists with diverse practice experience was assembled to identify quality indicators. A literature review was conducted to develop a list of proposed quality indicators applicable to preprocedure, intraprocedure, and postprocedure periods. The panelists reviewed the literature; identified and modified proposed quality indicators; rated them on the basis of scientific evidence, validity, and necessity; and determined proposed performance targets. Agreement and consensus with the proposed indicators were verified using the RAND/UCLA Appropriateness Method.

RESULTS

The voting procedure to prioritize metrics emphasized selecting measures to improve quality and overall patient care. Panelists rated indicators on the perceived appropriateness and necessity for clinical practice. After voting and discussion, 2 quality indicators ranked as inappropriate or uncertain were excluded. Each quality indicator was categorized by measure type, performance target, and summary of evidence. The task force identified 13 quality indicators for CE and DE.

DISCUSSION

Comprehensive quality indicators have not existed for CE or DE. The task force identified quality indicators that can be incorporated into clinical practice. The panel also addressed existing knowledge gaps and posed research questions to better inform future research and quality guidelines for these procedures.

Indications, Contraindications, and Considerations for Video Capsule Endoscopy

Video capsule endoscopy is indicated in a broad range of clinical settings, most commonly in evaluating suspected small bowel bleeding. It is also useful in diagnosing Crohn's disease and monitoring patients with known Crohn's. Video capsule endoscopy has a role in evaluating patients with refractory celiac disease symptoms and in surveying patients with polyposis syndromes. The only absolute contraindication to video capsule endoscopy is luminal gastrointestinal tract obstruction. Despite manufacturer statement, video capsule endoscopy can be used safely in patients with implantable cardiac devices including pacemakers, defibrillators, and ventricular assist devices.

Small Intestinal Bacterial Overgrowth: Clinical Features and Therapeutic Management

Small intestinal bacterial overgrowth (SIBO) is a common, yet underrecognized, problem. Its prevalence is unknown because SIBO requires diagnostic testing. Although abdominal bloating, gas, distension, and diarrhea are common symptoms, they do not predict positive diagnosis. Predisposing factors include proton-pump inhibitors, opioids, gastric bypass, colectomy, and dysmotility. Small bowel aspirate/culture with growth of 10-10 cfu/mL is generally accepted as the "best diagnostic method," but it is invasive. Glucose or lactulose breath testing is noninvasive but an indirect method that requires further standardization and validation for SIBO. Treatment, usually with antibiotics, aims to provide symptom relief through eradication of bacteria in the small intestine. Limited numbers of controlled studies have shown systemic antibiotics (norfloxacin and metronidazole) to be efficacious. However, 15 studies have shown rifaximin, a nonsystemic antibiotic, to be effective against SIBO and well tolerated. Through improved awareness and scientific rigor, the SIBO landscape is poised for transformation.

Small intestinal bacterial overgrowth as a cause of protracted wound healing and vitamin D deficiency in a spinal cord injured patient with a sacral pressure sore: a case report

BACKGROUND

Pressure sores are sometimes refractory to treatment, often due to malnutrition. Small intestinal bacterial overgrowth (SIBO) obstructs absorption in the digestive tract and causes malnutrition. However, little is known about the association between pressure sore wound healing and SIBO. Here, we report a case of a patient with a refractory sacral pressure sore and SIBO.

CASE PRESENTATION

A 66-year-old woman who was spinal cord injured 14 years before visiting our hospital presented with the chief complaint of a sacral pressure sore, 10.0 × 6.5 cm in size, which was refractory to treatment. Physical examination showed abdominal distension and emaciation, with a body mass index of 15. Further examination revealed elevated serum alkaline phosphatase (1260 U/L), bilateral tibial fracture, multiple rib fracture, and osteoporosis. We diagnosed the patient with osteomalacia with vitamin D deficiency. Despite oral supplementation, serum levels of calcium, phosphorous, and vitamin D remained low. Also, despite concentrative wound therapy for the sacral pressure sore by plastic surgeons, no wound healing was achieved. Due to a suspicion of disturbances in nutrient absorption, we performed bacterial examination of collected gastric and duodenal fluid, which showed high numbers of bacteria in gastric content (10⁴ E. coli, 10⁵ Streptococcus species, and 10⁵ Neisseria species) and duodenal content (10⁶ E. coli, 10⁴ Candida glabrata). Therefore, we diagnosed the patient with SIBO and started selective decontamination of the digestive tract using polymyxin B sulfate and amphotericin B. After starting treatment for SIBO, the sacral pressure sore began to heal and was nearly healed after 285 days. The patient's serum levels of calcium, phosphorous, vitamin D, and other fat-soluble vitamins also gradually increased after starting treatment for SIBO.

CONCLUSION

We report a case of a patient with a refractory sacral pressure sore that healed after starting treatment for SIBO. We conclude that SIBO may be an overlooked cause of malnutrition and poor wound healing in patients with chronic pressure sores.

Small-Intestinal Bacterial Overgrowth is Associated With Concurrent Intestinal Inflammation But Not With Systemic Inflammation in Crohn's Disease Patients

GOALS

We studied the prevalence and predictors of small-intestinal bacterial overgrowth (SIBO) in Crohn's disease (CD) outpatients and the relationship between SIBO and intestinal and/or systemic inflammation.

BACKGROUND

The relationship of SIBO with systemic and intestinal inflammation in CD patients is unclear.

STUDY

In this cross-sectional study, conducted between June, 2013 and January, 2015, 92 CD patients and 97 controls with nonchronic gastrointestinal complaints were assessed for the presence of SIBO using the H2/CH4 glucose breath test. Multivariate logistic regression was performed to investigate the potential association between SIBO and demographic, disease-related data, systemic markers of inflammation (C-reactive protein, and erythrocyte sedimentation rate), and biomarker of intestinal inflammation [fecal calprotectin concentration (FCC)].

RESULTS

The SIBO rate was significantly higher in CD patients than in controls (32.6% vs. 12.4%, respectively, P=0.0008). Patients with and without SIBO were comparable with regard to demographics, systemic inflammatory biomarkers, and disease characteristics, except for the stricturing phenotype being more common in SIBO-positive CD patients (43.3% vs. 19.3%, P=0.015). Notably, FCC was significantly higher in SIBO-positive patients (median of 485.8 vs.132.7 μg/g; P=0.004). Patients presenting increased FCC and stricturing disease had an odds of 9.43 (95% confidence interval, 3.04-11.31; P<0.0001) and 3.83 (95% confidence interval, 1.54-6.75; P=0.025) respectively, for SIBO diagnosis.

CONCLUSIONS

In CD patients, SIBO is a highly prevalent condition. Stricturing phenotype and increased FCC were strongly and independently associated with the presence of SIBO. SIBO diagnostic work-up followed by directed treatment is recommended in CD patients who present stricturing disease, especially in those with concurrent intestinal inflammation.

Clinical Practice Guidelines for the Use of Video Capsule Endoscopy

BACKGROUND & AIMS

Video capsule endoscopy (CE) provides a noninvasive option to assess the small intestine, but its use with respect to endoscopic procedures and cross-sectional imaging varies widely. The aim of this consensus was to provide guidance on the appropriate use of CE in clinical practice.

METHODS

A systematic literature search identified studies on the use of CE in patients with Crohn's disease, celiac disease, gastrointestinal bleeding, and anemia. The quality of evidence and strength of recommendations were rated using the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The consensus includes 21 statements focused on the use of small-bowel CE and colon capsule endoscopy. CE was recommended for patients with suspected, known, or relapsed Crohn's disease when ileocolonoscopy and imaging studies were negative if it was imperative to know whether active Crohn's disease was present in the small bowel. It was not recommended in patients with chronic abdominal pain or diarrhea, in whom there was no evidence of abnormal biomarkers typically associated with Crohn's disease. CE was recommended to assess patients with celiac disease who have unexplained symptoms despite appropriate treatment, but not to make the diagnosis. In patients with overt gastrointestinal bleeding, and negative findings on esophagogastroduodenoscopy and colonoscopy, CE should be performed as soon as possible. CE was recommended only in selected patients with unexplained, mild, chronic iron-deficiency anemia. CE was suggested for surveillance in patients with polyposis syndromes or other small-bowel cancers, who required small-bowel studies. Colon capsule endoscopy should not be substituted routinely for colonoscopy. Patients should be made aware of the potential risks of CE including a failed procedure, capsule retention, or a missed lesion. Finally, standardized criteria for training and reporting in CE should be defined.

CONCLUSIONS

CE generally should be considered a complementary test in patients with gastrointestinal bleeding, Crohn's disease, or celiac disease, who have had negative or inconclusive endoscopic or imaging studies.

Contraindications for video capsule endoscopy

Video capsule endoscopy (VCE) has been applied in the last 15 years in an increasing field of applications. Although many contraindications have been put into perspective, some precautions still have to be considered. Known stenosis of the gastrointestinal tract is a clear contraindication for VCE unless surgery is already scheduled or at least has been considered as an optional treatment modality. In patients with a higher incidence of stenosis, as in an established diagnosis of Crohn’s disease, clinical signs of obstruction, prior radiation or surgical small bowel resection, a preceding test with the self-dissolving patency capsule can override this contraindication. Endoscopic placement of the capsule should be considered in patients with swallowing disorders to avoid aspiration. Esophageal or gastric motility disorders may require endoscopic capsule transport or application of prokinetics if the real-time viewer proofs delayed transit. In pregnant women, VCE should be restricted to urgent cases where diagnosis cannot be postponed after delivery, as data on safety are missing. There is theoretical and clinical evidence that patients with implanted cardiac devices such as a pacemaker, cardioverters or left heart assist devices, can safely undergo VCE in spite of still existing contraindication by manufacturers. Children from the age of 2 years have safely undergone VCE. Although video capsules are not proven safe with magnetic resonance imaging (MRI), first single cases of patients incidentally undergoing MRI with an incorporated capsule have been reported, showing susceptibility artifacts but no signs of clinical harm.

Role of intestinal infection in pathogenesis of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional digestive disorder characterized by abdominal pain/discomfort and changes in bowel habit (diarrhea and/or constipation). Its etiology and pathogenesis are still not completely clear. In recent years, the relationship between intestinal infection and IBS has attracted increasing attention, since intestinal infection may play a role in the pathogenesis of IBS. This article will review the role of intestinal infection in the pathogenesis of IBS.

Recurrent ascending cholangitis due to small intestinal bacterial overgrowth, gastrointestinal dysmotility and an afferent loop

We report a complex case involving an extremely rare cause of gastrointestinal dysmotility and an afferent loop, which together predisposed to the development of small intestinal bacterial overgrowth. The bacteria subsequently became multi-resistant. As a further consequence of the dysmotility, repeated bile duct reflux occurred despite the afferent loop being unobstructed. This bile duct reflux produced recurrent sepsis through repeated episodes of ascending cholangitis. Ultimately, the patient was referred to a National Small Intestinal Transplant Centre for consideration for enterectomy and subsequent transplantation. We describe the difficulties encountered in managing this unique case and discuss the underlying aetiology.

Dysmotility and proton pump inhibitor use are independent risk factors for small intestinal bacterial and/or fungal overgrowth

BACKGROUND

Whether intestinal dysmotility and the use of a proton pump inhibitor (PPI) either independently or together contributes to small intestinal bacterial overgrowth (SIBO), and/or small intestinal fungal overgrowth (SIFO) is not known.

AIM

To investigate the role of dysmotility and PPI use in patients with persistent gastrointestinal complaints.

METHODS

Patients with unexplained gastrointestinal symptoms and negative endoscopy/radiology tests completed a validated symptom questionnaire and underwent 24-h ambulatory antro-duodeno-jejunal manometry (ADJM). Simultaneously, duodenal aspirate was obtained for aerobic, anaerobic and fungal culture. Dysmotility was diagnosed by (>2): absent phase III MMC, absent/diminished postprandial response, diminished amplitude of antral/intestinal phasic activity, impaired antro-duodenal coordination. Bacterial growth ≥10³ CFU/mL or fungal growth was considered evidence for SIBO/SIFO. PPI use was documented. Correlation of symptoms with presence of SIBO or SIFO was assessed.

RESULTS

One hundred and fifty subjects (M/F = 47/103) were evaluated; 94/150 (63%) had overgrowth: 38/94 (40%) had SIBO, 24/94 (26%) had SIFO and 32/94 (34%) had mixed SIBO/SIFO. SIBO was predominately due to Streptococcus, Enterococcus, Klebsiella and E. coli. SIFO was due to Candida. Eighty of 150 (53%) patients had dysmotility and 65/150 (43%) used PPI. PPI use (P = 0.0063) and dysmotility (P = 0.0003) were independent significant risk factors (P < 0.05) for overgrowth, but together did not pose additional risk. Symptom profiles were similar between those with or without SIBO/SIFO.

CONCLUSIONS

Dysmotility and PPI use were independent risk factors for SIBO or SIFO and were present in over 50% of subjects with unexplained gastrointestinal symptoms. Diagnosis of overgrowth requires testing because symptoms were poor predictors of overgrowth.

Quantitative estimates of motility from videocapsule endoscopy are useful to discern celiac patients from controls

BACKGROUND

Prior work has shown that videocapsule endoscopy image features are a useful tool for quantitatively distinguishing the intestinal mucosal surface of untreated celiac patients from that of controls. The use of dynamic estimates of wall motility may further help to improve classification.

METHODS

Videocapsule endoscopy clips (200 frames each, 2 frames/s, 576 × 576 pixels/frame) were acquired at five small intestinal locations in 11 untreated celiac patients (celiacs) and ten controls. Color images were converted to grayscale and analyzed frame-by-frame. Variations in the position and width of the center of the small intestinal lumen were quantitatively estimated. The darkest grayscale pixels were used as an estimate of the lumen center. Over 200 frames, the standard deviation of the lumen center xy position and the mean and standard deviation in lumen center width were used as dynamic estimates of wall motility. These parameters were plotted in three-dimensional space, and the best discriminant function was used to classify celiacs versus controls at each of the following five locations: (1) duodenal bulb, (2) distal duodenum, (3) jejunum, (4) ileum, and (5) distal ileum.

RESULTS

The overall sensitivity for the classification of celiacs versus controls at all five locations was 98.2 %, while the specificity was 96.0 %. From location 1 to 5, there was a tendency for the lumen center width to diminish in terms of frame-to-frame variability by 7.6 % in celiacs (r (2) = 0.4) and 9.7 % in controls (r (2) = 0.7).

CONCLUSIONS

In addition to examining the mucosal surface, videocapsule endoscopy can assess small bowel intestinal motility and aid in distinguishing celiac patients from controls.

Quantitative estimates of motility from videocapsule endoscopy are useful to discern celiac patients from controls

BACKGROUND

Prior work has shown that videocapsule endoscopy image features are a useful tool for quantitatively distinguishing the intestinal mucosal surface of untreated celiac patients from that of controls. The use of dynamic estimates of wall motility may further help to improve classification.

METHODS

Videocapsule endoscopy clips (200 frames each, 2 frames/s, 576 × 576 pixels/frame) were acquired at five small intestinal locations in 11 untreated celiac patients (celiacs) and ten controls. Color images were converted to grayscale and analyzed frame-by-frame. Variations in the position and width of the center of the small intestinal lumen were quantitatively estimated. The darkest grayscale pixels were used as an estimate of the lumen center. Over 200 frames, the standard deviation of the lumen center xy position and the mean and standard deviation in lumen center width were used as dynamic estimates of wall motility. These parameters were plotted in three-dimensional space, and the best discriminant function was used to classify celiacs versus controls at each of the following five locations: (1) duodenal bulb, (2) distal duodenum, (3) jejunum, (4) ileum, and (5) distal ileum.

RESULTS

The overall sensitivity for the classification of celiacs versus controls at all five locations was 98.2 %, while the specificity was 96.0 %. From location 1 to 5, there was a tendency for the lumen center width to diminish in terms of frame-to-frame variability by 7.6 % in celiacs (r (2) = 0.4) and 9.7 % in controls (r (2) = 0.7).

CONCLUSIONS

In addition to examining the mucosal surface, videocapsule endoscopy can assess small bowel intestinal motility and aid in distinguishing celiac patients from controls.

Motility disorders of the upper gastrointestinal tract in the intensive care unit: pathophysiology and contemporary management

Upper gastrointestinal (GI) dysmotility, an entity commonly found in the intensive care unit setting, can lead to insufficient nutrient intake while increasing the risk of infection and mortality. Further, overcoming the altered motility with early enteral feeding is associated with a reduced incidence of infectious complications in intensive care unit patients. Upper GI dysmotility in critical care patients is a common occurrence, and there are many causes for this problem, which affects a very heterogenous population with a multitude of underlying medical abnormalities. Therefore, it is of utmost importance to identify this widespread problem and subsequently institute a proper therapy as rapidly as possible. Prokinetic pharmacotherapies are currently the mainstay for the management of disordered upper GI motility. Future therapies, aimed at the underlying pathophysiology of this complex problem, are under investigation. These aim is to reduce the side effects of the currently available options, while improving on nutrition delivery in the critically ill. This review discusses the pathophysiology, clinical manifestations, diagnosis, and treatment of upper GI motility disturbances in the critically ill.

Small bowel capsule endoscopy performance in octogenarians: a case-control study

BACKGROUND AND STUDY AIMS

Capsule endoscopy is a high-sensitive tool for the investigation of suspected small bowel disorders, but its effectiveness in elderly patients is unknown. We sought to determine capsule endoscopy feasibility and diagnostic yield in octogenarians.

PATIENTS AND METHODS

Records of patients ≥ 80 years old (Group A) were retrieved from a database of 827 consecutive capsule endoscopy performed on as many patients. Capsule endoscopy failures, complications, diagnostic yield, and findings were recorded and compared with those of patients younger than 80 (Group B), randomly extracted from the same database in a > 2:1 ratio.

RESULTS

Group A consisted of 79 patients, 84 ± 6 years old and Group B of 188, 44 ± 11 years old (p < .0001). We visualized the entire small bowel in 59 (74.6%) patients of Group A and in 169 (89%) of Group B (odds ratio = 0.33, 95% confidence interval: 0.16-0.66, p = .0025), mainly for capsule failures in reaching the duodenum; this event occurred in 10 patients of Group A and in 3 of Group B (odds ratio = 9, 95% confidence interval: 2.4-33.4, p = .0004). The rate of adverse events and diagnostic yield did not differ between the two groups. Inflammatory and neoplastic lesions were more common in Group A (odds ratio = 2.60, 95% confidence interval: 1.07-6.28, p = .03 and odds ratio = 2.01, 95% confidence interval: 1.02-3.97, p = .04, respectively).

CONCLUSIONS

In octogenarians, small bowel capsule endoscopy may be troublesome for capsule failure in reaching the duodenum. However, the diagnostic yield of small bowel capsule endoscopy and the rate of clinically significant lesions are high.

Small intestinal bacterial overgrowth syndrome

Human intestinal microbiota create a complex polymicrobial ecology. This is characterised by its high population density, wide diversity and complexity of interaction. Any dysbalance of this complex intestinal microbiome, both qualitative and quantitative, might have serious health consequence for a macro-organism, including small intestinal bacterial overgrowth syndrome (SIBO). SIBO is defined as an increase in the number and/or alteration in the type of bacteria in the upper gastrointestinal tract. There are several endogenous defence mechanisms for preventing bacterial overgrowth: gastric acid secretion, intestinal motility, intact ileo-caecal valve, immunoglobulins within intestinal secretion and bacteriostatic properties of pancreatic and biliary secretion. Aetiology of SIBO is usually complex, associated with disorders of protective antibacterial mechanisms (e.g. achlorhydria, pancreatic exocrine insufficiency, immunodeficiency syndromes), anatomical abnormalities (e.g. small intestinal obstruction, diverticula, fistulae, surgical blind loop, previous ileo-caecal resections) and/or motility disorders (e.g. scleroderma, autonomic neuropathy in diabetes mellitus, post-radiation enteropathy, small intestinal pseudo-obstruction). In some patients more than one factor may be involved. Symptoms related to SIBO are bloating, diarrhoea, malabsorption, weight loss and malnutrition. The gold standard for diagnosing SIBO is still microbial investigation of jejunal aspirates. Non-invasive hydrogen and methane breath tests are most commonly used for the diagnosis of SIBO using glucose or lactulose. Therapy for SIBO must be complex, addressing all causes, symptoms and complications, and fully individualised. It should include treatment of the underlying disease, nutritional support and cyclical gastro-intestinal selective antibiotics. Prognosis is usually serious, determined mostly by the underlying disease that led to SIBO.

Disorders of intestinal secretion and absorption

The gastrointestinal tract possesses a huge epithelial surface area and performs many different tasks. Amongst them are the digestive and absorptive functions. Disorders of intestinal absorption and secretion comprise a variety of different diseases, e.g. coeliac disease, lactase deficiency or Whipple's disease. In principle, impaired small intestinal function can occur with or without morphological alterations of the intestinal mucosa. Therefore, in the work up of a malabsorptive syndrome an early small intestinal biopsy is encouraged in conjunction with breath tests and stool analysis to guide further management. In addition, there is an array of functional tests, the clinical availability of which becomes more and more limited. In any case, early diagnosis of the underlying pathophysiology is most important, in order to initiate proper therapy. In this chapter, diagnostic procedure of malabsorption is discussed with special attention to specific disease like coeliac disease, Whipple's disease, giardiasis and short bowel syndrome. Furthermore, bacterial overgrowth, carbohydrate malabsorption and specific nutrient malabsorption (e.g. for iron or vitamins) and protein-losing enteropathy are presented with obligatory and optional tests as used in the clinical setting.

Abdominal surgery affects small bowel transit time and completeness of capsule endoscopy

The aim of the study was to evaluate bowel dysmotility in patients with a history of abdominal surgery by measuring both gastric transit time and small bowel transit time during capsule endoscopy and assessing the completeness of the examination. The study included 26 patients who had undergone abdominal surgery (postoperative group) and 52 patients who had not (control group). The capsule reached the cecum in 50.0% of the postoperative group and 80.8% of the control group (P=0.005). While there was no significant difference in gastric transit time between the two groups (P=0.882), small bowel transit time was significantly longer in the postoperative group (338.3+/-119.2 min) than in the control group (266.4+/-110.8 min, P=0.010). This is the first study to report that the small bowel transit time during capsule endoscopy is prolonged in patients who had a history of abdominal surgery, resulting in a lower frequency of complete examination.

Small intestinal motility

PURPOSE OF REVIEW

To review recently published studies presenting novel and relevant information on small intestinal motility.

RECENT FINDINGS

The reviewed studies covered a variety of topics with several themes emerging. Our understanding of the influence of systemic disorders, intestinal and extraintestinal infections and enteric bacteria on digestive motor function continues to involve. Elegant and important new studies have been published that better define the physiology of intestinal gas handling along with the genesis of symptoms commonly attributed to excessive intestinal gas. While interest in small intestinal bacterial overgrowth in irritable bowel syndrome continues, the utility and specificity of lactulose hydrogen breath testing is yet again questioned and further data are needed before the practice of routinely prescribing antibiotics to patients with irritable bowel syndrome can be endorsed.

SUMMARY

Small intestinal motility remains an understudied area. Recent publications provide additional new information related to physiology and pathophysiology of small bowel motility. These findings should be of interest to clinician and investigator alike.