1,721,087 research outputs found
Fecal calprotectin in systemic sclerosis: Light and shade of a promising tool
No full textWe read with great interest the study by Marie et al, who investigated the relationship between fecal calprotectin (FC) and gastrointestinal involvement in an unselected population of patients affected by systemic sclerosis (SSc). In their series and according to current literature, 74% of patients were affected by severe esophageal motor impairment, 51.7% had delayed gastric emptying and 35% had interstitial lung disease. Moreover, the authors reported that about two thirds of patients referred for testing had abnormal FC levels (>50mcg/g), whose increase was directly related to the severity of gastrointestinal symptoms, evaluated by means of the Global Symptom Score (GSS), and with the impairment of esophageal and gastric motility. Finally, prevalence of Small Intestinal Bacterial Overgrowth (SIBO), as assessed by means of glucose H2/CH4 breath test, was about 35%. Highly elevated levels of FC (>200 mcg/g) strictly related with the presence of SIBO reaching its highest diagnostic accuracy for values > 275mcg/g (ROC 0.97±0.0001).
We really appreciated this work which underlines the utility of a non-invasive fecal test to identify patients with gastro-intestinal involvement in SSc. Moreover, the correlation between fecal calprotectin levels and response to therapy provides additional confirmation to this diagnostic approach. Nevertheless, we believe that the strength of their findings should be considered with caution because of the following considerations: 1. the criteria employed to diagnose SIBO by Glucose Breath Test (GBT). the lack of oral-cecal transit time (OCTT) measurements. It is well known that methane production is higher and more frequently found in subjects with constipation and its concentration in breath samples, when increased, is usually constant during the test. Moreover, it has been also reported that SSc patients often present prolonged OCTT. Accordingly, the decision to consider an increase of CH4 > 10 ppm on two consecutive measurements within the 2 h of the examination as a positive GBT for SIBO may have led to over diagnose a proportion of SSc patients with constipation as affected by SIBO. At this regard, the assessment of OCTT rather than gastric emptying would have provided more valuable information to the study. In fact, about 2/3 of the patients they studied had severe esophageal motility impairment and it has been shown that this occurs often in association with an intestinal involvement. This aspect might have also affected the relative low eradication rate (9/22; 41%) the Authors achieved, despite 3 months of rotating courses of antibiotics. In a recent study by our group, indeed, eradication of SIBO was obtained in 73% of SSc patients with a single 10-day course of rifaximin 1200mg/d, with a significant reduction of symptoms in 73% of them. In a further study conducted in patient with SIBO, we showed that the association of rifaximin with soluble fibers, rather than the use of antibiotics alone, increased the eradication rate from 62% to 87%. In our opinion, similar approaches should be preferred to increasing the dosage or prolonging the administration of antibiotics.
In conclusion, the study by Marie et al provides new approaches to the management of SSc patients. The dosage of fecal calprotectin alone or in combination with other tests might be able to identify patients with gastrointestinal involvement, such as impaired gastro-esophageal motility, which, in turn, may favor malnutrition and interstitial lung disease, as well as SIBO with its complications (i.e. abdominal symptoms, malabsorption and ultimately body wasting). These comorbidities should be always carefully investigated with appropriate tests that must be accurately interpreted, because they are highly common in scleroderma and may severely impact the quality of life of these patients
Caution About Overinterpretation of Number of Reflux Episodes in Reflux Monitoring for Refractory Gastroesophageal Reflux Disease
No full textWe read with great interest the study by Cheng et al,1 who investigated patients with gastroesophageal reflux disease (GERD) refractory to antisecretory therapy by means of endoscopy and impedance-pH monitoring offtherapy and concluded that roughly half of these patients referred for testing actually underwent investigations and received medications with no evidence of GERD; they were affected by functional heartburn, functional disorders other than heartburn, or by undetermined disorders. These data confirm previous studies2,3 on the importance of investigating refractory patients and also emphasize the need of stopping antisecretory therapy to reduce overuse of proton pump inhibitors.4 However, we believe that the decision taken by the authors of using the impedance-pH parameters (ie, number of reflux episodes) rather than the symptom association analysis for the categorization of nonerosive reflux disease patients requires further comments. Although the number of reflux episodes has been shown as a reproducible parameter in patients investigated twice with impedance-pH testing, its role for the diagnosis and management of patients with GERD is still unknown.
To the best of our knowledge, to date, only 1 retrospective study focused its attention on this issue. Frazzoni et al5 reported that one-third of their refractory patients with remission of persistent symptoms at 3-year follow-up after
surgical fundoplication had an abnormal distal number of total refluxes as the only preoperative impedance-pH finding. This suggests that this parameter is promising for GERD management, but further outcome studies are
mandatory. On the other hand, a recent study by Patel et al6 emphasized the importance of the impedancedetected reflux-symptom association to predict a positive outcome after medical or surgical therapy. Thus, unless further data will be available on the importance of reflux numbers and because of the emerging advantages provided by impedance to symptoms analysis, we believe such approach should be preferred when investigating patients with suspected refractory GERD, particularly when the pretest probability of GERD diagnosis is low.
Moreover, we think that the 95th percentile value of 73, set as the upper limit of normality in a previous article on healthy volunteers, should be regarded with caution. Recently, the French Group of Neuro-Gastroenterology
modified their original cutoff from 75 to 53.7 The explanation provided by these authors was that after a decade of impedance-pH experience, a more careful manual evaluation of impedance-pH tracings permitted to reduce significantly the number of false-positive episodes detected by current available software. Interestingly, in 2006 we published our set of normal values, and we found a 95th percentile value of 54, which is in line with that observed by the French Group of Neuro-Gastroenterology.8 As a consequence, a considerable proportion of patients classified by the authors as “hypersensitive” or “functional” could instead be subjects with a non-acid reflux disease who may benefit from different therapeutic approaches (ie, surgery instead of visceral pain modulator). Therefore, further studies on normal impedance values are desirable to confirm previous data
Interstitial lung disease in systemic sclerosis patients may benefit more from anti-reflux therapies than from immunosuppressants.
No full textProactive Measures Aimed at Improving Appropriateness of Use of Proton Pump Inhibitors in Clinical Practice
No full textApplicability of Parameters for the Non-Invasive Diagnosis of Esophageal Varices Needing Treatment to Cured HCV Patients
No full textIt is Time to Re-Think the Role of Small Intestinal Bacterial Overgrowth in IBS Patients
No full textWe read with great interest the debate on the use of breath testing to diagnose small intestinal bacterial overgrowth (SIBO) and the suggestion of treating with antibiotics this dysbiosis in IBS patients. Gupta and Chey have emphasized the relevance of an accurate diagnosis of SIBO in order to maximize the benefits of rifaximin and to minimize the dangerous overuse of antibiotics for wrong clinical indications. In fact, there are many investigations showing the better yield of glucose breath test (GBT) over lactulose breath test (LBT) in detecting SIBO, when compared with jejunal aspiration, because the latter examination leads substantially to an overdiagnosis of this condition in IBS. On the other hand, Pimentel proposes to treat empirically IBS patients with rifaximin, due to the fact that at present there is no valid gold standard to validate breath testing.
However, all the above Authors continue to consider SIBO as one of the main causes of IBS, although many studies have strongly denied the very high prevalence (84%) found first by Pimentel et al in IBS and have questioned the role of SIBO in determining IBS symptoms. On the other hand, IBS is a common functional condition, which is characterized by abdominal pain and alterations in the consistency and frequency of stool movements, which are often associated with bloating. This clinical presentation is totally shared by SIBO and therefore it cannot be excluded that patients with this condition have only IBS-like symptoms, but do not pertain to the IBS realm. This difference can explain the good success of antibiotics in many clinical situations linked to SIBO, as we have shown in past studies, and their poor benefit in IBS (4), whose pathophysiological conditions are complex and not related to a unique mechanism. We suggest that GBT should be reserved to patients with bowel symptoms and predisposing conditions to the occurrence of SIBO, such as previous abdominal surgery (i.e. intestinal resections or cholecystectomy), prolonged acid suppressive therapy impairing the sterilizing power of acid, chronic use of antidepressant drugs capable to reduce intestinal motility, connective tissue disorders or the existence of functional constipation. In these cases, normalization of GBT after rifaximin therapy provided significant improvement of intestinal symptoms as shown in the above-mentioned clinical trials, but this success is probably due to the fact that treatment is addressed against an evident etiologic factor, which is unfortunately lacking in IBS
It is Time to Re-Think the Role of Small Intestinal Bacterial Overgrowth in IBS Patients.
No full text
- …
