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The most popular regimes today are based on polyethylene glycol (PEG)–electrolyte lavage solution. 5 PEG is a non-absorbable solution that should pass through the bowel without net absorption or secretion. To improve the adherence to PEG solutions, reduced volume (2 L) preparations coupled with irritant laxatives such as bisacodyl or magnesium citrate have been developed to increase patient compliance and are recognized to be as effective as the standard 4 L PEG preparation. 6 An alternative approach has been to split the 4 L PEG dosing to the day before and on the day of the procedure, which has been suggested to reduce adverse gastrointestinal (GI) symptoms and improve adherence. 7 In this issue of JGH OPEN, Yang et al. have reported a randomized trial comparing predominantly 4 L PEG solution and 2 L PEG in combination with Linaclotide as bowel preparation for colonoscopy in 266 patients. 8 There was no difference in bowel preparation quality or colon polyp detection rate between the two groups. Linaclotide, a guanylate cyclase-C (GC-C) agonist, which increases intestinal chloride and fluid secretion by activating the guanosine cyclic phosphate (cGMP) cascade, has been shown to be effective in the treatment of constipation-predominant irritable bowel syndrome (IBS-C) and chronic idiopathic constipation (CIC).

Eradicating H. pylori facilitates the reduction of gastric cancer, 1 and it is an effective method of healing peptic ulcer disease. 2 Testing and treating adult patients with un-investigated dyspepsia, even in Asia, have been shown to be more cost-effective than an endoscopy-based approach. 3 In Asia, the 1-week standard triple therapy, comprising a proton pump inhibitor (PPI), amoxicillin, and clarithromycin, 4 was recommended as first-line therapy due to its effectiveness, good tolerability, and high patient compliance in the early 21st century. 5 The first-line therapy for patients with penicillin allergy would have metronidazole, clarithromycin, and a PPI. [...]the re-treatment with clarithromycin-based regimes, despite having been used in the first-line regime, has been shown to lead to a lower eradication rate. 6 In summary, refractory H. pylori infection can be challenging to treat in resource-limited settings. [...]re-treatment with clarithromycin-based regimes tends to lead to more resistance and should be avoided.

Background and AimsSodium-glucose cotransporter-2 (SGLT2) inhibitors are a novel class of drugs that lower glucose by inducing renal glycosuria. We aimed to explore whether SGLT2 inhibitor added to the usual care for patients with type 2 diabetes mellitus (T2DM) and biopsy-proven nonalcoholic steatohepatitis (NASH) will benefit NASH histology.MethodsIn this investigator-initiated, single-arm, open-label, pilot study, nine biopsy-proven NASH patients with T2DM were given empagliflozin 25 mg daily for 24 weeks. Liver biopsy was repeated at the end of treatment. The histological outcomes were compared with the placebo group of a previous 48-week clinical trial.ResultsThere was a significant reduction in body mass index (median change, Δ = −0.7 kg per m2, p = 0.011), waist circumference (Δ = −3 cm, p = 0.033), systolic blood pressure (Δ = −9 mmHg, p = 0.024), diastolic blood pressure (Δ = −6 mmHg, p = 0.033), fasting blood glucose (Δ = −1.7 mmol/L, p = 0.008), total cholesterol (Δ = −0.5 mmol/L, p = 0.011), gamma glutamyl transpeptidase (Δ = −19 U/L, p = 0.013), volumetric liver fat fraction (Δ = −7.8%, p = 0.017), steatosis (Δ = −1, p = 0.014), ballooning (Δ = −1, p = 0.034), and fibrosis (Δ = 0, p = 0.046). All histological components either remained unchanged or improved, except in one patient who had worsening ballooning. Empagliflozin resulted in significantly greater improvements in steatosis (67% vs. 26%, p = 0.025), ballooning (78% vs. 34%, p = 0.024), and fibrosis (44% vs. 6%, p = 0.008) compared with historical placebo.ConclusionThis pilot study provides primary histological evidence that empagliflozin may be useful for the treatment of NASH. This preliminary finding should prompt larger clinical trials to assess the effectiveness of empagliflozin and other SGLT2 inhibitors for the treatment of NASH in T2DM patients.Trial registry number ClincialTrials.gov number, NCT02964715.

Clinical benefits have been demonstrated in inflammatory bowel diseases (particularly pouchitis) and are suggested in antibiotic‐related diarrhea, Clostridioides difficile toxin‐induced colitis, infectious diarrhea, hepatic encephalopathy, and irritable bowel syndrome. 1 The GI tract is recognized to communicate with the brain via a network of neuronal, immunological, and metabolic signaling. 2 The brain influences the GI system by regulating motility, secretion, absorption, and blood flow, while the gut can affect brain function and behavior. Interestingly, recent developments in the understanding of the pathophysiology of neurodegenerative diseases such as Alzheimer's Dementia and Parkinson's Disease (PD) have demonstrated increased intestinal permeability and intestinal inflammation in these conditions. 2 Furthermore, alterations in the gut microbiota (aka gut dysbiosis) and their metabolites have been demonstrated in adults with PD compared to non‐PD controls. 3 Importantly, gut dysbiosis has also been associated with more severe PD symptoms. 4 The mechanism for the benefit of probiotics is thought to include suppression of growth or epithelial binding/invasion by pathogenic bacteria, improvement of intestinal barrier function, modulation of the immune system, and modulation of pain perception. 5 In this issue of JGH Open, Tan et al. have summarized some of the current evidence for the role of probiotics in PD. 6 They reported that probiotics not only led to a reduction in neurotoxic metabolites but was able to improve motor function in studies conducted on mouse models of PD. Probiotics have also been shown to downregulate proinflammatory cytokines and upregulate anti‐inflammatory cytokines in cellular model studies using blood samples from PD patients. In human clinical trials, the best evidence for the efficacy of probiotics has been demonstrated in its efficacy for improving constipation symptoms in PD. Constipation is extremely common, causing significant distress to patients with PD, and is notoriously resistant to current laxatives . 7 Two randomized controlled trials have demonstrated the superiority of multistrain probiotics over placebo in improving constipation in PD over a 4‐week period. 6 As constipation is recognized to predate the onset of motor symptoms in PD, 8 it is possible that prolonged or higher doses of probiotics may be able to reduce debilitating motor symptoms, but this is yet to be proven.

[...]GERD is now recognized not just as a gastrointestinal disorder but as a condition with systemic implications affecting multiple body systems [1]. Conducting subgroup analyses based on factors such as age, gender, geographic location, and study design could help identify sources of heterogeneity and enhance the interpretation of findings. [...]asymmetry observed in the DOI and funnel plots suggests potential distortion of the pooled effect estimates. [...]current evidence points to a potential association between GERD and hypertension; however, several limitations still hinder a clear understanding of the exact nature of this relationship.

The association between body mass index (BMI) and functional gastrointestinal disorders (FGIDs) has been inconsistent. We aimed to explore the association of BMI with FGIDs in a primary care setting to provide more data in this area. A cross-sectional study of consecutive Asian adults attending a primary healthcare setting was conducted. This study was conducted in 2 phases: The association between BMI and common FGIDs (functional diarrhea/FD, irritable bowel syndrome/IBS, functional diarrhea and functional constipation/FC) was studied initially. The influence of anxiety and depression on BMI and FGIDs was additionally explored in phase 2. A total of 1002 subjects (median age 32 years, 65.4% females, 90.7% Malay ethnicity, 73.2% higher than secondary level education) were recruited between August 2019 to January 2020. The majority of subjects were obese (39.2%), and had central obesity (51.7%), while 6.1% had metabolic syndrome. The prevalence of FD, IBS, functional diarrhea and FC were 7.5% (n = 75), 4.0% (n = 40), 1.2% (n = 12) and 10.5% (n = 105) respectively, based on the Rome III criteria. Among individual FGIDs, FD subjects had more underweight adults (BMI<18.5kg/m2) compared to controls (13.3% vs 3.5%, P = 0.002) and being underweight remained as an independent association with FD [OR = 3.648 (95%CI 1.494-8.905), P = 0.004] at multi-variate analysis. There were no independent associations between BMI and other FGIDs. When psychological morbidity was additionally explored, anxiety (OR 2.032; 95%CI = 1.034-3.991, p = 0.040), but not depression, and a BMI<18.5kg/m2 (OR 3.231; 95%CI = 1.066-9.796, p = 0.038) were found to be independently associated with FD. FD, but not other FGIDs, is associated with being underweight. This association is independent of the presence of anxiety.

A case–control study comparing 794 patients with polyps with 708 colonoscopy-negative controls found that the male sex was significantly associated with an increase in all polyps [5]. [...]the differences are small, and even in combinations that do show a difference, the wide and overlapping 95% confidence intervals seem to preclude any daily practical use when compared to a protocol-driven colonoscopy done for the correct indication and with good bowel preparation. D. A. Corley, C. D. Jensen, A. R. Marks, et al., “Variation of Adenoma Prevalence by Age, Sex, Race, and Colon Location in a Large Population: Implications for Screening and Quality Programs,” Clinical Gastroenterology and Hepatology 11, no. 2 (2013): 172–180.

Previous exposure to hepatitis B virus (HBV) may increase the risk of hepatocellular carcinoma (HCC) in patients with chronic hepatitis C. We aim to study the impact of previous HBV infection on the severity and outcomes of patients with nonalcoholic fatty liver disease (NAFLD). This was a multicenter study of 489 patients with biopsy-proven NAFLD and 69 patients with NAFLD-related or cryptogenic HCC. Antihepatitis B core antibody (anti-HBc) was used to detect the previous HBV infection. In the biopsy cohort, positive anti-HBc was associated with lower steatosis grade but higher fibrosis stage. 18.8% and 7.5% of patients with positive and negative anti-HBc had cirrhosis, respectively (P < 0.001). The association between anti-HBc and cirrhosis remained significant after adjusting for age and metabolic factors (adjusted odds ratio 2.232; 95% confidence interval, 1.202-4.147). At a mean follow-up of 6.2 years, patients with positive anti-HBc had a higher incidence of HCC or cirrhotic complications (6.5% vs 2.2%; P = 0.039). Among patients with NAFLD-related or cryptogenic HCC, 73.9% had positive anti-HBc. None of the patients had positive serum HBV DNA. By contrast, antihepatitis B surface antibody did not correlate with histological severity. Positive anti-HBc is associated with cirrhosis and possibly HCC and cirrhotic complications in patients with NAFLD. Because a significant proportion of NAFLD-related HCC may develop in noncirrhotic patients, future studies should define the role of anti-HBc in selecting noncirrhotic patients with NAFLD for HCC surveillance.

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders (FGIDs) encountered in the community, primary care, and specialist clinics. 1–3 It is recognized to have a complex multifactorial pathophysiology, including psychological and cultural factors, previous gut infections, visceral hypersensitivity, increased permeability, and bile acid malabsorption. 4 IBS does not cause mortality but results in an increased healthcare burden and impaired quality of life due to its poor response to standard medical therapy. 5 To date, there are no specific endoscopic/imaging features, or biomarkers, to diagnose the condition. [...]for the purposes of standardization and research, a group of experts have attempted to define IBS according to certain symptom clusters, which have now been internationally accepted as the Rome Foundation diagnostic criteria. Since their initial iteration, the Rome criteria have been updated every 10 years, with the latest Rome IV criteria developed in 2016. F3: Epigastric pain or burning affected by eating, which gets better after bowel movement or passing gas and preceded by a change in the number of bowel movements F7: Upper abdominal pain or discomfort associated with passing less frequent or passing harder stools Cluster 1:

The prevalence of metabolic syndrome is increasing disproportionately among the different ethnicities in Asia compared to the rest of the world. This study aims to determine the differences in the prevalence of metabolic syndrome across ethnicities in Malaysia, a multi-ethnic country. In 2004, we conducted a national cross-sectional population-based study using a stratified two-stage cluster sampling design (N = 17,211). Metabolic syndrome was defined according to the International Diabetes Federation/National Heart, Lung and Blood Institute/American Heart Association (IDF/NHLBI/AHA-2009) criteria. Multivariate models were used to study the independent association between ethnicity and the prevalence of the metabolic syndrome. The overall mean age was 36.9 years, and 50.0% participants were female. The ethnic distribution was 57.0% Malay, 28.5% Chinese, 8.9% Indian and 5.0% Indigenous Sarawakians. The overall prevalence of the metabolic syndrome was 27.5%, with a prevalence of central obesity, raised triglycerides, low high density lipoprotein cholesterol, raised blood pressure and raised fasting glucose of 36.9%, 29.3%, 37.2%, 38.0% and 29.1%, respectively. Among those <40 years, the adjusted prevalence ratios for metabolic syndrome for ethnic Chinese, Indians, and Indigenous Sarawakians compared to ethnic Malay were 0.81 (95% CI 0.67 to 0.96), 1.42 (95% CI 1.19 to 1.69) and 1.37 (95% CI 1.08 to 1.73), respectively. Among those aged ≥40 years, the corresponding prevalence ratios were 0.86 (95% CI 0.79 to 0.92), 1.25 (95% CI 1.15 to 1.36), and 0.94 (95% CI 0.80, 1.11). The P-value for the interaction of ethnicity by age was 0.001. The overall prevalence of metabolic syndrome in Malaysia was high, with marked differences across ethnicities. Ethnic Chinese had the lowest prevalence of metabolic syndrome, while ethnic Indians had the highest. Indigenous Sarawakians showed a marked increase in metabolic syndrome at young ages.