Special Issue: Challenges and Opportunities in Gastroenterology

Introduction

Gastroenterology is a dynamic and diverse specialty that encompasses the study and management of the digestive system and its disorders. Gastroenterologists are constantly challenged by the emergence of new diseases, the evolution of existing diseases, and the development of new technologies and techniques.

This special issue of the official journal of the European Society of Medicine showcases some of the recent advances and controversies in gastroenterology. It includes original research articles, review articles, and editorials from eminent experts in the field. The articles span a broad spectrum of topics, such as:

• Gastro-Oesophageal Reflux Disease

• Crohn’s disease

• Gastritis

• Celiac Disease

We hope that this special issue will stimulate discussion and debate among clinicians, researchers, and educators in gastroenterology. We invite you to read the articles and share your opinions with us.

Hill’s Classification of Gastro-Oesophageal Flap Valve weakness: A valuable Tool for Endoscopic Grading of Gastro-Oesophageal Reflux Disease

Dr. Kaundinya Kiran Bharatam

Assistant Professor in General Surgery, Sri Ramachandra Medical College and Hospital, Chennai, TN, India.

Abstract
Introduction: Gastro-Oesophageal Reflux Disease is one of the most common conditions needing an endoscopy evaluation. The evaluation of this condition also needs 24-hour pH-monitoring and oesophageal manometry, but in reality, these investigations are not easily available and are cumbersome.

Methodology: We used the Hill’s classification for the gastro-oesophageal flap valve and objectified the evaluation of the reflux present. We were able to objectively assess the findings during endoscopy mainly the Gastro-Oesophageal Flap Valve using the Hill’s Classification and correlate its grade with the presentation of gastro-oesophageal reflux disease and its possible treatments with outcome.

Inference and conclusion: We find this tool to be easy to perform and interpret as compared to the more cumbersome and complex 24-hour pH monitoring and Oesophageal Manometry. With our study we wish to encourage the use of Hill’s Classification in all endoscopies done for reflux disease.

Word of Caution: Investigations like the 24-hour pH-monitoring and Oesophageal Manometry can be reserved for select cases that may either need further evaluation of this condition or have the need to rule out functional conditions of the oesophagus like the oesophageal motility disorders.

Keywords: Gastro-Oesophageal Reflux Disease (GERD), Gastro-Oesophageal Flap Valve (GEFV), Hill’s classification, Laryngopharyngeal reflux disease (LPRD), H. pylori infection, Atrophic Gastritis, Erosive Esophagitis, Laparoscopic Sleeve Gastrectomy

Popular Beverages Stimulate Oropharyngeal and Gut Receptors Eliciting Modulation of the Upper Digestive Processes

Michael Kevin McMullen

Abstract

This paper reports clinical studies on the effect of agonists of taste and chemethesis receptors in the oropharyngeal cavity and the gut. The peripheral nerve system plays a vital role in our selection or rejection of what we eat and drink. Although the degree to which it is hard-wired has not been determined, it is known that our food and drink choices change with age. Scientific studies on the impact of food and drink on the body have been concerned predominantly with nutritional factors and, more recently, impacts on cholesterol and blood sugar levels. On the other hand, the sensations we experience during eating and drinking have long been regarded, perhaps even dismissed, as purely hedonistic. The idea that foods and drinks may actually influence digestion is a novel one and is based on the discovery 20 years ago of taste buds, innervated by the vagi, in stomach and intestinal tissues. Studies indicate some of our most popular drinks modulate both postprandial hyperaemia and gastric emptying. It is proposed that the bitter taste experienced with some foods and drinks promotes increased blood flow to the splanchnic circulation and slows the flow of chyme to the small intestine. In cases of toxicity, these actions promote emesis whereas at non-toxic levels, bitter substances promote digestion by increasing postprandial hyperaemia and slowing gastric emptying. Additionally, chemethesis agonists can act on the oropharyngeal receptors resulting in a slower gastric emptying. These effects may lead to a learned behaviour and subsequent enjoyment of bitter tastants, rather than their rejection, amongst those with reduced digestive capacity. It provides a rationale for the popularity of certain bitter tasting aperitifs and digestive alcoholic beverages originating in southern Europe.

Are gastrointestinal signals the principal guides to human appetite and energy balance?

Katarina T. Borer

School of Kinesiology The University of Michigan, Ann Arbor, MI 48109, USA

Abstract

In view of the exponential rise of global obesity in the past three quarters of the century, it is useful to examine what is driving this change and what approaches can curb it. The chief drivers of weight gain are, on one hand our misunderstanding of the mechanisms controlling energy balance, and, on the other, reliance on current, potentially misleading conflicting scientific opinions and government policies regarding the controls of human appetite. This review outlines the evidence that: (1) there is no direct bioenergetic feedback from energy metabolism or energy stores to the brain mechanisms guiding feeding and energy expenditure, (2) human appetite is controlled by signals originating from an empty or full stomach, food palatability and opportunities to eat as well by the rate of food absorption, that (3) humans bear a genetic burden of having high ability and capacity to store fat and mechanisms that curb body- mass and fat loss, (4) humans are motivated to overconsume while maintaining low energy expenditure, and (5) commercial interests of food businesses marketing highly palatable foods, and wide-spread mechanization of living tasks and urban design reduce the need for physical work and movement. The non-pharmacological and non-surgical solutions to obesity involve an understanding of human genetic impediments and environmental obstacles to maintaining healthy weight, coupled with deliberate corrective or preventive behaviors, such as understanding and using gastrointestinal tract signals that provide sufficient, albeit subtle, cues for sensible food intake, and using daily weight monitoring and activity tracking devices to record and motivate healthy levels of physical activity.

Keywords: gastrointestinal signals, human appetite, energy balance, principal guides to human appetite

Gastrovigilance: A Close Watch on Gastrointestinal and Hepatic Disorders- An Indian Perspective

Dr. Gourdas Choudhuri

Chairman, Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Medical Research Institute, Gurgaon, NCR

Dr. Philip Abraham

Consultant, Division of Gastroenterology, P. D. Hinduja Hospitals, Mumbai

Dr. Manu Tandan

Senior Consultant, Asian Institute of Gastroenterology, Hyderabad

Dr. Naresh Bhat

Chief of GI & Liver Services, Aster CMI Hospital, Bangalore

Dr. Akash Shukla

Professor & Head, Department of Gastroenterology, GSMC & KEM Hospital, Mumbai

Dr. Pratyusha Gaonkar

Medical Advisor, Pfizer India Ltd., Capital building G block, Bandra (E), Mumbai

Dr. Akshay Desai

Medical Lead, Pfizer India Ltd., Capital building G block, Bandra (E), Mumbai

Dr. Charles Adhav

Medical Lead, Pfizer India Ltd., Capital building G block, Bandra (E), Mumbai

Abstract

Gastrointestinal and hepatic disorders account for about 25% of consultations among general practitioners in India. Errors in clinical judgement and hesitancy in recommending necessary tests owing to lack of health insurance could result in delayed diagnosis and increased patient morbidity and mortality. Clinicians should thus be well equipped with effective strategies for skilful diagnosis and in a position to weigh the benefit-risk-ratio of recommending pertinent and disregarding less useful diagnostic tests. ‘Gastrovigilance’ includes disease-specific training for recognising risk factors, algorithms and referral pathways. This narrative review focuses on the common challenges or errors in managing these conditions in Indian clinical practice and their proposed solutions. Literature searches were performed using PubMed/MEDLINE and Google Scholar following the shortlisted gastrointestinal conditions. Based on the published literature and expertise of the senior gastroenterologists, improving disease-specific knowledge can enhance rates of correct diagnosis. Improved screening and patient education can reduce the risk of presentation at advanced stages and consequently improve prognosis. Another significant contributory factor is the patient-physician interaction which affects every stage of the disease management and methods to improve it, therefore vital in improving gastrointestinal and hepatic disease conditions. The most important means of improving gastrovigilance is optimising knowledge access in primary care. This shall improve diagnostic accuracy and reduce the burden of misdiagnosis. In the current narrative review, we have tried to elucidate the concept of gastrovigilance for gastrointestinal and hepatic conditions and substantiate it with published evidence.

Keywords: Inflammatory bowel disease, Gastroesophageal Reflux Disease, Irritable bowel syndrome, Constipation, Gastrointestinal cancer

Managing Pregnancy and Nursing Affecting African American Women with Inflammatory Bowel Disease: Clinical Outcomes and Parenthood

Amosy E. M’Koma

Departments of Biochemistry, Cancer Biology, Neuroscience and Pharmacology

Jamie N. Ware

Departments of Obstetrics and Gynecology

Rosemary K. Nabaweesi

Center for Health Policy, Meharry Medical College, Nashville, TN 37208, USA.

Sanika S. Chirwa

Departments of Biochemistry, Cancer Biology, Neuroscience and Pharmacology

Abstract

Inflammatory bowel disease (IBD) is a term for two autoimmune diseases encompassing Crohn’s disease (CD) and ulcerative colitis (UC) which are lifelong diseases affecting more than 3 million adults (1.3%) in the United States. IBD is characterized by chronic inflammation of the whole digestive system which results in damage to the gastrointestinal (GI) tract. IBD often emerges during adolescence and young adulthood. Maternal morbidity includes physical and psychological conditions that result from or are aggravated by pregnancy and have an adverse effect on a woman’s health, the baby’s health or both. Some women have health challenges that arise before or during pregnancy that could lead to complications. It is recommended for women to receive health care counseling before and during pregnancy. Compared to other developed countries, the United States has the highest rate of women dying of pregnancy related complications. During the past 25 years maternal mortality has been getting worse. African American women (AAW) with and/or without IBD are dying at significantly higher rates than other groups. This is linked to several factors, i.e., systemic, institutionalized, and structural racism in health-care delivery and subsequent toxic stress from people’s lived experiences of racism, limited knowledge about healthcare system function, lack of access to healthcare, (inclusiveness and insurance policies) all of which negatively impact these patients. African Americans (AAs) are also up to three times as likely to experience severe maternal morbidity: unexpected outcomes of labor and delivery, deficient or lacking prenatal care and social determinants of health like lack of transportation, adequate employment, limited literacy, and limited healthcare access contribute to poor health outcomes. Studies on IBD patients indicate Medicaid expansion is associated with reduced rates of maternal morbidity, particularly for African American Women (AAW) and increased access to preconception and prenatal services that make pregnancy and childbirth safer for parent and baby. Herein we examine the physiological changes of pregnancy in patients diagnosed with inflammatory bowel disease and their relationship perinatal outcomes and parenthood.

Presentation and Patterns of Celiac Disease in Indian Subcontinent: A Literature Review

Anjum Siddiqui

Dr. Anjum Siddiqui, Senior Resident, Department of Medicine, LHMC & Smt.SK Hospital, New Delhi

Aparna Agrawal

Director Professor, Department of Medicine, LHMC& Smt S.K Hospital, New Delhi

Praveen Kumar

Director Professor, Department of Paediatrics, LHMC& Kalawati Saran Children’s Hospital, New Delhi

Lekhraj Hemraj Ghotekar

Head of Department and Director Professor, Department of Medicine, LHMC& Smt S.K Hospital, New Delhi

Sanjana Taneja

MBBS, Lady Hardinge Medical College and associated Hospitals, New Delhi

Abstract

Gluten, in genetically susceptible individuals induces an immune mediated enteropathy called Celiac disease (CD). It is an established cause of malabsorption, with the worldwide prevalence being 1% in the general population. It is found across all age groups, from infants to the elderly with 20% patients being diagnosed in the seventh decade of life. It has varying clinical presentations ranging from silent asymptomatic forms which are diagnosed during screening to life threatening forms with severe malabsorption to atypical presentations, with the symptom spectrum extending beyond the gastrointestinal tract which are more common in adults. High index of suspicion, robust screening and testing, followed by strict adherence to gluten free diet is a must to curb and cure the disease. Patients tend to face difficulties not only during diagnosis, but also with compliance and availability of a gluten free diet, in addition to significant economic and psychosocial burden, which is more predominant in developing countries. Screening of high-risk groups like first-degree relatives of celiac disease, patients with severe malnutrition, other autoimmune diseases, refractory anaemia and irritable bowel syndrome should be done to enhance case detection. In low middle income countries, judicious resource utilisation takes precedence, hence, tackling a multifactorial disease such as celiac disease becomes challenging. Repeated follow ups, awareness among patients and doctors, encouragement, availability of testing and dietary counselling is necessary for management of the disease in such settings. Improving sanitation and feeding practices may also play role in decreasing incidence, considering childhood GI infections are a well-established risk factor. Increased availability of serological tests (IgA/IgG anti-tTG, anti -EMA and anti-DGP), biopsy, genetic testing and other newer modalities under research have improved the diagnostic accuracy. Poor compliance increases the risk of GI malignancy, non-Hodgkin’s lymphoma, Hepatocellular carcinoma and MALToma. Hence adherence is a must to prevent complications. A wide variety of treatment modalities are being evaluated to bring into force alternative strategies for management. Only providing gluten free diet is often not sufficient for improvement of nutritional status in patients with CD. Hence, micronutrient supplementation should also be encouraged to meet the unmet needs.

Pathogenesis of Crohn’s Disease

Herbert J Van Kruiningen, MD

Department of Pathobiology, University of Connecticut, 61 north Eagleville Road, Unit 3089, Storrs, CT 06269-3089

Abstract

There was a time when “pathogenesis” meant the genesis of the pathology, patho plus genesis. Today, however, the word is used to introduce topics such as immunodysregulation, alterations in the microbiome, or an imbalance of the two, some sort of disconnect between the patient’s flora and the immune system of the gastrointestinal tract. Pathogenesis, pathophysiology, and etiopathogenesis seem to be buzzwords, introduced to catch the eye of the reader or the editor. Few who use those words have seen any “pathology” since second year medical school, or perhaps they have viewed biopsies of the surface but not cut sections of resection specimens. Dalziel was the first to describe Crohn’s disease. Pathologists, or groups of pathologists, elucidated the pathogenesis, often referring to the granulomas, the obstructed lymphatics of the wall and the edema. Dalziel called this disease “chronic interstitial enteritis”. Those writing about microflora, immune dysregulation, cytokine cascades, fibrosis, and mouse models would do well to study the early pathology that is the essence of Crohn’s disease.

Keywords: Dalziel’s Disease, Crohn’s disease, Regional enteritis, Lymphatics, Elephantiasis, Early Pathology

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Special Issue: Challenges and Opportunities in Gastroenterology

Introduction

Hill’s Classification of Gastro-Oesophageal Flap Valve weakness: A valuable Tool for Endoscopic Grading of Gastro-Oesophageal Reflux Disease

Popular Beverages Stimulate Oropharyngeal and Gut Receptors Eliciting Modulation of the Upper Digestive Processes

Abstract

Are gastrointestinal signals the principal guides to human appetite and energy balance?

Abstract

Gastrovigilance: A Close Watch on Gastrointestinal and Hepatic Disorders- An Indian Perspective

Abstract

Managing Pregnancy and Nursing Affecting African American Women with Inflammatory Bowel Disease: Clinical Outcomes and Parenthood

Abstract

Presentation and Patterns of Celiac Disease in Indian Subcontinent: A Literature Review

Abstract

Pathogenesis of Crohn’s Disease

Abstract

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