To evaluate current international clinical practice in the assessment and management of rectal stump disease activity following colectomy in paediatric ulcerative colitis (UC). A web-based survey comprising 18 questions was distributed to paediatric gastroenterologists via European Porto inflammatory bowel disease (IBD) interest group and North America and the United Kingdom pediatric inflammatory bowel disease (PIBD) network groups over 6 months. The questionnaire recorded centre demographics, colectomy practices, rectal stump assessment methods, and management approaches. Responses were analysed using descriptive statistics with subgroup analysis by continent and centre size. Eighty paediatric gastroenterologists from 24 countries completed the survey. Most centres (n = 62, 78%) reported fewer than five colectomies annually, with 59% indicating that all patients retained a rectal stump for at least 3 months post-colectomy. Only 11% of centres had a formal protocol for rectal stump management. Clinical assessment tools varied, with 39% using none, and the remainder favouring Pediatric Ulcerative Colitis Activity Index (PUCAI) or Physician's Global Assessment. Frank rectal bleeding and painful rectal discharge were rated as the most significant symptoms. Endoscopy and histology were the most common investigations. Rectal therapy was the preferred first-line treatment for rectal stump disease recurrence, followed by systemic therapy and observation. There was wide variation in estimates of rectal disease activity at 6 months post-colectomy. There is considerable international variation and lack of standardisation in the management of rectal stump disease in paediatric UC. These findings underscore the need for evidence-based guidelines and collaborative research to optimise care for this understudied population.
Restoration of intestinal barrier integrity and function in inflammatory bowel disease (IBD) has been associated not only with a reduced burden of persistent symptoms but also with improved long-term outcomes, prompting growing interest in intestinal barrier healing as a potential new therapeutic target. To date, no clinical trials have specifically evaluated therapies aimed at restoring intestinal barrier function in IBD, and there is currently no consensus on how such trials should be designed or how the intestinal barrier should be assessed. The aim of this initiative was to develop consensus recommendations on the optimal design of clinical trials and the selection of tools to evaluate therapies targeting the intestinal barrier in IBD. A panel of 12 international specialists with recognised expertise in the intestinal barrier and/or IBD clinical trials evaluated statements developed from a systematic literature review. Statements were discussed and anonymously voted on using a modified Delphi methodology. Consensus was predefined as at least 75% agreement among participants. The study was conducted and reported in accordance with the Conducting and REporting of DElphi Studies framework. Fourteen statements reached consensus and were approved. These statements addressed key aspects of clinical trial design, including the role of intestinal barrier assessment as an endpoint, timing of reassessment, protocol requirements and disease-specific considerations. Additional statements focused on the selection and standardisation of tools for intestinal barrier assessment, encompassing imaging-based techniques, functional permeability assays and endogenous biomarkers, as well as considerations for implementation and future research directions. This international consensus provides a structured framework to guide the design of future clinical trials evaluating efficacies of therapies in restoring intestinal barrier integrity and/or function in IBD.
Intestinal failure-associated liver disease (IFALD) remains difficult to define, diagnose, and manage in adults on home parenteral nutrition. We aimed to describe international expert practice patterns for IFALD monitoring, diagnosis, and treatment. Anonymous electronic survey was distributed to clinicians involved in HPN care. The survey collected respondent demographics, longitudinal monitoring practices after HPN initiation, and responses to adult clinical cases representing cholestatic, hepatocellular/steatotic, and advanced fibrotic clinical phenotypes. Because all clinical vignettes described adult patients, respondents were retained irrespective of their reported usual patient age group. Analyses were descriptive. Seventy-two clinicians from 29 countries across 5 continents responded. Routine laboratory panels and liver function tests were obtained monthly or more often by 94.4% of respondents during the first 3 months of HPN, but practice shifted towards quarterly surveillance beyond 12 months. Total bilirubin, AST, ALT, alkaline phosphatase, and platelet count were nearly universal routine markers, whereas direct bilirubin and GGT were less consistently included. Initial cholestatic, persistent (6 months) cholestatic, hepatocellular/steatotic, and advanced fibrotic cases were diagnosed as IFALD by 43.1%, 84.7%, 37.1% and 77.9% of respondents, respectively. Ultrasound and elastography scan were the preferred adjunctive diagnostic assessments, yet many respondents reported uncertainty regarding elastography and imaging thresholds. Management centered on parenteral nutrition modification, especially changes in lipid emulsion, whereas transplant referral was uncommon except in advanced disease. International expert practice is more consistent for surveillance intensity and lipid-focused management than for diagnostic thresholds and diagnostic work, particularly for non-cholestatic IFALD phenotypes. These findings support the development of phenotype-specific consensus, definitions, and validated adult diagnostic pathways for IFALD.
Atezolizumab plus bevacizumab (Atezo+Bev) is the most widely used first-line treatment for unresectable hepatocellular carcinoma (HCC), while lenvatinib remains a standard alternative. Previous studies suggest limited efficacy of Atezo+Bev in patients with HCC exhibiting a CRAFITY score of 2 (CRP ≥1 mg/dL and AFP ≥100 ng/mL). We conducted an international collaborative study to compare the efficacy of Atezo+Bev and lenvatinib stratified by the baseline CRAFITY score. We retrospectively analyzed 994 patients who initiated Atezo+Bev or lenvatinib as first-line therapy for unresectable HCC between September 2017 and March 2024 across 11 hospitals in Japan and 13 hospitals in Taiwan. Patients were categorized by baseline CRAFITY score, and progression-free survival (PFS) and overall survival (OS) were compared between treatment groups. The median age of the patients was 71 years, and 770 (77.5%) were male. The baseline CRAFITY score was 0 in 375 patients (37.7%), 1 in 402 patients (40.4%), and 2 in 217 patients (21.8%). In patients with a CRAFITY-0 score, median PFS (10.8 vs. 9.4 months; p = 0.548) and OS (21.1 vs. 29.3 months; p = 0.074) did not differ significantly between Atezo+Bev and lenvatinib. Similar findings were observed in CRAFITY-1 patients, with median PFS of 6.0 vs. 6.1 months (p = 0.943) and OS of 12.7 vs. 15.1 months (p = 0.168). In contrast, among CRAFITY-2 patients, lenvatinib was associated with significantly longer PFS (2.3 vs. 4.4 months; hazard ratio, 0.66; p = 0.017), while OS did not differ significantly between treatments (5.7 vs. 9.1 months; hazard ratio, 0.90; p = 0.586). A significant interaction was observed between CRAFITY score (0/1 vs. 2) and treatment regimen (Atezo+Bev vs. lenvatinib) for PFS (p = 0.002). Consistent findings were observed in adjusted analyses. Lenvatinib was associated with significantly longer PFS than Atezo+Bev in patients with a baseline CRAFITY score of 2. The CRAFITY score may be useful for identifying patients in whom lenvatinib could be considered as a first-line option, and prospective validation is warranted.
Functional dyspepsia (FD) is a prevalent yet challenging gastrointestinal disorder described as a group of upper gastrointestinal symptoms such as epigastric pain or burning, bloating, belching among many others, in the absence of an identifiable organic etiology. Its diagnosis is established according to the Rome IV criteria, which define the disorder by bothersome postprandial fullness, early satiety, epigastric pain and/or epigastric burning present for the last 3 months, with symptom onset at least 6 months before diagnosis. Despite its benign nature, functional dyspepsia can considerably affect patients' quality of life and constitutes a significant burden on healthcare systems worldwide, as it is estimated to affect over 20% of the population. FD can be subdivided into the three following subtypes - postprandial distress syndrome (PDS), epigastric pain syndrome (EPS) and a constellation of both - based on symptoms' pattern. This article provides a comprehensive overview of the epidemiology, pathophysiology, subtypes, clinical presentation as well as management strategies of functional dyspepsia. Understanding these aspects is crucial for improving diagnosis and applying effective treatment strategies for patients with functional dyspepsia. Narrative literature-based review. We conducted a search of PubMed/MEDLINE, Embase, and Google Scholar for publications from January 2010 to March 2025, including clinical studies, reviews, and international guidelines related to functional dyspepsia. The pathophysiology of functional dyspepsia remains poorly understood, largely due to its multifactorial nature. Several factors at both the macroscopic and microscopic level have been implicated in the pathogenesis of this disorder such as altered gastrointestinal motility, impaired barrier function, altered gut-brain axis, inflammation as well as psychological factors. Several clinical guidelines, both European and American, have been developed to guide the diagnosis of functional dyspepsia and its management with the primary goal of symptom control. Functional dyspepsia remains a complex disorder due its diverse clinical features and multifactorial etiology. A patient-centered approach and management based on recent guidlines are essential for effective management of this condition.
Heart failure and chronic liver disease account for substantial morbidity and mortality worldwide. Both conditions share common risk factors and a bidirectional pathophysiology, and the coexistence of both conditions is expected to increase over time. Management of coexisting heart failure and liver disease is challenged by the under-representation of participants with liver disease in landmark heart failure clinical trials, impaired hemodynamics at advanced stages of liver disease, altered drug metabolism, and higher risk of adverse events than portended by either condition alone. Moreover, diagnostic pitfalls might be encountered in relation to assessing the primary etiologies driving the disease process, estimating the degree of liver fibrosis, and differentiating primary liver disease from heart failure-related liver congestion particularly, given the complex interplay between sinusoidal pressure, congestion, and structural fibrosis. Cardiovascular-hepatic cross-thematic research, clinical education, and health care services could optimize management and patient outcomes. The purpose of the current review is to (i) highlight the growing epidemiology of concurrent heart failure-liver disease; (ii) provide diagnostic clues for liver disease and an approach for interpreting liver marker abnormalities amongst heart failure patients; (iii) describe the main therapeutic strategies in real-world clinical settings; and (iv) discuss current gaps in knowledge and future directions. This update on the framework of the heart failure-liver disease overlap phenomenon can inform clinical care policies and facilitate novel research in the field.
There is limited research into the impact of takeaway food on metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to evaluate the association between takeaway food consumption and MASLD in Chinese TCLSIH cohort (n = 3186) and UK Biobank (n = 99 781), plus 334 Chinese adults with biopsy-proven MASLD in the PERSONS cohort. Takeaway food consumption was assessed via questionnaires. MASLD was identified through liver ultrasonography and cardiometabolic factors (TCLSIH) and hospital records/death registries (UK Biobank). Cox proportional hazards regression models were used to evaluate hazard ratio (HR) and 95% confidence interval (CI). In the TCLSIH cohort, 724 participants developed MASLD within 12 941 person-years; the fully adjusted HRs (95% CIs) for MASLD across takeaway food consumption frequency were 1.00 (reference) for < 1 time/week, 0.92 (0.67, 1.27) for 1-3 times/week, 1.30 (1.07, 1.61) for ≥ 4 times/week in males. In the UK Biobank, 724 participants developed MASLD during 1 033 546 person-years; males eating takeaway food had a fully adjusted HR (95% CI) of 1.66 (1.08, 2.55) compared with non-consumers. In the PERSONS cohort, takeaway food consumption showed positive association with MASLD severity in males. These findings indicated that takeaway food consumption was positively associated with risk and severity of MASLD in adults, particularly among males.
The present document aims to present a reflection derived from a narrative review on the evolution of complementary feeding (CF) recommendations worldwide and their application in Mexico. Based on the analysis of international guidelines and consensus statements, such as those published by European Society for Pediatric Gastroenterology, Hepatology and Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology and Nutrition, and the World Health Organization, members of the Mexican Academy of Pediatrics review the main points of convergence and controversy related to the initiation, progression, and characteristics of CF during the first two years of life. The document highlights that this period is critical for growth, neurological development, immune maturation, and the establishment of healthy eating habits in the long term. Likewise, it emphasizes the relevance of the first 1000 days of life and the need to promote breastfeeding, dietary diversity, and the timely introduction of foods rich in essential nutrients. The review also addresses current topics such as the early introduction of allergenic foods, the role of different food textures, the prevention of obesity and allergies, as well as the importance of avoiding sugar-sweetened beverages, ultra-processed foods, and restrictive diets without specialized supervision. From the Mexican perspective, it is recognized that international recommendations must be contextualized according to the epidemiological, cultural, and social realities of the country. Finally, the Academia Mexicana de Pediatría proposes practical recommendations directed at healthcare professionals to promote responsive, safe, and evidence-based CF that contributes to the overall well-being of Mexican infants. El presente documento tiene como objetivo manifestar algunas reflexiones derivadas de una revisión narrativa sobre la evolución de las recomendaciones de la alimentación complementaria (AC) en el mundo y su práctica en México. A partir del análisis de consensos y guías internacionales, como las publicadas por la Sociedad Europea de Gastroenterología, Hepatología y Nutrición Pediátrica, la Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica y la Organización Mundial de la Salud, miembros de la Academia Mexicana de Pediatría revisan los principales puntos de convergencia y controversia relacionados con el inicio, progresión y características de la AC durante los primeros dos años de vida. El documento destaca que este periodo es crítico para el crecimiento, desarrollo neurológico, maduración inmunitaria y establecimiento de hábitos alimentarios saludables a largo plazo. Asimismo, se enfatiza la relevancia de los primeros 1,000 días de vida y la necesidad de promover la lactancia materna, la diversidad alimentaria y la introducción oportuna de alimentos ricos en nutrimentos esenciales. La revisión también aborda temas actuales como la introducción temprana de alimentos alergénicos, el papel de las diferentes texturas, la prevención de obesidad y alergias, así como la importancia de evitar bebidas azucaradas, ultraprocesados y dietas restrictivas sin supervisión especializada. Desde la perspectiva mexicana, se reconoce que las recomendaciones internacionales deben contextualizarse según las realidades epidemiológicas, culturales y sociales del país. Finalmente, la Academia Mexicana de Pediatría propone recomendaciones prácticas dirigidas a profesionales de la salud, con el fin de favorecer una AC perceptiva, segura y basada en evidencia científica, que contribuya al bienestar integral de las y los lactantes mexicanos.
Artificial intelligence (AI)-assisted endoscopy represents a promising approach for lesion detection, yet frequent false-positive detections impair clinical utility by disrupting examinations and diminishing physician confidence. Linked-color imaging (LCI), an image-enhanced endoscopy technique that amplifies mucosal and vascular contrast, may address this limitation. This investigation evaluated whether LCI reduces false-positive AI detections compared with white-light imaging (WLI). This retrospective study analyzed consecutive AI-assisted upper endoscopies performed between March 2024 and June 2025. WLI and LCI were performed sequentially within the same endoscopic session in each patient. False-positive AI detections were compared between modalities using two computer-aided detection (CAD) versions. Propensity score adjustment was used as a sensitivity analysis for baseline differences between CAD Versions I and II. Of 66 initially screened cases, 63 remained after excluding patients with prior gastric surgery. LCI reduced false-positive AI detections compared with WLI (median 2 vs. 5; p < 0.001). In CAD version-stratified sensitivity analyses, LCI reduced false-positive AI detections in both Version I (5 to 2; p = 0.01) and Version II (2 to 0; p = 0.03). This reduction remained consistent across atrophic grades. Both imaging modalities identified all gastric lesions, achieving 100% detection sensitivity. LCI assessment performed after WLI observation yielded fewer false-positive CAD-EYE detections while maintaining lesion detection sensitivity. However, because the observation sequence was fixed, these findings should be interpreted cautiously and require confirmation in prospective or counterbalanced studies. Trial Registration: N/A (retrospective study).
Hepatitis C virus (HCV) is a significant global health concern, particularly in Egypt, where its prevalence is estimated at 4.5%-6.7%. The Egyptian genotype, HCV-4, accounts for most infections and is a leading cause of cirrhosis, chronic liver disease, and hepatocellular carcinoma (HCC). A previous study was conducted in Egypt to examine certain single-nucleotide polymorphisms (SNPs) in both toll-like receptor 3 (TLR3) and interleukin-10 (IL-10) and their association to interferon therapy. However, there is still a remaining gap to examine the correlation of both TLR3 and IL-10 gene polymorphism to the disease progression and disease prognosis among Egyptian genotype, HCV-4. This study investigates the relationship between toll-like receptor 3 (TLR3) polymorphism (rs1879026) and interleukin-10 (IL-10) polymorphism (rs1800896) with liver disease progression among Egyptian HCV genotype 4 patients. A case-control study was conducted involving blood samples from Egyptian HCV patients, categorized into four groups: chronic hepatitis C, cirrhosis, HCC, and a healthy control group. Genotyping of IL-10 (rs1800896) and TLR3 (rs1879026) polymorphisms was performed using TaqMan SNP assays. Standard genomic analysis methods and international guidelines have been implemented for patient recruitment and analysis. The IL-10 rs1800896 CC genotype frequency increased progressively with disease severity, observed in 5% of controls, 26.67% fibrosis, 46.67% cirrhosis, and 66.67% HCC patients (p-value < 0.001), indicating a significant association with progression of HCV-related liver disease. In contrast, TLR3 rs1879026 genotype distribution showed no statistically significant differences across groups (p-value > 0.05). The IL-10 gene polymorphism (rs1800896) may contribute to genetic susceptibility in Egyptian patients, increasing the risk of HCV-related cirrhosis and HCC progression. In contrast, TLR3 rs1879026 had no clear impact on disease progression in Egyptian patients. To the best of our knowledge, this is the first report of testing the correlation between the IL-10 gene and the TLR3 polymorphism in disease progression among Egyptian HCV patients. Not applicable.
Hepatic encephalopathy (HE) is a reversible neuropsychiatric complication of cirrhosis associated with cognitive and psychomotor impairment that may compromise driving safety. Deficits in attention, visuospatial ability, reaction time and executive function contribute to impaired on-road performance and increased motor vehicle collision rates. Despite this, there are no standardised Australian guidelines addressing driving in patients with HE, and international guidelines remain heterogenous. This article reviews the impact of overt (OHE) and covert HE on driving performance and outlines a pragmatic, risk-stratified framework. For patients with prior OHE, our approach is a time-limited driving restrictions based risk assessment, with conditional return to driving following sustained clinical stability and adherence to therapy. This framework aims to balance public safety with preservation of patient autonomy and quality of life.
Background: Obesity markedly increases the risk of metabolic syndrome (MetS) and metabolic dysfunction-associated steatotic liver disease (MASLD), both of which are characterized by persistent low-grade inflammation. This study aimed to evaluate the diagnostic utility of complete blood count-derived inflammatory markers, including neutrophil-percentage-to-albumin ratio (NPAR), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR), for MASLD and MetS in children with obesity. Methods: Children with obesity aged 7-18 years were prospectively enrolled and underwent anthropometric assessment, laboratory evaluation, and transient elastography with controlled attenuation parameter (CAP) measurement. Participants were classified into MASLD (CAP ≥ 250 dB/m) and non-MASLD groups. Children aged ≥10 years were additionally evaluated for MetS according to the International Diabetes Federation criteria. Logistic regression analyses assessed associations between inflammatory markers and MASLD or MetS, while receiver operating characteristic (ROC) analysis evaluated their diagnostic performance. Results: Children with MASLD had significantly higher NLR and lower LMR values than those without MASLD. Higher NLR (OR = 1.946, 95% CI: 1.092-3.467, p = 0.024) and lower LMR (OR = 0.722, 95% CI: 0.539-0.966, p = 0.028) were associated with MASLD, whereas NPAR and PLR were not. After adjustment for age, sex, body mass index and C-reactive protein, both NLR and LMR remained independently associated with MASLD. ROC analysis showed moderate diagnostic performance (AUC = 0.629 for NLR and 0.616 for LMR). None of the evaluated markers were associated with MetS. Conclusions: NLR and LMR were independently associated with MASLD in children with obesity and may represent complementary screening biomarkers for pediatric MASLD. However, given the cross-sectional design and moderate diagnostic performance observed in this study, prospective multicenter studies are needed to validate these findings before clinical implementation.
Terlipressin is a synthetic vasopressin analogue that is indicated for the treatment of hepatorenal syndrome-acute kidney injury (HRS-AKI) to improve kidney function and haemodynamics. Despite its previous approval in Europe, terlipressin was Food and Drug Administration (FDA)-approved in 2022 in the United States. Historical standards of care, such as midodrine and octreotide (MO), are still used alternatively to terlipressin, and mortality benefit among treatments is unknown. To examine the effects of terlipressin vs MO in hospitalized patients with HRS-AKI. This single-centre, retrospective, cohort study was conducted at a large, tertiary academic medical centre. Data were collected from the electronic health record for patients admitted from July 2018 to July 2024. Patients ≥18 years of age admitted with International Classification of Diseases codes for cirrhosis, AKI, and clinical diagnosis of HRS were included. The primary outcome was the incidence of in-hospital mortality between patients receiving terlipressin vs MO. Descriptive statistics and parametric and non-parametric tests were utilized as appropriate. A total of 49 terlipressin patients and 30 MO patients were identified. The rate of in-hospital mortality was lower with terlipressin (n = 12, 24.5%) vs MO (n = 21, 70%) (P < .001). The mean hospital length of stay (days) was greater with terlipressin than MO (21.4 ± 14 vs 15.5 ± 8.4, P = .081) as was baseline serum creatinine (SCr) (2.94 ± 1.1 vs 1.89 ± 1.2 mg/dL, P < .05). Numerically more patients receiving terlipressin had a response to therapy (21/49 vs 12/30, P = .1033) with a similar decrease in SCr (-34.8 ± 21% vs -36.1 ± 21%, P = .86). The number of days from therapy initiation until the lowest SCr was less with terlipressin vs MO (4.97 ± 3.5 vs 7.92 ± 3.7, P = .02). Terlipressin appears to effectively improve renal function and in-hospital mortality in patients with HRS-AKI compared with MO. Terlipressin may be used as a first-line treatment for HRS-AKI or after a trial of MO based on the study's results.
In patients with cirrhosis, prolonged international normalized ratio (INR) is primarily driven by liver synthetic dysfunction. Thromboelastography more accurately reflects coagulability and can also predict short-term mortality. Nevertheless, INR is used to define coagulation failure in the European Foundation for the Study of Chronic Liver Failure criteria for acute-on-chronic liver failure (ACLF). To evaluate the association between TEG parameters and mortality in critically ill patients with cirrhosis and to justify future investigation into TEG as a prognostic tool in ACLF. We performed a retrospective study of 52 patients with cirrhosis admitted to the intensive care unit (ICU) who had TEG performed during their ICU admission prior to the administration of any blood products. We assessed the association between TEG parameters and 28-day mortality. Patients who did not survive beyond 28 days generally had more hypocoagulable TEG parameters (R time: 10.0 vs. 7.6, p = 0.03; K time: 3.4 vs. 2.2, p = 0.003; alpha angle: 53.1 vs. 63.5, p = 0.002; MA: 49.2 vs. 60.2, p = 0.001). Although global assessment of TEG demonstrated a state of rebalanced hemostasis among critically ill patients with cirrhosis, patients meeting diagnostic criteria for ACLF tended to have more hypocoagulable TEG parameters as compared to those who did not (coagulation index: 0.2 vs. 2.0, p = 0.004). As proof of concept, MA was incorporated into the definition of ACLF to replace INR as a marker of coagulation failure (TEG-ACLF). The area under the curve (AUC) for TEG-ACLF was 0.83 (0.72-0.95) compared to 0.8 (0.68-0.92) for the current ACLF-CLIF grading, with 9.6% (5/52) of patients being reclassified into a different ACLF grade. Hypocoagulable TEG parameters are associated with increased 28-day mortality in critically ill patients with cirrhosis, and incorporation of TEG parameters into a modified definition for ACLF may result in improved prediction of short-term mortality.
The EndoFLIP system is currently the only available impedance planimetry system, providing real-time, detailed information on the diameter, luminal area, distensibility, and compliance of the esophagogastric junction (EGJ), along with its 2D representation. EndoFLIP can support diagnosis and provide physiological feedback to potentially guide interventions for structural and functional gastroesophageal disorders. However, the lack of standardized usage protocols complicates the interpretation and comparability of results. This paper aims to establish a consensus on protocols to standardize the use of the EndoFLIP system in both diagnostic and intraoperative settings, so as to ensure consistent application across varied clinical and scientific settings. A multidisciplinary European Advisory Board (AB) comprising eight gastroenterologists and surgeons with extensive experience in EndoFLIP use undertook a structured international expert consensus process. Following a systematic literature review and a face-to-face expert meeting, candidate statements were developed and independently rated using an electronic survey. Consensus was predefined as ≥ 75% agreement ('agree' or 'strongly agree'), whereas statements requiring neutral responses to achieve this threshold were classified as weak consensus. A final expert meeting was convened to review the results and ratify the recommendations. Standardized protocols for obtaining EndoFLIP measurements in preoperative/diagnostic and intraoperative settings were developed. The statements forming the protocols (25 related to diagnostic use and 20 to intraoperative measurements) were voted on by the AB panel, with consensus reached for all statements. EndoFLIP has demonstrated great potential in complementing endoscopy for diagnosing achalasia and providing intraoperative guidance for treating achalasia and gastroesophageal reflux disease. The implementation of the developed standardized protocols in real-world settings is essential to validate them, as it will enable the collection of consistent data on the pre- and intraoperative use of EndoFLIP, facilitate its routine use, and better define patient pathways.
Malnutrition, whether pre-existing or acquired in the ICU, is common in critically ill children. This narrative review synthesizes current evidence on nutritional assessment and therapy, highlighting how illness phase, underlying disease, and medical interventions influence energy expenditure and nutrient requirements. International guidelines recommend comprehensive nutritional assessment and early initiation of enteral nutrition (EN) for all patients admitted to the Pediatric ICU. However, EN is frequently underutilized or insufficient to meet metabolic demands and sometimes contraindicated. Barriers to delivery persist, and parenteral nutrition (PN) may be required when EN is not feasible or adequate. Nutrition plays a crucial yet complex role in the care of critically ill children. Optimizing individualized nutrition strategies, including timely EN and appropriate PN use, is essential to improve clinical outcomes, support recovery, and enhance long-term rehabilitation, while highlighting the need for improved implementation and future research.
Chronic gastroduodenal symptoms affect > 7% of adults, yet current diagnostic frameworks are challenged by limited mechanistic specificity, weak symptom correlation, and variable reproducibility. This review evaluates how body surface gastric mapping (BSGM), a non-invasive technology combining high-resolution gastric myoelectrical recording with validated symptom profiling, may improve the diagnosis and management of gastric motility disorders. BSGM employs a high-resolution 64-electrode array to derive validated biomarkers of gastric motor function, including rhythm stability, frequency, and amplitude, alongside standardised digital symptom and psychometric profiling. A recent international consensus ('Auckland Classification v1.0'), derived from over 50 published studies and 4,500 + clinical tests, defined six BSGM phenotypes encompassing putative mechanisms of neuromuscular dysfunction, visceral hypersensitivity, centrally-mediated symptoms, and small bowel contributions. BSGM significantly increases diagnostic yield for motility disorders and appears synergistic with gastric emptying testing in joint studies. Observational data currently indicate that BSGM-guided management changes clinical decisions in ~ 80% of patients and is associated with reduced healthcare utilisation. Key benefits include capability to aid discrimination of motor vs sensory disorders, with specific phenotypes provisionally linked to differential treatment responses. Paediatric studies show concordant phenotype patterns, with BSGM dysrhythmia identified as a more severe phenotype. BSGM provides mechanism-based phenotyping that extends gastroduodenal evaluation beyond symptom classifications and gastric emptying status. Prospective validation of phenotype-guided treatment algorithms is now underway, and integrated multimodal diagnostic frameworks incorporating BSGM alongside complementary investigations are likely to reshape the clinical approach to these challenging disorders.
Digestive congenital anomalies (DCAs), the fourth leading cause of death and disability among all congenital birth defects, have a substantial impact on both the duration and quality of life. This study aimed to present the burden and socioeconomic associates of DCAs in the Middle East and North Africa (MENA) region from 1990 to 2021. DCAs were defined based on the International Classification of Diseases codes (ICD-9: 750-751.9, 756.6-756.79; ICD-10: Q38-Q45.8, Q79.0-Q79.59). Mortality was estimated using the Cause of Death Ensemble Model, and DisMod-MR 2.1 was employed to model cause-specific mortality and excess mortality. Metrics were presented as crude counts and age-standardized rates per 100,000, with 95% uncertainty intervals. The association between socio-demographic index (SDI) and DCAs burden was examined using smoothing spline models. In 2021, the age-standardized incidence rate of DCAs in the MENA region was 7.17 (5.64, 9.15), while the age-standardized point prevalence was 50.57 (40.88, 59.51) per 100,000 individuals. MENA had a DALY rate of 67.85 (47.56, 88.75) and a death rate of 0.74 (0.50, 0.97). From 1990 to 2021, there were significant reductions in the age-standardized rates of incidence (-25.99% [-33.70, -17.06]), prevalence (-10.55% [-18.88, -2.04]), DALY (-62.35% [-78.36, -10.86]), and death (-62.97% [-78.95, -10.76]) associated with DCAs in MENA. In 2021, Afghanistan had the greatest age-standardized DALY rate, while Qatar had the lowest. Males generally had a greater burden of DCAs. A negative association was identified between age-standardized DALY rates and the SDI for DCAs in the MENA. From 1990 to 2021, we observed a significant decrease in the burden of DCAs in MENA, although the trends vary across countries. These findings offer crucial insights for developing effective prevention and management strategies for these anomalies.
To evaluate the diagnostic performance of fecal elastase (FE) in exocrine pancreatic insufficiency (EPI) and examine the risk factors for EPI in children with acute recurrent pancreatitis (ARP) or chronic pancreatitis (CP). We analyzed prospectively collected demographic, clinical, and EPI data of children with ARP or CP (n=1007) enrolled in the INSPPIRE-2 (INternational Study group of Pediatric Pancreatitis: In search for a cuRE) consortium. FE performance was assessed against individual markers of fat malabsorption and a composite reference standard in which the presence of any 1 of the following was considered consistent with fat malabsorption in lieu of a gold-standard pancreas function test: (1) clinical diagnosis of EPI, (2) vitamin A or E deficiency, or (3) BMI z-score ≤-2. Cox regression models were used to identify predictors of EPI. EPI was diagnosed in 195/1007 (19.4%) children with ARP/CP, with FE being the most commonly used diagnostic tool. FE demonstrated low sensitivity (55.8% and 65.1%), moderate specificity (82.8% and 75.5%), and a high negative predictive value (92% and 93%), at cut-offs of 100 μg/g and 200 μg/g stool, respectively, in detecting at least 1 marker of fat malabsorption. The 7-year cumulative incidence of EPI after the first pancreatitis episode was 24%. Genetic risk factors were associated with earlier progression to EPI (HR 1.56; 95% CI 1.02-2.39). EPI affects nearly 20% of children with ARP/CP. FE is a valuable diagnostic tool in ruling out EPI. Children with genetic risk factors need closer surveillance due to an increased risk for developing EPI.
Neurogenic bowel dysfunction (NBD) affects many individuals with spina bifida (SB) and is associated with substantial physical, social, and emotional burdens. Although quality of life (QoL) is recognized as an important outcome in SB care, the tools used to measure the impact of NBD on QoL in the pediatric SB population have not been systematically evaluated. This systematic review aimed to identify instruments used to assess the impact of NBD on QoL of children and adolescents with SB and to document the specific domains evaluated. A methodological systematic review was conducted consistent with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were: (1) participants: children and adolescents (0-21 years of age) with SB and/or myelomeningocele (MMC), (2) outcome: utilization of an author-reported "QoL tool" to measure the impact of NBD on QoL, and (3) English-language publication. Data regarding study characteristics, respondent type, evaluation tools used, whether the tool focused on measurement of QoL or functioning, and tool domains were extracted and synthesized. Twenty studies met the inclusion criteria and were conducted across the United States, Europe, Asia, and Australia, with most authorship represented by surgical subspecialties. Sixteen unique tools were identified with six tools being classified as condition-specific tools and ten as generic tools. The Fecal Incontinence and Constipation Quality of Life questionnaire was the most used instrument and was used in six of the 20 studies. Half of the studies did not specify who completed the QoL instrument, and only one study relied exclusively on self-report. Notably, only two of the identified instruments primarily measured QoL rather than function. Generic QoL tools included broad domains that covered physical, emotional, and social functioning regardless of diagnosis, whereas condition-specific tools included additional domains assessing concepts such as financial impact and independence. There was significant variability observed in measurement approaches, professionals conducting QoL research, and respondents completing the QoL tools. An ideal QoL instrument is simple, condition-specific, clinically relevant, age-appropriate, available in both self- and proxy-report formats, and able to capture the multidimensional nature of QoL separate from function. The QUALAS emerged as a tool which fulfills these criteria for evaluation of the impact of NBD on QoL among individuals with SB. Given the global prevalence of SB and the growing international focus on promoting QoL, it is important that QoL instruments are culturally adaptable and available in multiple languages.