Jnm023 04 Cover Total

April 30, 2016
Volume 22 Number 2
Editorials
483 Can Acute Stress Cause Esophageal Hypersensitivity in Healthy Individuals?
Yu Kyung Cho
485 The Clinical Implications of Overlap Between Constipation and Common Functional Gastrointestinal Disorders
Kang Nyeong Lee
Reviews and Meta-analyses

487 Understanding the Chicago Classification: From Tracings to Patients
Francisco Schlottmann, Fernando A Herbella, and Marco G Patti
495 Reflux Hypersensitivity: A New Functional Esophageal Disorder
Takahisa Yamasaki and Ronnie Fass
504 Is Helicobacter pylori Associated Functional Dyspepsia Correlated With Dysbiosis?
Yeon-Ji Kim, Woo Chul Chung, Byung Wook Kim, Sung Soo Kim, Jin Il Kim, Na Jin Kim, Jinho Yoo, and Soo Hwan Kim
Original Articles
517 Relationship Between Salivary Pepsin Concentration and Esophageal Mucosal Integrity in Patients With Gastroesophageal
Reflux Disease
Yu-wen Li, Daniel Sifrim, Chenxi Xie, Minhu Chen, and Ying-lian Xiao
526 Intravenous Corticotropin-releasing Hormone Administration Increases Esophageal Electrical Sensitivity in Healthy
Individuals
Takahisa Yamasaki, Toshihiko Tomita, Mayu Takimoto, Takashi Kondo, Katsuyuki Tozawa, Yoshio Ohda, Tadayuki Oshima, Hirokazu Fukui, Jiro Watari,
and Hiroto Miwa
533 Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients
Shinji Ishii, Suguru Fukahori, Kimio Asagiri, Yoshiaki Tanaka, Nobuyuki Saikusa, Naoki Hashizume, Motomu Yoshida, Daisuke Masui,
Naoko Komatsuzaki, Naruki Higashidate, Saki Sakamoto, Tomohiro Kurahachi, Shiori Tsuruhisa, Hirotomo Nakahara, and Minoru Yagi
541 Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting
Mette W Klinge, Peter Rask, Lene S Mortensen, Kathrine Lassen, Niels Ejskjaer, Lars H Ehlers, and Klaus Krogh
550 The Ability of the Eating Assessment Tool-10 to Detect Aspiration in Patients With Neurological Disorders
Selen Serel Arslan, Numan Demir, Hasan E Kılınç, and Aynur A Karaduman
555 Psychiatric Co-morbidity in Patients With Irritable Bowel Syndrome at a Tertiary Care Center in Northern India
Yuman Kawoos, Zaid A Wani, Showkat A Kadla, Irfan A Shah, Arshad Hussain, M Maqbool Dar, Mushtaq A Margoob, and Kouser Sideeq
561 Prediction of Delayed Colonic Transit Using Bristol Stool Form and Stool Frequency in Eastern Constipated Patients:
A Difference From the West
Veeravich Jaruvongvanich, Tanisa Patcharatrakul, and Sutep Gonlachanvit
569 Nationwide Multicenter Study for Overlaps of Common Functional Gastrointestinal Disorders in Korean Patients With
Vol. 23, No. 4 October 2017

Constipation
Kyung Sik Park, Sam Ryong Jee, Bong Eun Lee, Kyoung Sup Hong, Jeong Eun Shin, Soo-Young Na, Joong Goo Kwon, Suck Chei Choi,
Yong Sung Kim, Hyun Seok Lee, Tae Hee Lee, Kyeong Ok Kim, Jongkyoung Choi, Hee Seok Moon, Yeon Soo Kim, Moo In Park, Soo Jung Park,
Seon-Young Park, Sung Noh Hong, and Constipation Research Group of Korean Society of Neurogastroenterology and Motility
578 Alterations of Food-specific Serum IgG4 Titers to Common Food Antigens in Patients With Irritable Bowel Syndrome
Hong Sub Lee and Kwang Jae Lee
585 Detecting the Non-physiological, Surgically Tailored Ileocolic Anastomosis Using the Wireless Motility Capsule. A Pre- and
Post-operative, Prospective, Within Subject Trial
Yngve Thorsen, Bojan V Stimec, Jens M Nesgaard, and Dejan Ignjatovic
592 Comparison of Changes in the Interstitial Cells of Cajal and Neuronal Nitric Oxide Synthase-positive Neuronal Cells With
Aging Between the Ascending and Descending Colon of F344 Rats
Sun Min Lee, Nayoung Kim, Hyun Jin Jo, Ji Hyun Park, Ryoung Hee Nam, Hye Seung Lee, Hyun Jin Kim, Moon Young Lee, Yong Sung Kim,
Pages 483-618
and Dong Ho Lee

606 The Effect of Deoxycholic Acid on Secretion and Motility in the Rat and Guinea Pig Large Intestine
Nam Hee Kim, Jung Ho Park, Jae-soon Park, and Yeun-Ho Joung
Letters to the Editor

616 A Rare Cause of Acute Colonic Pseudo-obstruction: Ogilvie’s Syndrome Caused by Herpes Zoster
Jae Yoon Chung, Jong Seol Park, and Yong Sung Kim
2017
618 Gastroesophageal Reflux Disease Could Progress to Achalasia October Volume 23 Number 4
Laura Bognar, Andras Vereczkei, and Ors Peter Horvath
JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility
Editor-in-Chief
Ronnie Fass (USA)
Deputy Editor
Kwang Jae Lee (Korea)
Moo In Park (Korea)
Associate Editors
Young-Tae Bak (Korea) Sutep Gonlachanvit (Thailand) Sang Don Koh (USA) Eamonn M M Quigley (USA)
William D Chey (USA) Kok Ann Gwee (Singapore) Joon Seong Lee (Korea) Poong-Lyul Rhee (Korea)
Myung-Gyu Choi (Korea) Xiaohua Hou (China) Oh Young Lee (Korea) Daniel Sifrim (UK)
Andrew S B Chua (Malaysia) Meiyun Ke (China) Hiroto Miwa (Japan) Yvette Taché (USA)
Shin Fukudo (Japan) Nayoung Kim (Korea) Hyojin Park (Korea) Jan Tack (Belgium)
Uday C Ghoshal (India)
Editorial Board Members

Giovanni Barbara (Italy) Young Woo Kang (Korea) Varocha Mahachai (Thailand) Max J Schmulson (Mexico)
Chang Hwan Choi (Korea) Gwang Ha Kim (Korea) Seung-Jae Myung (Korea) Chong-Il Sohn (Korea)
Suck Chei Choi (Korea) Hyun Jin Kim (Korea) Akihito Nagahara (Japan) Andreas Stengel (Germany)
Anita Gasiorowska (Poland) Yong Sung Kim (Korea) Tomas Navarro (Brazil) Xiaohong Sun (China)
Su Jin Hong (Korea) Rakesh Kochhar (India) John E Pandolfino (USA) Hidekazu Suzuki (Japan)
Hye-Kyung Jung (Korea) Lin Lin (China) Jung Ho Park (Korea) Justin C Y Wu (Hong Kong)
Motoyori Kanazawa (Japan) Ching-Liang Lu (Taiwan) Shaman Rajindrajith (Sri Lanka)
Statistical Editor Manuscript Editor Illustrator

Sung-Il Cho (Korea) Eun Ju Ko (Korea) Jae Yeon Lee (Korea)
Journal of Neurogastroenterology and Motility (J Neurogastroenterol Motil) is a joint official journal of the Korean
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Gastrointestinal Motility, the South East Asia Gastro-Neuro Motility Association, the Taiwan Neurogastroenterology and Motility
Society and the Asian Neurogastroenterology and Motility Association, launched in January 2010 after the title change from the
Korean Journal of Neurogastroenterology and Motility, published from 1994 to 2009.
The aim of the Journal is to foster and promote research activities in the area of the motor, sensory and functional disorders of the
gastrointestinal tract. The Journal provides researchers with accessible rooms for publication of their research results in the field of
neurogastroenterology and motility.
It publishes quarterly peer-reviewed articles in English (January, April, July, and October). Full text is accessible at: http://www.
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Committee of Asian Neurogastroenterology and Motility Association

President Hyojin Park (Korea)
Secretary General Justin Wu (Hong Kong)
Vice Secretary General Jung Ho Park (Korea)
Treasurer Tanisa Patcharatrakul (Thailand)
Auditor Minhu Chen (China)
Scientific Committee Chair Hiroto Miwa (Japan)
Members Kewin Siah Tien Ho (Singapore) Vivian Wong (Hong Kong)
Tadayuki Oshima (Japan) Xiaohua Hou (China)
Sanjiv Mahadeva (Malaysia) Chien-Lin Chen (Taiwan)
Yong Sung Kim (Korea)
Information and Chair Ching-Liang Lu (Taiwan)
Communication Committee Members Gwang Ha Kim (Korea) Kewin Siah Tien Ho (Singapore)
Jung Ho Park (Korea) Ping-Huei Tseng (Taiwan)
Board Members of the Korean Society of Neurogastroenterology and Motility

Congress Chairman Sung Pyo Hong
President Oh Young Lee
President elect Kwang Jae Lee
Secretary General In Kyung Seong
Director of the Scientific Committee Suck Chei Choi
Director of the Editorial and Publication Committee Moo In Park
Director of the Finance Committee Jung Ho Park
Director of the Education Committee Jae Myung Park
Director of the Insurance & Policy Committee Kee Wook Jung
Director of the Public Relation Committee Kang Nyeong Lee
Director of the Information & Communication Committee Hyuk Lee
Director of Clinical Practice Guidelines Committee Hye Kyoung Jung
Director of Public Relations Committee Kyu Chan Huh
Director of GERD and Esophageal Function Research Study Group Sang Kil Lee
Director of Functional Dyspepsia and Gastric Function Research Study Group Joong Goo Kweon
Director of IBS and Intestinal Function Research Study Group Sam Ryong Jee
Director of Constipation and Anorectal Function Research Study Group Kyung Sik Park
Director of Therapeutic Endoscopy and Instrument for Functional Gastrointestinal Disorders Su Jin Hong
Vice-secretary General (Research Support) Kang Nyeong Lee
Auditor Jin Il Kim
Auditor Byung Ik Jang
Publication Committee of the Korean Society of Neurogastroenterology and Motility

Kihong Chang Jae Hak Kim Yang Won Min
Yu Kyung Cho Jeong Hwan Kim Hee Kyong Na
Chang Hwan Choi Ji Hyun Kim Jung Hwan Oh
Su Jin Hong Seong-Eun Kim Jung Ho Park
Jae Yeoul Jun Yong Sung Kim Cheol Min Shin
Kee Wook Jung Hong Sub Lee Jeong Eun Shin
Gwang Ha Kim Moon Young Lee Kyung Ho Song
Hee Man Kim Tae Hee Lee Young Hoon Youn
Hyun Jin Kim Cheol-Hyun Lim
Journal of Neurogastroenterology and Motility Volume 23 ∙ Number 4 ∙ October 30, 2017
October 2017
Editorials
Yu Kyung Cho
485 The Clinical Implications of Overlap Between Constipation and Common Functional
Gastrointestinal Disorders
Kang Nyeong Lee



Yeon-Ji Kim, Woo Chul Chung, Byung Wook Kim, Sung Soo Kim, Jin Il Kim, Na Jin Kim, Jinho Yoo,
and Soo Hwan Kim
Original Articles
517 Relationship Between Salivary Pepsin Concentration and Esophageal Mucosal Integrity in Patients
With Gastroesophageal Reflux Disease
526 Intravenous Corticotropin-releasing Hormone Administration Increases Esophageal Electrical

Sensitivity in Healthy Individuals
Takahisa Yamasaki, Toshihiko Tomita, Mayu Takimoto, Takashi Kondo, Katsuyuki Tozawa, Yoshio Ohda,
Tadayuki Oshima, Hirokazu Fukui, Jiro Watari, and Hiroto Miwa
533 Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in
Neurologically Impaired Patients
Shinji Ishii, Suguru Fukahori, Kimio Asagiri, Yoshiaki Tanaka, Nobuyuki Saikusa, Naoki Hashizume,
Motomu Yoshida, Daisuke Masui, Naoko Komatsuzaki, Naruki Higashidate, Saki Sakamoto,
Tomohiro Kurahachi, Shiori Tsuruhisa, Hirotomo Nakahara, and Minoru Yagi
541 Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and
Vomiting
550 The Ability of the Eating Assessment Tool-10 to Detect Aspiration in Patients With Neurological
Disorders
555 Psychiatric Co-morbidity in Patients With Irritable Bowel Syndrome at a Tertiary Care Center in
Northern India
Yuman Kawoos, Zaid A Wani, Showkat A Kadla, Irfan A Shah, Arshad Hussain, M Maqbool Dar,
Mushtaq A Margoob, and Kouser Sideeq
561 Prediction of Delayed Colonic Transit Using Bristol Stool Form and Stool Frequency in Eastern
Constipated Patients: A Difference From the West
This journal was supported by the Korean Federation of Science and Technology Societies (KOFST) Grant funded
by the Korean Government.
569 Nationwide Multicenter Study for Overlaps of Common Functional Gastrointestinal Disorders in
Korean Patients With Constipation
Kyung Sik Park, Sam Ryong Jee, Bong Eun Lee, Kyoung Sup Hong, Jeong Eun Shin, Soo-Young Na,
Joong Goo Kwon, Suck Chei Choi, Yong Sung Kim, Hyun Seok Lee, Tae Hee Lee, Kyeong Ok Kim,
Jongkyoung Choi, Hee Seok Moon, Yeon Soo Kim, Moo In Park, Soo Jung Park, Seon-Young Park,
Sung Noh Hong, and Constipation Research Group of Korean Society of Neurogastroenterology and Motility
578 Alterations of Food-specific Serum IgG4 Titers to Common Food Antigens in Patients With
Irritable Bowel Syndrome
585 Detecting the Non-physiological, Surgically Tailored Ileocolic Anastomosis Using the Wireless
Motility Capsule. A Pre- and Post-operative, Prospective, Within Subject Trial
592 Comparison of Changes in the Interstitial Cells of Cajal and Neuronal Nitric Oxide Synthase-
positive Neuronal Cells With Aging Between the Ascending and Descending Colon of F344 Rats
Sun Min Lee, Nayoung Kim, Hyun Jin Jo, Ji Hyun Park, Ryoung Hee Nam, Hye Seung Lee, Hyun Jin Kim,
Moon Young Lee, Yong Sung Kim, and Dong Ho Lee
606 The Effect of Deoxycholic Acid on Secretion and Motility in the Rat and Guinea Pig Large
Intestine

618 Gastroesophageal Reflux Disease Could Progress to Achalasia

ON THE COVER
The 3 consecutive examinations in 1 patient. (A) The pre-operative test demonstrating the stereotypical pattern.
(B) Three weeks after surgery the same characteristic pattern is present. (C) Six months after surgery the small
bowel transit time is normalized. See Thorsen et al on page 585.
JNM
J Neurogastroenterol Motil, Vol. 23 No. 4 October, 2017
pISSN: 2093-0879 eISSN: 2093-0887
https://doi.org/10.5056/jnm17118
Journal of Neurogastroenterology and Motility Editorial
Can Acute Stress Cause Esophageal Hypersensitivity

in Healthy Individuals?
Yu Kyung Cho
Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
Article: Intravenous corticotropin releasing hormone administration increases esophageal electrical sensitivity in healthy
individuals
Yamasaki T, Tomita T, Takimoto M, et al
(J Neurogastroenterol Motil 2017;23:526-532)
Stress exacerbates heartburn symptoms in gastroesophageal to acid-suppressive therapy.5 There is an association between distal
reflux disease (GERD) patients and also affects visceral sensitivity.1 esophageal acid exposure and esophageal hypersensitivity among
The mechanism of visceral hypersensitivity in functional gastroin- the reflux-related disorders.
testinal disorders and functional heartburn remains unclear. How- Esophageal pain can be induced by mechanical distension,
ever, the involvement of stress in relation to esophageal sensitivity chemical stimuli, and others. A high percentage of patients with
has been reported.1,2 Fass et al3 demonstrated that GERD patients functional chest pain reported pain after balloon distension of the
who were exposed to acute auditory stress experienced increased esophagus.6 Enhanced chemosensitivity in functional heartburn
levels of heartburn induced by intraesophageal acid perfusion, and patients has also been reported.7 Factors that influence visceral hy-
the stress from disturbed sleep has also been shown to cause similar persensitivity in the esophagus, include stress, mucosal integrity, and
esophageal hypersensitivity. microinflammation in the esophagus, though the mechanisms by
In the revised Rome IV criteria, functional esophageal disorders which visceral hypersensitivity of the esophagus occurs are incom-
include functional chest pain, functional heartburn, reflux hyper- pletely understood.1
sensitivity, globus, and functional dysphagia.4 The Rome IV adopts Corticotropin-releasing hormone (CRH) plays a key role in the
a more rigorous definition of GERD. GERD patients are sub- acute regulation of stress- and anxiety-related behaviors and in the
grouped as erosive esophagitis, non-erosive reflux disease (NERD), regulation of endocrine responses during chronic stress via activa-
reflux hypersensitivity, and functional heartburn.4 The pathophysi- tion of the hypothalamic-pituitary-adrenal axis. Peripheral CRH
ology of erosive esophagitis and NERD is the result of pathologic is a key mediator of the gut stress response, and has been shown to
acid exposure in contrast to the functional disorders that are related influence visceral hypersensitivity in humans.8 Stress affects esopha-
to esophageal hypersensitivity. Esophageal hypersensitivity is one of geal motility. A previous study demonstrated that intravenous
the important mechanisms in GERD patients who are refractory CRH administration enhanced esophageal sensitivity to mechani-
Received: September 23, 2017 Revised: None Accepted: September 26, 2017
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work
is properly cited.
*Correspondence: Yu Kyung Cho, MD
Department of Internal Medicine, The Catholic University of Korea, College of Medicine, Seoul, Korea
Tel: +82-2-2258-6017, Fax: +82-2-2258-2064, E-mail: ykcho@catholic.ac.kr
ⓒ 2017 The Korean Society of Neurogastroenterology and Motility

www.jnmjournal.org
483
Yu Kyung Cho
cal distension, increased esophageal contractility, and decreased

LES relaxation, therefore improving esophageal bolus clearance.8
The changes after CRH administration in esophageal contractile
References
properties may be associated with the increased sensitivity to balloon 1. Kondo T, Miwa H. The role of esophageal hypersensitivity in functional
distention after CRH. heartburn. J Clin Gastroenterol 2017;51:571-578.
2. Farmer AD, Ruffle JK, Aziz Q. The role of esophageal hypersensitivity
Stress is able to alter esophageal sensitivity. In this issue of the
in functional esophageal disorders. J Clin Gastroenterol 2017;51:91-99.
Journal of Neurogastroenterology and Motility , Yamasaki et al9 3. Fass R, Naliboff BD, Fass SS, et al. The effect of auditory stress on per-
demonstrated CRH administration increased esophageal electrical ception of intraesophageal acid in patients with gastroesophageal reflux
sensitivity in normal subjects, emphasizing the important role of disease. Gastroenterology 2008;134:696-705.
stress in esophageal sensitivity. The results of this study were mean- 4. Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Func-
ingful in studying the mechanisms of esophageal functional pain in tional esophageal disorders. Gastroenterology Published Online First: 15
Feb 2016. doi: 10.1053/j.gastro.2016.02.012.
refractory GERD or functional heartburn.
5. Nasr I, Attaluri A, Hashmi S, Gregersen H, Rao SS. Investigation of
There is increasing evidence that esophageal hypersensitivity esophageal sensation and biomechanical properties in functional chest
in patients with proton proton pump inhibitor (PPI)-refractory pain. Neurogastroenterol Motil 2010;22:520-526, e116.
GERD symptoms is of a multisensory nature. Many solutions 6. Farmer AD, Coen SJ, Kano M, et al. Psychophysiological responses to
are suggested as the next therapeutic or diagnostic option in PPI- visceral and somatic pain in functional chest pain identify clinically rel-
refractory NERD patients. Some of these patients proved to have evant pain clusters. Neurogastroenterol Motil 2014;26:139-148.
7. Tamura Y, Funaki Y, Izawa S, et al. Pathophysiology of functional heart-
functional heartburn and reflux hypersensitivity. Esophageal hyper-
burn based on Rome III criteria in Japanese patients. World J Gastroen-
sensitivity will be a new therapeutic target in addition to PPIs for terol 2015;21:5009-5016.
those patients. 8. Broers C, Melchior C, Van Oudenhove L, et al. The effect of intra-
venous corticotropin-releasing hormone administration on esophageal
sensitivity and motility in health. Am J Physiol Gastrointest Liver Physiol
Financial support: None. 2017;312:G526-G534.
9. Yamasaki T, Tomita T, Takimoto M, et al. Intravenous corticotropin re-
Conflicts of interest: None. leasing hormone administration increases esophageal electrical sensitivity
in healthy individuals. J Neurogastroenterol Motil 2017;23:526-532.
484 Journal of Neurogastroenterology and Motility

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Editorial
The Clinical Implications of Overlap Between

Constipation and Common Functional
Gastrointestinal Disorders
Kang Nyeong Lee

Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
Article: Nationwide multicenter study for overlaps of common functional gastrointestinal disorders in Korean patients with
constipation
Park KS, Jee SR, Lee BE, et al
Functional gastrointestinal disorders (FGIDs) are classified authors publish a prospective, nationwide multicenter study using
and categorized by the Rome criteria based on patients’ symptoms, validated questionnaires including quality of life (QOL).5 In their
but some FGIDs have common pathophysiologic mechanisms, study, the authors report the prevalence of overlap between consti-
such as visceral hypersensitivity, dysmotility, altered interactions of pation and FD or GERD, risk factors for such overlap, and the
gut and brain, dysregulated mucosal immunity, and so on. Probably influence of overlap on QOL. Of the 759 study subjects with con-
because of these shared pathophysiologic mechanisms, patients with stipation enrolled from 19 centers (59.4% of functional constipation
one FGID may also have other FGIDs, or complain of the cor- and 40.6% of constipation-predominant IBS [IBS-C]) 17.9% also
responding symptoms. Such overlap of FGIDs has been reported had GERD, 10.5% had FD, and 6.7% had both GERD and FD.
between functional dyspepsia (FD), gastroesophageal reflux disease On the other hand, 492 (64.8%) of the 759 subjects did not have
(GERD), and irritable bowel syndrome (IBS).1 Also, non-gastro- GERD or FD. Overlap with GERD or FD was more frequent in
intestinal (GI) diseases, including functional somatic syndromes those with IBS-C than in those with functional constipation. The
such as fibromyalgia and overactive bladder syndrome, can overlap authors also show that overlap was associated with such factors as
with FGIDs. The most frequent overlap has been reported between laxatives use, low intake of fiber, pulmonary diseases, and herniated
FD and IBS: studies have shown that 32% of patients with FD also nucleus pulposus. Constipated patients with overlaps with other
have IBS, and up to 37% of IBS patients also have FD.2,3 A Korean FGIDs also showed more severe symptoms, and constipation-as-
study has also reported an approximately 50% overlap between FD sociated or general QOL was poorer than those without. Although
and IBS.4 the authors did not subdivide FD and GERD-dividing FD into
However, whether constipation overlaps with common FGIDs epigastric pain syndrome and postprandial distress syndrome, and
such as FD and GERD has been infrequently investigated. In this GERD into erosive esophagitis, non-erosive reflux disease, reflux
edition of the Journal of Neurogastroenterology and Motility , the hypersensitivity, and functional heartburn, a previous study has re-
Received: September 17, 2017 Revised: None Accepted: September 22, 2017
is properly cited.
*Correspondence: Kang Nyeong Lee, MD, PhD
Department of Internal Medicine, Hanyang University College of Medicine, 222 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea
Tel: +82-2-2290-8339, Fax: +82-2-2290-8314, E-mail: leekn@hanyang.ac.kr

www.jnmjournal.org
485
Kang Nyeong Lee
ported that postprandial distress syndrome patients frequently suffer table bowel syndrome - are both diseases mutually exclusive? J Neurogas-
from IBS-C.6 troenterol Motil 2011;17:360-365.
3. Nakajima S, Takahashi K, Sato J, et al. Spectra of functional gastroin-
The question whether the various manifestations of constipated
testinal disorders diagnosed by Rome III integrative questionnaire in a
patients define a single disease entity, or rather are shared symptoms Japanese outpatient office and the impact of overlapping. J Gastroenterol
of two or more types of FGID, has not been clearly answered. Hepatol 2010;25(suppl 1):S138-S143.
Regardless, in managing patients with constipation, and with other 4. Park JM, Choi MG, Cho YK, et al. Functional gastrointestinal disorders
common FGIDs as well, overlap syndromes between constipa- diagnosed by Rome III questionnaire in Korea. J Neurogastroenterol
tion and GERD or FD should be recognized and considered. As Motil 2011;17:279-286.
5. Park KS, Jee SR, Lee BE, et al. Nationwide multicenter study for over-
shown by this study, patients with overlap syndromes tend to com-
laps of common functional gastrointestinal disorders in Korean patients
plain of severer symptoms7 as well as psychological comorbidities8 with constipation. J Neurogastroenterol Motil 2017;23:569-577.
and poorer QOL.9 Although there is no consensus on the optimal 6. Talley NJ, Dennis EH, Schettler-Duncan VA, Lacy BE, Olden KW,
management of patients with overlap syndromes, appropriate medi- Crowell MD. Overlapping upper and lower gastrointestinal symptoms
cations, such as motility modulators and pain modulators, should in irritable bowel syndrome patients with constipation or diarrhea. Am J
be selected.10,11 Importantly, management of patients with such Gastroenterol 2003;98:2454-2459.
7. Corsetti M, Caenepeel P, Fischler B, Janssens J, Tack J. Impact of co-
overlaps should also be focused on psychological factors influencing
existing irritable bowel syndrome on symptoms and pathophysiological
QOL, because their responses to general treatments are likely to be mechanisms in functional dyspepsia. Am J Gastroenterol 2004;99:1152-
poorer than those of patients with constipation alone. 1159.
8. Piacentino D, Cantarini R, Alfonsi M, et al. Psychopathological features
of irritable bowel syndrome patients with and without functional dyspep-
Financial support: None. sia: a cross sectional study. BMC Gastroenterol 2011;11:94.
9. Kaji M, Fujiwara Y, Shiba M, et al. Prevalence of overlaps between
Conflicts of interest: None. GERD, FD and IBS and impact on health-related quality of life. J Gas-
troenterol Hepatol 2010;25:1151-1156.
10. Drossman DA. Beyond tricyclics: new ideas for treating patients with
References painful and refractory functional gastrointestinal symptoms. Am J Gas-
1. Fujiwara Y, Arakawa T. Overlap in patients with dyspepsia/functional troenterol 2009;104:2897-2902.
dyspepsia. J Neurogastroenterol Motil 2014;20:447-457. 11. Sperber AD, Drossman DA. Review article: the functional abdominal
2. Suzuki H, Hibi T. Overlap syndrome of functional dyspepsia and irri- pain syndrome. Aliment Pharmacol Ther 2011;33:514-524.

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Review
Understanding the Chicago Classification:

From Tracings to Patients
Francisco Schlottmann,1* Fernando A Herbella,2 and Marco G Patti1

1
Department of Surgery and Center for Esophageal Diseases, University of North Carolina, Chapel Hill, NC, USA; and 2Department of Surgery,
Escola Paulista de Medicina, Federal University of Sao Paulo, Sao Paulo, Brazil
Current parameters of the Chicago classification include assessment of the esophageal body (contraction vigour and peristalsis), lower
esophageal sphincter relaxation pressure, and intra-bolus pressure pattern. Esophageal disorders include achalasia, esophagogastric
junction outflow obstruction, major disorders of peristalsis, and minor disorders of peristalsis. Sub-classification of achalasia in types
I, II, and III seems to be useful to predict outcomes and choose the optimal treatment approach. The real clinical significance of other
new parameters and disorders is still under investigation. (J Neurogastroenterol Motil 2017;23:487-494)
Key Words
Chicago classification; Esophageal achalasia; Esophageal motility disorders; High-resolution manometry
scheme for the diagnosis of esophageal motility disorders in esopha-

geal pressure topography plots, under the name of the Chicago
Introduction classification.3 This allowed for improved recognition of motility
High-resolution manometry (HRM) provides an intuitive and disorders, and easier interpretation than conventional manometry
panoramic view of the proximal digestive physiology from the phar- line tracings.
ynx to the stomach (Fig. 1). As compared to conventional manom- The Chicago classification was recently revised (version 3.0) to
etry, HRM determines more comfort and speediness to the test, exclude some previous parameters without clear clinical application,
reduces inter-observer variability, and compensates movements’ ar- define parameters to be used, and classify esophageal motility disor-
tefacts. These improvements allow a better evaluation of sphincters ders.4
relaxation, and the identification of segmental defects of peristalsis The aim of this study was to review the Chicago classification
not covered by the spacing of sensors in conventional systems.1,2 version 3.0, and assess the clinical implications of the parameters
The more comprehensive and more appealing to the eyes and disorders defined by this classification.
HRM plots provoked the imagination of esophageal physiologists
to create new investigative parameters and reclassify esophageal
motility disorders. This led to the development of an algorithmic
Received: February 22, 2017 Revised: April 26, 2017 Accepted: June 9, 2017
is properly cited.
*Correspondence: Francisco Schlottmann, MD
University of North Carolina at Chapel Hill, 4030 Burnett Womack Building, 101 Manning Drive, CB 7081, Chapel Hill, NC 27599-
7081, USA
Tel: +1-919-966-8436, Fax: +1-919-966-8440, E-mail: fschlottmann@hotmail.com

www.jnmjournal.org
487
Francisco Schlottmann, et al
mmHg
200.0
180
160
140
120
100
80
60
50
40
Figure 1. Normal high-resolution

30
20
10
0
manometry plot (left) compared to the
10
20
same swallow at the conventional ma-
25.0 nometry (right).
mmHg mmHg
200.0 200.0
190 190
180
180
170
170
160
160 150
150 140
140 130
130 120
110
120
100
110
90
100
80
90 70
80 60
55
70 50
45
60 40
55 35
50 30
25
45 20
40 15
35 10
30 5
25 0
20
15 6.0
10
5
0
8.0 Figure 3. Distal latency (DL) measures objectively the time frame of
the wave from the beginning of the swallow (upper esophageal relax-
Figure 2. Distal contractile integral (DCI). DCI value is calculated as ation) to the contractile deceleration point (CDP).
the product of the mean amplitude of contraction in the distal esopha-
gus (mmHg) times the duration of contraction (seconds) times the
length of the distal oesophageal segment (cm) exceeding 20 mmHg parameter is the distal contractile integral (DCI). DCI value is cal-
for the region spanning from the transition zone to the proximal aspect culated as the product of the mean amplitude of contraction in the
of the lower esophageal sphincter. distal esophagus (mmHg) times the duration of contraction (sec-
onds), times the length of the distal esophageal segment (cm) ex-
ceeding 20 mmHg for the region spanning from the transition zone
to the proximal aspect of the lower esophageal sphincter (LES) (Fig.
Parameters Evaluated by High-resolution 2). DCI classifies waves as failed (DCI < 100 mmHg ∙ sec ∙ cm),
Manometry weak (DCI 100-450 mmHg ∙ sec ∙ cm), ineffective (failed or weak),
normal (DCI 450-8000 mmHg ∙ sec ∙ cm), or hypercontractile (DCI
Esophageal Body > 8000 mmHg ∙ sec ∙ cm).5
Contraction vigour Peristalsis

HRM allows the evaluation of contractility not only by am- HRM evaluates peristalsis by the distal latency (DL) which
plitude measurement at fixed points, but through a combination measures objectively the timeframe of the wave from the beginning
of amplitude, time and length of the whole peristaltic wave. This of the swallow (upper esophageal sphincter relaxation) to an inflection

Understanding the Chicago Classification
of the peristaltic axis known as the contractile deceleration point (Fig. length or basal pressure, but simply recommended assessment of
3). Premature contractions are defined with a DL < 4.5 seconds. pressure as an average of inspiratory and expiratory values for 3
Fragmented contractions are considered segmental defects normal respiratory cycles. Relaxation, however, is measured not by
(break in the 20 mmHg isobaric contour > 5 cm) with normal the nadir pressure as previously done with conventional manometry,
contraction vigour. but with the integrated relaxation pressure (IRP) that corresponds
Table summarizes esophageal body parameters evaluated with to the mean pressure of 4 seconds of greatest post deglutitive relax-
HRM.
Lower Esophageal Sphincter mmHg

150.0
140
Lower esophageal sphincter pressure 130
The Chicago classification did not define parameters for LES 120
110
100
90
80
Table. Characterization of Esophageal Contractility 70
Contraction vigour
60
50
Failed DCI < 100 mmHg ∙ sec ∙ cm 40

35
Weak DCI 100-450 mmHg ∙ sec ∙ cm 30
25
20
Ineffective Failed or weak 15
10
Normal DCI 450-8000 mmHg ∙ sec ∙ cm 5
0
Hypercontractile DCI > 8000 mmHg ∙ sec ∙ cm 10.0
5
Contraction pattern
Premature DL < 4.5 sec
Figure 4. Integrated relaxation pressure (IRP) corresponds to the
Fragmented Break > 5 cm in the 20 mmHg isobaric
mean pressure of 4 seconds of greatest post deglutitive relaxation in
contour with normal DCI
a 10 seconds gap, triggered at the beginning of a swallow. Note dia-
Intact Not achieving the above criteria phragmatic contraction pressure (*) during relaxation excluded from
DCI, distal contractile integral; DL, distal latency. analysis.
Type I Type II Type III
Figure 5. Achalasia subtypes. Type I: absence of esophageal pressurization; Type II: panesophageal pressurization; Type III: premature contrac-
tions (distal latency < 4.5 seconds).
Vol. 23, No. 4 October, 2017 (487-494) 489

ation in a 10 seconds gap, triggered at the beginning of a swallow mmHg

150.0
(Fig. 4). This metric compensates for diaphragmatic contraction 140
during LES relaxation, and eliminates pseudo-relaxation due to 130

120
movement artefacts. 110
100
Intrabolus Pressure Pattern

90
80
Abnormal intrabolus pressure corresponds to regions of 70

60
esophageal pressurization > 30 mmHg. It may be panesophageal 50
(whole esophageal body), compartmentalized (from the contractile 40

35
30
deceleration point to the esophagogastric junction [EGJ]) or EGJ 25
20
15
pressurization (between the LES and the diaphragm). 10
5
0
5
10.0
Esophageal Motility Disorders

Figure 6. Distal esophageal spasm. Premature contractions (distal
latency [DL] < 4.5 seconds) in at least 20% of swallows.
Achalasia
Achalasia is defined by aperistalsis and abnormal LES relax-
mmHg
150.0
140
130
120
110
100
90
80
70
60
50
40
35
30
25
20
15
Figure 7. Hypercontractile esopha-
10
5 gus (jackhammer esophagus). Distal
0
5 contractile integral (DCI) > 8000
10.0
mmHg ∙ sec ∙ cm in at least 20% of swal-
lows and normal distal latency (DL).
mmHg
150.0
140
130
120
110
100
90
80
70
60
50
40
35
30
25
20
Figure 8. Absent contractility. Aperistal-
15
10
5
0
5 sis in the setting of normal lower esoph-
10.0
ageal sphincter relaxation (integrated
relaxation pressure < 10 mmHg).

mmHg
150.0
140
130
120
110
100
90
80
70
60
50
40
35
30
25
20
15
10
5
0
5
10.0
Figure 9. Ineffective esophageal motility. Failed or weak peristalsis in at least ≥ 50% of swallows. DCI, distal contractile integral.
ation (IRP > 15 mmHg). The disease is further classified into 3 mmHg
200.0
subtypes (Fig. 5). 190

180
170
Type I: incomplete LES relaxation, aperistalsis and absence of 160

150
esophageal pressurization. 140
Type II: incomplete LES relaxation, aperistalsis and panesoph-

130
120
ageal pressurization in at least 20% of swallows. 110

100
Type III: incomplete LES relaxation and premature contrac- 90
tions (DL < 4.5 seconds) in at least 20% of swal- 80

70
lows. 60
55
50
45
40
Esophagogastric Junction Outflow Obstruction

35
30
25
20
EGJ obstruction is characterized by an impaired LES relax-
15
10
5
0
ation (IRP > 15 mmHg) with normal or weak peristalsis. 7.0
Major Disorders of Peristalsis Figure 10. Fragmented peristalsis. ≥ 50% fragmented contractions
with distal contractile integral (DCI) > 450 mmHg ∙ sec ∙ cm.
Distal esophageal spasm
Distal esophageal spasm (DES) is defined by premature con- Absent contractility
tractions (DL < 4.5 seconds) in at least 20% of swallows with a Absent contractility is characterized by aperistalsis in the setting
normal IRP (Fig. 6). of normal LES relaxation (IRP < 10 mmHg) (Fig. 8).
Hypercontractile esophagus Minor Disorders of Peristalsis

Hypercontractile esophagus (jackhammer esophagus) is char-
acterized by DCI > 8000 mmHg ∙ sec ∙ cm in at least 20% of swal- Ineffective esophageal motility
lows and normal DL (Fig. 7). Ineffective esophageal motility is defined by ≥ 50% ineffective
Vol. 23, No. 4 October, 2017 (487-494) 491

swallows (failed or weak––DCI < 450 mmHg ∙ sec ∙ cm) (Fig. 9). to the ability to a longer myotomy of the thoracic esophagus.
Overall, sub-classification of achalasia in types I, II, and III
Fragmented peristalsis with the Chicago classification seems to be useful to predict out-
Fragmented peristalsis is defined by ≥ 50% fragmented con- comes and choose the optimal treatment approach for this motility
tractions with normal contraction vigour (Fig. 10). disorder.
Esophagogastric Junction Outflow Obstruction

Impact of High-resolution Manometry on The definition of EGJ outflow obstruction based solely on
the Management of Esophageal Motility the IRP with the exclusion of achalasia allows this diagnosis to
Disorders be superimposed to other diagnoses dependent of the esophageal
The Chicago classification reclassified motility disorders previ- body motility. It may be caused by an anatomical abnormality at the
ously defined by conventional manometry.6 The clinical value of this cardia (hiatal hernia, diseases of the esophageal wall, etc) or be idio-
new classification is under scrutiny. A recent publication claims that pathic with normal anatomy.
the Chicago classification has a higher threshold for abnormality, Similar to achalasia, treatment is directed towards relief of the
resulting in fewer patients classified as abnormal motility.7 On the obstruction and can be accomplished by botulinum toxin injection,
other hand, a recent study that randomized patients with dyspha- PD, LHM, or POEM. Both botulinum injection and PD showed
gia to undergo either HRM or conventional manometry, found a good relief of dysphagia but with ephemeral duration.15 Scherer and
higher proportion of manometric diagnosis in the HRM arm.8 colleagues,16 among 1000 HRM diagnosed 16 patients (1.6%) with
EGJ outflow obstruction and treated them with botulinum toxin
Achalasia injection, PD or LHM. Only the 3 patients treated with LHM
The current main therapeutic options for achalasia include responded well.16 Interestingly, Pérez-Fernández et al17 reported
pneumatic dilatation (PD), peroral endoscopic myotomy (POEM), that over one-third of the patients with EGJ outflow obstruction
and laparoscopic Heller myotomy (LHM).9 presented a spontaneous resolution of the symptoms, concluding
The Chicago classification may help to predict the result of that surgical treatment should be considered with special caution in
treatment. Pandolfino and colleagues10 reported that type II achala- these patients. In the setting of an anatomic abnormality such as a
sia patients were significantly more likely to respond to PD (91%) hiatal hernia, surgical correction is associated with long-lasting and
or LHM (100%), as compared to type I (56% overall) and type excellent results.18
III (29% overall). Concordantly, Salvador et al11 evaluated 246 con- EGJ outflow obstruction is now recognized as a distinct entity
secutive patients who underwent LHM and found that treatment in the Chicago classification. However, the real clinical significance
failure rates were significantly different among the subtypes of acha- of this diagnosis is still uncertain. In fact, it could be an early or
lasia: type I (14.6%), type II (4.7%), and type III (30.4%) (P = incomplete expression of a variant of achalasia. Thus, the exact sig-
0.0007). A recent meta-analysis encompassing 9 studies and 727 nificance and clinical management of these patients remains unclear.
patients also showed that type II achalasia was associated with the
best prognosis after PD and LHM, while type III achalasia had Major Disorders of Peristalsis
the worst prognosis.12 As the symptoms and the manometric picture of esophageal
The Chicago classification may also help selecting the best ini- motility disorders can be due to gastroesophageal reflux disease
tial approach for patients with achalasia. Kumbhari and colleagues13 (GERD), it is of paramount importance to rule out abnormal reflux
reported that in patients with type III achalasia, clinical response by pH monitoring. If GERD is present, either medical or surgical
was achieved more frequently after POEM (98.0%), as compared treatment should be directed towards the control of the reflux.19
to LHM (80.8%) (P = 0.01). Recently, Khashab et al14 reported The management of DES remains elusive. The Chicago classi-
their experience with POEM for the treatment of 54 patients fication defines this disorder with a new parameter: the DL. Previ-
with type III achalasia refractory to medical therapy, and showed a ous reports showed good results in patients with “diffuse esophageal
96.3% clinical success rate. Hence, while in type I and II achalasia spasm” (Richter classification)6 who underwent LHM with an
both PD and LHM remain as good treatment alternatives, type III extended myotomy.20,21 However, scarce data are available after the
achalasia seems to be better managed with POEM, probably due new classification defined DES. A review of the publications after

this definition became publicized showed that botulinum toxin Financial support: None.
injection in the esophageal body was superior to placebo to relieve
dysphagia in patients with DES, and that POEM is a promising Conflicts of interest: None.
treatment for these patients.22 Author contributions: Francisco Schlottmann, Fernando A
The definition of hypercontractile esophagus (jackhammer ) Herbella, and Marco G Patti planned conception and design,
was updated in the last version of the Chicago classification to drafted the article, and approved the final article.
include only cases with ≥ 20% of swallows with a DCI > 8000
mmHg ∙ sec ∙ cm, excluding a single altered swallow from the
definition. Pharmacological relaxation of the smooth muscle with References
phosphodiesterase-5 inhibitor or anticholinergic agents has shown
1. Herbella FA, Patti MG. Can high resolution manometry parameters for
symptomatic improvement.23 Studies focusing on surgical therapy
achalasia be obtained by conventional manometry? World J Gastrointest
for hypercontractile esophagus based on the new classification are Pathophysiol 2015;15:58-61.
not available. Previous reports not using HRM or the Chicago 2. Herbella FA, Armijo PR, Patti MG. [A pictorial presentation of 3.0
classification, however, showed acceptable outcomes after surgical Chicago classification for esophageal motility disorders.] Einstein (Sao
myotomy.24,25 Paulo) 2016;14:439-442.[English, Portuguese]
Absent contractility is mostly diagnosed in patients with con- 3. Kahrilas PJ, Ghosh SK, Pandolfino JE. Esophageal motility disorders in
terms of pressure topography: the Chicago classification. J Clin Gastroen-
nective tissue diseases. There is no specific treatment to restore or
terol 2008;42:627-635.
improve peristalsis in these patients. Associated GERD is usually 4. Kahrilas PJ, Bredenoord AJ, Fox M, et al. The Chicago classifica-
the target of therapy.26 tion of esophageal motility disorders, v3.0. Neurogastroenterol Motil
2015;27:160-174.
Minor Disorders of Peristalsis 5. Roman S, Pandolfino JE, Chen J, Boris L, Luger D, Kahrilas PJ. Phe-
Therapeutic options for ineffective esophageal motility are still notypes and clinical context of hypercontractility in high-resolution esoph-
ageal pressure topography (EPT). Am J Gastroenterol 2012;107:37-45.
limited, as no effective treatment is available to restore impaired
6. Richter JE. Oesophageal motility disorders. Lancet 2001;358:823-828.
esophageal smooth muscle contractility.27 Treatment directed to- 7. Monrroy H, Cisternas D, Bilder C, et al. The Chicago classification 3.0
wards GERD is helpful when dysmotility is secondary to this dis- results in more normal findings and fewer hypotensive findings with no
ease. difference in other diagnoses. Am J Gastroenterol 2017;112:606-612.
The concept of fragmented peristalsis changed radically from 8. Roman S, Huot L, Zerbib F, et al. High-resolution manometry improves
previous versions to the version 3.0. Only large breaks (> 5 cm) the diagnosis of esophageal motility disorders in patients with dysphagia:
a randomized multicenter study. Am J Gastroenterol 2016;111:372-380.
with normal peristalsis are included. This is more clinically relevant,
9. Herbella FA, Moura EG, Patti MG. Achalasia 2016: treatment alterna-
since incomplete bolus transit is observed in 100% of the cases of tives. J Laparoendosc Adv Surg Tech A 2017;27:6-11.
large breaks but only in 16% of small breaks.28 It is unclear how to 10. Pandolfino JE, Kwiatek MA, Nealis T, Bulsiewicz W, Post J, Kahrilas
treat this finding since there are no studies focusing on the treat- PJ. Achalasia: a new clinically relevant classification by high-resolution
ment for this disease under these criteria. There are no studies manometry. Gastroenterology 2008;135:1526-1533.
evaluating changes in the motility pattern after therapy for GERD 11. Salvador R, Costantini M, Zaninotto G, et al. The preoperative mano-
metric pattern predicts the outcome of surgical treatment for esophageal
as well, since both conditions are frequently associated.
achalasia. J Gastrointest Surg 2010;14:1635-1645.
12. Ou YH, Nie XM, Li LF, Wei ZJ, Jiang B. High-resolution manomet-
ric subtypes as a predictive factor for the treatment of achalasia: a meta-
Conclusions analysis and systematic review. J Dig Dis 2016;17:222-235.
HRM and the Chicago classification certainly contributed to 13. Kumbhari V, Tieu AH, Onimaru M, et al. Peroral endoscopic myotomy
a better definition of esophageal motility disorders. Particularly for (POEM) vs laparoscopic heller myotomy (LHM) for the treatment of
type III achalasia in 75 patients: a multicenter comparative study. Endosc
achalasia, sub-classification in types I, II, and III seems to be useful
Int Open 2015;3:E195-E201.
to predict outcomes and choose the optimal treatment approach. 14. Khashab MA, Messallam AA, Onimaru M, et al. International multi-
The real clinical significance of other new parameters and disorders center experience with peroral endoscopic myotomy for the treatment of
is still under investigation. spastic esophageal disorders refractory to medical therapy (with video).
Gastrointest Endosc 2015;81:1170-1177.
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15. van Hoeij FB, Smout AJ, Bredenoord AJ. Characterization of idiopathic spasm. Br J Surg 2007;94:1113-1118.
esophagogastric junction outflow obstruction. Neurogastroenterol Motil 22. Roman S, Kahrilas PJ. Distal esophageal spasm. Curr Opin Gastroen-
2015;27:1310-1316. terol 2015;31:328-333.
16. Scherer JR, Kwiatek MA, Soper NJ, Pandolfino JE, Kahrilas PJ. 23. Hong YS, Min YW, Rhee PL. Two distinct types of hypercontractile
Functional esophagogastric junction obstruction with intact peristalsis: a esophagus: classic and spastic jackhammer. Gut Liver 2016;10:859-863.
heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg 24. Patti MG, Pellegrini CA, Arcerito M, Tong J, Mulvihill SJ, Way LW.
2009;13:2219-2225. Comparison of medical and minimally invasive surgical therapy for
17. Pérez-Fernández MT, Santander C, Marinero A, Burgos-Santamaría D, primary esophageal motility disorders. Arch Surg 1995;130:609-615;
Chavarría-Herbozo C. Characterization and follow-up of esophagogas- discussion 615-616.
tric junction outflow obstruction detected by high resolution manometry. 25. Herbella FA, Tineli AC, Wilson JL Jr, Del Grande JC. Surgical treat-
Neurogastroenterol Motil 2016;28:116-126. ment of primary esophageal motility disorders. J Gastrointest Surg
18. DeLay K, Austin GL, Menard-Katcher P. Anatomic abnormalities are 2008;12:604-608.
common potential explanations of manometric esophagogastric junction 26. Menezes MA, Herbella FA, Patti MG. Laparoscopic antireflux surgery
outflow obstruction. Neurogastroenterol Motil 2016;28:1166-1171. in patients with connective tissue diseases. J Laparoendosc Adv Surg
19. Herbella FA, Raz DJ, Nipomnick I, Patti MG. Primary versus second- Tech A 2016;26:296-298.
ary esophageal motility disorders: diagnosis and implications for treat- 27. Scheerens C, Tack J, Rommel N. Buspirone, a new drug for the manage-
ment. J Laparaoendosc Adv Surg Tech A 2009;19:195-198. ment of patients with ineffective esophageal motility? United European
20. Patti MG, Gorodner MV, Galvani C, et al. Spectrum of esophageal Gastroenterol J 2015;3:261-265.
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2005;140:442-448; discussion 448-449. of partial and total laparoscopic fundoplication on esophageal body motil-
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set B. Functional results after extended myotomy for diffuse oesophageal

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Review
Reflux Hypersensitivity: A New Functional

Esophageal Disorder
Takahisa Yamasaki and Ronnie Fass*

Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth Medical
Center, Cleveland, OH, USA
Reflux hypersensitivity, recently introduced by Rome IV as a new functional esophageal disorder, is currently considered as the
presence of typical heartburn symptoms in patients with normal upper endoscopy and esophageal biopsies, normal esophageal pH
test and with evidence of a close correlation between patients’ heartburn and reflux events. Reflux hypersensitivity is very common
and together with functional heartburn accounts for more than 90% of the heartburn patients who failed treatment with proton
pump inhibitor twice daily. In addition, reflux hypersensitivity affects primarily young to middle aged women, commonly overlaps with
another functional gastrointestinal disorders, and is often associated with some type of psychological comorbidity. Diagnosis is made
by using endoscopy with esophageal biopsies, pH-impedance, and high-resolution esophageal manometry. Reflux hypersensitivity
is primarily treated with esophageal neuromodulators, such as tricyclic anti-depressants and selective serotonin reuptake inhibitors
among others. Surgical anti-reflux management may also play an important role in the treatment of reflux hypersensitivity.
Key Words
Chest pain; Esophagus; Functional esophageal disorder; Heartburn; Reflux hypersensitivity
geal mucosa on upper endoscopy. Rome II suggested that patients

with heartburn and normal endoscopy are divided into patients
Introduction with NERD (abnormal esophageal acid exposure) and those with
The composition and definition of functional esophageal dis- functional heartburn (normal esophageal acid exposure).2 The
orders have evolved over the years, primarily driven by the widely
accepted Rome criteria. Presently, there are 5 functional esophageal
disorders, functional heartburn, functional chest pain, reflux hyper- Table 1. Functional Esophageal Disorders (Rome IV)
sensitivity, globus, and functional dysphagia (Table 1).1 Functional chest pain
The evolution of the definitions of non-erosive reflux disease Functional heartburn
(NERD), functional heartburn, and recently reflux hypersensitiv- Reflux hypersensitivity
ity, went in tandem with our improved capability to physiologically Globus
Functional dysphagia
assess patients with heartburn who demonstrated normal esopha-
Received: August 23, 2017 Revised: None Accepted: September 8, 2017

is properly cited.
*Correspondence: Ronnie Fass, MD
Division of Gastroenterology and Hepatology, Esophageal and Swallowing Center, Case Western Reserve University, MetroHealth
Medical Center, 2500 MetroHealth Drive, Cleveland OH 44109, USA
Tel: +1-216-778-3145, E-mail: rfass@metrohealth.org

www.jnmjournal.org
495
functional heartburn group was further divided into patients with association indexes. More importantly, Rome IV recognized that
reflux related symptoms (hypersensitive esophagus) and those with diagnosis of a functional esophageal disorder may take place while
heartburn unrelated to reflux symptoms. Rome III, on the other the patient is on anti-reflux treatment. In addition, Rome IV sug-
hand, proposed that patients with heartburn and normal endoscopy gests for the first time the possibility of having functional heartburn
are divided into those with NERD and those with functional heart- or reflux hypersensitivity overlapping with gastroesophageal reflux
burn.3 However, unlike Rome II, Rome III divided NERD into disease (GERD).4 Figure 1 summarizes the evolution of reflux hy-
3 subgroups: patients with abnormal esophageal acid exposure, the persensitivity from Rome II to Rome IV.
hypersensitive esophagus group, and patients with non-reflux re- As a group, functional esophageal disorders are characterized
lated symptoms who are responsive to proton pump inhibitor (PPI) by the presence of chronic symptoms attributed to the esophagus
treatment. In contrast, Rome IV proposed the introduction of the without evidence of structural, inflammatory, motor or metabolic
reflux hypersensitivity group (formerly called the hypersensitive disorder as the underlying etiology. According to the Rome IV
esophagus) as a new functional esophageal disorder.1 Consequently, criteria, diagnosis of a functional esophageal disorder requires hav-
the group of NERD was reduced to only include patients with ab- ing symptoms for the past 3 months with symptom onset at least
normal esophageal acid exposure with or without positive symptom 6 months before diagnosis. Non-esophageal causes for symptoms
A Rome II B Rome III

Heartburn and normal endoscopy Heartburn and normal endoscopy
NERD Functional heartburn NERD Functional heartburn
Reflux hypersensitivity Non-reflux related Reflux hypersensitivity Abnormal acid Non-reflux related heartburn
(hypersensitive esophagus) heartburn (hypersensitive esophagus) exposure responsive to PPI
C Rome IV
Heartburn
Normal endoscopy and biopsies
Unproven GERD
Off PPI
pH monitoring + impedance
Normal acid exposure Normal acid exposure Abnormal acid exposure

Negative symptom Positive symptom Positive or negative symptom
reflux association reflux association reflux association
Functional heartburn Reflux hypersensitivity NERD
Figure 1. The evolution of reflux hypersensitivity. NERD, non-erosive reflux disease; PPI, proton pump inhibitor; GERD, gastroesophageal re-
flux disease.

Reflux Hypersensitivity: A New Functional Esophageal Disorder
should be excluded first before esophageal etiology is entertained. sessment is done off or on therapy.
GERD, major esophageal motility disorders, and eosinophilic
esophagitis may be responsible for chronic heartburn symptoms.
Hence, it is imperative that these conditions be ruled out before a
Epidemiology
diagnosis of any of the aforementioned functional esophageal disor- Studies have demonstrated that up to 70% of patients with
ders is established. heartburn have normal endoscopy.6 Of those, 50% have an abnor-
Although benign in nature, functional esophageal disorders mal pH test and thus belong to the NERD group. The other 50%
including reflux hypersensitivity cause considerable impairment are divided into functional heartburn (60%) and reflux hypersensi-
in quality of life and result in a significant economic burden on the tivity (40%). Thus, reflux hypersensitivity accounts for 14% of all
health care system. Additionally, the limited understanding of the patients presenting with heartburn (Fig. 2).
pathophysiologic basis of these conditions commonly results in Several recent studies, using pH-impedance monitoring
frustration of patients as well as physicians. Moreover, therapies are evaluated the prevalence of reflux hypersensitivity. Savarino et al7
mainly empiric in nature and, in many cases, of limited value. assessed 329 endoscopy negative patients with a pH-impedance
monitoring off PPI treatment. The authors demonstrated that 40%
of the patients had NERD, 24% functional heartburn, and 36%
Definition reflux hypersensitivity. The higher prevalence of reflux hypersensi-
Known in the past as the hypersensitive esophagus group, tivity in non-treated heartburn patients in this study likely reflects
reflux hypersensitivity is a new functional esophageal disorder that the incorporation of non-acidic reflux into the symptom indexes.
was introduced for the first time by Rome IV.5 The prevalence of reflux hypersensitivity in patients with heart-
Based on the Rome IV criteria, the definition of reflux hyper- burn who failed PPI twice a day varies greatly. Savarino et al8 dem-
sensitivity includes retrosternal symptoms including heartburn or onstrated in a retrospective study that 28% of the patients had reflux
chest pain, normal endoscopy, and absence of eosinophilic esophagi- hypersensitivity and 39% functional heartburn. Patel et al9 reported
tis or major esophageal motor disorders (achalasia, esophagogastric that 29% of 266 refractory heartburn patients were found to have
junction outflow obstruction, distal esophageal spasm, jackhammer positive symptom association probability (SAP) with acidic reflux,
esophagus, and absent contractility) as the etiology of symptoms, weakly acidic reflux or both. Importantly, 6.50% had positive SAP
and evidence of triggering of symptoms by reflux events despite only for acid reflux, 50.65% for weakly acidic reflux, and 42.86%
normal acid exposure on pH or pH-impedance monitoring (Table for both. In another study, the authors demonstrated that 35.90% of
2).5 Criteria must be fulfilled for the last 3 months, with symptom 78 refractory heartburn patients who failed PPI twice-daily had re-
onset at least 6 months prior to diagnosis with a frequency of at least flux hypersensitivity.10 The last 2 trials suggest that both functional
twice a week. Importantly, response to anti-secretory therapy does heartburn and reflux hypersensitivity account for more than 90%
not exclude the diagnosis. In addition, like functional heartburn, of the heartburn patients who failed twice-daily PPI. Thus, the in-
reflux hypersensitivity may overlap with GERD.5 troduction of Rome IV criteria for functional esophageal disorders
The definition of reflux hypersensitivity emphasizes the need clarified the main underlying mechanisms for failure of PPI treat-
for positive symptom indexes to acidic or nonacidic reflux in the ment and consequently allowed new therapeutic options for these
context of normal esophageal acid exposure, regardless if reflux as- challenging patients.
Table 2. Diagnostic Criteria for Reflux Hypersensitivity (Rome IV)
Must include all of the following:

1. Retrosternal symptoms including heartburn and chest paina
2. Normal endoscopy and absence of evidence that eosinophilic esophagitis is the cause of the symptoms
3. Absence of major esophageal motor disordersb
4. Evidence of triggering of symptoms by reflux events despite normal acid exposure on pH or pH-impedance monitoringc
a
Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis with a frequency of at least twice a week.
b
Achalasia/esophagogastric junction outflow obstruction, diffuse esophageal spasm, jackhammer esophagus, and absent peristalsis.
c
Response to anti-secretory therapy dose not exclude the diagnosis.
Vol. 23, No. 4 October, 2017 (495-503) 497

Heartburn
Upper endoscopy
30% 70%
Erosive esophagitis Normal endoscopy
pH test
50% 50%
Abnormal pH test Normal pH test

Non-erosive reflux disease
Symptom indexes
40% 60%
Positive Negative
reflux hypersensitivity functional heartburn
(overall, 14% of all heartburn patients)
Figure 2. Percentage of functional heartburn patients among patients with normal endoscopy.
Altered central processing of

esophageal stimuli
CNS Altered autonomic activity
Psychological comorbidity
Peripheral sensitization
Spinal cord Central sensitization
Esophagus
Stomach
14
Figure 3. Underlying mechanisms for esophageal hypersensitivity in reflux hypersensitivity. Adapted from Miwa et al.
demonstrating increased chemo- and mechano-receptor sensitivity

to acid perfusion and balloon distension, respectively, as compared
Pathophysiology
with healthy subjects, patients with NERD, and those with func-
Assessments of the underlying mechanisms for reflux hyper- tional heartburn.12
sensitivity have been relatively scarce. As with the other functional Other proposed underlying mechanisms for reflux hypersen-
esophageal disorders, esophageal hypersensitivity due to peripheral sitivity include altered central processing of esophageal stimuli,
and/or central sensitization appears to be the main underlying hypervigilance, altered autonomic activity, and psychological com-
mechanism for symptom generation. Esophageal hypersensitivity is modity (Fig. 3).13,14
defined as the perception of non-painful esophageal stimuli as being What is unique about patients with reflux hypersensitivity as
painful and the perception of painful esophageal stimuli as being compared to those with functional heartburn is their sensitivity to
more painful.11 In one study, the authors demonstrated that the physiological amounts of gastroesophageal reflux. Originally, it was
reflux hypersensitivity group has the highest percentage of patients noted that the reflux hypersensitivity group is sensitive to physiolog-

ic levels of acidic reflux. The introduction of the pH-impedance test Regarding acid sensitive receptors, it was shown by immu-
revealed esophageal sensitivity to non-acid reflux as well in the con- nostaining that transient receptor potential vanilloid-1 (TRPV1)-
text of normal esophageal acid exposure. In one study, the authors positive nerve fibers are increased in erosive esophagitis mucosa. In
demonstrated that 29% of the patients (normal endoscopy and pH addition, an increased expression of TRPV1 has been demonstrated
test) had a positive SAP with acid reflux using pH testing alone.15 in NERD patients as well.20 Recently, Yoshida et al21 reported that
However, when using pH-impedance, the percentage increased esophageal hypersensitivity in NERD patients is related to neuro-
by an additional 19%, and thus 48% of the patients with normal genic inflammation with an increase in both substance P release and
esophageal acid exposure had positive SAP with acidic and /or non- neurokinin-1 receptor expression, which may be associated with the
acidic reflux. activation of TRPV1 and protease-activated receptor 2. These acid-
Studies have produced conflicting results regarding the role sensitive receptors are likely involved in esophageal hypersensitivity
of non-acidic reflux or proximal esophageal migration of gastro- of patients with reflux hypersensitivity.
esophageal reflux in reflux hypersensitivity. Savarino et al7 demon- Studies have also demonstrated that central factors, such as
strated that an increased number of weakly acidic reflux events and stress, hypervigilance psychological disorders, and poor sleep,
a high rate of proximal reflux are the main causes of symptoms in play an important role in enhancing perception of intraesophageal
reflux hypersensitivity patients who were evaluated with multichan- stimuli.22 Psychological factors have been shown to be an important
nel impedance (MII)-pH monitoring. In contrast, Tamura et al16 factor in the generation and exacerbation of the overlap syndrome
reported that the total and proximal acid reflux events were signifi- in functional gastrointestinal disorders.23 Acute psychological
cantly higher in NERD patients with abnormal esophageal acid stress has been shown to increase sensitivity to intraesophageal acid
exposure as compared with reflux hypersensitivity patients. In addi- perfusion in patients with GERD.24 The increase in perceptual
tion, another study compared high-resolution esophageal manom- responses to acid was associated with greater emotional response
etry (HREM) and MII-pH monitoring values between NERD to the stressor and was not related to the presence or absence of
and reflux hypersensitivity patients. The authors demonstrated that esophageal mucosal breaks. Recent daily stressful life events have
NERD and reflux hypersensitivity patients showed similar values been associated with symptom onset or exacerbation and may alter
on HREM. However, NERD patients had greater acid exposure perception thresholds for pain.5 Acute stress by itself can lead to
time, bolus exposure time, proximal and distal acid reflux events, increase in esophageal mucosal permeability and the development
and increased impairment of chemical clearance and mucosal integ- of dilated intraepithelial spaces.25,26 These mechanisms suggest a
rity than reflux hypersensitivity patients. The authors also showed complex relationship among stress, acid exposure, and esophageal
that distal non-acid reflux events were significantly more common hypersensitivity in generating reflux symptoms.
in reflux hypersensitivity patients as compared with NERD pa-
tients.17
Frazzoni et al18 developed pH-impedance related parameters,
Clinical Presentation
post-reflux swallow-induced peristaltic wave index, and mean The clinical presentation of reflux hypersensitivity is not dif-
nocturnal baseline impedance. The former parameter may assess ferent from the clinical presentation of functional heartburn pa-
esophageal chemical clearance and the latter mucosal integrity. tients. Many of the original studies, using the Rome II criteria for
While these parameters have not achieved wide use in clinical prac- functional heartburn, did not distinguish between the 2 groups of
tice and their clinical value remains to be determined, the authors patients. However, like functional heartburn, one cannot differ-
have demonstrated that both parameters were significantly lower entiate among any of the phenotypic presentations of GERD and
in NERD patients as compared to those with reflux hypersensitiv- heartburn-related functional esophageal disorders, using patients’
ity, and in both NERD and reflux hypersensitivity as compared to severity, frequency, or duration of heartburn symptoms.27 Overlap
those with functional heartburn.18 However, the definition of reflux symptoms with other functional bowel disorders, GERD and psy-
hypersensitivity used in this study included PPI responsiveness, chological comorbidity are not uncommon.5,28 A recent study sug-
which is not required by the Rome IV criteria. A recent study suggested that anxiety may be more common in reflux hypersensitivity
gested that reflux hypersensitivity patients demonstrate a hypercon- patients as compared with functional heartburn patients.29
tractile response of the distal esophagus due to acid swallowing as In one study, the authors demonstrated that 66.5% of reflux
compared with functional heartburn patients.19 hypersensitivity patients were woman, 15.1% smokers, 39.0% alco-
Vol. 23, No. 4 October, 2017 (495-503) 499

Refractory heartburn
Upper endoscopy Abnormal Treat mucosal abnormality
Normal
MII-pH monitoring on treatment or wireless

pH capsule off treatment
Abnormal acid exposure Normal acid exposure
Positive or negative Positive symptom association Negative symptom association

symptom association
Esophageal motility testing Esophageal motility testing

GERD/NERD
Major motor disorder No major motor disorder No major motor disorder Major motor disorder
Motility disorder Reflux hypersensitivity Functional heartburn Motility disorder
Figure 4. Diagnostic algorithm of reflux hypersensitivity in refractory heartburn patients (failed proton pump inhibitor twice daily). MII, multi-
channel impedance; GERD, gastroesophageal reflux disease; NERD, non-erosive reflux disease.
hol consumers, 47.7% with hiatal hernia, 4.1% Helicobacter pylori - Table 3. A Typical Wireless pH Capsule of a 52 Year Old Female
positive, 48.2% with irritable bowel syndrome diagnosis, 35.8% With Reflux Hypersensitivity, Who Failed Proton Pump Inhibitor
Twice Daily. The Test Was Done Off Treatment
with anxiety, 6.0% with depression, and the mean body mass index
was 24.1 kg/m2.30 Using multivariate logistic regression analysis as Fraction time pH < 4 (%)
Days
compared with GERD, the authors found that female gender, irri- Upright Supine Total
table bowel syndrome diagnosis, hiatal hernia, H. pylori status, and Day #1 2.6 0.0 1.4
anxiety are associated with reflux hypersensitivity. However, more Day #2 1.3 0.0 0.8
studies were needed to better describe the typical demographics of Combined 1.9 0.0 1.1
reflux hypersensitivity patients. Heartburn (%) Chest pain (%)
Symptom index 22.2 50.0
Diagnosis Symptom association probability 99.9 99.6
The process of diagnosing reflux hypersensitivity is similar to

the algorithm required for diagnosing functional heartburn. Rome done off PPI treatment. In case any of the aforementioned tests is
IV proposed 2 diagnostic pathways for reflux hypersensitivity: one normal, symptom indexes should be assessed and, if positive, then
in patients on anti-reflux treatment and the other in patients off anti- the diagnosis of reflux hypersensitivity is established. All patients
reflux treatment.5 In patients on PPI treatment, assessment should should undergo HREM to exclude major esophageal motor
start with an upper endoscopy and biopsies to rule out eosinophilic disorders. In patients with a history of GERD (abnormal upper
esophagitis. If the test is normal, then the GERD history of the endoscopy and/or abnormal pH test), the diagnosis would be reflux
patient will determine the next step. If the patient has a positive his- hypersensitivity that is overlapping with GERD (Fig. 4). Table 3
tory of GERD (abnormal endoscopy and/or pH testing), then pH- demonstrates a typical wireless pH capsule result.
impedance on PPI treatment should be performed. If the patient In patients with burning retrosternal discomfort or pain who
has no history of GERD, then a wireless pH capsule should be are not on anti-reflux medication, then the diagnostic algorithm is

basically similar to those on anti-reflux treatment, except the patients very carefully selected patients.
should undergo pH testing using the wireless pH capsule. As with all functional esophageal disorders, neuromodulators
are considered to be the cornerstone of therapy of reflux hypersen-
sitivity. However, there are almost no studies assessing their value in
Treatment this patient population.
Patients with reflux hypersensitivity will likely benefit from Tricyclic anti-depressants (TCA) have been shown to be ef-
assurance about the nature of their disorder. However, many pa- ficacious in controlling esophageal pain in patients with functional
tients may require further medical intervention, some with a more esophageal disorders (functional chest pain, globus, and non-
comprehensive approach. The latter may include psychologists or cardiac chest pain).11 Presently, there are no TCA studies in reflux
psychiatrists, alternative/complimentary medicine therapists, acu- hypersensitivity patients. The range of initial therapeutic dose is 10-
puncturists as well as other experts in functional medicine. 50 mg/day, and the range of maximal therapeutic dose is 25-150
Because patients with reflux hypersensitivity have symptoms mg/day. Dosing changes of TCAs should depend on symptom
that are triggered by reflux events, anti-reflux therapeutic modali- improvement and development of side effects. Generally, patients
ties have been considered as first line therapy. They include medi- are started on 5-10 mg once a day. Due to their anti-cholinergic
cal, endoscopic, and surgical interventions that are also used to and sedative side effects, TCAs are commonly administered before
treat GERD. The role of diet and lifestyle modification related to bedtime.
GERD in patients with reflux hypersensitivity remains unknown.31 Selective serotonin reuptake inhibitors (SSRIs) have also
Histamine-2 receptor antagonists (H2RA) have been shown to been shown to be efficacious in various patients with functional
reduce esophageal chemoreceptor sensitivity to acid.32 Ranitidine esophageal disorders including, functional chest pain, esophageal
(single 150 mg dose) significantly decreased esophageal sensitivity hypersensitivity, NERD, and refractory heartburn.37-41 It is the only
to acid infusion as compared with placebo in patients with Rome II- neuromodulator that was tested in patients with reflux hypersen-
defined functional heartburn.33 These studies suggest that patients sitivity. In a randomized, double-blind, placebo-controlled study,
with reflux hypersensitivity may benefit from a trial of H2RA. 75 patients with reflux hypersensitivity were randomized to receive
When patients with Rome II-defined functional heartburn received citalopram 20 mg or placebo. At the end of the follow-up period
PPI twice daily, only those with positive symptoms index (the reflux which lasted 6 months, 38.5% of the patients receiving citalopram
hypersensitivity group) responded to treatment.34 This study sug- and 66.7% of those receiving placebo continued to report heartburn
gests that further suppression of gastric acid and minimization of symptoms (P = 0.021).42 The study suggested that citalopram was
esophageal acid exposure may improve symptoms in patients with effective in controlling heartburn in patients with reflux hypersensi-
reflux hypersensitivity. It is unclear if standard dose twice-daily PPI tivity.
is a “ceiling dose,” like in GERD patients, or, in those with reflux SSRIs have only 5-hydroxytryptamine activity and thus have
hypersensitivity, an even higher dose may still have a therapeutic ef- less side effects as compared with TCAs. In addition, this class of
fect. drugs is better tolerated than TCAs. Dosing (initial and maximal
It has been reported that patients with a positive symptom dose) of SSRIs in functional disorders differ from one medication
index and SAP who are not responsive to PPI therapy, but demon- to another, fluoxetine, 10-80 mg/day, paroxetine, 10-60 mg/day,
strate evidence of persistent non-acid or acid reflux using MII-pH citalopram, 10-40 mg/day, and sertraline, 25-200 mg/day, respec-
monitoring can be treated successfully with laparoscopic Nissen tively.
fundoplication.35 Surgical anti-reflux management can provide Another neuromodulator is Trazodone, which was solely evalu-
reflux control for carefully selected reflux hypersensitivity patients.9 ated for the treatment of non-cardiac chest pain. Its value in reflux
Similarly, Broeders et al36 reported that laparoscopic Nissen fundo- hypersensitivity remained to be elucidated.
plication drastically reduced the incidence of acid and weakly acidic Of all serotonin-norepinephrine reuptake inhibitors, only ven-
reflux, as well as liquid and mixed reflux episodes. However, there lafaxine has been studied in a functional esophageal disorder. While
are still very few studies that have assessed the value of surgical fun- considered to be the most efficacious anti-depressant in reducing
doplication in reflux hypersensitivity patients and thus more data are esophageal pain and improving global health assessment, it has been
needed. The current clinical approach is to avoid surgery in reflux associated with agitation and inability to fall asleep.
hypersensitivity patients and to consider it only in a small number of Other esophageal neuromodulators include adenosine antago-
Vol. 23, No. 4 October, 2017 (495-503) 501

nists (theophylline), ondansetron, tegaserod, octreotide, gabapentin side. J Neurogastroenterol Motil 2010;16:353-362.
and pregabalin. All of them have been scarcely studied in functional 15. Savarino E, Zentilin P, Tutuian R, et al. The role of nonacid reflux in
NERD: lessons learned from impedance-pH monitoring in 150 patients
esophageal disorders with some level of success. Thus far, none of
off therapy. Am J Gastroenterol 2008;103:2685-2693.
those compounds was evaluated in patients with reflux hypersensi- 16. Tamura Y, Funaki Y, Izawa S, et al. Pathophysiology of functional heart-
tivity. burn based on Rome III criteria in Japanese patients. World J Gastroen-
terol 2015;21:5009-5016.
17. Gao F, Gao Y, Chen X, Qian J, Zhang J. Comparison of oesophageal
Financial support: None. function tests between Chinese non-erosive reflux disease and reflux hy-
persensitivity patients. BMC Gastroenterol 2017;17:67.
Conflicts of interest: None. 18. Frazzoni M, de Bortoli N, Frazzoni L, et al. Impairment of chemical
clearance and mucosal integrity distinguishes hypersensitive esophagus
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Vol. 23, No. 4 October, 2017 (495-503) 503

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Meta-analysis
Is Helicobacter pylori Associated Functional

Dyspepsia Correlated With Dysbiosis?
Yeon-Ji Kim,1 Woo Chul Chung,1* Byung Wook Kim,1 Sung Soo Kim,1 Jin Il Kim,1 Na Jin Kim,2 Jinho Yoo,3 and Soo Hwan Kim3
1
Department of Internal Medicine, The Catholic University of Korea, Seoul, Korea; 2Medical Library, The Catholic University of Korea, Seoul,
Korea; and 3Bio-age, Medical Development Institute, Seoul, Korea
Background/Aims
To assess the long-term effect of Helicobacter pylori eradication on symptomatic improvement according to the type of antibiotic and
the duration of treatment in H. pylori -associated functional dyspepsia.
Methods
We searched Pubmed, Embase, CINAHL, and the Cochrane library databases for randomized controlled trials written in English and
undertaken up to August 2016 that met our eligibility criteria. The search methodology used combinations of the following keywords:
Helicobacter pylori OR H. pylori OR HP; dyspepsia OR functional dyspepsia OR non-ulcer dyspepsia; eradication OR cure OR treatment.
The study outcome was the summary odds ratio (OR) for symptomatic improvement in H. pylori -associated functional dyspepsia with
successful eradication therapy. Subgroup analyses were performed based on the type of antibiotic, and the duration of treatment,
whether or not patients had symptoms of irritable bowel syndrome, and on race.
Results
Sixteen randomized controlled trials met the inclusion criteria. The summary OR for symptomatic improvement in patients in our
eradication group was 1.33 (95% confidence interval [CI], 1.16-1.54; P < 0.01). In a subgroup analysis on type of antibiotic,
symptomatic improvement with metronidazole-containing regimen (OR, 1.87; 95% CI, 1.26-2.77) was better than treatment
with clarithromycin (OR, 1.29; 95% CI, 1.11-1.50). H. pylori eradication therapy given for 10-14 days was the more effective for
symptom improvement than 7-day therapy. When the studies excluding irritable bowel syndrome cases were analyzed, there were no
therapeutic effects of H. pylori eradication on symptomatic improvement.
Conclusions
In the clinical setting, the most effective H. pylori eradication regimen for functional dyspepsia to provide relief of symptoms is a
metronidazole-based treatment regimen for at least 10 days. The explanation for this is that H. pylori -associated functional dyspepsia
could be associated with dysbiosis.
Key Words
Eradication; Functional dyspepsia; Helicobacter pylori
Received: May 22, 2017 Revised: July 15, 2017 Accepted: September 5, 2017
is properly cited.
*Correspondence: Woo Chul Chung, MD
Division of Gastroenterology, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University,
Korea
Tel: +82-31-249-7138, Fax: +82-31-249-8898, E-mail: jwchulkr@catholic.ac.kr
504 J Neurogastroenterol Motil, Vol. 23 No. 4 October, 2017

www.jnmjournal.org
A Meta-analysis of Efficacy of H. pylori Eradication on Symptomatic Improvement
of them would also have irritable bowel syndrome (IBS).

Previous meta-analyses reported that eradication therapy
Introduction produced marginal therapeutic gain and relief of symptoms in H.
Functional dyspepsia (FD) is a common functional gastroin- pylori -associated FD, although results differed depending on trial
testinal disorder with reported prevalence rates of between 11% and design and study selection criteria and quality.10-12,18-20 However,
29.2%.1 Its symptoms are characterized by multifunctional disor- there has been no systemic review of the differences in efficacy ac-
ders of the upper gastrointestinal (GI) tract mediated by altered cording to the eradication regimen. We hypothesized that we would
GI motility,2 abnormal acid secretion,3 visceral hypersensitivity,4 an find different therapeutic effects for different eradication regimens.
imbalance of the autonomic nervous system,5 psychological factors, Broad spectrum antibiotics and longer treatment durations that had
and Helicobacter pylori infection.6 The role of H. pylori infection a sufficient effect on gut microbial imbalance would result in better
in functional dyspepsia is not fully elucidated, and the therapeutic symptomatic improvements after H. pylori eradication. The aim
gains and symptomatic improvements following H. pylori eradica- of this study was to evaluate whether the therapeutic gain would
tion have been matters of debate. be different in patients with H. pylori -associated FD according to
In the literature, the main mechanisms of symptom develop- the type of antibiotic and duration of treatment. When FD studies
ment in H. pylori -associated functional dyspepsia reported were excluding IBS cases were analyzed, we compared the therapeutic
altered GI motility and mucosal inflammation.6-12 Increasing effects of H. pylori eradication on symptomatic improvement. We
eosinophils of the duodenum secondary to the exposure of gastric also compared the therapeutic effects in Asian and non-Asian popu-
acid or food allergens to the duodenum might correlate with FD, lations, because there is considerable heterogeneity of symptoms
and it has been suggested that there is a correlation between eo- and pathophysiology based on ethnic differences.
sinophils and low-grade inflammation.13,14 Furthermore, it has been
shown that the patients with microscopic duodenitis achieve greater
symptomatic responses to H. pylori eradication than those without
Materials and Methods
microscopic duodenitis.15 In addition to a direct inflammatory re-
sponse of the GI tract mucosa, decreased gastric acid secretions are Search Strategy
common in patients with H. pylori -associated FD.7,8 This could be The meta-analysis was conducted according to the Preferred
closely related to dysbiosis of gut microbiota. Recently, sequencing Reporting Items for Systematic Reviews and Meta-analysis (PRIS-
analysis of gut microbiota showed that H. pylori was not alone in MA) statement.21 The following procedure was used to collect
the stomach and the interaction of H. pylori with those microorgan- clinical randomized controlled trials (RCTs) written in English un-
isms might play a role in H. pylori -associated functional dyspep- dertaken up to August 2016 from the Pubmed, Embase, Cochrane
sia.16,17 In this study, we hypothesize that H. pylori infected patients library and CINAHL digital dissertation databases (undertaken by
diagnosed as FD might have dysbiosis of the gut microbiota. Most N.J.K., Medical Library, The Catholic University of Korea, Seoul,
Database search (N = 1130)
Duplicates removed (n = 403)
Abstract retrieved (n = 727)

Records excluded (n = 656)
: available only as abstracts (n = 6)
irrelevant (n = 650)
Full text of article retrieved (n = 71)
Full text studies excluded (n = 45)

: not dichotomous outcome (n = 3)
non-English language (n = 1)
not meeting the inclusion criteria (n = 41)
Article finally enrolled (n =16)

Figure 1. Flow diagram of the study.
Vol. 23, No. 4 October, 2017 (504-516) 505

Yeon-Ji Kim, et al
Korea). We used the following Medical Subject Heading (MeSH)

Control
25.6%
27.8%
14.3%
4.9%
16.3%
36%
41%
23.2%
30%
terms and/or text words: H. pylori OR Helicobacter pylori OR
HP AND dyspepsia OR functional dyspepsia OR non-ulcer dys-
Drinking
pepsia OR FD AND eradication OR treatment OR cure. Two

Treatment
persons (Y.J.K. and W.C.C.) independently reviewed all potentially

28.0%
17.9%
15.4%
7.2%
13.0%
38%
41%
20.6%
28%
relevant material to determine whether or not it met the inclusion
criteria.
Control
16.5%
36%
26.7%
39.4%
14.6%
59%
11.6%
20%
33%
27.5%
26%
26.8%
27%
Inclusion and Exclusion Criteria
Smoking
To be included in our meta-analysis studies had to meet follow-

ing criteria; (1) RCTs with at least a 12-month follow-up period, (2)
Treatment
18.3%
33%
30.7%
45.3%
15.7%
33%
54%
17.4%
34%
20%
27%
34.7%
26%
study population of patients with dyspepsia (symptom-based Rome
I, II, or III classification), (3) symptoms of dyspepsia defined as an
outcome measurement of the study, (4) H. pylori infection verified
Control
37.3%
43.3%
46.3%
19.2%
40%
28%
47.6%
39%
25.6%
35.7%
47%
33%
48%
50.0%
46%
by rapid urease test, 13C breath test, or histologic examination, (5)

treatment group received triple or quadruple therapy for 7-14 days,
Sex
and (6) control group who only received placebo as intervention

Treatment
and were not treated with any other antibiotics or bismuth.

35.2%
39.6%
23.4%
29.3%
49%
30%
43.9%
49.4%
30%
19.6%
51%
38%
43%
41.3%
43%
Studies were excluded if they were available only as an abstract,

a review study, a case report, a study without raw data available for
43.6 ± 12.4 45.6 ± 14.2
44.7 ± 11.4 36.1 ± 12.1
46.1 ± 12.4 46.0 ± 12.2

50.3 ± 15.1 51.6 ± 16.4
51.5 ± 9.5 51.8 ± 11.8
43.2 ± 11.9 39.2 ± 13.8
retrieval, a duplicate publication or if they were not written in Eng-

42 ± 12 42.2 ± 13
49 ± 13
49 ± 13
52 ± 14
Control
38.4
46.5
lish. When the patients of enrolled studies complained of reflux-like

47
41
43
symptoms only, those studies were excluded.

Age
Treatment
51 ± 14
47 ± 13
50 ± 16
Study Outcomes
38.6
46.3
47
42
46
The primary outcome of this study was the weighted summary

odds ratio (OR) of symptomatic improvement in patients with and
Control
HP eradication rate
0%
2%
4%
4.9%
7.4%
0%
1%
0%
5%
6.6%
4%
2%
6%
18%
4.9%
without H. pylori eradication with 95% CI. All of these analyses

were planned a priori. Additional post hoc analyses were performed
based the type of antibiotic, duration of therapy, and racial differ-
Treatment
73.2%
79%
75%
76%
68.3%
91.3%
78%
82%
88.6%
88%
66.6%
85%
90%
82%
69%
80.3%
ences. The secondary outcomes were to analyze and compare the

Table 1. The Baseline Characteristics of the Enrolled Studies
0.0
Multicenter
Switzerland
Country
Singapore
Singapore
Australia
Australia
Finland
Canada
0.1
France
China
Brazil
Brazil
Spain
India
Iran
UK
0.2
Standard error
0.3
Veldhuyzen van Zanten et al,36 2003
Bruley Des Varannes et al,24 2001
0.4
0.5
Koskenpato et al,29 2001
Yazdanbod et al,37 2015

Mazzoleni et al,31 2011
Mazzoleni et al,30 2006
Studies
HP, Helicobacter pylori .

Froehlich et al,25 2001
McColl et al,32 1998
0.6
Gisbert et al,26 2004
Talley et al,34 1999

Talley et al,35 1999
Sodhi et al,33 2013
Gwee et al,27 2009
Blum et al,23 1998
Hsu et al,28 2001

Ang et al, 2006
0.7
22
0.5 1.0 2.0 5.0

Odds ratio
Figure 2. Funnel plot. P = 0.338.

OR for each eradication antibiotic and duration of treatment (1 whether IBS was included in methods of the articles. Since it was
week vs longer than 10 days). Racial differences were compared by not clear if that IBS included the all studies, we reviewed the articles
comparing Asian and non-Asian study populations. To evaluate the which mentioned IBS exclusion definitely studies using criteria of
association of H. pylori -associated FD and IBS, we tried to find out Rome II/III and explicit mentioned studies of IBS exclusion.
Table 2. The Results of Meta-analysis for the Effects of Helicobacter pylori Eradication on Functional Dyspepsia
Treatment Control
95% 95%
Studies Improved Improved OR lower upper Weights P -value
Total Total
patients Proportion patients Proportion CI CI
(n) (n)
(n) (n)
Ang et al,22 2006 45 71 0.634 40 59 0.678 0.822 0.397 1.704 3.8
Blum et al,23 1998 45 164 0.274 34 164 0.207 1.446 0.868 2.408 7.8
Froehlich et al,25 2001 15 92 0.163 13 88 0.148 1.124 0.501 2.521 3.1
Gisbert et al,26 2004 21 34 0.618 8 16 0.500 1.615 0.487 5.361 1.4
Gwee et al,27 2009 10 41 0.244 3 41 0.073 4.086 1.034 16.155 1.1
Hsu et al,28 2001 47 81 0.580 44 80 0.550 1.131 0.606 2.110 5.2
Koskenpato et al,29 2001 16 77 0.208 11 74 0.149 1.502 0.646 3.496 2.8
Mazzoleni et al,31 2011 94 201 0.468 72 203 0.355 1.598 1.072 2.383 12.7
Mazzoleni et al,30 2006 16 46 0.348 9 45 0.200 2.133 0.825 5.514 2.2
McColl et al,32 1998 33 160 0.206 11 158 0.070 3.472 1.686 7.152 3.9
Sodhi et al,33 2013 95 259 0.367 72 260 0.277 1.513 1.044 2.192 14.7
Talley et al,34 1999 32 133 0.241 31 142 0.218 1.135 0.646 1.991 6.4
Talley et al,35 1999 69 170 0.406 71 167 0.425 0.924 0.599 1.425 10.7
Veldhuyzen van Zanten 44 75 0.587 46 82 0.561 1.111 0.590 2.093 5.0
et al,36 2003
Bruley Des Varannes 55 129 0.426 38 124 0.306 1.682 1.003 2.821 7.5
et al,24 2001
Yazdanbod et al,37 2015 87 186 0.468 83 173 0.480 0.953 0.630 1.443 11.7
Total (Fixed effect model) 1.334 1.157 1.537 100.0 < 0.01
P -value of test of heterogeneity among studies = 0.152; Higgins’ I2 = 27.0% (0.0%, 60.0%).
Study Odds Ratio OR 95% CI Weights

22
Ang et al, 2006 0.82 [0.40; 1.70] 3.8%
23
Blum et al, 1998 1.45 [0.87; 2.41] 7.8%
25
Froehlich et al, 2001 1.12 [0.50; 2.52] 3.1%
26
Gisbert et al, 2004 1.62 [0.49; 5.36] 1.4%
27
Gwee et al, 2009 4.09 [1.03; 16.15] 1.1%
28
Hsu et al, 2001 1.13 [0.61; 2.11] 5.2%
29
Koskenpato et al, 2001 1.50 [0.65; 3.50] 2.8%
31
Mazzoleni et al, 2011 1.60 [1.07; 2.38] 12.7%
30
Mazzoleni et al, 2006 2.13 [0.83; 5.51] 2.2%
32
McColl et al, 1998 3.47 [1.69; 7.15] 3.9%
33
Sodhi et al, 2013 1.51 [1.04; 2.19] 14.7%
34
Talley et al, 1999 1.13 [0.65; 1.99] 6.4%
35
Talley et al, 1999 0.92 [0.60; 1.42] 10.7%
36
Veldhuyzen van Zanten et al, 2003 1.11 [0.59; 2.09] 5.0%
24
Bruley Des Varannes et al, 2001 1.68 [1.00; 2.82] 7.5%
Yazdanbod et al, 2015
37
0.95 [0.63; 1.44] 11.7% Figure 3. Forest plot for the effects of
Helicobacter pylori eradication on the
Fixed effect model 1.33 [1.16; 1.54] 100% symptom relief in patients with func-
0.1 0.5 1 2 10 tional dyspepsia.
Vol. 23, No. 4 October, 2017 (504-516) 507

Yeon-Ji Kim, et al
pylori eradications, definition of symptom relief and study outcome.

Study Selection and Data Extraction When the results were combined and any disagreement occurred,
Two investigators (Y.J.K. and W.C.C.) independently as- this was resolved by the investigators.
sessed the titles and abstracts of all retrieved papers and assessed
their eligibility for inclusion in our meta-analysis. Full articles were Statistical Methods
scrutinized if the title and abstract were ambiguous. The reviewers The R language meta-package version 3.2.0 (R Foundation for
used a standardized approach to conduct the literature search, data Statistical Computing, Vienna, Austria) was used for the meta-anal-
extraction, and quality assessment. The data sought included the ysis. The summary OR with 95% CI was evaluated for quantitative
study population, baseline characteristics of the participants, details analyses. Heterogeneity among the studies was measured using
related to the protocol, year of publication, therapy regimen of H. Higgin’s I2 statistics and 95% CIs were calculated. When there was
Table 3. Meta-analysis on Symptomatic Improvement Following Helicobacter pylori Eradication by the Regimen Including Nitroimidazole Anti-
microbial (Metronidazole and Tinidazole)
Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Gwee et al,27 2009 10 41 0.244 3 41 0.073 4.086 1.034 16.155 8.2
Hsu et al,28 2001 47 81 0.580 44 80 0.550 1.131 0.606 2.110 40.1
Koskenpato et al,29 2001 16 77 0.208 11 74 0.149 1.502 0.646 3.496 21.8
McColl et al,32 1998 33 160 0.206 11 158 0.070 3.472 1.686 7.152 29.8
Total (Fixed effect model) 1.870 1.260 2.774 100.0 < 0.01
2
P -value of test of heterogeneity among studies = 0.223; Higgins’ I = 56.0% (0.0%, 85.4%).
Table 4. Meta-analysis on Symptomatic Improvement Following Helicobacter pylori Eradication by the Regimen Including Clarithromycin
Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Ang et al,22 2006 45 71 0.634 40 59 0.678 0.822 0.397 1.704 4.3
Blum et al,23 1998 45 164 0.274 34 164 0.207 1.446 0.868 2.408 8.8
Froehlich et al,25 2001 15 92 0.163 13 88 0.148 1.124 0.501 2.521 3.5
Gisbert et al,26 2004 21 34 0.618 8 16 0.500 1.615 0.487 5.361 1.6
Gwee et al,27 2009 10 41 0.244 3 41 0.073 4.086 1.034 16.155 1.2
Mazzoleni et al,31 2011 94 201 0.468 72 203 0.355 1.598 1.072 2.383 14.4
Mazzoleni et al,30 2006 16 46 0.348 9 45 0.200 2.133 0.825 5.514 2.5
Sodhi et al,33 2013 95 259 0.367 72 260 0.277 1.513 1.044 2.192 16.6
Talley et al,34 1999 32 133 0.241 31 142 0.218 1.135 0.646 1.991 7.2
Talley et al,35 1999 69 170 0.406 71 167 0.425 0.924 0.599 1.425 12.2
et al,36 2003
et al,24 2001
Yazdanbod et al,37 2015 87 186 0.468 83 173 0.480 0.953 0.630 1.443 13.3
Total (Fixed effect model) 1.286 1.106 1.497 100.0 0.001
2
P -value of test of heterogeneity among studies = 0.351; Higgins’ I = 9.5% [0.0%, 47.9%]

substantial heterogeneity (I2 > 50%), all analyses were based on the mous outcomes, and 41 trials did not meet the eligibility criteria.
random-effect model (DerSimonian-Laird method); otherwise (I2 Reviewing the full manuscripts, we identified 16 RCTs with a total
< 50%), the fixed effect model (inverse variance method) was used. of 1920 subjects that met the inclusion criteria (Table 1 and Fig.
To test for publication bias, we used a test for asymmetry of the 1).22-37
funnel plot. A P -value of less than 0.05 was considered statistically
significant. Meta-analysis of variance (ANOVA) was used for sub- Study Result
group analysis based on type of antibiotic and duration of treatment The cumulative eradication rate of H. pylori in the treatment
regimen. All the statistical methods of this study were performed by group was 80.3% (Table 1). In the meta-analysis of all 16 RCTs, 13
S.H.K. and J.H.Y. from Bio-Age, Medical Development Institute, trials reported successful symptom relief results. Figure 2 shows the
Seoul, Korea. existence of publication bias according to the test for the asymmetry
of the funnel plot (P = 0.338). Because there was no significant
heterogeneity (Higgins’ I2 = 27.0%), we summarized OR using a
Results fixed effect model. The summary OR was 1.33 (95% CI, 1.16-1.54;
P < 0.01), indicating that the patients with H. pylori -associated
Study Characteristics FD had a greater than 1.33-fold increased probability of symptom
The initial search strategy identified 1130 articles. After re- relief after eradication. (Table 2 and Fig. 3)
moval of duplicates, the 727 remaining articles were screened. After We analyzed symptom improvement according to the anti-
reviewing the title and abstracts, 6 trials were available only as ab- biotic type. The meta-ANOVA analysis showed more significant
stracts and 650 trials were irrelevant, leaving 71 potentially relevant improvements with metronidazole (OR, 1.87; 95% CI, 1.26-2.77;
studies. In the remaining articles, 1 study was excluded because the P < 0.01) compared to clarithromycin (OR, 1.29; 95% CI, 1.11-
manuscript was not written in English, 3 trials did not use dichoto- 1.50; P < 0.01) in the eradication group. Tinidazole was included
A
27
Gwee et al, 2009 4.09 [1.03; 16.15] 8.2%
28
Hsu et al, 2001 1.13 [0.61; 2.11] 40.1%
29
Koskenpato et al, 2001 1.50 [0.65; 3.50] 21.8%
32
McColl et al, 1998 3.47 [1.69; 7.15] 29.8%
Fixed effect model 1.87 [1.26; 2.77] 100%

0.1 0.5 1 2 10
B
22
Ang et al, 2006 0.82 [0.40; 1.70] 4.3%
23
Blum et al, 1998 1.45 [0.87; 2.41] 8.8%
25
Froehlich et al, 2001 1.12 [0.50; 2.52] 3.5%
26
Gisbert et al, 2004 1.62 [0.49; 5.36] 1.6%
27
Gwee et al, 2009 4.09 [1.03; 16.15] 1.2%
31
Mazzoleni et al, 2011 1.60 [1.07; 2.38] 14.4%
30
Mazzoleni et al, 2006 2.13 [0.83; 5.51] 2.5%
33
Sodhi et al, 2013 1.51 [1.04; 2.19] 16.6%
34
Talley et al, 1999 1.13 [0.65; 1.99] 7.2%
35
Talley et al, 1999 0.92 [0.60; 1.42] 12.2%
36 Figure 4. Forest plots for the effects of
24
Bruley Des Varannes et al, 2001 1.68 [1.00; 2.82] 8.6% Helicobacter pylori eradication on the
37
0.95 [0.63; 1.44] 13.3% symptom relief in patients with function-
al dyspepsia according to antibiotic use.
Fixed effect model 1.29 [1.11; 1.50] 100% (A) Metronidazole containing regimen.
0.1 0.5 1 2 10 (B) Clarithromycin containing regimen.
Vol. 23, No. 4 October, 2017 (504-516) 509

Yeon-Ji Kim, et al
in the metronidazole group as antibiotics of the same drug class, When exclusive diagnostic criteria for FD (excluding IBS)
nitroimidazole antimicrobial. The metronidazole-based regimen were adopted in the study enrollment, 8 studies were sub-analyzed -
produced more therapeutic gain than the clarithromycin-based regi- studies using criteria of Rome II/III24,30,31,34 and explicit mentioned
men in H. pylori -associated FD (Table 3 and 4 and Fig. 4). studies of IBS exclusion.22,25,27,28 The summary OR was statistically
The selected studies used different treatment regimen durations insignificant (OR, 1.12; 95% CI, 0.99-1.26; P = 0.263) (Fig. 6).
(7, 10, or 14 day regimen). We divided the trials into 2 subgroups Thirteen studies that were performed on non-Asian populations
according to the duration of treatment regimen. Eight trials used a showed statistically significant benefits for dyspeptic symptom relief,
7-day regimen and the remaining 8 trials administered a regimen whereas the 3 trials performed on Asian populations revealed insig-
of 10 days or more. Subgroup analysis confirmed that a regimen nificant results (Table 6 and Fig. 7).
of 10 days or more yielded superior relief of symptoms (OR, 1.45;
95% CI, 1.09-1.93; P = 0.011). There was a significant difference
between the 2 groups (Table 5 and Fig. 5).
Table 5. Meta-analysis on Symptomatic Improvement Following Helicobacter pylori Eradication According to Duration
(A) 7-day regimen
Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Ang et al,22 2006 45 71 0.634 40 59 0.678 0.822 0.397 1.704 9.5
Blum et al,23 1998 45 164 0.274 34 164 0.207 1.446 0.868 2.408 19.5
Froehlich et al,25 2001 15 92 0.163 13 88 0.148 1.124 0.501 2.521 7.8
Gwee et al,27 2009 10 41 0.244 3 41 0.073 4.086 1.034 16.155 2.7
Hsu et al,28 2001 47 81 0.580 44 80 0.550 1.131 0.606 2.110 13.0
Talley et al,34 1999 32 133 0.241 31 142 0.218 1.135 0.646 1.991 16.0
et al,36 2003
et al,24 2001
2
(B) 10-day or more regimen

Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Gisbert et al,26 2004 21 34 0.618 8 16 0.500 1.615 0.487 5.361 4.7
Koskenpato et al,29 2001 16 77 0.208 11 74 0.149 1.502 0.646 3.496 8.1
Mazzoleni et al,31 2011 94 201 0.468 72 203 0.355 1.598 1.072 2.383 17.8
Mazzoleni et al,30 2006 16 46 0.348 9 45 0.200 2.133 0.825 5.514 6.8
McColl et al,32 1998 33 160 0.206 11 158 0.070 3.472 1.686 7.152 9.9
Sodhi et al,33 2013 95 259 0.367 72 260 0.277 1.513 1.044 2.192 18.7
Talley et al,35 1999 69 170 0.406 71 167 0.425 0.924 0.599 1.425 16.8
Yazdanbod et al,37 2015 87 186 0.468 83 173 0.480 0.953 0.630 1.443 17.3
Total (random effect model) 1.447 1.088 1.925 100.0 0.011
2

A
22
Ang et al, 2006 0.82 [0.40; 1.70] 9.5%
23
Blum et al, 1998 1.45 [0.87; 2.41] 19.5%
25
Froehlich et al, 2001 1.12 [0.50; 2.52] 7.8%
27
Gwee et al, 2009 4.09 [1.03; 16.15] 2.7%
28
Hsu et al, 2001 1.13 [0.61; 2.11] 13.0%
34
Talley et al, 1999 1.13 [0.65; 1.99] 16.0%
36
24
Bruley Des Varannes et al, 2001 1.68 [1.00; 2.82] 18.9%

0.1 0.5 1 2 10
B
26
Gisbert et al, 2004 1.62 [0.49; 5.36] 4.7%
29
Koskenpato et al, 2001 1.50 [0.65; 3.50] 8.1%
31
Mazzoleni et al, 2011 1.60 [1.07; 2.38] 17.8%
30
Mazzoleni et al, 2006 2.13 [0.83; 5.51] 6.8% Figure 5. Forest plots for the effects of
32
McColl et al, 1998 3.47 [1.69; 7.15] 9.9%
33 Helicobacter pylori eradication on the
Sodhi et al, 2013 1.51 [1.04; 2.19] 18.7%
35
Talley et al, 1999 0.92 [0.60; 1.42] 16.8% symptom relief in patients with func-
37
Yazdanbod et al, 2015 0.95 [0.63; 1.44] 17.3% tional dyspepsia according to duration
of regimen. (A) Treatment period: 1
Random effects model 1.45 [1.09; 1.93] 100% week. (B) Treatment period: longer than
0.1 0.5 1 2 10 1 week.
Study Risk Ratio OR 95% CI Weights

22
Ang et al, 2006 0.93 [0.73; 1.20] 22.5%
25
Froehlich et al, 2001 1.10 [0.56; 2.18] 3.0%
27
Gwee et al, 2009 3.33 [0.99; 11.24] 0.9%
28
Hsu et al, 2001 1.05 [0.80; 1.38] 19.0%
31
Mazzoleni et al, 2011 1.32 [1.04; 1.67] 24.9%
30
Mazzoleni et al, 2006 1.74 [0.86; 3.52] 2.8%
34 Figure 6. Forest plots for the effect of
Talley et al, 1999 1.10 [0.71; 1.70] 7.5%
36
Veldhuyzen van Zanten et al, 2003 1.05 [0.80; 1.37] 19.3% Helicobacter pylori eradication on the
symptom relief in patients with func-
Fixed effect model 1.12 [0.99; 1.26] 100% tional dyspepsia - its diagnostic criteria
Heterogeneity: I-squared=21%, tau-squared=0.0084, P=0.2626 excluding irritable bowel syndrome was
0.1 0.5 1 2 10 adopted.
nal inflammation by intestinal microbiota; our results support such

a theory.
Discussion
Several studies on H. pylori -associated FD have focused on
It is still unclear whether H. pylori infection causes dyspeptic changes in the intestinal environment.15-17,38 Intestinal microbiota
symptoms. Our meta-analysis is a comprehensive study focusing on play an important role in the maintenance of host health by provid-
a comparison of efficacy based on antibiotic type used and the dura- ing energy, nutrients, and immunological protection and its imbal-
tion of the eradication regimen on symptomatic improvements after ance can provoke various GI symptoms and disease.39 Because H.
H. pylori eradication. The strength of this meta-analysis was that it pylori -associated FD and intestinal dysbiosis could be shared with
includes more recent trials and subgroup analysis according to H. common pathogenesis such as impaired motility, there is a close
pylori eradication regimens. Multiple complex factors are thought relationship.14 Another possible pathogenesis is based on the de-
to be involved in the pathophysiology of FD such as gastro-duode- creased secretion of gastric acid by long-term infection of H. pylori .
Vol. 23, No. 4 October, 2017 (504-516) 511

Yeon-Ji Kim, et al
Table 6. Meta-analysis on Symptomatic Improvement Following Helicobacter pylori Eradication by Ethnic Difference
(A) Asian
Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Ang et al,22 2006 45 71 0.634 40 59 0.678 0.822 0.397 1.704 37.8
Gwee et al,27 2009 10 41 0.244 3 41 0.073 4.086 1.034 16.155 10.6
Hsu et al,28 2001 47 81 0.580 44 80 0.550 1.131 0.606 2.110 51.6
2
(B) Non-Asian
Treatment Control
95% 95%
Total Total
(n) (n)
(n) (n)
Blum et al,23 1998 45 164 0.274 34 164 0.207 1.446 0.868 2.408 8.6
Froehlich et al,25 2001 15 92 0.163 13 88 0.148 1.124 0.501 2.521 3.4
Gisbert et al,26 2004 21 34 0.618 8 16 0.500 1.615 0.487 5.361 1.6
Koskenpato et al,29 2001 16 77 0.208 11 74 0.149 1.502 0.646 3.496 3.1
Mazzoleni et al,31 2011 94 201 0.468 72 203 0.355 1.598 1.072 2.383 14.1
Mazzoleni et al,30 2006 16 46 0.348 9 45 0.200 2.133 0.825 5.514 2.5
McColl et al,32 1998 33 160 0.206 11 158 0.070 3.472 1.686 7.152 4.3
Sodhi et al,33 2013 95 259 0.367 72 260 0.277 1.513 1.044 2.192 16.3
Talley et al,34 1999 32 133 0.241 31 142 0.218 1.135 0.646 1.991 7.1
Talley et al,35 1999 69 170 0.406 71 167 0.425 0.924 0.599 1.425 11.9
et al,36 2003
et al,24 2001
Yazdanbod et al,37 2015 87 186 0.468 83 173 0.480 0.953 0.630 1.443 13.1
Total (fixed effect model) 1.356 1.167 1.575 100.0 < 0.001
2
P -value of test of heterogeneity among studies = 0.191; Higgins’ I = 25.0% (0.0 %, 61.0%).
In patients with severe atrophy induced by H. pylori infection, acid etiology and dominant pathogenesis. Recent clinical data revealed
secretion would be compromised and subsequently it results in that intestinal dysbiosis was diagnosed in FD patients with refrac-
bacterial overgrowth in the intestine. Previously, it has been demon- tory symptoms.38 Another study on H. pylori -negative Asian FD
strated that patients who complained of dyspeptic symptoms would patients without IBS-overlap showed that 2-week therapy with
have an increased risk of intestinal dysbiosis.14,38,40 Further prospec- rifaximin was efficient in a randomized placebo-controlled trial.41
tive evaluations are necessary to investigate whether patients with This evidence suggested that low-level inflammation of the intes-
severe atrophic change would benefit on symptomatic improvement tine caused by imbalance of intestinal microbiome might be one of
from H. pylori eradication. mechanisms of functional dyspepsia. In the near future, new clas-
Altered gut microbiota have been considered as a main patho- sification of functional GI disorder should be categorized according
physiology of IBS and manipulation of gut microbiota represents to the state of small intestinal microbiome. In addition, the concept
a new strategy for the treatment of IBS. In the overlap syndrome of “colo-gastric reflex” is another pathophysiology of IBS. In recent
consisting of FD and IBS, intestinal dysbiosis might be a common human data, gastric accommodation regularly affects lower GI tract

A
22
Ang et al, 2006 0.82 [0.40; 1.70] 37.8%
27
Gwee et al, 2009 4.09 [1.03; 16.15] 10.6%
28
Hsu et al, 2001 1.13 [0.61; 2.11] 51.6%

0.1 0.5 1 2 10
B
23
Blum et al, 1998 1.45 [0.87; 2.41] 8.6%
25
Froehlich et al, 2001 1.12 [0.50; 2.52] 3.4%
26
Gisbert et al, 2004 1.62 [0.49; 5.36] 1.6%
29
Koskenpato et al, 2001 1.50 [0.65; 3.50] 3.1%
31
Mazzoleni et al, 2011 1.60 [1.07; 2.38] 14.1%
30
Mazzoleni et al, 2006 2.13 [0.83; 5.51] 2.5%
32
McColl et al, 1998 3.47 [1.69; 7.15] 4.3%
33
Sodhi et al, 2013 1.51 [1.04; 2.19] 16.3%
34
Talley et al, 1999 1.13 [0.65; 1.99] 7.1%
35
Talley et al, 1999 0.92 [0.60; 1.42] 11.9%
36
24
Bruley Des Varannes et al, 2001 1.68 [1.00; 2.82] 8.4% Figure 7. Forest plots for the effects of
37
0.95 [0.63; 1.44] 13.1% Helicobacter pylori eradication on the
symptom relief in patients with func-
Fixed effect model 1.36 [1.17; 1.58] 100% tional dyspepsia according to ethnics.
0.1 0.5 1 2 10 (A) Asian. (B) Non-Asian.
function and colonic gaseous distension or constipation decrease Several antibiotics with various spectra of activity have been
gastric accommodation or gastric emptying. It was called as the used for H. pylori eradication therapy. Clarithromycin is a repre-
“colo-gastric reflex.”42 In other words, the relationship between dys- sentative of the macrolide antibiotics and these provide coverage of
pepsia and the colonic distension could be even more important. gram-positive bacteria, whereas metronidazole is the drug of choice
We hypothesized that many patients with H. pylori -associated for the treatment of anaerobic infection and the representative
FD might have FD-IBS overlap and this concept was first ap- treatment drug for intestinal dysbiosis.45 Metronidazole-combined
plied. When all patients with IBS criteria were excluded, there was with these antibiotics are thought to be combinations that can cover
no statistical significance of symptomatic improvement after H. broader antibacterial spectrum including anaerobes. Our results
pylori eradication. However, it was insufficient to make a concrete revealed that metronidazole-containing regimens were significantly
conclusion because the different types of Rome criteria applied to more effective for symptom relief compared to clarithromycin-
the different studies and the diagnostic criteria of FD and IBS were containing regimens. This was because the use of metronidazole in
mutually exclusive. It was not until recently that overlap syndrome the treatment of H. pylori eradication brought about the secondary
was paid attention. In this point of view, H. pylori -associated FD therapeutic effect of modifying the gut microbiota.
could be a new disease category. Previous reports revealed that In FD, mucosal inflammation could play an important role
responders at 3 months and H. pylori eradicated status were associ- and it was demonstrated that increased mast cells or eosinophils in
ated with improvement of dyspeptic symptoms at 1 year, regardless the gastroduodenal mucosa were associated with symptom genera-
of the overplayed IBS.43 Gastric mucosal inflammation induced by tion.46,47 However, it was questionable whether inflammatory cells
H. pylori infection was a crucial role in symptom generation, and were eliminated or lymphoid follicles healed completely after H.
the control of inflammation resulted in symptom improvement. pylori eradication. Moreover, the influence of antibiotics on the
Therefore, the Kyoto Global Consensus report insisted that H. intestinal flora could be temporary, and it would return to previous
pylori-associated dyspepsia was not as a FD, but a kind of infectious state after antibiotic therapy.48 Previously, several researchers insisted
disease.44 that at least 6 to 12 months of observation period should be re-
Vol. 23, No. 4 October, 2017 (504-516) 513

Yeon-Ji Kim, et al
quired to judge the outcome of dyspeptic symptoms after successful direct comparison of metronidazole and other antibiotic regimens
eradication. Gastric mucosal inflammation activity and physiologic for treating this disorder.
functions including acid secretion could recover or stabilize after
6 months.44 The restoration of gastric physiologic functions would
have a possibility to modify intestinal dysbiosis. Financial support: None.
In 13 studies performed on a non-Asian population, there were Conflicts of interest: None.
statistically significant benefits for dyspeptic symptom relief, where-
as the 3 trials performed on Asian populations revealed insignificant Author contributions: Woo Chul Chung was responsible for
results. These differences in race-to-race efficacy are contrary to the conception of the review question and final approval of manu-
the predicted results. In Asia, H. pylori infection is common at a script; Na Jin Kim was responsible for the the acquisition; Soo
younger age, and it is more likely that atrophic gastritis has pro- Hwan Kim analyzed the data and interpreting data; Yeon-Ji Kim
gressed over a longer period of time. In general, more advanced and Woo Chul Chung was responsible for the study selection, data
hypo-secretory stomach due to long-term H. pylori infection and extraction, and drafting the manuscript; Byung Wook Kim, Sung
atrophy of the gastric mucosa is known as a risk factor of dysbiosis. Soo Kim, and Jin Il Kim assisted in review design, interpretation
Therefore, Asian H. pylori -infected patients are more likely to have and revision, and drafting of the manuscript; and Yeon-Ji Kim and
a more advanced hypo-secretory stomach. As a result, dysbiosis Woo Chul Chung contributed to the revision of the manuscript.
is more likely to be more prominent in Asian H. pylori -infected
patients, and the potential for efficacy with antibiotic treatment may
increase. However, in the all trials on Asian populations, the 7-day References
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Original Article
Relationship Between Salivary Pepsin

Concentration and Esophageal Mucosal Integrity
in Patients With Gastroesophageal Reflux Disease
Yu-wen Li,1 Daniel Sifrim,2 Chenxi Xie,1 Minhu Chen,1* and Ying-lian Xiao1*
1
Department of Gastroenterology, First affiliated Hospital, Sun Yat-sen University, Guangzhou, GuangDong Province, China; and
2
Wingate Institute of Neurogastroenterology, Queen Mary University of London, London, UK
Background/Aims
Increased salivary pepsin could indicate an increase in gastro-esophageal reflux, however, previous studies failed to demonstrate a
correlation between salivary pepsin concentrations and 24-hour esophageal acid exposure. This study aims to detect the salivary pepsin
and to evaluate the relationship between salivary pepsin concentrations and intercellular spaces (IS) in different gastroesophageal
reflux disease phenotypes in patients.
Methods
A total of 45 patients and 11 healthy volunteers were included in this study. All subjects underwent upper gastrointestinal endoscopy,
24-hour ambulatory multichannel impedance-pH (MII-pH) monitoring, and salivary sampling at 3-time points during the 24-hour
MII-pH monitoring. IS were measured by transmission electron microscopy, and salivary pepsin concentrations were determined by
enzyme-linked immunosorbent assay.
Results
The IS measurements were greater in the esophagitis (EE), non-erosive reflux disease (NERD), and hypersensitive esophagus (HO)
groups than in the functional heartburn (FH) and healthy volunteer groups, and significant differences were indicated. Patients with
NERD and HO had higher average pepsin concentrations compared with FH patients. A weak correlation was determined between IS
and salivary pepsin among patients with NERD (r = 0.669, P = 0.035).
Conclusions
We confirmed the presence of a higher level of salivary pepsin in patients with NERD than in patients with FH. Salivary pepsin
concentrations correlated with severity of mucosal integrity impairment in the NERD group. We suggest that in patients with NERD,
low levels of salivary pepsin can help identify patients with FH, in addition the higher the pepsin concentration, the more likely the
severity of dilated IS.
Key Words
Acid exposure time; Dilated intercellular spaces; Gastroesophageal reflux disease; Salivary pepsin
Received: October 13, 2016 Revised: May 1, 2017 Accepted: Aug 16, 2017
is properly cited.
*Correspondence: Minhu Chen and Ying-lian Xiao are equally responsible for this study.
Minhu Chen, MD
Department of Gastroenterology and Hepatology, First affiliated hospital, Sun Yat-sen University, Guangzhou 510080, China
Tel: +86-020-28823388-8155, Fax: +86-02087333122, E-mail: chenminhu@vip.163.com
Ying-lian Xiao, MD
Department of Gastroenterology and Hepatology, First affiliated hospital, Sun Yat-sen University, Guangzhou 510080, China
Tel: +86-020-28823388-8455, Fax: +86-02087333122, E-mail: yinglian_xiao@163.com

www.jnmjournal.org
517
Yu-wen Li, et al
sure was not demonstrated in previous studies. Another possibility

could be that salivary pepsin concentration correlates better with a
Introduction more stable or chronic manifestation of reflux, such as microscopic
Gastroesophageal reflux disease (GERD) is a common mucosal damage, rather than a variable 24-hour reflux measure-
disorder which develops when reflux of gastric contents causes ment. The relationship between salivary pepsin concentration and
uncomfortable symptoms and/or complications.1 The prevalence esophageal mucosal integrity measured in intercellular spaces (IS)
of GERD has increased both in Western countries and Asia.2 remains undetermined. This study aims to evaluate the relationship
Diagnostic methods for GERD include GERD-specific question- between salivary pepsin concentrations and IS in different GERD
naires, gastrointestinal (GI) endoscopy, ambulatory reflux monitor- phenotypes in patients.
ing, and treatment with empirical proton pump inhibitors (PPIs).
Unfortunately, these approaches fail to achieve high sensitivity and
specificity, particularly in patients with non-erosive reflux disease
(NERD). In addition, some of these methods may be poorly toler-
ated, invasive, and costly. Endoscopy can detect erosive esophagitis Study Design
(EE). However, most patients with heartburn and regurgitation Studies were performed on 45 patients who presented with
have no erosive disease.3 Reflux monitoring with pH or impedance- recurrent heartburn and/or regurgitation (≥ 2 days/week). The
pH metry is also considered critical for the diagnosis of GERD. symptoms had lasted for at least 3 months. All patients manifested
However, this measurement enables only short-term analysis4 and at least moderate reflux symptoms. Patients were excluded if any
includes certain disadvantages, such as patient discomfort and cath- one of the following conditions was present: (1) peptic ulcer, erosive
eter displacement rendering the test cumbersome and error-prone.5 gastritis, or GI tumors detected by endoscopy; (2) inability to com-
Moreover, patients cannot tolerate the catheter-based test.6 Dietary plete all investigations, (3) women in pregnancy or lactation; and (4)
modifications can lead to false negative study results. Empirical PPI severe systemic diseases (such as severe heart, liver, kidney, brain,
treatment exhibits moderate sensitivity and low specificity for the and other organ damage).
diagnosis of GERD.7 Several studies have demonstrated various All patients underwent upper GI endoscopy and 24-hour am-
ultrastructural lesions in patients with GERD, with dilated intercel- bulatory multichannel impedance-pH (MII-pH) monitoring after
lular spaces (DIS) being one of the common changes.8 DIS occurs at least 1 week of pharmacological washout.
mainly in the basal layer of patients with GERD. DIS can favor lu- Eleven healthy volunteers without any GI symptoms during
minal ion flow through the epithelium, which could activate epithe- the last 3 months were also recruited for comparison. Signed in-
lial and neural receptors leading to symptoms.9,10 Some researchers formed consent was obtained from each individual prior to study
have suggested that DIS can be used as an objective indicator for inclusion. The study was approved by the Ethics Committee of the
NERD.11,12 However, this method of GERD diagnosis is invasive First Affiliated Hospital of Sun Yat-Sen University.
and costly. Therefore, researchers have shifted their attention toward
a simpler and less expensive technique: saliva pepsin testing. Upper Gastrointestinal Endoscopy and Preparation
Pepsin plays an important role in the pathophysiology of of Esophageal Biopsies for Electron Microscopy
GERD.13 A recently published article has found that in patients All patients underwent upper GI endoscopy after overnight
with symptoms suggestive of GERD, testing for salivary pepsin fasting. Esophageal biopsy was performed by taking a tissue 2-4
may facilitate the diagnosis of GERD, the study also suggested cm above the gastroesophageal junction Z-line, and immediately
that salivary pepsin may reduce the use of unnecessary antireflux placing into 2.5% glutaraldehyde-2% paraformaldehyde-0.1 mol/
therapy and the need for further invasive and expensive diagnostic L phosphate buffer for 4 hours. The tissue was washed using a
methods.14 Saliva can easily be obtained in many patient groups buffer solution 3 times, with each wash-out period lasting for 10
(particularly in adults, children, and neurologically impaired pa- minutes, and then fixing in 1% osmic acid-0.1 mol/L phosphate
tients) and can be easily detected.15 However, high variation in buffer for 1.5 hours. Three additional wash-outs were performed
salivary pepsin is present, increased salivary pepsin could indicate using the same method. The tissue was then dehydrated with 50%,
an increase in acid reflux, although a good correlation between 70%, 80%, 90%, and 100% of ethanol, minimum exposure to each
salivary pepsin concentrations and 24-hour esophageal acid expo- medium for 10-15 minutes, followed by exposure to 100% acetone

Pepsin in Saliva and GERD Detection
twice, each time lasting for 10-15 minutes. The tissue was placed exceeded 4%. A symptom association probability (SAP) exceeding
in acetone:embedding medium = 1:1, soaked for 1 hour, and then 95% was defined as positive.
acetone:embedding medium = 1:2, soaked for 3 hours. The tissue The patients were categorized into the following groups: erosive
was placed in a pure embedding medium for overnight soaking, esophagitis group EE group (mucosal lesion under upper endos-
picked and placed into the embedding plate for aggregation at copy according to the Los Angeles classification); NERD group
60°C for about 48 hours to harden. The tissue was sliced into 1-2 (pathologic esophageal acid exposure); hypersensitive esophagus
μm sections to locate the target and then into 50-60 nm ultrathin (HO) group (SAP positive to acid reflux); and functional heart-
sections and pulled into the copper grid. Saturated uranium acetate burn (FH) group (no mucosal lesion on upper endoscopy, negative
and lead citrate were used to dye the tissue. 24-hour MII-pH monitoring, and negative SAP).
Electron Microscopy Salivary Collection and Pepsin Measurement

Distal esophageal biopsies were examined using an electron The patients underwent 24-hour MII-pH and were asked to
microscope (Tecnai G2 Spirit Twin; FEI company, Hillsboro, collect saliva before bedtime, after awakening (before eating and
Oregon, USA) at × 5000 magnification. For each biopsy, 10 ran- drinking and before brushing teeth), and at the time of symptom
domly selected fields from the basal cell of the epithelial layer were manifestation. For healthy volunteers who manifested no symptoms,
photographed for subsequent analysis. Image-Pro Plus 6.0 software saliva was collected 0.5 hours after meals rather than at the time of
(Media Cybernetics, Inc, Rockville, MD, USA) was used to mea- symptom manifestation. Two milliliters of saliva was collected into
sure the IS. Mean IS in μm was calculated in each subject by using tubes containing 0.5 mL of 0.01 M citric acid. All samples were
the 10 photographs, and in each photograph the average diameters centrifuged 4000 rpm for 5 minutes on the same day the subjects
in 10 random transects (drawn perpendicular to the neighboring returned the samples, together with the reflux monitoring system.
membranes) was evaluated, and no 2 transects were drawn closer The collected supernatant was stored at -80°C until further analy-
than 1 μm apart. This procedure resulted in 100 transects available sis. Salivary pepsin concentrations were detected using the human
for IS measurement in each patient, as previously described by To- pepsin ELISA kit (Catalog No. CSB-E08919h; CUSABIO,
bey et al.16 IS measurement was conducted in a blinded manner by WuHan, HuBei, China). The analyses were performed with the
2 observers, with no knowledge of the study groups of subjects. researchers blinded to whether subjects were healthy volunteers or
patients with GERD and to any reflux monitoring parameter.
24-Hour Ambulatory Multichannel Impedance-pH
Monitoring Statistical Methods
The MII-pH monitor assembly (Sandhill Scientific Inc, The IS and salivary pepsin concentrations are presented as
Highlands Ranch, CO, USA) was positioned with the proximal medians (quartile). SPSS version 17.0 (IBM Corp, Armonk, NY,
pH electrode placed 5 cm above the lower esophageal sphincter USA) software was used to analyze the data. Kruskal–Wallis test
(LES). The 6 impedance measuring segments were located 3, 5, were used to compare the parameters and Pearson’s correlation was
7, 9, 15, and 17 cm above the LES. The times of meals, changes employed to compare the correlation between IS and salivary pep-
in body posture and occurrence of symptoms were recorded by sin. P -values < 0.05 were considered statistically significant.
the patients. According to the total percentage time of esophageal
pH values below 4, pathologic esophageal acid reflux (pH [+])
was present if the total percentage time of esophageal pH below 4
Table. Demographic Characteristics of All Subjects
EE (n = 10) NERD (n = 10) HE (n = 10) FH (n = 10) HV (n = 10)

Gender (F:M) 5:5 4:6 4:6 6:4 8:2
Age (mean ± SD, yr) 50.80 ± 10.33 45.20 ± 14.37 42.10 ± 10.42 48.30 ± 9.33 24.30 ± 2.00
BMI (mean ± SD, kg/m2) 24.84 ± 1.94 22.52 ± 2.00 22.40 ± 3.39 23.21 ± 4.02 20.03 ± 2.41
EE, Erosive esophagitis; NERD, non-erosive reflux disease; HE, hypersensitive esophagus; FH, functional heartburn; HV, healthy volunteer; F, female; M, male;
BMI, body mass index.
Vol. 23, No. 4 October, 2017 (517-525) 519

Yu-wen Li, et al
excluded because of abnormal findings in the upper GI endoscopy

test (1 gastric ulcer, 3 duodenal ulcer, and 1 stomach submucosal
Results mass). Among the healthy volunteers, 1 was excluded because of an
artifact during the 24-hour MII-pH monitoring. Thus, 40 patients
Demographic Characteristics with reflux symptoms (21 males; mean age: 46.60 ± 11.33 years;
A total of 45 patients were recruited into the study; 5 were mean body mass index: 23.24 ± 3.03 kg/m2) and 10 healthy adults
*
*
A *
B
*
1.5
*
*
1.0
DIS (m)
0.5
0.0
EE NERD HO FH HV
C D
E F
Figure 1. (A) Comparison of intercellular space among the esophagitis (EE), non-erosive reflux disease (NERD), hypersensitive esophagus (HO),
functional heartburn (FH), and healthy volunteer (HV) groups. (B-F) Electron microscope image of EE, NERD, HO, FH, and HV groups.
DIS, dilated intercellular spaces.

(2 males; mean age: 24.30 ± 2.00 years; mean body mass index:
20.03 ± 2.41 kg/m2) were included in the final analysis. The 40 Comparison of Intercellular Space Diameter
patients consisted of 10 patients with EE, 10 patients with NERD, Measurements (see Fig. 1)
10 patients with HO, and 10 patients with FH patients (Table). The IS in EE, NERD, HO, FH, and the healthy volunteer
groups had the following IS measurements: 0.95 (0.79-1.15), 1.00
(0.88-1.12), 0.97 (0.78-1.05), 0.72 (0.61-0.88), and 0.70 (0.63-
A Before bedtime B After awakening

* *
250 200
* *
200
Pepsin conc. (ng/mL)

150
150
100
100
50
50
0 0
EE NERD HO FH HV EE NERD HO FH HV
C At the time of symptoms D The maximal pepsin concentration

200 250 *
*
200
150
150
100
100
50
50
0 0
EE NERD HO FH HV EE NERD HO FH HV
E Average
200
150
100
50
Figure 2. Salivary pepsin concentration (conc.) in different time
points. EE, esophagitis; NERD, non-erosive reflux disease; HO,
0
hypersensitive esophagus; FH, functional heartburn; HV, healthy
EE NERD HO FH HV volunteer. *P < 0.05.
Vol. 23, No. 4 October, 2017 (517-525) 521

Yu-wen Li, et al
0.74) μm, respectively. The measurements were greater in the EE, After awakening
NERD, and HO groups than in the FH and healthy volunteer A total of 50 samples were collected. The pepsin concentrations
groups, significant differences were indicated (Fig. 1). measured after awakening in EE, NERD, HO, FH, and healthy
volunteer groups were 39.08 (25.76-52.30), 68.50 (45.29-112.89),
Comparison of Salivary Pepsin (see Fig. 2) 61.54 (42.24-107.27), 25.36 (16.77-65.59), and 61.51 (51.25-
72.41) ng/mL, significant difference (P = 0.011) in salivary pepsin
Before bedtime after awakening was indicated. Compared with the FH group, the
A total of 50 samples were collected, saliva pepsin concentra- NERD and HO groups showed higher salivary pepsin concentra-
tions measured before bedtime in the EE, NERD, HO, FH, and tions (P = 0.007 and P = 0.035, respectively).
healthy volunteer groups were 62.46 (31.19-100.12), 67.95 (55.57-
151.39), 73.03 (34.01-114.10), 31.59 (23.93-63.98), and 57.08 At the time of symptoms arise
(35.78-66.43) ng/mL; no significant difference (P = 0.101) in A total of 50 samples were collected. The salivary pepsin
salivary pepsin before bedtime was indicated. However, the NERD concentrations at the time of symptom manifestation in the EE,
and HO groups had a higher salivary pepsin concentration than the NERD, HE, FH, and healthy volunteer groups were 53.64
FH group (P = 0.019 and P = 0.035, respectively). (36.06-72.31), 52.13 (42.77-71.85), 47.76 (34.26-73.10), 34.35
(22.24-64.87), and 51.46 (32.73-69.06) ng/mL. No significant dif-
ference in salivary pepsin at the time of symptom manifestation was
A Before bedtime B IS and AET

250 r = 0.308 15 r = 0.320
P = 0.030 P = 0.024
200
Acid exposure time (%)
10
150
100
5
50
0 0
0.0 0.5 1.0 1.5 0.0 0.5 1.0 1.5
IS (m) IS (m)
C The maximal pepsin concentration

All subjects
250 of the 3 time points
r = 0.669 NERD patients
P = 0.035
200
150
100
Figure 3. Relationship between salivary pepsin and intercellular

50 spaces (IS) or acid exposure time (AET). (A) IS correlates with
salivary pepsin in saliva in all subjects at the time point of before
0 bedtime; (B) IS correlates with AET in all subjects; (C) IS corre-
0.0 0.5 1.0 1.5 lates with maximal pepsin concentration (conc.) during the 24-hour
IS (m) monitoring in patients with non-erosive reflux disease (NERD).

indicated (P = 0.593). patients with symptoms suggestive of GERD, testing for salivary
pepsin may facilitate the diagnosis of GERD.14 However, a high
The Maximal Pepsin Concentration During 24-hour variation of salivary pepsin concentration was observed, and wheth-
Monitoring er salivary pepsin could reflect mucosal damage is undermined.
The maximal salivary pepsin concentration during the 24-hour Earlier studies demonstrated that under the microscope, vari-
monitoring of the EE, NERD, HE, FH, and healthy volunteer ous ultrastructural lesions with DIS were commonly observed.8
groups were 66.55 (49.06-102.35), 88.47 (64.59-151.39), 82.26 Caviglia et al17 suggested that DIS is a feature present in patients
(42.24-157.10), 35.60 (28.4-75.56), and 73.72 (61.53-95.57) ng/ with NERD, regardless of esophageal acid exposure and can be
mL. No significant difference in the maximal salivary pepsin con- considered as an objective, structural marker of GERD symptoms.
centrations during 24-hour monitoring was indicated (P = 0.072), Carney et al17,18 observed that acid was perfused in vivo into the
but compared with the FH group, the NERD, and HO groups lower esophagus, dilation of IS and reduction in potential difference
showed higher salivary pepsin concentrations (P = 0.015 and P = were observed, which might have been caused by the inhibition of
0.029, respectively). sodium transport attributed to injury from acid, bile, or pepsin. In
acid-exposed tissues, dilation of IS was observed in both animal
Average Pepsin Concentration During the 24-hour models and humans.19,20 In patients with EE and NERD, DIS
Monitoring was detected using transmission electron photomicrographs.16,20 In
The average pepsin concentration during the 24-hour monitor- the present study, we found that the EE, NERD, and HO groups
ing of patients in the EE, NERD, HE, FH, and healthy volunteer had wider IS than those of the FH and healthy volunteer groups,
groups were 48.89 (37.59-67.81), 71.25 (52.55-99.67), 60.76 significant differences were indicated. The DIS could suggest that
(37.78-104.88), 27.90 (21.82-63.07), and 55.62 (50.98-65.24) ng/ patients with reflux disease exhibited increased paracellular per-
mL. No significant difference in average salivary pepsin concentra- meability in the esophageal epithelium.21 Sensory neurons in the
tions during the 24-hour monitoring was indicated (P = 0.056), esophageal epithelium reside within the intercellular spaces; thus,
The NERD and HO groups had the higher level of average pep- an increase in paracellular permeability can potentially explain the
sin level compared with the FH group (P = 0.011 and P = 0.043, presence of heartburn symptoms during esophageal acid exposure
respectively). in patients with NERD.21 Weijenborg et al22 also demonstrated
that compared with healthy volunteers, patients with GERD are
The Relationship Between Intercellular Spaces and more sensitive to acid. This occurrence is related to the damage to
Salivary Pepsin Concentrations esophageal mucosal integrity. Treatment with PPIs not only heals
A weak correlation exhibited between the IS and salivary pepsin the erosion of the esophageal mucosa, but promotes the normaliza-
concentration before bedtime of all subjects (r = 0.308, P = 0.030). tion of DIS as well, thereby reducing the stimulation caused by the
Among patients with pathologic acid exposure, IS correlated with reflux events, and relieving the symptoms.23 Thus, DIS can be used
maximal pepsin concentration during the 24-hour monitoring (r = as an objective indicator for NERD.11,12 Characteristic features in
0.669, P = 0.035) (Fig. 3). However, no correlation was found esophageal endoscopic biopsies have been proposed for a differen-
in other subgroups, the data are presented in the Supplementary tial diagnosis between NERD and FH.24 However, evaluation of
Table. the DIS is invasive and expensive, and can only be conducted by
A weak correlation was determined between IS and acid ex- endoscopy.
posure time (AET) (r = 0.320, P = 0.024) among all subjects. Saliva pepsin has recently been proposed as a non-invasive di-
However, no correlation was obtained between AET and salivary agnostic method for reflux disease.14 In the current study, we found
pepsin concentration. that healthy volunteers had low pepsin concentrations, suggesting
that physiological reflux can bring small amounts of pepsin into
the oral cavity. Patients with reflux-related symptoms (NERD and
Discussion HO) have higher pepsin concentrations compared with the FH
Current diagnostic methods for GERD has some limitations. and healthy volunteer groups. Similar to previous studies, our study
In the clinical setting, a simpler and less costly method that can showed that patients with FH had low pepsin concentrations, this
reflect mucosal damage is required. Previous studies found that in finding is closely relevant to that in clinical practice, as having all
Vol. 23, No. 4 October, 2017 (517-525) 523

Yu-wen Li, et al
negative pepsin samples (less than 16 ng/mL) suggested that the rendering this test inaccurate for AET detection in patients. An-
symptoms might not be due to reflux.14 These findings may lead other limitation is the lack of follow-up data. In addition, we failed
us to avoid unnecessarily prolonged PPI treatment or anti-reflux to recruit age-matched healthy volunteers. The healthy volunteers
surgery for these patients. A recent study indicated that the DIS is were in the young age bracket, which could be regarded as a factor
a characteristic GERD feature and can also be observed as reflux affecting the reliability of the results. However, we conducted a sub-
esophagitis progressed in patients under study.25 At the time point group analysis among patients in the 19-40 years age range, and
of symptom manifestation for patients and the time point of half an patients older than 40 years, and no significant differences in acid
hour after dinner for health volunteers, the pepsin concentrations exposure, salivary pepsin concentration, and IS were indicated be-
are similar. This effect could be attributed to the high incidence of tween these 2 subgroups. Moreover, the patients in the younger age
transit LES relaxation rate in both healthy volunteer and patient bracket had significant acid exposure and IS compared with healthy
groups. In addition, previous studies showed similar gastric pepsin volunteers. Regardless, we acknowledge that this is still a potential
secretion rates in healthy volunteers and patients with esophagitis.25 confounding variable.
No findings indicate the EE group has higher pepsin concentration To conclude, a higher salivary pepsin concentration was found
than the FH and healthy volunteer groups, the reason may be that in patients with NERD than in patients with FH, and salivary pep-
none of the patients with esophagitis had a grade of C or D accord- sin concentrations correlated with severity of mucosal integrity im-
ing to Los Angeles classification of esophagitis. Most patients with pairment. The findings suggest that the higher the pepsin concen-
GERD were found to have mild esophagitis or NERD in China, tration, the more likely the severity of mucosal damage. In addition,
particularly South China, as confirmed by our previously reported low salivary pepsin concentrations could help identify patients with
epidemiology study.25 FH. However, further research is needed to elucidate the factors
A weak correlation was found between IS and pepsin concen- that determine salivary pepsin concentration.
trations before bedtime in all subjects (r = 0.308, P = 0.030). In
patients with pathologic acid exposure, IS correlated with the maxi-
mal pepsin level during the 24-hour monitoring (r = 0.669, P =
Supplementary Material
0.035). A recently published review by Vakil26 suggested that use of Note: To access the supplementary table mentioned in this
questionnaires for the diagnosis of uncomplicated GERD in pri- article, visit the online version of Journal of Neurogastroenterol-
mary care is economical and convenient to a patient. Saliva testing ogy and Motility at http://www.jnmjournal.org/, and at https://doi.
combined with specific questionnaires on GERD can keep the costs org/10.5056/jnm16178.
and inconvenience to patients to a minimum.14 The results obtained
in the present study suggested a weak relationship between salivary
pepsin concentration and DIS. Financial support: This study was supported by China National
Natural Science Foundation 81400582 (Yinglian Xiao) and the
In our study, we confirmed previous findings on the lack of cor-
Research Fund for the Doctoral Program of Higher Education of
relation between salivary pepsin concentration and total esophageal
China 20110171120080 (Yinglian Xiao).
acid exposure. About one-third of healthy asymptomatic individuals
have detectable pepsin in the saliva.14 The average pepsin concen- Conflicts of interest: None.
tration of the healthy volunteers in our study was also higher than
16 pg/mL, which is the cut-off value for pepsin positivity.14 This Author contributions: Acquisition of data, analysis, and draft-
result suggest that physiological reflux can bring small amounts ing: Yuwen Li; acquisition of data and analysis: Chenxi Xie; study
of pepsin into the oral cavity. Similar to DIS, AET describes the concept, editing the English language, and finalizing the manu-
consequences of reflux, whereas pepsin in the saliva describes the script: Daniel Sifrim; and acquisition of data, analysis, drafting,
occurrence of reflux regardless of mucosal consequences, which can study supervision, and finalizing the manuscript: Minhu Chen and
be affected by other factors, such as clearance and mucus. Yinglian Xiao.
This study has several limitations. The “gold standard” selected
for considering “real” GERD was reflux monitoring. However,
reflux monitoring cannot achieve a 100% sensitivity and specificity
References
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definition and classification of gastroesophageal reflux disease: a global 14. Hayat JO, Gabieta-Somnez S, Yazaki E, et al. Pepsin in saliva for the
evidence-based consensus. Am J Gastroenterol 2006;101:1900-1920. diagnosis of gastro-oesophageal reflux disease. Gut 2015;64:373-380.
2. Dent J, El-Serag H, Wallander MA, Johansson S. Epidemiology of 15. Streckfus CF, Bigler LR. Saliva as a diagnostic fluid. Oral Dis 2002;8:69-
gastro-oesophageal reflux disease: a systematic review. Gut 2005;54:710- 76.
717. 16. Tobey NA, Carson JL, Alkiek RA, Orlando RC. Dilated intercellular
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GERD. J Gastroenterol Hepatol 2004;19(suppl 3):S33-S43. 21. Orlando RC. Pathophysiology of gastroesophageal reflux disease. J Clin
8. Yerian L, Fiocca R, Mastracci L, et al. Refinement and reproducibility Gastroenterol 2008;42:584-588.
of histologic criteria for the assessment of microscopic lesions in patients 22. Weijenborg PW, Smout AJ, Verseijden C, et al. Hypersensitivity to acid
with gastroesophageal reflux disease: the Esohisto Project. Dig Dis Sci is associated with impaired esophageal mucosal integrity in patients with
2011;56:2656-2665. gastroesophageal reflux disease with and without esophagitis. Am J Gas-
9. Van Malenstein H, Farré R, Sifrim D. Esophageal dilated intercel- trointest Liver Physiol 2014;307:G323-G329.
lular spaces (DIS) and nonerosive reflux disease. Am J Gastroenterol 23. Xue Y, Zhou L-Y, Lin S-R. Dilated intercellular spaces in gastroesopha-
2008;103:1021-1028. geal reflux disease patients and the changes of intercellular spaces after
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structural alterations and relief of symptoms after omeprazole treatment. 25. Fiorucci S, Distrutti E, Di Matteo F, et al. Circadian variations in gastric
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Vol. 23, No. 4 October, 2017 (517-525) 525

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Intravenous Corticotropin-releasing Hormone

Administration Increases Esophageal Electrical
Sensitivity in Healthy Individuals
Takahisa Yamasaki, Toshihiko Tomita, Mayu Takimoto, Takashi Kondo, Katsuyuki Tozawa, Yoshio Ohda, Tadayuki Oshima,
Hirokazu Fukui, Jiro Watari, and Hiroto Miwa*
Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
Background/Aims
When a person is experiencing stress, corticotropin-releasing hormone (CRH) can modulate gut physiologies, such as visceral sensation
or gastrointestinal motility, and its intravenous administration mimics stress-induced physiological changes. However, the influence of
CRH on the esophagus is yet unknown. Accordingly, we investigated whether intravenous CRH administration increases esophageal
sensitivity to electrical stimulation in healthy Japanese subjects.
Methods
Twenty healthy subjects were recruited. We quantified the initial perception threshold (IPT) every 15 minutes after CRH injection.
Venous blood was collected with a cannula, and both plasma adrenocorticotropic hormone (ACTH) and cortisol were measured at
pre-stimulation, 0, 30, 60, 90, and 120 minutes. The results from each time point were compared against a baseline IPT obtained
before electrical stimulation was initiated.
Results
When compared to the baseline IPT value (16.9 ± 4.5), CRH significantly decreased electrical threshold of the esophagus at 30, 45,
60, 75 minutes (14.1 ± 4.2, 13.1 ± 5.0, 12.1 ± 5.7, 14.0 ± 5.8 minutes, P < 0.01, respectively) after CRH injection, suggesting
that CRH increased esophageal sensitivity to the electrical stimulus. CRH also significantly increased plasma ACTH levels at 30 minutes
(50.3 ± 17.7, P < 0.01), and cortisol levels at 30 minutes (22.0 ± 6.7 minutes, P < 0.01) and 60 minutes (20.3 ± 6.7 minutes, P <
0.01) after CRH injection, when compared to the pre-stimulation ACTH and cortisol values.
Conclusion
Intravenous CRH administration increased esophageal electrical sensitivity in normal subjects, emphasizing the important role of stress
in esophageal sensitivity.
Key Words
Corticotropin-releasing hormone; Electric stimulation; Esophagus
Received: May 25, 2017 Revised: July 12, 2017 Accepted: August 16, 2017
is properly cited.
*Correspondence: Hiroto Miwa, MD, PhD
Division of Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, 1-1, Mukogawa-cho, Nishinomiya,
Hyogo 663-8501, Japan
Tel: +81-798-45-6665, Fax: +81-798-45-6661, E-mail: miwahgi@hyo-med.ac.jp
Takahisa Yamasaki and Toshihiko Tomita contributed equally to this work.

www.jnmjournal.org
CRH Administration Increases Esophageal Electrical Sensitivity
Introduction Materials and Methods

In recent years, as knowledge of functional gastrointestinal
disorders (FGID) has advanced, esophageal hypersensitivity has Study Design
been shown to play a significant role in the onset of upper gastro- This observational study was held in an academic medical
intestinal tract symptoms, such as heartburn.1 However, hypersen- center. A total of 20 Japanese volunteers were recruited through ad-
sitivity is not necessarily common to all nociceptive stimulation; for vertisements (local newspaper annoucements and in-house leaflets)
example, a patient may experience hypersensitivity to mechanical between October 2012 and April 2013. The frequency scale for the
stimuli but not to chemical stimuli.2 The pathogenesis of visceral symptoms of gastroesophageal reflux disease (GERD) (FSSG)
hypersensitivity is mediated by several factors, including periph- was validated,10 and only subjects with FSSG scores of 0-2 were re-
eral hypersensitivity, central hypersensitivity, and hypersensitivity cruited. We asked the subjects to fast for at least 6 hours before the
mediated by psychosocial factors. Peripheral hypersensitivity arises examination. An electric catheter was inserted via the nasal passage
from peripheral sites, such as the esophageal mucosa, and central and was placed in the lower esophagus. Placement was confirmed
hypersensitivity occurs in the neurons of the spinal cord and the with an esophageal manometric catheter using high-resolution ma-
brain. Psychosocial factors are known to modulate both peripheral nometry. We quantified the initial perception threshold (IPT: the
and central hypersensitivity. Stress modulates visceral sensation as minimum current intensity at which the subject first perceived the
well as other physiological functions.3 The bidirectional association stimulus). We infused CRH without the subject’s knowledge and
between stress and the gastrointestinal tract has received attention, evaluated IPT. In addition, plasma adreno-corticotropic hormone
as researchers have sought to understand how psychological stress (ACTH) and cortisol levels were measured using radioimmunoas-
can affect the gastrointestinal tract as well as how changes in the say pre-stimulation from the start of electrical stimulation until 120
gastrointestinal tract can affect stress sensitivity in the brain.4 This minutes later at 30-minute intervals. These values were compared
general interaction among stress, the brain, and the gastrointesti- against a value obtained from a sample taken before the electrical
nal tract is termed brain-gut interaction.5 Corticotropin releasing stimulation began. For all subjects, this process was initiated at the
hormone (CRH), a neuropeptide, is known to be one of the most same time in the afternoon. This study was approved by the ethics
important factors precipitating the onset of symptoms in stress- committee of Hyogo College of Medicine (Approval No. 1324),
related disease or FGID.6,7 Gastrointestinal physiologies, such as and written informed consent was obtained from all participants.
colonic motor and sensory functions, are known to be altered by
stress induced by intravenous administration of CRH in patients Healthy Participants
with irritable bowel syndrome (IBS).8,9 This evidence suggests that As noted above, participants were recruited by advertisements.
altered brain-gut interactions resulting from a magnified response Candidates were excluded from participation if they were younger
to CRH lead to changes in colonic functions and could be relevant than 20 years or older than 80 years of age, had overt symptoms
to the pathophysiology of IBS. However, the influence of CRH on of FGID, had used an histamine-2 receptor antagonist or proton
the esophagus has not yet been fully elucidated. The esophagus has pump inhibitors within 2 weeks of the study start date, were regular
a number of advantages as a site for study of visceral sensation. For users of corticosteroids or nonsteroidal anti-inflammatory drugs
example, it is relatively easy to determine the location where esopha- (NSAIDs) and had used those drugs within the past month, had a
geal symptoms originate, and a typical symptom is heartburn. history of allergy to drugs, had a history of gastric surgery, had a se-
Therefore, we aim to further explore this relationship between stress rious concomitant disease that would affect their ability to complete
and esophageal function by determining whether intravenous CRH the study, or were otherwise judged by a physician to be unable to
administration increases esophageal sensitivity to electrical stimula- participate in this study.
tion in healthy Japanese subjects.
Electrical Stimulation Test
To evaluate electrical sensitivity, a 7-Fr electrode (Esogold 4;
Taisho Biomed Instruments, Osaka, Japan) was inserted and placed
5 cm above the superior border of the lower esophageal sphincter.
Vol. 23, No. 4 October, 2017 (526-532) 527

Takahisa Yamasaki, et al
Placement was determined using high-resolution manometry (IN-

SIGHTTM Sandhill Scientific, Highlands Ranch, CO, USA). Statistical Methods
The electrode was connected to an electrical stimulator (SEN-3401; All results are expressed as the mean ± standard deviation.
Nihon Kohden, Tokyo, Japan). The waveform was 200 microsec- Statistical differences in IPT between participants were determined
onds at a stimulation frequency of 1 Hz. The current intensity was using a two-way analysis of variance (ANOVA). Statistical signifi-
gradually increased by 2 mA every 20 seconds. Subjects sat upright cance was defined as a value of P < 0.05.
in a comfortable chair throughout the study. Additionally, electro-
cardiogram monitoring was performed during the examination.
For the end point IPT, we quantified the IPT; that is, the minimum
Results
current intensity at which subjects perceived stimulation for the first
time by electrical stimulation as it gradually increased. We measured Enrollment and Baseline Characteristics of the
IPT at 15, 30, 45, 60, 75, 90, 105, and 120 minutes after CRH Participants
(Tanabe Mitsubishi Corporation, Osaka, Japan) injection (2 μg/ Twenty subjects were recruited to this study. There were 19
kg). We secured vascular access with a saline port to the forearm men and 1 woman, with a mean age of 35.1 ± 7.5 (range, 27-51)
of the subject at the time of admission. In this way, we could intra- years. The mean body mass index of all subjects was 23.1 ± 1.8 kg/
venously administer CRH without the subject’s knowledge. We m2. There was a history of drinking alcohol in 7 subjects, and a his-
prepared CRH 1 hour before administration and preserved it in a tory of smoking in 5 subjects (Table).
refrigerator. IPT was measured 6 times before CRH administration
(every 5 minutes). Baseline IPT was defined as the average of each Corticotropin-releasing Hormone Increased
subject’s pre-CRH IPT measurements, excluding the subject’s Esophageal Sensitivity to the Electrical Stimulus
maximum and minimum values. We compared the baseline IPT The words most commonly used by subjects to describe the
with the IPT at each time point. Venous blood (5 mL) was obtained sensation elicited by electrical stimulation of the esophagus were
via a cannula placed in the antebrachial vein, and plasma concentra- “pulsing,” “sharp,” and “throbbing.” When compared to baseline
tions of ACTH and cortisol were measured by radioimmunoassay IPT (16.9 ± 4.5), CRH significantly decreased the electrical
at pre-stimulation, 0, 30, 60, 90, and 120 minutes after CRH injec-
tion (Fig. 1). We compared the pre-stimulation value with those
values. Table. Characteristics of Subjects
Total (N = 20)
Outcome Measures Gender (M:F) 19:1
The primary end point was the esophageal IPT after electrical BMI (kg/m2) 23.1 ± 1.8
stimulation. The secondary end points were the plasma ACTH Drinking habit 7
and cortisol levels after electrical stimulation, which were compared Smoking habit 5
against pre-stimulation values. BMI, body mass index.
CRH iv
Electrical stimulate
(2 g/kg)
Time (min) 0 15 30 45 60 75 90 105 120
Blood drawing
(Pre-stimulation)
Figure 1. Study protocol. We measured the the initial perception threshold (IPT) at 15, 30, 45, 60, 75, 90, 105, 120 minutes after corticotropin-
releasing hormone (CRH) injection. IPT was measured 6 times before CRH injection. Then, baseline IPT was defined as the average of IPTs
except for maximum and minimum IPTs. Blood was drawn and plasma adrenocorticotropic hormone and cortisol were measured at 0, 30, 60, 90,
and 120 minutes after CRH injection. iv, intravenous.

stimulation threshold of the esophagus at 30 minutes (14.1 ± 4.2,

P < 0.01), 45 minutes (13.1 ± 5.0, P < 0.01), 60 minutes (12.1 Corticotropin-releasing Hormone Significantly
± 5.7, P < 0.01), and 75 minutes (14.0 ± 5.8, P < 0.01) after Increased Plasma Adreno-corticotropic Hormone
CRH injection. IPT was lowest at 60 minutes after CRH injec- and Plasma Cortisol Levels Compared to
tion. Thereafter, it gradually recovered showing a similar value to Pre-stimulation Levels
the baseline IPT at 120 minutes (16.5 ± 4.7) after CRH injection CRH significantly increased plasma ACTH levels at 30
(Fig. 2). minutes (50.3 ± 17.7, P < 0.01) after CRH injection, compared
to pre-stimulation ACTH values (28.7 ± 12.3) (Fig. 3A). Ad-
ditionally, cortisol levels at 30 minutes (22.0 ± 6.7, P < 0.01) and
60 minutes (20.3 ± 6.7, P < 0.01) after CRH injection were sig-
nificantly increased compared to the pre-stimulation cortisol values
19 (13.8 ± 4.6) (Fig. 3B). There was no correlation between degree of
18 ACTH/cortisol change and degree of IPT change.
17
16
* * Discussion
IPT (mA)
15
*
14 This is the first reported study in which a simulated stress load
*
13 was caused by intravenous administration of CRH, which is con-
12 sidered physiologically equivalent to stress, to analyze esophageal
11 perception in healthy Japanese individuals by using an electrical
10 stimulation test. A recent study from Belgium demonstrated that
Baseline 15 30 45 60 75 90 105 120 intravenous CRH administration increased esophageal sensitivity to
Time (min) mechanical distention in healthy subjects.11 Our study demonstrat-
CRH iv
ed that acute stress, simulated by intravenous CRH, significantly
Figure 2. Changes in esophageal sensitivity to the electrical stimulus
decreased the electrical threshold of esophageal perception. In ad-
induced by corticotropin-releasing hormone (CRH). CRH signifi-
cantly decreased electrical threshold of the esophagus after CRH
dition, to the IPT, we also measured ACTH and cortisol levels to
injection. IPT, initial perception threshold; iv, intravenous. *P < 0.01. verify that subjects were exposed to a true stress load.
Recent studies have reported that an important factor in the
A B
70 * 30 *
60
25
*
Cortisol (g/mL)
ACTH (pg/mL)
50
40 20
30
15
20
10 10
Pre- 0 30 60 90 120 Pre- 0 30 60 90 120
stimulation Time (min) stimulation Time (min)
CRH iv CRH iv
Figure 3. Effects of corticotropin-releasing hormone (CRH) on plasma ACTH and plasma cortisol levels. (A) CRH significantly increased plas-
ma ACTH levels 30 minutes after CRH injection, when compared to pre-stimulation ACTH value. (B) Plasma cortisol levels 30 minutes and 60
minutes after CRH injection were significantly increased compared to pre-stimulation cortisol values. iv, intravenous. *P < 0.01.
Vol. 23, No. 4 October, 2017 (526-532) 529

pathogenesis of non-erosive reflux disease (NERD), functional than healthy individuals.24 These results indicate that sensitivity to
dyspepsia, and IBS may be hyperresponsiveness to stress in the gas- intraesophageal acid stimulation is clearly higher in NERD patients
trointestinal tract.9,12-14 In daily life, we experience various symptoms than healthy individuals.
due to excessive “stress” on the body. When the human brain per- In the present study, we used a previously employed electrical
ceives stress, CRH is released from the hypothalamus. CRH acts method that directly stimulates afferent nerves rather than recep-
on the pituitary gland to secrete ACTH, which induces the secre- tors,25,26 to analyze esophageal perception. Prior methods used
tion of cortisol from the adrenal cortex, resulting in various physi- to evaluate the threshold of esophageal perception have included
ological reactions necessary for adaptation to stress.6 Central and chemical stimulation, an acid perfusion test, a mechanical stimula-
gastrointestinal responses to stress can be pronounced, particularly tion method, and a barostat test. Each method has advantages and
in patients with FGID such as IBS.7,8,15,16 disadvantages with regard to simplicity, reproducibility, and inva-
The association between stress and visceral perception has been siveness.27 Catheters used in electrical stimulation tests can be easily
reported in a number of colonic studies. Fukudo et al17 showed inserted, as they have significantly smaller diameters than barostat
that peripherally administered CRH induced more frequent bowel catheters. Thus, the degree of invasiveness is relatively low with the
movements in patients with IBS as compared to healthy individu- electrical stimulation method. Moreover, whether subjects actually
als. One study demonstrated a greater increase in perception of perceive esophageal stimulation can be verified by simply adjust-
colonic distension after intravenous CRH administration in healthy ing the intensity of the stimulation current yielding a high level of
individuals, in contrast to the response prior to administration or reproducibility.
following placebo.18 Another study reported that when a-helical It is important to analyze the kinetics of ACTH after CRH ad-
CRH was peripherally administered in IBS patients, the hyperre- ministration, as an increase in ACTH confirms exposure to stress.28
sponsiveness to stress induced by colonic electrical stimulation was In the present study, we were able to analyze ACTH kinetics using
suppressed.8 These results indicate that stress is closely associated intravenous CRH after electrical stimulation, enabling us to show
with colonic perception and bowel movements. that subjects underwent the electrical stimulation test under condi-
Previous animal studies have analyzed esophageal perception tions of stress. Therefore, we consider the results of the present
after stress loading. Stress induced by CRH administration in rats study to be reliable. CRH administration may be useful in identify-
causes acute enlargement of the esophageal intercellular space, ing the onset of stress and the threshold of esophageal perception in
which may be associated with the pathogenesis of GERD.19 It has a clinical setting. This method suggests the possibility of investigat-
also been reported that CRH affects gastric peristalsis in rats.20-22 No ing the difference in the response to stress between individuals as
study on the effect of intraesophageal stimulation following stress well as between organs.
loading with CRH has been reported in humans. In the present There are several limitations in the present study. First, this was
study, we analyzed the threshold of esophageal perception and mea- an observational study performed at a single institution. In addition,
sured ACTH and cortisol levels in response to electrical stimula- we performed analyses in healthy individuals rather than patients.
tion, before and after acute stress loading with intravenous CRH. Therefore, it remains unclear whether the values for the IPT caused
The aim was to determine whether acute stress enhances esophageal by CRH administration in healthy individuals are applicable to
perception. hypersensitive patients, such as those with NERD, and whether the
Several studies have characterized aspects of visceral hyperes- IPT values in patients are similar to those in healthy individuals, or
thesia in esophageal disease. A study of mechanosensitivity using instead indicate greater sensitivity than in healthy individuals. This
an esophageal barostat showed that NERD patients felt pain in re- is a subject for future study.
sponse to a significantly smaller volume of instilled air than healthy The small number of subjects (n = 20) may have affected the
individuals,23 indicating that NERD patients are significantly more results. Furthermore, the majority of enrolled subjects in the pres-
sensitive to mechanical stimulation. Using an esophageal acid per- ent study were men. These are considered limitations, since gender
fusion test in Japanese, we observed a significantly shorter time to differences in CRH reactivity have been demonstrated.29,30 In these
pain onset and greater pain due to acid stimulation in patients with studies, women were shown to be more sensitive to stimulation than
NERD as compared to patients with erosive esophagitis or healthy men. In the present study, 19 of 20 subjects were men.
individuals. In addition, sensory scores, which are the mathemati- In conclusion, our study demonstrated that acute stress signifi-
cal products of pain onset and pain levels, were significantly higher cantly decreases the threshold of esophageal electrical sensitivity in

healthy subjects, indicating that CRH plays an important role in the sensitivity and motility in health. Am J Physiol Gastrointest Liver Physiol
brain-gut interaction. The effect of CRH in both healthy individu- 2017;312:G526-G534.
12. Mayer EA. The neurobiology of stress and gastrointestinal disease. Gut
als and patients with FGID, as well as in those with GERD, will be
2000;47:861-869.
further explained by future studies. 13. Geeraerts B, Vandenberghe J, Van Oudenhove L, et al. Influence of ex-
perimentally induced anxiety on gastric sensorimotor function in humans.
Gastroenterology 2005;129:1437-1444.
Financial support: None. 14. Van Oudenhove L, Vandenberghe J, Geeraerts B, et al. Determinants of
symptoms in functional dyspepsia: gastric sensorimotor function, psycho-
Conflicts of interest: None. social factors or somatisation? Gut 2008;57:1666-1673.
15. Kanazawa M, Hongo M, Fukudo S. Visceral hypersensitivity in irritable
Author contributions: Takahisa Yamasaki and Toshihiko To-
bowel syndrome. J Gastroenterol Hepatol 2011;26:119-121.
mita contributed to the concept and design of the study; Takahisa
16. Lee YJ, Park KS. Irritable bowel syndrome: emerging paradigm in
Yamasaki, Toshihiko Tomita, and Mayu Takimoto were involved in pathophysiology. World J Gastroenterol 2014;20:2456-2469.
data acquisition and analysis; Tadayuki Oshima provided statistifi- 17. Fukudo S, Nomura T, Hongo M. Impact of corticotropin-releasing
cal design; Hiroto Miwa coordinated acquisition of data and trial hormone on gastrointestinal motility and adrenocorticotropic hormone
supervision; and all authors contributed to data interpretation, criti- in normal controls and patients with irritable bowel syndrome. Gut
1998;42:845-849.
cally reviewed the manuscript for important intellectual contents,
18. Nozu T, Kudaira M. Corticotropin-releasing factor induces rectal hyper-
and approved final version of the manuscript.
sensitivity after repetitive painful rectal distention in healthy humans. J
Gastroenterol 2006;41:740-744.
19. Cho YJ, Kim JH, Yim HE, Lee DM, Im SK, Lee KJ. Role of corti-
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The role of CRF in behavioral aspects of stress. Ann N Y Acad Sci 23. Trimble KC, Pryde A, Heading RC. Lowered oesophageal sensory
1995;771:92-104. thresholds in patients with symptomatic but not excess gastro-oesophageal
7. Nozu T, Okumura T. Corticotropin-releasing factor receptor type 1 reflux: evidence for a spectrum of visceral sensitivity in GORD. Gut
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9. Taché Y, Million M. Role of corticotropin-releasing factor signaling in of central sensitisation to the development of non-cardiac chest pain. Lan-
stress-related alterations of colonic motility and hyperalgesia. J Neurogas- cet 2000;356:1154-1159.
troenterol Motil 2015;21:8-24. 26. Anand P, Aziz Q, Willert R, van Oudenhove L. Peripheral and central
10. Kusano M, Shimoyama Y, Sugimoto S, et al. Development and evalua- mechanisms of visceral sensitization in man. Neurogastroenterol Motil
tion of FSSG: frequency scale for the symptoms of GERD. J Gastroen- 2007;19(1 suppl):29-46.
terol 2004;39:888-891. 27. Fass R. Sensory testing of the esophagus. J Clin Gastroenterol
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Severe Delayed Gastric Emptying Induces

Non-acid Reflux up to Proximal Esophagus in
Neurologically Impaired Patients
Shinji Ishii,1 Suguru Fukahori,1* Kimio Asagiri,1 Yoshiaki Tanaka,1,2 Nobuyuki Saikusa,1 Naoki Hashizume,1 Motomu Yoshida,1
Daisuke Masui,1 Naoko Komatsuzaki,1 Naruki Higashidate,1 Saki Sakamoto,1 Tomohiro Kurahachi,1 Shiori Tsuruhisa,1 Hirotomo
Nakahara,1 and Minoru Yagi1
Departments of 1Pediatric Surgery and 2Division of Medical Safety Management, Kurume University School of Medicine, Fukuoka, Japan
Background/Aims
The aim of this study is to investigate the degree of delayed gastric emptying (DGE) and evaluate how the severity of DGE affects
gastroesophageal reflux disease (GERD) in neurologically impaired (NI) patients utilizing 24-hour multichannel intraluminal impedance
pH measurements (pH/MII) and 13C-acetate breath test (13C-ABT) analyses.
Methods
13
C-ABT and pH/MII were conducted in 26 NI patients who were referred to our institution due to suspected GERD. At first, correlation
analyses were performed to investigate the correlation between the 13C-ABT parameters and the clinical or pH/MII parameters.
Thereafter, all patients were divided into 2 groups (DGE and severe DGE [SDGE] group) according to each cut off half emptying time
(t1/2, 90-170 minutes). Each pH/MII parameter was compared between the 2 groups in each set-up cutoff t1/2.
Results
The mean t1/2 of all patients was 215.5 ± 237.2 minutes and the t1/2 of 24 (92.3%) patients were > 100 minutes. Significant
moderate positive correlations were observed between both t1/2 and lag phase time and the non-acid reflux related parameters.
Furthermore, the patients in the SDGE group demonstrated higher non-acid reflux related parameters than those of the DGE groups
when the cutoff was t1/2 ≥ 140 minutes.
Conclusion
The present study demonstrated that GE with t1/2 ≥ 140 minutes was related to an increase of non-acid exposure reaching up to the
proximal esophagus in NI patients, and indicating that NI patients with SDGE might have a high risk of non-acid GERD.
Key Words
Breath test; Disabled patient; Gastric emptying; Gastroesophageal reflux; Multichannel intraluminal impedance measurements
Received: December 13, 2016 Revised: March 4, 2017 Accepted: April 2, 2017
is properly cited.
*Correspondence: Suguru Fukahori, MD, PhD
Department of Pediatric Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
Tel: +81-942-31-7631, Fax: +81-942-31-7705, E-mail: s_fukahori@med.kurume-u.ac.jp

www.jnmjournal.org
533
Shinji Ishii, et al
reflux and DGE in NI patients.18 Thus, the detailed pathophysiol-

ogy of DGE in NI patients with GERD including non-acid reflux
Introduction remains controversial.
Gastroesophageal reflux disease (GERD) has been one of the The aim of this study is to investigate the degree of GE in NI
most critical conditions for neurologically impaired (NI) patients patients and to evaluate how the severity of DGE affects GERD,
with a high incidence.1,2 including both acid and non-acid reflux, in NI patients by utiliz-
Although the relationship between delayed gastric emptying ing both 24-hour pH/MII and 13C-acetate breath test (13C-ABT)
(DGE) and GERD is still controversial, with some authors report- analyses.
ing a significant association between the 2 conditions3,4 and others
reporting no correlation,5,6 several authors have described that the
presence of DGE increases the probability and rate of gastroesoph-
ageal reflux (GER) episodes.7-10 DGE has also been documented This retrospective study included NI patients, who underwent
with an increasing frequency in infants and children with symptoms gastrointestinal examinations between 2011 and 2014 at the Ku-
of GERD. In particular, DGE is common in patients with esopha- rume University hospital. Medications for GERD were stopped
geal atresia or NI11-14 at an incidence of > 50.0%. As an empirically at least 3 days before entering the study, and upper gastrointestinal
acceptable pathophysiology, it has been suggested that DGE could endoscopy and barium swallowing were performed in all cases—
be an important contributor to GER by increasing esophageal there were no abnormal findings that affected gastric emptying. All
exposure in the postprandial period,3,4 indicating the accentuation enrolled NI patients were evaluated using both GE measurements
of postprandial reflux is likely due to an increased volume of reflux- and 24-hour pH/MII. The study protocol was approved by the
ate per episode of reflux through an underlying incompetent lower Kurume University Ethical Committee (No. 2575 and 11049). In-
esophageal sphincter (LES).3 A reduction in meal size or adding formed consent was obtained from their families before their enroll-
pyloroplasty to fundoplication with the aim of reducing the post- ment in this study.
operative complications and recurrence of GERD10,15,16 have been GE was evaluated using the 13C-ABT (the Breath ID system;
used in clinical practice as therapeutic options for GERD accompa- Oridion Breath ID Ltd, Jerusalem, Israel) after the ingestion of a
nying DGE. liquid meal (Racol; Otsuka Pharmaceutical Co, Ltd, Tokyo, Ja-
As mentioned above, it is well recognized that DGE contrib- pan), which is a semi-digested (osmotic pressure: 330-360 mOsm/
utes to the aggravation of GERD in NI patients. However, most L) as a test meal. The nutrient compositions of 100 mL of the
reports have only referred to the relationship between acid GERD liquid meal (100 kcal/mL) were 4.4 g of protein extracted from
and DGE according to pH monitoring, which only examines acid casein and soybean, 15.6 g of carbohydrate, and 2.2 g of fat. The
GERD. Indeed, a previous report evaluated by pH monitoring test meal was administered via a nasogastric tube in 24 patients, and
indicated that although a large proportion of NI patients manifest via gastrostomy in 2 patient within 5 minutes. The breath test was
moderate to severe GERD and its complications, they do not have performed by accumulating each subject’s exhaled gas via a nasal
DGE.5 Moreover, it remains unclear how the severity of DGE af- cannula for breath testing. After a baseline collection of the patient’s
fects the aggravation of GERD. breath, all patients were administered 10 mL/kg (maximum dose
Twenty-four hour multichannel, intraluminal impedance pH 100 mL) of the test meal, in which 100 mg of 13C-labeled sodium
measurements (pH/MII) have recently emerged as a novel tech- acetate was dissolved, and were tested in the semi-Fowler’s position
nique to evaluate GERD irrespective of the pH value. As pH/MII after more than 6 hours of fasting. The test meal was processed and
has recently been introduced for clinical use, non-acid GERD has emptied by the stomach. After absorption and metabolism, 13C was
received attention and a close relationship between non-acid GERD derived and exhaled in the breath as CO2. The device continuously
and NI has been suggested. Additionally, a previous study reported measures the ratio of 13C and 12C in the CO2 of the exhaled breath
that more than half of the reflux events in NI children were non- for 4 hours using molecular correlation spectroscopy. The Breath
acidic detected by pH/MII.17 ID device measures the ratio and the 13C substrate and dose, and
Although the presence of non-acid reflux is potentially related provides the percentage dose recovery and cumulative percentage
to DGE in NI patients, to the best of our knowledge, only one dose recovery. It then calculates the half emptying time (t1/2, min-
report thus far has investigated the relationship between non-acid ute), the lag phase time (tlag), and the gastric emptying coefficient

Severe DGE Induces Non-acid Reflux in Neurologically Impaired Patients
(GEC), based on a non-linear analysis as described by Ghoos et utes). Each of the pH/MII parameters were compared between the
al.19 GE was expressed as t1/2. tlag and GEC was also evaluated as 2 groups in each set-up cutoff t1/2.
automatically analyzed parameters. t1/2 is the time required for half All statistical analyses were performed with the JMP Pro 11
of the gastric contents to be emptied. tlag is the time at the point of software program (SAS Institute Inc, Cary, NC, USA). The nu-
inflection of the curve after mathematical integration, and GEC is merical data were expressed as the mean ± standard deviation and
an index of the global gastric emptying rate. A shorter t1/2 and tlag range. A Spearman’s correlation analysis was used to investigate the
and a higher GEC suggest accelerated gastric emptying. correlation between the 13C-ABT and the clinical or pH/MII pa-
In the analysis of 24-hour pH/MII, a multiple intraluminal rameters. The Mann-Whitney U test was used for nonparametric
impedance catheter (outer diameter, 2 mm) with 2 pH antimony analyses. P -values less than 0.05 were considered to be statistically
electrodes and 7 impedance electrodes (Sandhill Scientific, Inc, significant.
Highlands Ranch, CO, USA) was used. This technique can assess
the esophageal flow by measuring changes in conductivity (imped-
ance value) of the esophageal content between multiple electrode
Results
pairs on a catheter. The main advantage of this device is its ability Twenty-six NI patients were enrolled in this study (male/fe-
to detect not only acid, but also non-acid reflux episodes and the male, 12/14; mean age, 17.11 ± 15.59 years [range, 11 months-41
height of refluxate. The catheter was inserted transnasally through years]; mean height, 1.16 ± 0.32 [range, 0.70-1.58] m; mean
the esophagus, and pH sensor placement was confirmed by radiog- body weight, 20.47 ± 12.21 [range, 5.00-44.00] kg; mean body
raphy. Obtained data from the 24-hour pH/MII was automatically mass index, 13.86 ± 3.06 [range, 8.61-20.09] kg/m2). All patients
evaluated using the BioVIEW analysis software program (Sandhill had profound NI due to a congenital disorder (cerebral palsy [n =
Scientific, Inc, Highlands Ranch, CO, USA) and each tracing was 15], chromosomal anomaly [n = 5]) or acquired disorder (hypoxic
manually reviewed by the same investigators (S.I. and S.F.). Liq- brain damage [n = 6]), and were referred to our institution due to
uid reflux was defined as a fall in impedance more than or equal to symptoms of suspected GERD. Feeding was achieved orally (n =
50.0% from the baseline occurring in at least 2 consecutive channels 1) or enterally (n = 25) (nutrients were continuously administered
in an abnormal direction. Each type of reflux was defined as fol- for more than an hour, 3 to 5 times a day), via a nasogastric tube (n
lows: acid reflux, associated pH drop to ≤ 4, and non-acid reflux, = 23) and via a gastrostomy (n = 2). The mean Cobb angle of all
associated pH value above 4. The pH index was defined as the NI patients was 38.89 ± 34.81 degrees.
percentage of time with a pH value ≤ 4. A high cut-off value was Based on the GERD examination by 24-hour pH/MII analy-
defined as 4.0% according to the definition of the Working Group ses, 14 patients were diagnosed with pathological GERD (53.8%),
of Japanese Society for Pediatric Alimentary Motility.20 The bolus and 12 were diagnosed with non-pathological GERD (46.2%).
exposure index (BEI) was defined as the percentage of time with The above data for the clinical parameters and details results of pH/
retrograde movement of intraluminal esophageal material. A high MII parameters in all NI patients are shown in Tables 1 and 2, re-
cut-off value was defined as 1.4% (higher than the 95th percentile spectively.
of normal 24-hour pH/MII values, as suggested by Shay et al21 in In the GE measurements by 13C-ABT in all NI patients, the
an adult series of healthy patients). Pathological GERD was de- mean t1/2, tlag, and GEC for all NI patients were 215.5 ± 237.2
fined as a pH index > 4.0% or a BEI > 1.4%. (range, 105.4-1061.6) minutes, 81.7 ± 67.9 (range, 26.2-316.9)
At first, correlation analyses were performed to investigate the minutes, and 3.2 ± 0.6 (range, 2.0-3.9), respectively. The t1/2 of 24
correlation between the 13C-ABT parameters (t1/2, tlag, and GEC) (92.3%) patients was over 100 minutes (Figure).
and the clinical parameters (age, gender, height, body weight, causal The correlation analyses between the 13C-ABT and clinical pa-
disorders of NI [congenital or acquired], and the degree of scolio- rameters revealed no significant correlations between the 13C-ABT
sis) or the pH/MII parameters (BEI [total, acid, and non-acid], parameters and the clinical parameters (Table 1). The correlation
and the number of reflux and proximal reflux episodes [total, acid, analyses between the 13C-ABT parameters and the pH/MII pa-
and non-acid]), respectively. rameters revealed significant moderate positive correlations between
Thereafter, all patients were divided into 2 groups (the DGE both t1/2 and tlag and the non-acid related parameters (BEI [non-ac-
group and the severe DGE [SDGE] group) according to each set- id] and the numbers of total and non-acid reflux and total and non-
up cut off t1/2 (90, 100, 110, 120, 130, 140, 150, 160, and 170 min- acid proximal reflux episodes). In contrast, no significant correlation
Vol. 23, No. 4 October, 2017 (533-540) 535

Shinji Ishii, et al
13
Table 1. The Correlation Analyses Between the Clinical and C-acetate Breath Test Parameters
Clinical parameters No. or mean ± SD tlag (P -value) t1/2 (P -value) GEC (P -value)
Age (yr) 17.11 ± 15.59 0.609 0.583 0.489
Gender (M/F) 12/14 0.939 0.738 0.980
Height (m) 1.16 ± 0.32 0.822 0.599 0.294
Body weight (kg) 20.47 ± 12.21 0.270 0.164 0.630
Causal disorder (C/A) 20/6 0.879 0.692 0.605
Scoliosis (Cobb angle, degree) 38.89 ± 34.81 0.370 0.176 0.500
Pathological GERD (+/−) 14/12 0.625 0.625 0.898
tlag, lag phase time; t1/2, half-emptying time; GEC, gastric emptying coefficient; M/F, male/female; C/A, congenital (cerebral palsy and chromosomal anomaly)/ac-
quired (hypoxic brain damage); GERD, gastroesophageal reflux disease.
13
Table 2. The Correlation Analyses Between C-acetate Breath Test and Multichannel Intraluminal Impedance pH Measurement Parameters
Mean Median tlag t1/2 GEC

Parameters
Mean ± SD Median (range) r P -value R P -value r P -value
pHI (%) 6.07 ± 8.94 2.15 (0.0-39.1) -0.076 0.714 -0.043 0.836 0.322 0.109
BEI (total, %) 2.21 ± 4.03 1.1 (0.1-20.4) 0.226 0.267 0.216 0.289 -0.020 0.925
BEI (acid, %) 1.58 ± 3.87 0.65 (0.0-20.2) 0.060 0.772 0.035 0.865 0.082 0.691
BEI (non-acid, %) 0.62 ± 1.24 0.25 (0.0-6.4) 0.412 0.036a 0.450 0.021a -0.264 0.193
REs (total, n) 43 ± 22 45 (1-80) 0.466 0.016a 0.445 0.023a -0.310 0.124
REs (acid, n) 26 ± 18 25 (0-69) 0.221 0.278 0.181 0.375 -0.071 0.730
REs (non-acid, n) 17 ± 13 13 (1-59) 0.463 0.017a 0.466 0.016a 0.305 0.130
PREs (total, n) 15.27 ± 15.05 13.5 (0-76) 0.315 0.117 0.403 0.041a -0.237 0.244
PREs (acid, n) 9.58 ± 9.33 7 (0-42) 0.177 0.387 0.228 0.263 -0.013 0.949
PREs (non-acid, n) 5.69 ± 7.52 3 (0-34) 0.324 0.106 0.429 0.029a -0.315 0.117
a
P < 0.05.
tlag, lag phase time; t1/2, half emptying time; GEC, gastric emptying coefficient; pHI, pH index; BEI, bolus exposure index; REs, reflux episodes; PREs, proximal
reflux episodes.
A B C
1250 350 4.5
300 4.0
1000
250
3.5
t1/2 (min)
750
tlag (min)
200
GEC
3.0
500 150
2.5
100
250
50 2.0
0 0 1.5
All NI patients All NI patients All NI patients
13 13
Figure. In the gastric emptying measurements by C-acetate breath test ( C-ABT) in all neurologically impaired (NI) patients, the mean half
emptying time (t1/2), lag phase time (tlag), and gastric emptying coefficient (GEC) for all NI patients were 215.5 ± 237.2 (range, 105.4-1061.6)
minutes (A), 81.7 ± 67.9 (range, 26.2-316.9) minutes (B), and 3.2 ± 0.6 (range, 2.0-3.9) (C), respectively. The t1/2 of 24 (92.3%) patients was
over 100 minutes.

was observed between the acid-related parameters (pH index, BEI
Table 3. The Comparison Analyses of Multichannel Intraluminal Impedance pH Measurement Parameters Between Delayed Gastric Emptying and Severe Delayed Gastric Emptying Groups According to
DGE(2) SDGE(24) DGE(7) SDGE(19) DGE(12) SDGE(14) DGE(14) SDGE(12) DGE(18) SDGE(8) DGE(20) SDGE(6)
[total/acid], and the number of acid reflux and acid proximal reflux
1.8b
33.2b
14.5b
27.8a
0.7
1.1
2.5
56.2
23.0
13.3
episodes) and any 13C-ABT parameters. GEC showed no signifi-
t1/2, half emptying time; DGE, delayed gastric emptying; SDGE, severe delayed gastric emptying; pHI, pH index; BEI, bolus exposure index; REs, reflux episodes; PREs, proximal reflux episodes.
170
cant correlations with any pH/MII parameters (Table 2).
1.8
7.6
2.1
0.3
38.6
26.9
11.7
11.5
8.5
3.1
The detailed pH/MII parameters of the patients classified
into the DGE and SDGE groups according to each cutoff t1/2 are
shown in Table 3.
55.1 a
1.4b
28.6b
24.4a
11.3a
0.7
3.6
2.1
26.5
13.1
In the comparison of the pH/MII parameters between the
140-160
DGE and SDGE groups at each set-up cutoff t1/2 value, a signifi-
cant difference in the BEI (non-acid) values and the number of
7.2
2.2
2.0
25.8
11.3
0.3
37.1
11.2
8.0
3.2
total reflux episodes was observed between the DGE and SDGE
groups when the cutoff t1/2 was set to ≥ 130 minutes. Furthermore,
when it was set to ≥ 140 minutes, there were significant differences
54.3b
1.0a
2.4
7.5
3.4
31.9
22.3
20.8
12.7
8.1
between the 2 groups in the numbers of non-acid reflux episodes
and the numbers of proximal total and non-acid reflux episodes
130
(Table 3).
0.9
0.3
4.8
1.2
32.7
20.9
11.8
10.6
6.9
3.6
Discussion
2.1
0.9
6.5
3.0
49.9
29.5
20.4
19.1
11.5
7.6
The present study investigated gastric emptying using the 13C- 120
ABT and the liquid test meal because most NI patients receive
enteral feeding via a nasogastric tube or gastrostomy. Several reports
0.3
5.6
1.3
1.0
34.2
21.9
12.3
10.8
7.3
3.5
thus far have evaluated the normal value of t1/2 in neurologically
normal subjects analyzed by technetium-99m scintigraphy or 13C-
octanoic acid breath test analysis.5,19,22-24 Regarding the normal
6.5
2.5
1.8
0.8
46.0
27.9
18.1
17.3
10.5
6.8
range of gastric emptying analyzed by the 13C-ABT, Gatti et al22
110
reported that the mean t1/2 with milk as the test meal was 74 ± 12
minutes in healthy children. Hauser et al25 reported that the median
0.3
4.9
1.4
1.1
33.6
20.9
12.7
9.7
7.0
2.7
t1/2 value in 21 healthy children was 81 (65-112) minutes. These
previous reports set a longer threshold of t1/2 at 90 minutes. Ad-
ditionally, several reports have attempted to investigate GE of NI
1.6
0.6
6.3
2.3
44.1
27.1
17.0
15.8
10.1
5.8
patients, although no report has demonstrated the normal range in

100
NI patients. Kawahara et al12,13 examined GE of 30 NI patients and

0.5
2.8
1.4
0.9
25.0
13.0
12.0
8.5
3.5
5.0
their t1/2 ranged from 75-204 minutes; 16 (53.0%) patients had a t1/2
longer than 100 minutes. Okada et al26 examined 5 NI patients and
DGE(1) SDGE(25)
their mean t1/2 was 1.8 hours.

5.92
6.3
2.3
1.6
0.6
44.3
27.0
17.3
15.9
10.0
In the present study, the mean t1/2 of all patients was 215.5
P < 0.05 vs DGE, bP < 0.01 vs DGE.
minutes and the t1/2 of 24 (92.3%) patients were over 100 minutes.
90
Each Cutoff Half Emptying Time
These results appear to be longer than those that previously report-

0.0
0.1
0.0
0.1
1.0
0.0
1.0
0.0
0.0
0.0
ed. The mechanisms of DGE in NI patients, similar to GERD,

might be considered as the cause of aggravated gastric emptying via
PREs (non-acid, n)
BEI (non-acid, %)
Cutoff t1/2 (min)
REs (non-acid, n)
affected gastric motility, such as abnormal modulation of extrinsic

Parameters
PREs (total, n)
PREs (acid, n)
BEI (total, %)
BEI (acid, %)
REs (total, n)
REs (acid, n)
innervations due to a damaged central nervous system or hypoxic-

ischemic damage to the enteric nerves.27 Moreover, a combination
pHI (%)
of several factors, such as scoliosis, horizontal position and long-

a
Vol. 23, No. 4 October, 2017 (533-540) 537

Shinji Ishii, et al
term anticonvulsant use potentially delays GE. Gatti et al22 also were observed in the non-acid related parameters of the patients of
indicated that severe NI in children is associated with a high prob- the SDGE group when the cut off t1/2 was set to ≥ 140 minutes.
ability of DGE. We speculated that the patients enrolled in the pres- These findings indicate that t1/2 ≥ 140 minutes potentially increases
ent study were complicated by more of the above-mentioned factors the exposure of non-acid reflux in the distal as well as the proximal
that affect GE than the patients in previous studies. esophagus in NI patients. Our oppositional findings from that of
The relationship between the clinical parameters, such as causal Kawahara et al12,13 might be due to the high proportion of DGE
disorders and scoliosis and the t1/2 and tlag values in NI patients was in the present study. It has been suggested that long-term retained
evaluated. However, no significant difference was observed. As a enteral feeding buffers gastric juice; when the gastric pressure is
consequence, the present study could not detect the cause of SDGE higher than the LES, such as in the condition of seizures or the
according to the clinical parameters. Furthermore, no significant presence of transient LES relaxations, then the buffered gastric
difference was observed in any 13C-ABT parameters between content flows into the esophagus. Schwizer et al31 reported that the
GERD (+) and GERD (-), findings which were the opposite of severity of GERD in patients with DGE was lower than that in
what was expected. We suspect that other factors, such as the proxi- patients without DGE, indicating that buffering of the gastric juice
mal gastric accommodation, reported to be closely related to an in- due to the presence of DGE changes acid reflux to weakly-acid re-
crease in the transient LES relaxation,28 which is known as the main flux, which reduces damage to the esophageal mucosa.
mechanism of GERD, might have affected the present results. Rebound acid hypersecretion after the discontinuation of pro-
GEC is an index, equivalent to the slope in the early phase of the ton pump inhibitor has been reported to be a factor affecting the
velocity curve of GE, and a higher GEC suggests an accelerated pH.32 In the present study, four patients received proton pump
GE. Previous studies also measured the GEC, but did not mention inhibitors before stopping the medication, while 21 did not. No
its significance. In the present study, GEC did not demonstrate a significant difference was observed between these 2 groups with
significant relationship with any parameters, so we were unable to regard to the percentage of time for which the gastric pH was < 4
clarify its meaning. (P = 0.972).
Following the introduction of pH/MII in clinical practice, A previous study described a close relationship between non-
studies evaluating non-acid reflux have increased, gradually clarify- acid reflux reaching the proximal esophagus and aspiration in chil-
ing its pathophysiology. Regarding the relationship between non- dren.33 This suggests that a certain percentage of NI patients are
acid reflux and NI, Del Buono et al17 reported that more than half likely at risk of aspiration due to non-acid reflux.
of the reflux events in NI children were non-acid; we also indicated Based on the present results, improving the SDGE detected
13
that NI patients fed via a nasogastric tube suffered more non-acid by C-ABT might reduce the risk of aspiration due to non-acid
reflux episodes than those fed orally.29 GER reaching the proximal esophagus in NI patients requiring
Few reports thus far have analyzed the relationship between enteral feeding. Therefore, as these patients cannot complain their
gastric emptying and non-acid GERD using pH/MII, although symptoms, the administration of prokinetic drugs with enteral feed-
a close relationship between DGE and GERD in both adults and ing may be beneficial, although ideally, gastric emptying of all NI
children has been reported from a considerable number of studies. patients should be evaluated by 13C-ABT, regardless of symptoms.
Emerenziani et al30 reported a significant relationship between re- In summary, a considerably high proportion of NI patients
flux acidity and gastric emptying; namely, the slower the emptying, demonstrated DGE with t1/2 above 100 minutes, and the patients
the higher the pH of the refluxate. To the best of our knowledge, with t1/2 ≥ 140 minutes suffered more non-acid exposure reaching
Kawahara et al12,13 are the only investigators who reported the re- up to the proximal esophagus, whereas no obvious clinical causes
lationship between DGE and GERD in NI patients by utilizing of SDGE were detected in the present study. Generally, NI pa-
both pH/MII and 13C-ABT analyses; they concluded that there tients tended to show a higher frequency of DGE in comparison to
was no significant relationships between DGE and GERD. healthy individuals. As a result, it remains debatable whether a com-
The primary findings in the present study were that signifi- parison of gastric emptying between NI patients and neurologically
cant moderate correlations were observed between all of the non- normal patients is appropriate. Considering that most NI patients
acid related parameters and the t1/2 or tlag values. Moreover, in the spend the majority of their lives under abnormal circumstances,
comparison analyses of the pH/MII parameters and the cutoff such as feeding via a nasogastric tube in the supine position com-
values of t1/2 in the DGE and SDGE groups, significant increases pared to neurologically normal patients, the normal range of gastric

emptying in NI patients might be defined separately from that of M. Surgery in disabled children: general gastroenterological aspects. Acta
neurologically healthy subjects. Paediatr 2006;95(suppl 452):34-37.
3. Estevão-Costa J, Campos M, Dias JA, Trindade E, Medina AM,
There are several limitations associated with the present study.
Carvalho JL. Delayed gastric emptying and gastroesophageal reflux: a
First, the age of the enrolled patients ranged from children to adults pathophysiologic relationship. J Pediatr Gastroenterol Nutr 2001;32:471-
because gastric emptying of children has been reported to be the 474.
same as that of adults.19,22-24 Therefore, we did not take age distribu- 4. Argon M, Duygun U, Daglioz G, Omür O, Demir E, Aydogdu S.
tion into consideration. However, the possibility that the age differ- Relationship between gastric emptying and gastroesophageal reflux in
ence affected the gastric emptying cannot be ruled out. Second, the infants and children. Clin Nucl Med 2006;31:262-265.
5. Spiroglou K, Xinias I, Karatzas N, Karatza E, Arsos G, Panteliadis C.
dosage of the test meal was calculated according to the body weight
Gastric emptying in children with cerebral palsy and gastroesophageal
of each patient because in NI patient, it might be difficult to de- reflux. Pediatr Neurol 2004;31:177-182.
termine the optimal dose due to the presence of growth failure and 6. Machado RS, Yamamoto E, da Silva Patrício FR, Reber M, Kawakami
wasting, compared to neurologically normal subjects of the same E. Gastric emptying evaluation in children with erosive gastroesophageal
age. However, several reports have determined the optimal dose reflux disease. Pediatr Surg Int 2010;26:473-478.
according to the body surface area11,12 or recommended as a dose of 7. Benini L, Sembenini C, Castellani G, Caliari S, Fioretta A, Vantini I.
Gastric emptying and dyspeptic symptoms in patients with gastroesopha-
200 mL for adults. Such limitations in the present study might have
geal reflux. Am J Gastroenterol 1996;91:1351-1354.
affected the results. 8. Cunningham KM, Horowitz M, Riddell PS ,et al. Relations among
In conclusion, the present study demonstrated that GE with autonomic nerve dysfunction, oesophageal motility, and gastric emptying
t1/2 ≥ 140 minutes was related to an increase of non-acid exposure in gastro-oesophageal reflux disease. Gut 1991;32:1436-1440.
reaching up to the proximal esophagus in NI patients, indicating 9. McCallum RW, Berkowitz DM, Lerner E. Gastric emptying in patients
that NI patients with SDGE might have a risk of non-acid GERD. with gastroesophageal reflux. Gastroenterology 1981;80:285-291.
10. Richter JE. Delayed gastric emptying in reflux patients: to be or not to
Further studies enrolling a large number of subjects are required to
be? Am J Gastroenterol 1997;92:1077-1078.
elucidate the precise pathophysiological mechanism involved in the 11. Alexander F, Wyllie R, Jirousek K, Secic M, Porvasnik S. Delayed gas-
relationship between non-acid GERD and SDGE in NI patients. tric emptying affects outcome of Nissen fundoplication in neurologically
impaired children. Surgery 1997;122:690-697; discussion 697-698.
12. Kawahara H, Mitani Y, Nomura M, et al. Impact of rikkunshito, an
Financial support: None. herbal medicine, on delayed gastric emptying in profoundly handicapped
patients. Pediatr Surg Int 2009;25:987-990.
Conflicts of interest: None 13. Kawahara H, Tazuke Y, Soh H, Yoneda A, Fukuzawa M. Does lapa-
roscopy-aided gastrostomy placement improve or worsen gastroesopha-
Author contributions: Shinji Ishii performed the experiments geal reflux in patients with neurological impairment? J Pediatr Surg
and data analysis, and prepared the manuscript; Suguru Fukahori, 2014;49:1742-1745.
Kimio Asagiri, and Yoshiaki Tanaka supervised the planning and 14. Fonkalsrud EW, Ament ME. Gastroesophageal reflux in childhood.
execution of the experiments and statistical analysis, and reviewed Curr Probl Surg 1996;33:1-70.
the manuscript; Nobuyuki Saikusa assisted with conducting some 15. Bustorff-Silva J, Fonkalsrud EW, Perez CA, et al. Gastric emptying
procedures decrease the risk of postoperative recurrent reflux in children
of the experiments; Naoki Hashizume, Motomu Yoshida, Daisuke
with delayed gastric emptying. J Pediatr Surg 1999;34:79-82; discussion
Masui, Naoko Komatsuzaki, Naruki Higashidate, Saki Sakamoto,
82-83
Tomohiro Kurahachi, Shiori Tsuruhisa, and Hirotomo Nakahara 16. Fonkalsrud EW, Foglia RP, Ament ME, Berquist W, Vargas J. Opera-
assisted with the execution of the experiments and reviewed the tive treatment for the gastroesophageal reflux syndrome in children. J
manuscript; and Minoru Yagi supervised the planning and execu- Pediatr Surg 1989;24:525-529.
tion of the experiments, and reviewed the manuscript. 17. Del Buono R, Wenzl TG, Rawat D, Thomson M. Acid and nonacid
gastro-oesophageal reflux in neurologically impaired children: investiga-
tion with the multiple intraluminal impedance procedure. J Pediatr Gas-
troenterol Nutr 2006;43:331-335.
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21. Shay S, Tutuian R, Sifrim D, et al. Twenty-four hour ambulatory simul- meal intake determines the occurrence of transient lower esophageeal
taneous impedance and pH monitoring: a multicenter report of normal sphincter relaxations and reflux events in patients with gastro-esophageal
values from 60 healthy volunteers. Am J Gastroenterol 2004;99:1037- reflux disease. Neurogastroenterol Motil 2014;26:581-588.
1043. 29. Fukahori S, Asagiri K, Ishii S, et al. Pre and post-operative evaluation
22. Gatti C, di Abriola FF, Dall’Oglio L, Villa M, Franchini F, Amarri S. Is of gastroesophageal reflux and esophageal motility in neurologically
the 13C-acetate breath test a valid procedure to analyse gastric emptying in impaired children using combined pH-multichannel intraluminal imped-
children? J Pediatr Surg 2000;35:62-65. ance measurements. Pediatr Surg Int 2013;29:545-551.
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24. Lysy J, Israeli E, Strauss-Liviatan N, Goldin E. Relationships between emptying contribute to gastroesophageal reflux disease? Am J Surg
hypoglycaemia and gastric emptying abnormalities in insulin-treated dia- 1989;157:74-81.
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26. Okada T, Sasaki F, Asaka M, Kato M, Nakagawa M, Todo S. Delay reflux in children with suspected pulmonary aspiration. Dig Liver Dis
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Early Assessment of Cost-effectiveness of Gastric

Electrical Stimulation for Diabetic Nausea and
Vomiting
Mette W Klinge,1,2* Peter Rask,2 Lene S Mortensen,3 Kathrine Lassen,4 Niels Ejskjaer,1 Lars H Ehlers,4 and Klaus Krogh1
Departments of 1Hepatology and Gastroenterology, 2Abdominal Surgery, and 3Endocrinology and Internal Medicine, Aarhus University Hospital,
Aarhus, Denmark; and 4Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
Background/Aims
Recurrent nausea and/or vomiting are common complications of diabetes mellitus. The conditions severely impact the quality of life
of patients and often cause repeated admissions to hospital incurring significant healthcare costs. If standard treatment fails, gastric
electrical stimulation (GES) may be offered in selected cases, as a minimally invasive, but expensive, therapeutic option. Our aims are
to evaluate the clinical effect and the cost-utility of GES as a treatment for severe diabetic recurrent nausea and/or vomiting.
Methods
Among 33 diabetes patients implanted with GES because of recurrent nausea and/or vomiting, 30 were available for evaluation.
The effect of treatment was assessed prospectively using symptom-diaries and the SF-36 questionnaires at baseline, after 6 and 12
months, and thereafter yearly. The number of days in hospital due to symptoms related to gastrointestinal dysfunction was calculated
using hospital records 12 months prior to and 12 months after implantation.
Results
The surgical procedures were performed without mortality or major complications. Six months after surgery 78% of the respondents
had at least 50% reduction in time with nausea and 48% had at least 50% reduction in days with vomiting. Symptom relief persisted
at follow-up after at least 4 years. Quality adjusted life years improved after GES, which was cost-effective after 24 months.
Conclusions
GES reduces symptoms and improves quality of life in diabetes patients with recurrent nausea and/or vomiting. The procedure is
supposed as cost-effective over a 2-year time horizon.
Key Words
Diabetes mellitus; Electrical stimulation; Health care costs; Nausea; Vomiting
Received: October 15, 2016 Revised: January 4, 2017 Accepted: February 27, 2017
is properly cited.
*Correspondence: Mette W Klinge, MD
Department of Hepatology and Gastroenterology, Aarhus University Hospital, Noerrebrogade 44, building 1C, 1st floor, 8000
Aarhus C, Denmark
Tel: +45-78462800, Fax: +45-78462820, E-mail: meteader@rm.dk

www.jnmjournal.org
541
Mette W Klinge, et al

Gastroparesis (GP) is defined as a chronic gastric emptying
disorder with absence of mechanical obstruction.1 The 3 main Patients
groups of GP are diabetic, postsurgical, and idiopathic. The clinical Between August 2005 and August 2013, 33 diabetes patients
characteristics of diabetes related GP include recurrent nausea and/ (16 men, median age 41 [range 23-75] years) with severe recurrent
or vomiting, early satiety, bloating, and abdominal pain. Symptoms nausea and/or vomiting had a gastric electrical stimulator (Enterra
of GP typically occur at least 10 years after diagnosis of diabetes Therapy; Medtronic Inc, Minneapolis, MN, USA) implanted at
mellitus (DM).2 The estimated 10-year cumulative incidence of the Department of Abdominal Surgery, Aarhus University Hospi-
symptomatic GP is 5% in type 1 DM and 1% in type 2 DM.3 The tal, Aarhus, Denmark. The department is currently the only one in
condition is associated with significantly reduced quality of life and Denmark performing this procedure.
frequent admissions to hospital because of recurrent vomiting lead- All patients had a history of recurrent episodes of severe nausea
ing to dehydration and poor glycaemic control.4 The pathophysiol- and/or vomiting for more than 12 months and none had sufficient
ogy of diabetic GP is not fully established, but it is associated with relief of symptoms after dietary instructions and medical treatment
neuropathy of extrinsic and intrinsic neurons, abnormal function of for a minimum of 6 months. None of the patients had a history of
smooth muscle cells, and neuropathy of glia cells and the interstitial major abdominal surgery and all had undergone standard evalua-
cells of Cajal.5 The majority of diabetes patients with delayed gastric tion including upper endoscopy.
emptying remain asymptomatic, and severe symptoms can be pres-
ent even if gastric emptying tests are normal.6 Thus, treatment is Pre-operative Gastric Emptying Tests
usually initiated based on recurrent episodes of nausea and/or vom- Since the first GES was implanted at our department in 2005,
iting rather than a diagnosis of GP based on gastric emptying tests. the gastric emptying tests used had been refined from the radi-
Dietary modifications are the first line of intervention for re- opaque meal, to the paracetamol absorption test, and finally gastric
current nausea and/or vomiting in diabetes patients. This is often emptying scintigraphy. Thus, gastric emptying was assessed using
insufficient and treatment is supplemented with prokinetics and a radiopaque meal in 7 (4 prolonged), paracetamol absorption test
antiemetics. If medical therapy fails, gastric electrical stimulation in 18 (7 prolonged), or gastric emptying scintigraphy in 5 patients
(GES) is a minimally invasive option. More extensive surgical pro- (1 prolonged). The paracetamol absorption test and gastric empty-
cedures are only rarely performed as their rate of success is low and ing scintigraphy were performed according to previously published
complications are common.7 Previous studies have shown that GES protocols.15,16 The radiopaque meal consisted of a veal steak, pota-
reduces nausea and/or vomiting and improves quality of life in pa- toes, sauce, and a glass of X-ray contrast. It was performed after at
tients with DM.8-11 GES is performed by a laparoscopic procedure least 3 hours fasting with radiolucency performed for 2-3 minutes at
and usually only requires a few days in the hospital. The stimulator is, baseline and again after 6 hours.
however, relatively expensive and previous analysis of cost-utility was
based on very few patients who mainly had idiopathic GP.12 Results Surgical Procedure
from patients with idiopathic GP may not be directly applicable to The GES was implanted under laparoscopic guidance under
patients with symptoms due to DM, as this group demonstrates general anaesthesia. Access was through the umbilicus followed by
progression in their condition, and often other diabetes related com- a 5-mm port in the right flank and a 12-mm port in the lower left
plications might be present. Although definitive assessment of cost- quadrant. Two intramuscular electrodes (Medtronic model 4351;
effectiveness may require long-term evidence from randomized Medtronic, Inc) were placed 1 cm apart along the major curvature
trials, it is important early in the life-cycle of new technologies to approximately 10 cm from the pylorus. Upper endoscopy was per-
begin to estimate likely cost-effectiveness.13 Such estimates can help formed to ensure that the electrodes had not penetrated the gastric
prioritize new research and inform early adopters of the technolo- mucosa. The leads from the electrodes were extracted through
gy.13,14 Thus, the aims of the present study were to assess the clinical the port in the lower left quadrant and connected to the pulse-
effects of GES and to perform an early cost-utility analysis of GES stimulator (Medtronic model 3116; Medtronic, Inc). The pulse-
for severe recurrent nausea and/or vomiting in patients with DM. stimulator was placed subcutaneously and sutured to the abdominal

Gastric Electrical Stimulation
fascia to the left of the umbilicus. A standard program was set for surveys_tools/mos/mos_core_36item.html).
the stimulator (standard: Medtronic N’vision 8840; Medtronic, In the present paper, all data are given at baseline, 6, and 12
Inc; intensity 5 mA, frequency 14 Hz, pulse width 330 microsec- months after surgery, and at long-term which is the longest follow-
onds, cycle on 0.1 seconds, cycle off 5 seconds). up for each individual with a follow-up of at least 4 years. Our pre-
Pre-operatively 1500 mg of cephalosporin was given intrave- defined main criteria for success were: (1) at least 50 % reduction
nously and gentamicin sulphate was placed locally over the stimula- in time with nausea and (2) at least 50% reduction in the number of
tor. Post-operatively, the patients were restricted to a liquid diet for episodes with vomiting.
24 hours until discharged on their usual diet. If the patients did not The study fulfilled the criteria within the Helsinki II declara-
have symptom relief the intensity of the current was increased from tion and was approved by the Danish Data Protection Agency (Ref.
5 mA to 10 mA during follow-up at our outpatients’ hospital after 1, No. 2007-58-0010).
3, 6, and 12 months and hereafter yearly.
Cost-utility Analysis
Assessment of Symptoms and Quality of Life In order to generate quality adjusted life years (QALYs), SF-
The symptoms were evaluated by having patients fill in a di- 36 data were converted to SF-6D using the algorithm by Brazier et
ary for 2 weeks before GES-surgery (baseline), 6 and 12 months al.17 Single imputation was used on missing data points. The total
post-surgery, and hereafter every year. The diaries were sent to the cost for the GES procedure was composed of the device cost, surgi-
patients by mail or issued at scheduled visits in the outpatient’s cal procedure, 3 days of hospital admission in relation to surgery, 5
hospital. The diaries included: episodes of vomiting (episodes/day), out-patient visits before or after surgery, and costs for pre-operative
number of hours with nausea (hours/day), satiety (graded on a scale endoscopy (Table 1). As 1 re-operation was performed in 1 of our
from 0 to 4, where 0 represents no satiety and 4 represents severe 30 patients, 1/30 of the surgical costs for that were added to all.
satiety), bloating (0 represents no bloating and 3 represents severe One of the authors (L.S.M.) read hospital records of all the pa-
bloating), and general well-being (0 represents a state where the patients in this study and counted the number of days in hospital due
tient is able to do whatever she/he likes and 4 represents a miserable to symptoms related to gastrointestinal dysfunction for 12 months
state where the patient is confined to bed). Vomiting was defined prior to surgery and for 12 months after. Costs of hospital contacts
as a forceful expulsion of the contents of the stomach through the were calculated from Danish diagnose related group (DRG) rates
mouth. Reiterate expulsions at the same time only counted as one as given by the Danish healthcare authorities for the year of 2016.18
episode of vomiting. According to these, the average cost of one day in hospital for a pa-
Alongside the diaries patients filled in the Short Form 36 health tient with the diagnosis DE108 (Type 1 diabetes with complication
survey (SF-36). SF-36 is divided into 8 domains, which were added unspecified) or DE118 (Type 2 diabetes with complication unspeci-
into the 2 summary scores: a physical component summary score fied) is 742 Euros (€). The DRG has a set trim point at 11 days,
and a mental component summary score. In each, 0 represents meaning that if patients are continuously in hospital for more than
worst and 100 the best function (SF-36 version 1; RAND Cor- 11 days, a lower extensive-stay rate of €265 is used. All costs were
poration, Santa Monica, CA, USA; http://www.rand.org/health/ reported in Euros (1 € = 7.45 Danish kroner).
Table 1. Cost of Gastric Electrical Stimulation for Diabetes Patients With Recurrent Symptoms of Nausea and/or Vomiting.
Service Cost (€) No. Total cost (€)

Pre-operative outpatients hospital visit 76 1 76
Upper endoscopy 410 1 410
GES device 13.423 1 13.423
Laparoscopy 2.416 1 2.416
Post-operative follow-up visit in outpatients hospital 217 4 868
Re-operation for electrode adjustment 2.416 1/30 81
In hospital days related to surgery 742 3 2.226
Total cost per patient 19.500
GES, gastric electrical stimulation.
Costs are given in Euros (€).
Vol. 23, No. 4 October, 2017 (541-549) 543

To test for uncertainties in the sample population, bootstrap re- Table 2. Summary Table Showing Descriptive Data in the Included
sampling was performed on both costs and effects at baseline, at 12 Diabetes Patients in Numbers and Percent
months, and for an estimated 24-month’s sample. For each param- n (%)
eter the sample was re-sampled 500 times and confidence intervals Gender
for the mean were calculated. An incremental cost-effectiveness Women 15 (50)
ratio (ICER) scatterplot was made to visualize the data in relation Men 15 (50)
to an assumed Danish willingness to pay of €40.268 per QALY Diabetes
Diabetes type 1 20 (67)
gained (corresponding to British pound (£) 30.000/QALY). Since
Diabetes type 2 10 (33)
there is no exact threshold value for the Danish decision-makers’ Death in follow-up period
willingness to pay per QALY, we applied the £30.000/QALY pro- Cause of death: purulent meningitis (1), 4 (13)
posed by the British National Institute for Health and Care Excel- heart arrest (1), unknown (1),
disseminated lung cancer (1)
lence to indicate a limit for what may be considered cost-effective.19 Diabetes complications before operation
The “control group” used in the calculations were the patients’ Retinopathy 9 (30)
own baseline data during the 12 months prior to surgery. Nephropathy 9 (30)
HbA1C 74.5 mmol/mol
Late onset diabetes complications 6 (20)
Statistical Methods Diabetic foot ulcer 6 (20)
All statistical calculations on patients’ symptoms were per- Kidney transplantation 0
formed using Stata Statistical Computer Program 2013 (STATA; Dialysis 0
StataCorp LP, College Station, TX, USA) with only descrip- Weight before operation (median 25 [range 15.6-33.1])
Underweight 2 (7)
tive statistics performed. Quartile-quartile plots showed that data
Normal 12 (41)
were not following normal distribution. Thus, results are given as Overweight 9 (31)
median and full range and comparisons made with the Wilcoxon Obese 6 (21)
signed rank test and Mann-Whitney test. P -values < 0.05 were Stomach emptying test
considered statistically significant. Calculations on cost-effectiveness Gastric emptying scintigraphy 5 (17)
Paracetamol absorption test 18 (60)
were made in Microsoft Excel (Microsoft, Corp, Redmond, WA,
Radiopaque meal test 13 (43)
USA). Post-operative complications
Feeding tube (permanent) 1 (3)
Death 0 (0)
Results Re-operation to adjust the position of the Stimulator 1 (3)
Pain in the subcutaneous pocket 3 (10)
Diffuse abdominal pain 2 (7)
Study Population Small seromas 2 (7)
Baseline data on symptoms were available for 30 of 33 patients Small hematomas 1 (3)
(Fig. 1). These included 20 patients with type 1 DM and 10 with HbA1C, glycated hemoglobin A1C.
Diabetes patients with

implanted gastric electrical
stimulator as a treatment for
severe gastrointestinal Figure 1. Flow diagram of the study
symptoms
N = 33 cohort of diabetes patients with recurrent
nausea and vomiting. Four patients died
Patients missing baseline data
after 3, 3, 5, and 7 years of follow-up re-
n=3 spectively. Data were not complete. Thus,
12 months follow-up included 4 patients
who had not returned their diary at 3-6
Patients returning their diary Patients returning their diary Patients returning their diary months whereas 4 years+ also included
at 6 months at 12 months after 4+ years some patients who had not returned their
n = 23 n = 23 n = 13 diary at either 3-6 or 12 months.

type 2 DM (Table 2). Median duration of diabetes was 21 (range months, and in 75% at follow-up after at least 48 (median 96 [range
3-37) years. Median time from debut of recurrent nausea and/or 48-120]) months. At least 50% reduction in episodes with vomiting
vomiting until GES implantation was 4 (range 1-10) years. was achieved in 48% of the diabetes patients after 6 months, in 43%
Late complications to diabetes included retinopathy in 22 after 12 months, and in 69% at follow-up after at least 48 (median
(73%), nephropathy in 9 (30%), macrovascular disease in 6 (20%), 96 [range 48-120]) months.
and diabetic foot ulcer in 6 (20%) patients. None had received a Changes in individual symptoms are shown in Table 3. At 6
kidney transplant or were in dialysis treatment before the GES months follow-up there was a statistically significant improvement
operation. The median follow-up was 35 (range 1-120) months. in vomiting, nausea, satiety, bloating, and general well-being. Most
During the follow-up period; 8 (27%) developed a diabetic foot ul- patients still reported improvement at long-term follow-up even
cer, 5 (17%) started dialysis treatment, and 1 (3%) received kidney though improvement of some symptoms did not reach statistical
transplantation. significance as the number of subjects became fewer (Table 3). The
None of the batteries for the GES had exceeded its lifetime effect on symptoms did not differ between patients with normal or
during the follow-up period. prolonged gastric emptying tests before implantation and GES.
The median number of days in hospital was 4.5 (range 0-172) in
Complications to Surgery
The surgical procedure was without mortality or major complica-
SF-36 summary score
tions. The following minor complications were reported within 30
1200 Physical
days. Pain near the subcutaneous pocket for the stimulator (n = 3), Mental * *
diffuse abdominal pain (n = 2), small seroma (n = 2), and small 1000
hematoma (n = 1). None of the complications required surgical
800 *
intervention. One patient required re-operation to adjust the position
* *
of the stimulator and another had a permanent jejunostomy feeding 600
tube because of chronic malnutrition. Twenty-one of the patients had
400
the current of the stimulator raised to 10 mA because of lack of effect.
During the follow-up period four patients died of causes not related 200
to the procedure (purulent meningitis [n = 1], unexpected cardiac
arrest [n = 1], unknown [n = 1], disseminated lung cancer [n = 0
Baseline 6 months 12 months 4 years+
1]). Death of the above occurred after 3, 3, 5, and 7 years respectively.
Figure 2. Short form 36 health survey (SF-36) summary scores
for physical and mental health at baseline and after gastric electrical
Clinical Effects stimulation. The highest possible scores in healthy individuals are
At least 50% reduction in time with nausea was achieved respectively 2100 for physical and 1500 for mental health. Asterisk (*)
in 78% of the diabetes patients after 6 months, in 30% after 12 shows significant changes compared to baseline.
Table 3. Symptoms of Included Patients With Diabetes at Baseline and After Gastric Electrical Stimulation
Baseline 6 months 12 months At least 4 years

Symptoms
(median [range]) (median [range]) (median [range]) (median [range])
Vomiting (episodes/wk) 4.5 [0-110] 1 [0-15] 0.6 [0-21] 0 [0-3.5]
P = 0.009 P = 0.207 P = 0.004
Nausea (hr/wk) 31.2 [0-112] 5 [0-31] 11.5 [0-71] 0.3 [0-26]
P < 0.001 P = 0.003 P = 0.002
Satiety (scale 0-4) 2.2 [0-4] 1.4 [0-3.8] 1.9 [0-4] 1.8 [0-4]
P = 0.003 P = 0.091 P = 0.077
Bloating (scale 0-3) 2.1 [0-3] 1.8 [0-3] 1.8 [0-3] 1.2 [0-3]
P = 0.032 P = 0.292 P = 0.077
Well-being (scale 0 [best]-4 [worst]) 2.4 [0.9-4] 1 [0-2.9] 1.7 [0-7] 1.9 [0.1-3.3]
P < 0.001 P = 0.032 P = 0.583
Vol. 23, No. 4 October, 2017 (541-549) 545

Table 4. Incremental Cost and Effects 12 Months and 24 Months After Surgery
Incremental cost (€) Incremental effect (QALY)

12 months 24 months 12 months 24 months
Mean 10 031 104 0.076 0.154
95% CI 9630-10431 –723-932 0.075-0.078 0.151-0.157
SD 4567 9454 0.019 0.038
Minimum-maximum –10 117-19 810 –35 059-19 599 0.018-0.131 0.057-0.279
ICER (€/QALY) 132.161 676
€, Euro; QALY, quality adjusted life year; ICER, incremental cost-effectiveness ratio.
300 000 GES 12 months one year with GES. The incremental QALY after 24 months was
GES 24 months 0.1539. This gives an estimated ICER after 24 months of €676 per
200 000
Additional costs with GES
Linear (WTP)
QALY (Table 4). The computed bootstrap analysis of the ICER
100 000 after 12 months follow-up and estimated 24-months follow-up (28
patients) is shown in Figure 3.
0
0 0.05 0.1 0.15 0.2 0.25 0.3
100 000
Discussion
200 000 The present study confirms previous studies demonstrating
300 000
GES to be a safe and clinically effective procedure8,9,20,21 which im-
Additional QALYs with GES proves quality of life22 in a substantial proportion of highly selected
Figure 3. Bootstrap analysis showing incremental cost-effectiveness patients with diabetes and severe recurrent nausea or vomiting. Our
ratios at 12 months (blue) and estimated at 24 months (red) after gas- study is, however, the first to provide health economic-evaluation,
tric electrical stimulation (GES). Data from the 28 patients included
and the data indicate that the procedure is cost-effective after 2
in the analysis were re-sampled 500 times for each patient. As seen in
the figure, more samples are located under the line for willingness to years. As the lifetime of the GES-battery is at least 10 years and the
pay (WTP) after 24 months (red) than after 12 months (blue). Based clinical effects seem to persist during follow-up, the procedure must
on the analysis GES was cost-effective after 24 months. QALY, qual- be considered to be very cost-effective over a longer range of years.
ity adjusted life year. GES has proven to be superior to placebo in 4 placebo-
controlled trials in patients with diabetic, post-surgical, or idiopathic
the 12 months before surgery, and 0 (range 0-74) during the 12 recurrent nausea and/or vomiting.11,23-26 In a double-blinded, ran-
months after (P = 0.005). domized, crossover study, symptoms and quality of life improved
The SF-36 summary scores for physical health and for mental significantly more while the stimulator was on than when off.11
health both improved significantly after 6 months, 12 months, and However, in another study from the same group, vomiting and
at long-term follow-up (Fig. 2). Before GES the median hemoglo- nausea improved both during on and off periods.25 In a double-
bin A1C was 75 mmol/mol (9%) (range 45-128 mmol/mol), and blinded, randomized crossover study among 32 patients with
following GES it was 76 mmol/mol (9,1%) (range 45-121 mmol/ idiopathic GP, nausea and vomiting improved non-significantly
mol) (P = 0.358). both with the stimulator on and off, but with a trend towards more
improvement with the stimulator on. However, the lack of a wash-
Cost-utility out period between the on and off phases may have compromised
Mean health economic costs were €16.611 per year at baseline the data in the study.23 Interpretation of the previously mentioned
and €26.549 at 12 months after GES implantation, giving an incre- studies is hampered by a large variation in time between implanta-
mental cost of €10.031. The incremental cost after 24 months was tion of GES and inclusion into the randomized trials. Furthermore,
€104. The mean utility value was 0.5204 at baseline and 0.5963 at the crossover design may not be appropriate for GES as the carry-
12 months follow-up, giving an incremental QALY of 0.0759 after over effect and the necessary washout period are unknown.

In spite of severe symptoms, only 12 of 30 of our patients had symptoms and poor quality of life without sufficient relief from any
prolonged gastric emptying-time before GES. The poor correlation other treatment attempted. The effect of GES on symptoms has
between symptoms and objective measures of gastric emptying is been shown in previous studies, and for ethical reasons patients
well known.6,27,28 Thus, the decision to offer the individual diabetes could only have been randomized to placebo/standard treatment
patient GES was based on a history of recurrent nausea and/or for a relatively short period of time. Symptoms of gastroparesis are
vomiting and not on a strict diagnosis of GP. very variable and a much longer time is probably needed to estimate
GES is a relatively expensive procedure, mainly because of the the cost/effect, especially in terms of number of days in hospital.
price of the electrode and battery, which is approximately €13.000. Thus, we had to choose between a control group without GES that
The immediate cost is probably the major limitation to a more com- was followed for a relatively short period of time, or an appropriate
mon use of the procedure. A previous study comparing the use of follow-up period, which was compared to patients’ baseline data.
healthcare resources among patients with idiopathic GP having Compared to the 2 previous studies on cost-effectiveness of
either GES or medical treatment concluded that GES was the most GES, our study included approximately the same number of pa-
cost-effective. This study had 3 years follow-up, but it was unfor- tients. As the clinical effects were maintained after more than 2
tunately not randomized.12 An open study among 37 patients, of years, we find the assumption that the cost would be reduced too is
whom 24 had diabetic GP, followed for 12 months found that days valid.
in hospital were significantly reduced after GES, but no cost-ef- First line intervention against GP is dietary modification.
fectiveness analysis was performed.29 Our study is the first to focus Patients are asked to minimize the meal-content of fat and fibers
on the early cost-effectiveness of GES in a population with diabetic and consume frequent but smaller meals. Liquid meals are recom-
recurrent nausea and/or vomiting. The data strongly indicate that mended because they require a minimum of mechanical process-
GES is cost-effective after approximately 2 years and demonstrate ing.7,32 In addition to that, hyperglycemia per se can cause delayed
that the clinical effect is maintained for a longer period of time. In gastric emptying and it is important that patients control their blood
a study on 188 patients, McCallum et al.9 found that the clinical glucose levels.33
improvement persisted up to 10 years. Medical treatment including antiemetics and prokinetics
The mechanism of action of GES remains unclear. The current should be attempted. If medical therapy fails, GES or a jejunostomy
intensity is too low to cause contractions of the antrum or initiate a feeding tube are alternatives to more extensive surgical procedures.
peristaltic wave.11 No associations between changes in symptoms Surgical interventions; as pyloric injection with botulin toxin,34 py-
and gastric emptying have been found.11 Changes in central control loroplasty,35 and total or subtotal gastrectomy36 have been described
of nausea and vomiting mediated through the vagal nerve have but their effect is poorly documented.
been suggested. Thus, vagal activity increases during GES, which In conclusion, our data support previous reports that GES is a
may increase the threshold for discomfort during gastric distension. safe procedure, which markedly reduces symptoms and improves
Data indicate increased thalamic and caudate nuclei activity during quality of life in diabetes patients with recurrent nausea and/or vom-
chronic high-frequency GES therapy.30 In a canine model, gastric iting. Our study is the first to perform an early regular cost-effective
emptying during GES correlated well with plasma motilin levels. analysis of GES in diabetes patients with symptoms of GP. We
The authors concluded that motilin levels could be important to found that GES reduced the days in hospital by 61% during the
alter gastric motility during GES.31 first year and that treatment seems to be cost-effective after a 2-year
The main limitations in the present study are the low number horizon.
of patients and that the reduced cost from days in hospital between
12 and 24 months was assumed to be the same as during the first
year after GES. The “control group” used in the calculations was Financial support: The study was supported by the Novo Nor-
patients own baseline data during the 12 months prior to surgery. disk Foundation, Denmark (Grant No. 13159).
It is assumed that an actual control group would have the same Conflicts of interest: None.
amount of in-hospital days the following years as the patients had
before surgery. A randomized placebo-controlled design has obvi- Author contributions: Mette W Klinge: analysing data from
ous advantages. However, such a design would have restricted SF-36 and diaries, and writing article; Peter Rask: collecting data
the study period to weeks or a few months. All patients had severe and study-design; Lene S Mortensen: collecting data and reading
Vol. 23, No. 4 October, 2017 (541-549) 547

hospital records; Katrhrine Lassen: calculations in the cost-utility 14. Sculpher MJ, Claxton K, Drummond M, McCabe C. Whither trial-
analysis included Fig C; Niels Ejskjaer: initiating the project, col- based economic evaluation for health care decision making? Health Econ
2006;15:677-687.
lecting data, and proofreading article; Lars H Ehlers: calculations
15. Medhus AW, Sandstad O, Bredesen J, Husebye E. Delay of gastric
in cost-utility analysis and proofreading article; and Klaus Krogh: emptying by duodenal intubation: sensitive measurement of gastric
study-design, writing article, and proofreading the final version of emptying by the paracetamol absorption test. Aliment Pharmacol Ther
the article. 1999;13:609-620.
16. Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying
using a low fat meal: establishment of international control values. Am J
Gastroenterol 2000;95:1456-1462.
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Vol. 23, No. 4 October, 2017 (541-549) 549

JNM
pISSN: 2093-0879 eISSN: 2093-0887
The Ability of the Eating Assessment Tool-10 to

Detect Aspiration in Patients With Neurological
Disorders
Selen Serel Arslan,* Numan Demir, Hasan E Kılınç, and Aynur A Karaduman
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey
Background/Aims
Dysphagia is common in patients with neurological disorders. There is a need to identify patients at risk early by a useful clinical
tool to prevent its serious complications. The study aims to determine the ability of the Turkish version of Eating Assessment Tool-10
(T-EAT-10) to detect aspiration in patients with neurological disorders.
Methods
Two hundred fifty-nine patients with neurological disorders who had complaints about swallowing difficulty and referred for a
swallowing evaluation were included. Oropharyngeal dysphagia was evaluated with the T-EAT-10 and videofluoroscopic swallowing
study in the same day. The penetration-aspiration scale (PAS) was used to document the penetration and aspiration severity.
Results
The mean age of the patients was 59.72 ± 17.24 years (minimum [min] = 18, maximum [max] = 96), of which 57.1% were male.
The mean T-EAT-10 of patients who had aspiration (PAS > 5) was 25.91 ± 10.31 (min = 1, max = 40) and the mean T-EAT-10 of
patients who did not have aspiration (PAS < 6) was 15.70 ± 10.54 (min = 0, max = 40) (P < 0.001). Patients with a T-EAT-10 score
higher than 15 were 2.4 times more likely to aspirate. A linear correlation was found between T-EAT-10 and PAS scores of the patients
(r = 0.416, P < 0.001). The sensitivity of a T-EAT-10 higher than 15 in detecting aspiration was 81.0% and the specificity was 58.0%.
A T-EAT-10 score of higher than 15 has a positive predictive value of 72.0% and a negative predictive value of 69.0%.
Conclusion
The T-EAT-10 can be used to detect unsafe airway protection in neurology clinics to identify and refer dysphagic patients for further
evaluation.
Key Words
Aspiration; Deglutition; Deglutition disorders; Dysphagia; Screen
Received: October 7, 2016 Revised: February 20, 2017 Accepted: March 12, 2017
is properly cited.
*Correspondence: Selen Serel Arslan, PT, PhD
Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Hacettepe University, Altındağ, Ankara, Turkey
Tel: +90-3123052525, Fax: +90-3123052012, E-mail: selen.serel@hacettepe.edu.tr

www.jnmjournal.org
Eating Assessment Tool-10
current study aims to determine the ability of the Turkish version of

EAT-10 (T-EAT-10) to detect aspiration in patients with neurologi-
Introduction cal disorders.
Neurogenic dysphagia is the sensorimotor impairment of the
oropharyngeal swallowing phases as a result of a neurological dis-
order including cerebrovascular diseases, Parkinson’s disease (PD),
motor neuron disease, multiple sclerosis (MS), and myopathy.1-3
Dysphagia symptoms include impaired labial closure, difficulty in Participants
initiating swallowing, residue, choking/coughing during swallow- Two hundred fifty-nine patients with neurological disorders
ing, and piecemeal deglutition, which allow caregivers and clinicians who had complaints about swallowing difficulty and referred for a
suspect from dysphagia. It is important to detect dysphagia symp- swallowing evaluation after routine ear, nose, and throat examination
toms in an early period because neurogenic dysphagia can result with endoscopy were included in the study. A neurology specialist at
in dehydration, malnutrition, respiratory complications, and also Hacettepe University confirmed the diagnosis of the patients. The
reduce the quality of life of the patients and their families due to its inclusion criteria were (1) having a confirmed diagnosis of neuro-
psychosocial consequences if untreated.4 Thus, patients with a sus- logical disease, (2) having normal cognitive function according to
picion of oropharyngeal dysphagia should undergo an instrumental the Mini Mental State Examination (> 24 points),16 (3) complain-
swallowing evaluation as a videofluoroscopic swallowing study ing about dysphagia for at least 1 month, (4) no organic causes for
(VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) dysphagia according to endoscopy, no tracheotomy or mechanical
to evaluate airway protection to detect and manage dysphagia.5,6 ventilation, and (5) no allergies to barium. The Hacettepe Univer-
In busy neurology clinics, there is not enough time to evaluate sity Noninvasive Clinical Research Ethics Committee approved the
each patient with instrumental swallowing evaluations. However, study protocol. The patients signed the written informed consent to
early identification and management of oropharyngeal dysphagia participate in the study and all data were collected in a prospective
is crucial to ensure safe oral intake and reduce the serious dyspha- manner.
gia complications. Thus, there is a need for a useful clinical tool to
identify oropharyngeal dysphagia and aspiration risk accurately in Evaluation Procedures
patients with neurological disorders. The 10-item Eating Assess- The demographical information including age, gender, height,
ment Tool (EAT-10) is a clinical instrument to document the initial weight, and diagnosis of the patients were noted. The T-EAT-10
dysphagia symptom severity in patients with swallowing disorders.7 was used for screening oropharyngeal dysphagia in all patients and
It is rapidly administered, simply calculated, and easy to use scale the VFSS was performed for evaluation of swallowing function
which has excellent internal consistency, test retest reliability, and instrumentally in the same day. Independent clinicians who were
criterion-based validity.7 The EAT-10 is also used in clinics world- blinded to each other performed clinical and instrumental swallow-
wide, and translated and validated in English, Italian, Spanish, ing evaluations.
Brazilian, Japanese, and Turkish languages.7-12 There are 2 studies All patients completed the T-EAT-10. It is a reliable, valid,
performed in the general patient population and 1 study in patients quick, and practicable outcome tool specific to dysphagia.12 The T-
with amyotrophic lateral sclerosis (ALS) to show the ability of the EAT-10 includes 10 questions about the severity of symptoms of
EAT-10 to identify individuals who are at risk of aspiration.2,13,14 oropharyngeal dysphagia. Each question will be scored from 0 to
Besides the approximately 85.0% of ALS patients suffer from dys- 4 (“no problem” to “severe problem”). The total T-EAT-10 score
phagia due to progressive weakness and/or spasticity in the muscles is calculated by adding up the scores of each question, and higher
of oropharyngeal and esophageal regions,2,15 8.1-80.0% of patients scores indicate a self-perception of a high level of dysphagia severity.
with stroke, 11.0-81.0% of patients with PD, and 33.0-43.0% of The time to complete the instrument is less than 2 minutes. Patients
MS patients also encounter dysphagia.1-3 Thus, this ability of the completed the T-EAT-10 by themselves, and if they need guidance,
EAT-10 could be used in all neurological patient groups who are at their relatives helped.
risk of aspiration in clinical settings. With this in mind, the results of The VFSS was performed as a reference test. Patients were
the EAT-10 may be used as a direct instrument to perform further seated on a chair in the lateral plan to monitor the oral cavity, phar-
detailed evaluation of the swallowing function for clinicians. This ynx, larynx, and just below the upper esophageal sphincter in front
Vol. 23, No. 4 October, 2017 (550-554) 551

Selen Serel Arslan, et al
of the X-ray machine. All images were full resolution, continuous qualitative data and mean ± standard deviation for quantitative
and recorded at 30 frames per second. During the VFSS study, data. The mean T-EAT-10 for patients who had aspiration (PAS
oropharyngeal swallowing function was evaluated during swallow- > 5) was compared to the mean T-EAT-10 for patients who did
ing of 3 mL liquid barium. The parameters including impaired not have aspiration (PAS < 6) with the independent-samples t test.
labial seal closure, oral residue, pharyngeal residue, and piecemeal We determined the cut-off score according to the mean T-EAT-10
deglutition for swallowing function were analyzed and scored as scores of patients without dysphagia. A receiver operating charac-
either “absent” or “present.” Identification of at least 1 of these teristic curve was created with area under the curve. The sensitivity,
signs was considered as an impairment of the efficacy of swallow- specificity, and relative risk for the association between T-EAT-10
ing.14 The penetration-aspiration scale (PAS) was used to describe and aspiration on VFSS were calculated. A P -value of less than 0.05
the penetration and aspiration severity. The PAS is an ordinal scale was considered statistically significant.
ranging between 1 to 8, which has adequate intra and inter-rater
reliability. The PAS scores are determined according to the depth
to which food passes in the airway and whether or not food enter-
Results
ing the airway is removed.17 The PAS score 1 shows normal airway Two hundred fifty-nine patients with neurological disorders
protection without penetration and aspiration during swallowing. were included in the study. The mean age of the patients was 59.72
Scores between 2 to 5 are considered as penetration, which means ± 17.24 years (min = 18, max = 96), of which 57.1% were male.
that food enters the larynx but do not pass below the vocal folds, The mean weight was 68.16 ± 16.15 kg, and the mean height was
and scores between 6 to 8 are considered as aspiration, which means 165.57 ± 9.87 cm. Table 1 reports the diagnosis and VFSS results
that the food passes below the vocal folds. When a penetration or an of the patients.
aspiration was detected, an impairment of the safety of swallowing The mean T-EAT-10 score of patients who had aspiration
was considered.14 (PAS > 5) was 25.91 ± 10.31 (min = 1, max = 40) and the
mean T-EAT-10 of patients who did not aspirate (PAS < 6) was
Statistical Methods 15.70 ± 10.54 (min = 0, max = 40) (P < 0.001). A linear corre-
The IBM-SPSS for Windows version 20 (IBM Corp, Ar- lation between T-EAT-10 and PAS scores of the patients was found
monk, NY, USA) was used to perform all statistical analyses. (r = 0.416, P < 0.001). The T-EAT-10 was significant to detect
Descriptive statistics were calculated as a number per percent for patients with aspiration (PAS > 5) (area under the curve: 0.76, P
< 0.001). We determined the cut-off as 16 for risk and predictive
assessment because the mean T-EAT-10 score of the patients who
Table 1. Diagnosis and Videofluoroscopic Swallowing Study Results
did not aspirate was 16. Patients with a T-EAT-10 score higher
of the Patients
than 15 were 2.4 times more likely to aspirate. The sensitivity of a
Variables T-EAT-10 score higher than 15 in predicting aspiration was 81.0%
Diagnosis (n [%]) and the specificity was 58.0%. A T-EAT-10 score of higher than 15
Stroke 118 (45.6) has a positive predictive value of 72.0% and a negative predictive
Motor neuron disease 48 (18.5)
value of 69.0%. Table 2 summarizes the results, and Figure displays
Parkinson’s disease 26 (10.0)
Myasthenia gravis 25 (9.7)
Multiple sclerosis 24 (9.3)
Table 2. Aspiration results on Videofluoroscopic Swallowing Study
Myopathy 18 (6.9)
VFSS results (n [%]) Aspiration
T-EAT-10 Score
Impaired labial seal closure 15 (5.8) Present (n) Absent (n) Total
Oral residue 15 (5.8)
Pharyngeal residue 133 (51.4) > 15 119 (a) 47 (b) 166
Piecemeal deglutition 82 (31.7) < 16 28 (c) 65 (d) 93
Impaired swallowing efficacy 141 (54.4) Total 147 112 259
Impaired swallowing safety 181 (69.9) T-EAT-10, Turkish Eating Assessment Tool.
Penetration aspiration scale (mean [SD]) 5 (3.1) Sensitivity: a/(a + c) = 81.0%; specificity: d/(b + d) = 58.0%; positive pre-
dictive value = a/(a + b) = 72.0%; negative predictive value = d/(c + d) =
VFSS, videofluoroscopic swallowing study. 69.0%; relative risk = a/(a + b)/c/(c + d) = 2.4.

Eating Assessment Tool-10
1.0
ROC curve aspiration risk in 2 previous studies.2,13,14 Our findings regarding
high discriminant ability of the T-EAT-10 in detecting aspiration
0.8 in neurological patients are similar to the findings of these stud-
ies.2,13,14 Different criterion scores were used due to methodological
differences in these studies. For instance, Rofes et al14 investigated
Sensitivity
0.6
the ability of the EAT-10 in identifying oropharyngeal dysphagia,
0.4 thereby used a cut score of 2, and presented 89.0% of sensitivity and
82.0% of specificity. Plowman et al2 and Cheney et al13 determined
0.2 their cut-off scores according to the mean EAT-10 of patients
without aspiration as our methodology. The earlier investigation
0.0 used a cut value of 8, and reported that this score correctly identi-
0.0 0.2 0.4 0.6 0.8 1.0
1-Specificity fied 85.7% of ALS aspirators with 71.9% specificity.2 The cut score
according to the mean EAT-10 of non-aspirators in the study of
Figure. Receiver operating characteristic (ROC) curves for the ability
Cheney et al13 was 16 as our cut score from our neurological patient
of the Eating Assessment Tool-10 to identify neurological patients who
aspirate (penetration-aspiration scale ≥ 6). population. Cheney et al13 reported that the sensitivity of EAT-10
was 71.0%, the specificity was 53.0%, and the negative predictive
value was 89.0%. Although there are differences between these
the receiver-operating characteristic graphs. studies, the general interpretation of the results is that these authors
suggested the EAT-10 as a discriminative instrument for identifica-
tion of aspiration risk in general dysphagic population.
Discussion In our study, the ability of the T-EAT-10 to detect aspiration
Early identification of the risk for dysphagia in neurological was investigated in a group of neurological patients with different
patients is very important to prevent the complications including diagnoses. Our clinical experiences about the neurology clinic in
dehydration, malnutrition, and aspiration pneumonia.1 The find- our university showed that neurology clinics need a practical and
ings from this current study show that the T-EAT-10 can detect valid tool to determine the aspiration risk by health professionals
risk of aspiration in patients with neurological disorders, and that including not only dysphagia specialists but also physicians, nurses,
T-EAT-10 correlated with PAS scores. When determining the etc to refer patients for further evaluation of swallowing. Because
ability of the T-EAT-10 for identifying neurological patients with each patient cannot be evaluated by a dysphagia specialist and an
aspiration (PAS > 5), a T-EAT-10 score of 16 correctly identified instrumental swallowing evaluation cannot always be performed.
81.0% of neurological patients with aspiration and patients with a T- Early identification of dysphagia provides early intervention
EAT-10 > 15 were 2.4 times more likely to aspirate. therefore contributes to reduce dysphagia complications, length of
Instrumental swallowing evaluation methods including VFSS hospital stay, and healthcare costs especially for patients with neuro-
and FEES are essential to assess the swallowing efficacy, airway logical patients.21 We found that the T-EAT-10 correlated with PAS
protection, and determine any food penetration into the airway. scores, which means that neurological patients with aspiration pre-
These methods are the gold standards for swallowing evaluation, sented higher scores in T-EAT-10. To support our findings, we in-
however, there are some limitations for their use in busy clinics. vestigated the sensitivity and specificity of the T-EAT-10.2 The cut
These methods require special equipment, place, trained staff, and score was found as 16 according to the mean EAT-10 of patients
time.18,19 Thus, it is not possible to perform these methods for each without aspiration from our mixed neurological patient population.
patient in neurology clinics to detect potential aspiration risks. Ac- Neurological patients who had a T-EAT-10 score of higher than 15
cordingly, there is a need for a valid, reliable, and feasible screen- were 2.4 times more likely to be a patient with aspiration. This score
ing tool to be used in patients with neurological disorders. Validity accurately detected 81.0% of patients with neurological disorders in
encompasses sensitivity, which is the capability of a test to accurately terms of aspiration, and 69.0% of neurological patients without as-
show the presence of a problem, and specificity, which is the capa- piration had a T-EAT-10 score of below this criterion score. Thus,
bility of a test to accurately present the absence of a problem.20 The the T-EAT-10 is clinically useful and has ability to detect aspiration
EAT-10 was reported as a discriminative tool for identification of in patients with neurological disorders.
Vol. 23, No. 4 October, 2017 (550-554) 553

Selen Serel Arslan, et al
Besides the ability of the T-EAT-10 to identify aspiration, we 2008;117:919-924.

should also mention that the T-EAT-10 should not be considered 8. Schindler A, Mozzanica F, Monzani A, et al. Reliability and validity of the
Italian eating assessment tool. Ann Otol Rhinol Laryngol 2013;122:717-
equivalent to a clinical bedside evaluation or instrumental assess-
724.
ment. 9. Burgos R, Sarto B, Segurola H, et al. Translation and validation of the
In conclusion, the T-EAT-10 can be safely used to screen pa- Spanish version of the EAT-10 (Eating Assessment Tool-10) for the
tients with neurological disorders who are at risk of unsafe airway screening of dysphagia. Nutr Hosp 2012;27:2048-2054.
protection for referral to further swallowing evaluation. 10. Goncalves MI, Remaili CB, Behlau M. Cross-cultural adaptation of
the Brazilian version of the Eating Assessment Tool - EAT-10. Codas
2013;25:601-604.
Acknowledgements: We would like to thank the patients who 11. Wakabayashi H, Kayashita J. [Translation, reliability and validity of the
were willing to participate in our study. Japanese version of the 10-item eating assessment tool (EAT-10) for the
screening of dysphagia.] JJSPEN 2014;29:871-876. [Japanese]
Financial support: None. 12. Demir N, Serel Arslan S, İnal Ö, Karaduman AA. Reliability and va-
lidity of the Turkish Eating Assessment Tool (T-EAT-10). Dysphagia
Conflicts of interest: None. 2016;31:644-649.
13. Cheney DM, Siddiqui MT, Litts JK, Kuhn MA, Belafsky PC. The
Author contributions: Selen Serel Arslan, Numan Demir, and ability of the 10-item eating assessment tool (EAT-10) to predict as-
Aynur A Karaduman designed the study; Selen Serel Arslan and piration risk in persons with dysphagia. Ann Otol Rhinol Laryngol
Hasan E Kılınç collected and analyzed the data; and Selen Serel 2015;124:351-354.
14. Rofes L, Arreola V, Mukherjee R, Clave P. Sensitivity and specificity of
Arslan wrote the paper. All authors reviewed the results.
the eating assessment tool and the volume-viscosity swallow test for clini-
cal evaluation of oropharyngeal dysphagia. Neurogastroenterol Motil
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of the prevalence of oropharyngeal dysphagia in stroke, Parkinson’s terol Motil 2010;16:319-322.
disease, Alzheimer’s disease, head injury, and pneumonia. Dysphagia 16. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a
2016;31:434-441. comprehensive review. J Am Geriatr Soc 1992;40:922-935.
2. Plowman EK, Tabor LC, Robison R, et al. Discriminant ability of the 17. Rosenbek JC, Robbins JA, Roecker EB, Coyle JL, Wood JL. A penetra-
Eating Assessment Tool-10 to detect aspiration in individuals with amyo- tion-aspiration scale. Dysphagia 1996;11:93-98.
trophic lateral sclerosis. Neurogastroenterol Motil 2016;28:85-90. 18. DeMatteo C, Matovich D, Hjartarson A. Comparison of clinical and
3. Alali D, Ballard K, Bogaardt H. Treatment effects for dysphagia in adults videofluoroscopic evaluation of children with feeding and swallowing dif-
with multiple sclerosis: a systematic review. Dysphagia 2016;31:610-618. ficulties. Dev Med Child Neurol 2005;47:149-157.
4. Buchholz DW. Dysphagia associated with neurological disorders. Acta 19. Nacci A, Ursino F, La Vela R, Matteucci F, Mallardi V, Fattori B.
Otorhinolaryngol Belg 1994;48:143-155. Fiberoptic endoscopic evaluation of swallowing (FEES): proposal for
5. Cook IJ, Kahrilas PJ. AGA technical review on management of oropha- informed consent. Acta Otorhinolaryngol Ital 2008;28:206-211.
ryngeal dysphagia. Gastroenterology 1999;116:455-478. 20. Parikh R, Mathai A, Parikh S, Chandra Sekhar G, Thomas R. Under-
6. Lee T, Park JH, Sohn C, et al. Failed deglutitive upper esophageal standing and using sensitivity, specificity and predictive values. Indian J
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7. Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability gia risk in patients with stroke: a systematic review. Stroke 2012;43:892-
of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol 897.

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Psychiatric Co-morbidity in Patients With Irritable

Bowel Syndrome at a Tertiary Care Center in
Northern India
Yuman Kawoos,1* Zaid A Wani,1 Showkat A Kadla,2 Irfan A Shah,3 Arshad Hussain,1 M Maqbool Dar,1 Mushtaq A Margoob,1 and
Kouser Sideeq4
Departments of 1Psychiatry, 2Gastroenterology, 4Preventive and Social Medicine, Government Medical College Srinagar, Srinagar, Jammu and
Kashimir, India; and 3Department of Neurology, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
Background/Aims
Irritable bowel syndrome (IBS) is a chronic psycho-physiological disorder. It is considered to be the most common functional
gastrointestinal disorder, and about 50-90% of IBS patients have associated psychiatric co-morbidity. We aimed to study psychiatric
co-morbidities in patients with IBS visiting a tertiary care center.
Methods
This was a cross-sectional case-control study conducted over a duration of one and a half years from January 2014 to July 2015.
Patients were selected from the out-patient department of gastroenterology. About 160 patients with IBS who fulfilled the inclusion
criteria and who gave written informed consent were selected as study cases. The healthy attendants of cases were selected as
controls. A total of 200 controls were selected. Rome-III criteria were used to diagnose IBS. For diagnosing psychiatric disorders, we
used the Mini International Neuropsychiatric Interview Schedule Plus.
Results
Mean age of our cases and controls was 39.7 ± 11.4 and 37.7 ± 9.6 years, respectively. Females outnumbered males in our cases as
well as their controls by a ratio of 2:1 approximately. Psychiatric disorders were seen in 84.4% of IBS patients as compared to 41.5%
in controls. Major psychiatric disorders seen in our patients were generalized anxiety disorders (30.0%) and depression (28.0%).
Conclusions
The majority of patients with IBS who present to a tertiary care center have co-morbid psychiatric disorders. We need to screen these
patients for such co-morbidities and develop a holistic approach for better outcome in such cases.
Key Words
Anxiety disorder; Co-morbidity; Depression; Gastrointestinal diseases; Irritable bowel syndrome
Received: October 13, 2016 Revised: March 21, 2017 Accepted: April 2, 2017
is properly cited.
*Correspondence: Yuman Kawoos, MD
Department of Psychiatry, Government Psychiatric Diseases Hospital Srinagar, G1, Residential block, Srinagar, Jammu and Kashmir
190003, India
Tel: +91-9419405478, Fax: +91-9419009329, E-mail: yumankawoos@ymail.com

www.jnmjournal.org
555
Yuman Kawoos, et al
one and a half years from January 2014 to July 2015. Subjects for
the study were selected from outpatients visiting the Gastroenterol-
Introduction ogy department. After complete history and physical examination,
Irritable Bowel Syndrome (IBS) is a chronic gastrointestinal subjects who fulfilled the inclusion criteria were selected as cases.
(GI) disorder which is distinguished by repeated and inexplicable The healthy attendants of cases were selected as controls. A total
symptoms like diffuse or localized abdominal pain, constipation, of 160 patients were selected as cases and 200 attendants served
diarrhea and urgency.1 It is thought to be one of the most common as controls. Organic causes were ruled out by the gastroenterolo-
GI disorders, having an approximate prevalence of 1.1-29.2% in gist after appropriate investigations wherever necessary. All of the
the community.2-5 The disorder amounts to a major burden on cases were interviewed for socio-demographic parameters like
healthcare, and constitutes nearly half of the referrals to gastroenter- gender, age, employment and educational level, marital status, and
ology clinics.6-8 socioeconomic level. The socio-economic class was established by
The mechanism of development of IBS has not been fully means of the Kuppuswamy’s scale. The scale is used to ascertain the
explained. Post-infectious inflammation, impaired gut motility, psy- socio-economic level of urban populations, and takes into account
chological distress; adverse life events and alteration in the brain-gut education, occupation of the head of the family, and total income of
axis are among the various suggested pathophysiological explana- the family.17 Education and occupation of the head of family did not
tions which may result in the development of this syndrome.9-11 change with time, but income has to be updated from time to time.18
The treatment of this symptom complex consists of psychotherapy All patients provided a written informed consent for inclusion in the
alone or a combination of psychotherapy with psychotropic drugs research. The study was approved by the institute ethical committee
and symptomatic treatment for pain, constipation, and loose stools. of Government Medical College, Srinagar (IEC/GMCS Protocol
Among the psychotherapeutic interventions, cognitive behavioral No. 21/2012).
therapy is most effective for treatment of IBS.12 Subjects aged 18 years or above who satisfied the diagnostic
About 50-90% of IBS patients also have associated psychiatric criteria for IBS (Rome III criteria) and had no organic pathology
ailments; most commonly anxiety disorders and depression.13 Pa- on thorough investigations (upper GI endoscopy, colonoscopy, and
tients with this functional GI disorder have impairment in the health abdominal ultrasonography) were included in our study as cases.
related quality of life. Also, patients with severe disease have higher Healthy attendants accompanying the patients (most of whom were
prevalence of quality of life impairment.14 Studies have revealed that first or second degree relatives of cases) were included to serve as
patients seeking medical consultation have a higher number and controls. It was a sort of convenience sampling as the controls were
severity of symptoms15 and are more likely to be depressed and anx- interviewed in the same premises for presence of any psychiatric
ious.16 disorder. They were matched in terms of age and gender with cases.
The majority of the literature on IBS and associated psychiatric Patients diagnosed with any psychiatric disorder were referred to
diseases comes from western studies. Very little research has been the psychiatric out-patient department for treatment.
done on these interrelated disorders in this part of the world. Since Cases were diagnosed using Rome III criteria for IBS.19 For
major socio-cultural differences exist in the manifestation of these the diagnosis of psychiatric co-morbidity, we used the Mini Inter-
psychosomatic disorders, generalizing the outcomes of research national Neuropsychiatric Interview Schedule Plus.20,21
from western studies will be unrevealing. Only few studies have
been done in this area so far in India. Our aim therefore, was to Statistical Methods
strengthen the limited knowledge regarding the relation of psychi- Data were entered into excel sheet designed by Microsoft
atric disorders with IBS in our region. Corporation, Redmond, WA, USA. Continuous variables were
analyzed in the form of mean and standard deviation. Categori-
cal variables were summed up as frequency and percentages. Chi-
Materials and Methods square test was applied to analyze the relationship between categori-
The present study was conducted in the Institute of Mental cal variables. Fisher’s exact test was used wherever Chi-square test
Health and Neurosciences in collaboration with the Department of did not meet the Cochrane criteria. Difference between 2 means
Gastroenterology, Government Medical College Srinagar. It was a was analyzed using the unpaired t test. Odds ratio with 95% confi-
cross-sectional case-control study conducted for a length of about dence interval was calculated to estimate the odds ratio for general-

Psychiatric Disorders in Patients of IBS
ized anxiety disorder (GAD) and major depressive episode (MDE). bidity while among controls 25.0% males and 50.0% females had
Open Epi (www.openepi.com/Menu/OE_Menu.htm) and Primer co-morbid psychiatric illness. Major psychiatric disorders seen in
of Biostatistics were used for statistical analysis. our patients were GAD and MDE. GAD was seen in 30.0% of pa-
tients having IBS while MDE was present in 28.0%. Our controls
also had GAD and MDE as the major psychiatric disorder. GAD
Results was present in 13.0% and MDE in 16.0% of our controls. Mixed
The mean age of our IBS patients was 39.7 ± 11.4 years and anxiety depression was the next common psychiatric disorder seen
that of their healthy controls was 37.7 ± 9.6 years. Females out- in about 10.0% of IBS patients while only 2.0% of controls had the
numbered males in our patients as well as their controls by a ratio same disorder. Other common diagnoses seen in our patients were
of 2:1 approximately. An equal number of our patients and their post-traumatic stress disorder, somatization disorder, obsessive-
controls belonged to rural or urban backgrounds. The maximum compulsive disorder, panic disorder, and adjustment disorder (Table 2).
number of patients fitted into the upper-middle socio-economic The majority of our IBS patients had a mixed form of the ill-
class (Table 1). ness; IBS-M, 68 patients (42.5%). The least common form was
In our study, psychiatric disorders were seen in 135 (84.4%) the unclassified form of IBS; IBS-U, 16 patients (10.0%). Other
of IBS patients as compared to 83 (41.5%) of controls. Among the forms of IBS seen were constipation predominant IBS (IBS-C) in
cases, 86.3% males and 83.6% females had a psychiatric co-mor- 40 patients (25.0%) and diarrhea predominant IBS (IBS-D) in 36
patients (22.5%). The relation between psychiatric disorders and
various sub-types of IBS was not statistically significant as has been
Table 1. Socio-demographic Characteristics of Our Cases and Controls
studied in some other studies on IBS (Table 3).
Socio-demographic Healthy
IBS cases P -value
characteristics controls
Table 2. Psychiatric Co-morbidity in Cases and Controls
Mean age (yr) 39.7 ± 11.4 37.7 ± 9.6 0.720
Psychiatric disorder IBS cases Controls P -value
Male:Female (ratio) 44:116 (1:2.6) 74:126 (1:1.7) 0.056
Residence (rural:urban) 78:82 101:99 0.741 MDE 44 (27.5%) 32 (16.0%) 0.011
Socio-economic statusa GAD 48 (30.0%) 26 (13.0%) 0.000
I 3 (1.9%) 5 (2.5%) 0.850 Mixed anxiety depression 17 (10.6%) 4 (2.0%) 0.000
II 72 (45.0%) 81 (40.5%) Somatization 15 (9.4%) 8 (4.0%) 0.063
III 53 (33.1%) 77 (38.5%) OCD 1 (0.6%) 8 (4.0%) 0.047
IV 32 (20.0%) 37 (18.5%) PTSD 2 (1.25%) 0 (0.0%) 0.196
V 0 (0.0%) 0 (0.0%) Others 8 (5.0%) 5 (2.5%) 0.037
a
Kuppuswamy’s scale. MDE, major depressive episode; GAD, generalized anxiety disorder; OCD,
IBS, irritable bowel syndrome. obsessive compulsive disorder; PTSD, post-traumatic stress disorder; Others,
P -value was insignificant for all socio-demographic variables. panic disorder, adjustment disorder, and dysthymia.
Table 3. Relation Between Psychiatric Disorders and Various Forms of Irritable Bowel Syndrome
IBS-D IBS-C IBS-M IBS-U P -value

MDE 10 12 19 3 0.531
GAD 13 13 15 7 0.236
Mixed anxiety depression 4 2 10 1 0.414
Somatisation 4 6 3 2 0.287
OCD 0 0 1 0 0.714
PTSD 0 0 1 1 0.770
Others 0 2 6 0 0.237
No disorder 6 5 13 1 0.460
IBS, irritable bowel syndrome; IBS-D, diarrhea predominant IBS; IBS-C, constipation predominant IBS; IBS-M, mixed IBS; IBS-U, unclassified IBS; MDE,
major depressive episode; GAD, generalized anxiety disorder; OCD, obsessive compulsive disorder; PTSD, post-traumatic stress disorder; Others, panic disorder,
adjustment disorder, and dysthymia.
P -value was not significant for any psychiatric disorder. Applying Fishers exact test, no difference was seen between different forms of irritable bowel syndrome for
presence of psychiatric disorder
Vol. 23, No. 4 October, 2017 (555-560) 557

Yuman Kawoos, et al
Another reason could be that people from developing coun-

tries report more somatic symptoms in comparison with developed
Discussion countries, and IBS is one of the somatic symptom disorders.39 Also,
IBS is often considered to be the prototype of functional gas- the cases selected in our study were selected from a tertiary care cen-
trointestinal disorders with about 50-90% of IBS patients having ter where more severe forms of the illness are seen, and it has been
psychiatric co-morbidity.22 Patients showing manifestations of this studied that the severity of functional GI disorders increases the
disorder who report to a physician have a higher percentage of co- likelihood of having co-morbid psychiatric disorders.14 In our cases,
morbid psychological disturbances than patients who do not look an almost equal number of males and females had psychiatric co-
for medical help.15 The chronic and recurrent character of this dis- morbidity, while in controls more females had a psychiatric illness
ease may predispose patients to additional psychiatric disorders. The as compared to males. This may be due to the higher prevalence of
relation with psychiatric ailments may adversely affect the prognosis anxiety disorders and depression in females in the general popula-
of this GI disorder leading to more frequent medical consultations tion.40
by patients and escalating the health care costs.23 The major psychiatric disorders seen in our cases were MDE
Females outnumbered males in our study by a ratio of al- and GAD which has been found in many other studies done on
most 2:1 which is quite similar to the results seen in other studies, IBS. In a study done by Mayer et al,41 32.0% of patients of IBS
thereby showing that the disorder predominantly affects women.24,25 presented with GAD symptoms. In another epidemiological study
Researchers have hypothesized that sex hormones may affect the done in Hong Kong, the prevalence of GAD was seen to be consid-
mechanisms that regulate the brain-gut-microbiota axis which is erably higher in subjects reporting symptoms of IBS compared to
finally involved in the development of IBS.26 IBS is well thought to those who did not, and IBS was found to be associated with a 6-fold
have a shared etiopathogenesis with other functional and somatic higher chance of having GAD.42 In a study done by Kabra and
symptom disorders.27 It has been seen that females usually manifest Nadkarni43 in India, the prevalence of depression in IBS patients
psychiatric disorders as somatic complaints. In a study done in 2004 was about 37% which is slightly higher than our study. The prob-
by Haug et al,28 it was found that female patients were having high- able reason being different scales were used to assess depression in
er number of somatic symptoms than their male counterparts. Also, the 2 studies. GAD was found in 31.0% of IBS patients in the same
the study showed a strong relation of functional somatic symptoms study which is quite similar to that of our study.43
with anxiety and depression. The majority of patients had IBS-M with depression and
The most frequent sub-type of IBS in our study was IBS-M anxiety as the major psychiatric co-morbidities, but no major differ-
followed by IBS-C, and IBS-D. IBS-U was the least common ences were seen between the various types of IBS. In a study done
form seen in our study. These findings are in accordance with the in 2016 on IBS patients, it was seen that among the various types
results of some European and North American studies29,30 while of IBS, anxiety was predominantly seen in the IBS-M sub-type but
they differ from several other studies.31,32 It has been seen that the the sub-types did not differ significantly in depressive features. The
type of IBS is largely determined by the population under study higher rates of anxiety seen in IBS-M as compared to our study
and varies among different regions.33 could be due to different scales used for assessing psychiatric co-
In our study, psychiatric disorders were seen in about 84.4% of morbidities.44
IBS patients. This is quite high compared to the prevalence seen in Keeping in view the high rates of psychiatric co-morbidity in
western studies where the percentage of psychiatric disorders ranges patients of IBS as compared to the general population, all patients
from 40.0-60.0%,34,35 but is comparable to the rates seen in Indian of IBS should be scrutinized for associated psychiatric disorders in
studies.36 In the study done by Prashant Singh et al36 in 2012, co- order to build a holistic approach for managing these patients. By
morbid psychiatric disorders were found in 79.9% cases of IBS, doing so, we will be able to manage these patients as a whole, rather
which was considerably higher compared to 34.3% seen in controls. than treating their individual symptoms which will improve the
The higher prevalence of psychiatric disorders in our controls in quality of life of patients having IBS.
comparison to the above study could be due to the fact that Kash- Our study had a few limitations. We selected cases from a ter-
mir being a conflict zone, the prevalence of stress and psychiatric tiary care specialty center where severe forms of illness are referred;
diseases including anxiety disorders and depression is high when therefore there is a higher chance of associated psychiatric co-mor-
compared with other areas which are non-conflict zones.37,38 bidities in these patients compared to the ones in the general popu-

Psychiatric Disorders in Patients of IBS
lation or, those presenting to the primary care physicians. Also, most 9. Quigley EM. Changing face of irritable bowel syndrome. World J Gas-
of our controls were relatives of patients, thus sharing the genetics troenterol 2006;12:15.
which could have an influence on the prevalence of psychiatric co- 10. Tanaka Y, Kanazawa M, Fukudo S, Drossman DA. Biopsychosocial
model of irritable bowel syndrome. J Neurogastroenterol Motil 2011;17:
morbidity in the control group. Another limitation of our study is
131-139.
that we did not study the dietary habits of our cases which can have 11. Sykes MA, Blanchard EB, Lackner J, Keefer L, Krasner S. Psychopa-
an influence on presentation of symptoms. thology in irritable bowel syndrome: support for a psycho physiological
In conclusion, the majority of patients with IBS which pres- model. J Behav Med 2003;26:361-372.
ent to a tertiary care center have co-morbid psychiatric disorders. 12. Drossman DA, Toner BB, Whitehead WE, et al. Cognitive-behavioral
Only a few of them receive specific psychological treatment. We therapy versus education and desipramine versus placebo for moderate to
severe functional bowel disorders. Gastroenterology 2003;125:19-31.
emphasize screening of all patients with IBS for the presence of co-
13. Lydiard RB, Falsetti SA. Experience with anxiety and depression treat-
morbidities and timely referral to a psychiatrist for appropriate treatment studies: implications for designing irritable bowel syndrome clinical
ment. trials. Am J Med 1999;107(5A):65S-73S.
14. Jafari P, Asadollahi Z, Moini M, Seyed Mirzaie M. Health related qual-
ity of life in Iranian patients with irritable bowel syndrome: reliability and
Financial support: None. validity of the persian version of the IBS-QOL. Iran Red Crescent Med
J 2013;15:723-728.
Conflicts of interest: None. 15. Heaton KW, O’Donnell LJ, Braddon FE, Mountford RA, Hughes
AO, Cripps PJ. Symptoms of irritable bowel syndrome in a British urban
Author contributions: Yuman Kawoos and Zaid A Wani community: consulters and nonconsulters. Gastroenterology 1992;102:
planned and conducted the study; Showkat A Kadla helped in col- 1962-1967.
lecting the data and diagnosing functional gastrointestinal disorders; 16. Masand PS, Kaplan DS, Gupta S, et al. Major depression and irritable
Arshad Hussain, M Maqbool Dar, and Mushtaq A Margoob bowel syndrome: is there a relationship? J Clin Psychiatry 1995;56:363-
367.
helped in interpreting the data and revising the manuscript; Irfan A
17. Kuppuswamy B. Manual of Socioeconomic Status (urban). Delhi: Ma-
Shah helped in drafting the manuscript; and Kouser Sideeq did the
nasayan 1981:66-72.
statistical analysis. 18. Mishra D, Singh HP. Kuppuswamy’s socioeconomic status scale - A
revision. Indian J Pediatr 2003;70:273-274.
19. Drossman DA, ROME III: The functional gastrointestinal disorders.
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Prediction of Delayed Colonic Transit Using

Bristol Stool Form and Stool Frequency in Eastern
Constipated Patients: A Difference From the West
Veeravich Jaruvongvanich,1,2 Tanisa Patcharatrakul,2,3 and Sutep Gonlachanvit3*

1
Department of Internal Medicine, University of Hawaii, Honolulu, HI, USA; 2Department of Medicine, King Chulalongkorn Memorial Hospital,
Thai Red Cross Society, Bangkok, Thailand; and 3Gastrointestinal Motility Research Unit, Division of Gastroenterology, Department of Medicine,
Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Background/Aims
The correlation between the Bristol stool form scale (BSFS) and colonic transit time (CTT) has been reported in Western populations.
Our study aims to study the relationship between BSFS, stool frequency, and CTT in Eastern patients with chronic constipation.
Methods
A total of 144 chronic functional constipation patients underwent colonic transit study by using radio-opaque markers, anorectal
manometry, and balloon expulsion test. Stool diary including stool forms and frequency was recorded. Delayed CTT was defined as
the retention of more than 20.0% of radio-opaque markers in the colon on day 5.
Results
Twenty-five patients (17.4%) had delayed colonic transit. Mean 5-day BSFS (OR, 0.51; 95% CI, 0.34-0.79; P = 0.021) and stool
frequency (OR, 0.60; 95% CI, 0.44-0.83; P = 0.002) were independently associated with delayed CTT by logistic regression analysis.
Mean 5-day BSFS (area under the curve [AUC], 0.73; 95% CI, 0.62-0.84; P < 0.001) and stool frequency (AUC, 0.75; 95% CI, 0.63-
0.87; P < 0.001) fairly predicted delayed CTT. The optimal mean 5-day BSFS of ≤ 3 provided 68.0% sensitivity, 69.7% specificity, and
69.4% accuracy, and the optimal stool frequency ≤ 2 bowel movements in 5 days provided 64.0% sensitivity, 83.1% specificity, and
84.0% accuracy for predicting delayed CTT.
Conclusions
Both stool form and frequency were significantly associated with delayed CTT. Stool frequency ≤ 2 and BSFS 1-3 rather than BSFS 1-2
that was used in the Westerners could be used as surrogate for delayed CTT in Eastern patients with constipation.
Key Words
Bristol stool scale; Colonic motility; Colonic transit time; Constipation
Received: February 19, 2017 Revised: March 17, 2017 Accepted: April 2, 2017
is properly cited.
*Correspondence: Sutep Gonlachanvit, MD, MSc
Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Pathumwan, Bangkok
10330, Thailand
Tel: +662-256-4265, Fax: +662-256-4504, E-mail: gsutep@hotmail.com

www.jnmjournal.org
561
Veeravich Jaruvongvanich, et al
useful guide to standardize the stool forms and has been utilized in
various clinical and research practices.19 However, BSFS demon-
Introduction strated fair correlation with CTT in most studies.19-24 Two studies
Chronic constipation is a common gastrointestinal disorder in healthy volunteers using laxative or antidiarrheal medications
with the global prevalence of 12.0-17.0%.1 The prevalence of con- demonstrated that the longer CTT correlated with harder stools.19,22
stipation is different among geographic regions, which is lower in Stool frequency also demonstrated mixed results on CTT correla-
Southeast Asia (11.0%) compared with Europe (16.0%) and North tion.19-27
America (14.0%).1 Moreover, it accounts for one of the top 5 of BSFS of 1 to 2 are considered as hard or lumpy stools and have
gastrointestinal disorders in ambulatory clinics.2,3 Constipation not been used for classification of irritable bowel syndrome (IBS) with
only significantly impairs patient’s quality of life but also impacts constipation (IBS-C) subtype according to the Rome III criteria,
on the economic burden, both direct health-care costs pronouncing whereas BSFS of 1 to 3 are classified as IBS-C for Asian patients
7500 US dollars per patient annually and indirect costs including based on the Asian Neurogastroenterology and Motility Associa-
loss of work productivity and work absence.4-6 tion consensus.28,29 Asians demonstrated faster intestinal transit time
In chronic idiopathic cases who do not respond to standard in both healthy and IBS individuals compared with Westerners.29
treatment, patients need further specialized investigations for assess- However, the data on the association of stool form and CTT in
ing colonic and anorectal function to identify the underlying cause Asians is limited and more validated information from the Asian
for the better view of optimal management.7 Biofeedback therapy population is needed.
has been found to improve bowel symptoms and anorectal function The aim of this study is to explore the relationship between
in constipated patients with dyssynergic defecation according to the BSFS, stool frequency, and colonic transit study results in Eastern
American Neurogastroenterology and Motility Society and the Eu- patients with chronic constipation.
ropean Society of Neurogastroenterology and Motility consensus.8
Those who have slow transit constipation might gain benefits from
newer agents to restore colonic function, including serotoninergic
enterokinetic agents, and intestinal secretagogues. Some of these
patients might need more invasive approach including surgery Patients
(colectomy, ileostomy, or ileorectal anastomosis) or novel methods During the period of May 2013 to December 2015, patients
including neuromodulation therapy or sacral nerve stimulation.9-11 with chronic constipation who were not satisfied with laxatives and
Various methods to assess colonic transit have been utilized includ- who visited the outpatient gastroenterology clinic at King Chul-
ing radio-opaque marker (ROM) studies, colonic transit scintigra- alongkorn Memorial Hospital, Bangkok, Thailand, were prospec-
phy, and wireless motility capsule studies. Of these, the colonic tran- tively enrolled in this study. All patients had 2 or more following
sit study using ROM seems to be the most widely performed due symptoms of more than 3 months: straining, lumpy or hard stools,
to its simplicity, inexpensiveness, and lack of the need of specialized sensation of incomplete evacuation, manual maneuver to facilitate
equipment. Though most of the reported studies of colonic transit defecation, sensation of anorectal obstruction or blockage or/and
time (CTT) have been done in the West, a few studies from Asian less than 3 bowel movements (BMs) a week. No rescue drugs were
showed different findings. Previous studies in the West showed prescribed during the study period. Exclusion criteria were: (1) his-
mean normal CTT of 30-40 hours with the upper normal limit of tory of any gastrointestinal surgeries other than appendectomy, cho-
70 hours12-14 whereas studies in Asian healthy individuals showed lecystectomy, and cesarean section and (2) diagnosed as secondary
faster transit times as the mean CTT of 15.8 hours in Indians,15 constipation due to medication, anatomical disorders, and medical
16.8 hours in Koreans16 and 24.5 hours in Hong Kong people, re- conditions, eg, hypothyroidism, diabetes mellitus, cerebrovascular
spectively.17 This difference might be affected by race, ethnicity, and disease, and hypercalcemia. All included patients underwent ano-
dietary habits.18 rectal manometry, balloon expulsion test, and colonic transit study
In clinical practice, clinicians usually treat patients with symp- using solid ROMs. The techniques were described previously.30
toms-based approach by using stool form and stool frequency to Subjects were required to withhold any medications that effect
evaluate colonic transit. Bristol stool form scale (BSFS) was devel- gastrointestinal motility including laxatives, prokinetics, antidepres-
oped in 1970s by Lewis and Heaton with the aim to be a simple sants, anxiolytics, and antipsychotics for 7 days prior to testing.

Stool Characteristics and Delayed Colonic Motility
Patients were then categorized as having defecation disorders if they for Mac (SPSS Inc, Chicago, IL, USA). Data were presented as
have 2 of the following criteria during repeated attempts to defecate: mean ± SD or proportions (%). Comparisons between 2 groups
(1) evidence of impaired evacuation based on balloon expulsion were performed by unpaired Student’s t test for continuous data
test and (2) inappropriate contraction of the pelvic floor or less than and Chi-square test for nominal data. Relationship of stool form
20.0% relaxation of basal resting sphincter pressure or inadequate and frequency with GC was calculated using Spearman’s correla-
propulsive forces during attempted defecation by manometry.30 All tion. The strength of correlation is interpreted as weak (ρ = -0.3
patients completed a constipation symptom questionnaire which to -0.1 or 0.1 to 0.3), moderate (ρ = -0.5 to -0.3 or 0.3 to 0.5), and
included straining, lumpy or hard stools, sensation of incomplete strong (ρ = -1.0 to -0.5 or 1.0 to 0.5), respectively. Receiver operat-
evacuation, manual maneuver to facilitate defecation, and sensation ing characteristic (ROC) analysis was performed to calculate the
of anorectal obstruction/blockage. cut-off value, sensitivity, specificity, and accuracy for discriminating
Informed consent was obtained from all individual participants patients with delayed CTT from normal transit. An area under the
before enrolling in the study. This study was approved by the Hu- curve (AUC) of more than 0.7, 0.8, and 0.9 were considered as fair,
man Research Ethic Committee of King Chulalongkorn Memorial good, and excellent tests, respectively. The optimal cut-off value was
Hospital. determined when the point yields the best sensitivity and specificity
in ROC curve. Multivariate logistic regression analysis was used to
Assessment of Colonic Motility with Colonic Transit determine which factors were independently associated with delayed
Study CTT. The P -value of less than 0.05 was considered as statistically
All subjects ingested 20 solid ROMs manufactured locally (di- significant.
ameter 5 Fr, length 1 cm each; Introducer sheath, Terumo, Japan)
in 2 gelatin capsules, and the abdominal X-rays were obtained on
day 1, 3, and 5 after ingestion. Subjects were on normal diet and
Results
normal activities during the study period. The weighted mean of
ROM distribution in the (1) right colon, (2) left colon, (3) rectosig- Subject Characteristics
moid colon, and (4) stool was expressed as a geometric center (GC, This study cohort consisted of 144 patients with a mean age
1-4 respectively). The colon was divided into 3 parts defined by of 52.0 ± 16.6 years, and 70.8% were female. The prevalence of
bony landmarks as described in a previous study.31 Delayed colonic constipation symptoms was reported as followed: straining (84.0%),
transit was defined as the retention of more than 20.0% of ROMs hard stools (65.3%), sensation of incomplete evacuation (81.9%),
(more than 4 ROMs) in the colon on day 5 after ingestion.32 The manual maneuver to facilitate defecation (45.1%), and sensation
X-rays were interpreted by 2 independent investigators without of anorectal blockage (70.1%). Mean stool frequency was 4 (2.3-
knowing the stool characteristics, subjects’ profiles, and the date of 5.0) BMs per 5 days. The mean 5-day BSFS was 3.5 ± 1.3. Of all
imaging study. patients, 25 patients (17.4%) had delayed CTT, 70 patients (48.6%)
had IBS symptoms, and 58 patients (40.3%) had defecation disorder.
Assessment of Stool Form and Frequency
After ingestion of ROMs, all participants were asked to record Features Comparison Between Patients With
stool form of every BM in a stool diary during the 5-day study pe- Delayed Colonic Transit Time Versus Normal
riod. The stool form was graded using the BSFS ranging from 1 to Colonic Transit Time
7.19 The lower score reflects the harder stool. Because the stool form There was no significant difference in age, gender, body mass
is usually harder at the beginning and softer at the end of each BM, index, prevalence of defecation disorder and IBS symptoms, and
the BSFS was graded base on the hardest stool form at the begin- constipation symptoms including straining, hard stools, incomplete
ning of each BM. The mean BSFS of all BMs during the 5-day evacuation, manual maneuver to facilitate defecation, and sensation
study period was obtained from the stool diary. Stool frequency was of anorectal blockage, between patients with and without delayed
expressed as a total number of BMs in 5 days. CTT. Delayed CTT patients presented with significantly fewer
mean stool frequency (2.5 ± 2.0 vs 4.3 ± 1.9 BMs per 5 days, P
Statistical Methods < 0.001), and harder stool form (mean 5-day BSFS of 2.6 ± 1.4
All statistical analyses were performed by SPSS version 21.0 vs 3.7 ± 1.3, P < 0.001) compared to patients with normal CTT.
Vol. 23, No. 4 October, 2017 (561-568) 563

Table 1. Baseline Characteristics Compared Between Patients With Delayed and Normal Colonic Transit Study
Total Delayed CTT Normal CTT

P -value
(N = 144) (n = 25) (n = 119)
Age (yr) 52.0 ± 16.6 53.0 ± 16.5 51.8 ± 16.7 0.756
Sex (% female) 102 (70.8) 19 (76.0) 83 (69.7) 0.534
BMI (kg/m2) 22.8 ± 3.7 21.4 ± 2.8 23.1 ± 3.8 0.055
Defecation disorder (n [%]) 58 (40.3) 13 (52) 45 (37.8) 0.187
Fulfilled IBS criteria (n [%]) 70 (48.6) 12 (48) 58 (48.7) 0.946
Constipation symptoms (n [%])
Straining 121 (84.0) 23 (92.0) 98 (82.4) 0.230
Hard stools 94 (65.3) 19 (76.0) 75 (63.0) 0.222
Incomplete evacuation 118 (81.9) 22 (88.0) 96 (80.7) 0.394
Manual maneuver to facilitate defecation 65 (45.1) 12 (48.0) 53 (44.5) 0.746
Sensation of anorectal blockage 101 (70.1) 20 (80.0) 81 (68.1) 0.228
Stool characteristics
Average 5-day BSFS 3.5 ± 1.3 2.6 ± 1.4 3.7 ± 1.3 < 0.001
Stool frequency (BMs/5 days) 4.0 ± 2.0 2.5 ± 2.0 4.3 ± 1.9 < 0.001
Geometric center
Day 1 2.5 ± 0.9 1.8 ± 0.8 2.6 ± 0.9 < 0.001
Day 3 3.5 ± 0.7 2.6 ± 0.6 3.7 ± 0.5 < 0.001
Day 5 3.8 ± 0.4 3.1 ± 0.5 4.0 ± 0.02 < 0.001
CTT, colonic transit time; BMI, body mass index; IBS, irritable bowel syndrome; BSFS, Bristol stool form scale; BMs, bowel movements.
Data express as mean ± SD.
Table 2. Predictors of Delayed Colonic Transit Time by Using Mul- Table 3. Sensitivity, Specificity, and Accuracy of Mean 5-day Bristol
tivariate Logistic Regression Analysis Stool Form Scale and Stool Frequency in Diagnosing Delayed Co-
lonic Transit Time
Variable Adjusted ORa 95% CI P -value
Sensitivity Specificity Accuracy
Average 5-day BSFS 0.51 0.34-0.79 0.021
(%) (%) (%)
Stool frequency (BMs/5 days) 0.60 0.44-0.83 0.002
a
Adjusted to age, sex, body mass index, and irritable bowel syndrome. Mean 5-day BSFS
BSFS, Bristol stool form scale; BMs, bowel movements. 1 28.0 94.1 82.6
1-2 40.0 84.9 77.1
1-3 68.0 69.7 69.4
The GC was significantly more proximal in delayed CTT group 1-4 96.0 37.0 47.2
compared with normal colonic transit group for day 1 (1.8 ± 0.8 vs Stool frequency (BMs/5 days)
2.6 ± 0.9), day 3 (2.6 ± 0.6 vs 3.7 ± 0.5), and day 5 (3.1 ± 0.5 vs 0-1 32.0 95.0 84.0
4.0 ± 0.02) (all P -values < 0.001). The main features of subjects 0-2 64.0 83.1 84.0
are summarized in Table 1. 0-3 68.0 66.4 66.7
0-4 80.0 51.3 56.3
Accuracy of Stool Form and Frequency for BSFS, Bristol stool form scale; BMs, bowel movements.
Predicting Delayed Colonic Transit Time

Multivariate logistic regression analysis indicated that the mean < 0.001), and stool frequency (AUC, 0.75; 95% CI, 0.63-0.87; P
5-day BSFS (OR, 0.51; 95% CI, 0.34-0.79; P = 0.020) and stool < 0.001) fairly predicted delayed CTT. The optimal value of mean
frequency (OR, 0.60; 95% CI, 0.44-0.83; P = 0.002) were in- 5-day BSFS for predicting delayed CTT was less than or equal to
dependently associated with delayed CTT after adjusting for age, 3 providing 68.0% sensitivity, 69.7% specificity, 69.4% accuracy,
gender, and body mass index (Table 2). 32.1% positive predictive value, and 91.2% negative predictive
The ROC analysis for predicting delayed CTT indicated that value. Optimal stool frequency was less than or equal to 2 BMs per
BSFS of the mean 5-day BSFS (AUC, 0.73; 95% CI, 0.62-0.84; P 5 days providing 64.0% sensitivity, 83.1% specificity, 84% accuracy,

Table 4. Spearman’s Correlation of Stool Characteristics and Constipation Symptoms With Geometric Center
GC day 1 GC day 3 GC day 5

a a
Mean 5-day BSFS 0.35 0.38 0.32a
Stool frequency (BMs/5 days) 0.31a 0.33a 0.36a
Constipation symptoms
Straining -0.57 -1.21 -0.71
Hard stools -1.51 -0.13 0.005
Incomplete evacuation -0.03 -0.05 -0.06
Manual maneuver to facilitate defecation 0.002 0.08 0.05
Sensation of anorectal blockage 0.04 0.04 -0.03
a
P < 0.01.
GC, geometric center; BSFS, Bristol stool form scale; BMs, bowel movements.
44.4% positive predictive value, and 91.7% negative predictive study to determine the association between stool characteristics us-
value (Table 3). A combined stool form (mean 5-day BSFS ≤ ing BSFS, stool frequency, and colonic transit in Asian constipated
3) and frequency (≤ 2 BMs in 5 days) provided 50.0% sensitivity, individuals.
92.4% specificity, 59.1% positive predictive value, and 90.2% nega- Most previous studies investigated the association of stool form
tive predictive value. and colonic transit in healthy and IBS individuals.19-24,34 Only a
study from Saad et al26 investigated this association in constipated
Correlation of Stool Characteristics and with adults by using ROM to define delayed CTT. They showed that
Geometric Center the mean 5-day BSFS of less than or equal to 2 was optimal for
Both the mean 5-day BSFS and stool frequencies moderately predicting delayed CTT with 80.0% sensitivity and 69.0% specific-
and positively correlated with GC on day 1, 3, and 5, meaning that ity. Our study was also done in well-defined chronic constipated
the looser stool and higher frequency of BMs correlated with faster individuals and showed significant correlation of stool form and
colonic motility (Table 4). All constipation symptoms demonstrated CTT, which supports the finding from Saad et al.26 However, our
non-significant correlation with GC. study showed that the optimal value of mean 5-day BSFS for pre-
dicting delayed CTT was less than or equal to 3 providing 68.0%
Subgroup Analysis sensitivity, 69.7% specificity, and 69.4% accuracy. This finding sug-
Our patients were divided into 2 subgroups: IBS and non-IBS. gests that, in Eastern constipation patients, not only BSFS 1 and 2
In IBS patients, stool form and frequency were not associated with but also BSFS 3 was associated with delayed colonic transit. This
delayed CTT and the correlation between stool form, frequency, difference might be attributed to different ethnic groups, dietary
and colonic motility were either weaker or not significant. Whereas, habits, and quantity of fiber intake between the Asian and the West-
the association and the correlation of stool form, frequency, and co- ern patients.33 Moreover, our findings also supported the previous
lonic motility remain significant in non-IBS patients (Supplementary consensus from the Asian Neurogastroenterology and Motility As-
Tables 1 and 2). sociation that used BSFS 1 to 3 to characterize IBS with constipa-
tion,29 which differed from the West (BSFS 1 to 2).28 Furthermore,
we assessed the correlation of BSFS and GC, after which we found
Discussion only moderate correlation. For practical purposes, the mean 5-day
Clinical information easily obtained from constipated patients BSFS can discriminate delayed CTT from normal CTT quali-
during outpatient visits including stool characteristics (stool form tatively, but the BSFS may not be used for grading the severity of
and frequency) and other gastrointestinal symptoms might guide delayed colonic transit.
doctors’ treatment strategies. However, different diet and bowel The correlation of stool frequency and colonic transit in
habits in different populations limit its application in general.33 constipation, IBS, and healthy adults have shown contradictory
Available studies on the association of stool characteristics and CTT results.19-21,23,24 Glia et al34 showed that less than 2 BMs per week
were from the West. To the best of our knowledge, this is the first was the independent predictor for slow-transit constipation, whereas
Vol. 23, No. 4 October, 2017 (561-568) 565

Saad et al26 showed no correlation when measured by wireless lonic motility alone or delayed colonic motility-defecation disorder
motility capsule and ROM. Our study demonstrated that stool fre- overlapping diseases.
quency is an independent predictor for delayed CTT and it showed In summary, moderate correlation exists between stool form,
moderate correlation with GC. Stool frequency also had a fair pre- frequency, and colonic motility. Stool form and frequency were in-
dictive ability for delayed CTT with the optimal stool frequency of dependently associated with delayed colonic transit. We suggest that
less than or equal to 2 BMs per 5 days providing 64.0% sensitivity, both stool form and frequency can be used as a simple office-based
83.1% specificity, and 84.0% accuracy. surrogate for colonic motility. A combined stool form (mean 5-day
Besides stool characteristics, physicians frequently assess gas- BSFS ≤ 3) and frequency (≤ 2 BMs in 5 days) could provide
trointestinal symptoms during an ambulatory visit. So far, only a 50.0% sensitivity, 92.4% specificity, 59.1% positive predictive value,
few studies evaluated the association between symptoms and co- and 90.2% negative predictive value. An mean 5-day BSFS of less
lonic motility and have reported different results.23,35 There was a than or equal to 3 or stool frequency of less than or equal to 2 BMs
large cohort study of IBS patients that investigated the association per 5 days could be used as surrogate markers for predicting de-
of three gastrointestinal symptoms (abdominal pain, bloating, and layed colonic motility in chronic constipation patients in Asia.
flatulence) with colonic motility, showing only weak correlation
of abdominal pain with CTT.23 Whereas the other cohort found
significantly higher severity of urgency and bloating in delayed
Supplementary Materials
CTT compared with normal CTT.35 All 5 constipation symptoms Note: To access the supplementary tables mentioned in this
(straining, hard stools, incomplete evacuation, manual maneuver to article, visit the online version of Journal of Neurogastroenterol-
facilitate defecation, and sensation of anorectal blockage) were not ogy and Motility at http://www.jnmjournal.org/, and at https://doi.
good markers for discriminating delayed CTT from normal CTT org/10.5056/jnm17022.
individuals as shown in our study.
Our study found weaker correlation and non-significant as-
sociation between stool form, frequency, and colonic motility in Acknowledgements: We thank Mrs Amporn Tanawatsug-
gasere and Ms Sukuma Suksri, Gastrointestinal Motility Research
IBS patients, whereas those findings remain significant in non-IBS
Unit, Division of Gastroenterology, Department of Medicine, Fac-
patients. There are a few plausible explanations on these findings.
ulty of Medicine, Chulalongkorn University for their assistance on
First, in IBS patients, stool consistency varies greatly within each in-
data acquisition.
dividual, and bowel habits were also found to change overtime,36,37
thus the reliability of the measurements of stool form and frequency Financial support: This study was supported in part by the
in IBS patients come into question given this day-to-day variation. Ratchadapiseksompotch Endowment Fund (GI Motility Research
Second, colonic absorption and secretion may be different in pa- Unit grant).
tients with IBS compared to those without IBS.38
Our study has limitations that should be acknowledged. First, Conflicts of interest: None.
we assessed colonic motility in patients with constipation, therefore
Author contributions: Veeravich Jaruvongvanich contributed
the correlation of BSFS and rapid colonic transit could not be
to the acquisition, analysis, and interpretation of the data, and draft-
demonstrated. Second, psychological stress was found to enhance
ed the article; and Tanisa Patcharatrakul and Sutep Gonlachanvit
colonic motor activity.39,40 However, psychological stressors were
designed the study, recruited patients, drafted the article, and criti-
not assessed in our study. Caution should be noted in interpreting
cally revised the manuscript for important intellectual content.
our study findings. According to the American Gastroenterological
Association medical position statement on constipation,41 defecation
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Nationwide Multicenter Study for Overlaps of

Common Functional Gastrointestinal Disorders
in Korean Patients With Constipation
Kyung Sik Park,1 Sam Ryong Jee,2 Bong Eun Lee,3 Kyoung Sup Hong,4 Jeong Eun Shin,5 Soo-Young Na,6 Joong Goo Kwon,7
Suck Chei Choi,8* Yong Sung Kim,9 Hyun Seok Lee,10 Tae Hee Lee,11 Kyeong Ok Kim,12 Jongkyoung Choi,13 Hee Seok Moon,14
Yeon Soo Kim,15 Moo In Park,16 Soo Jung Park,17 Seon-Young Park,18 Sung Noh Hong,19 and Constipation Research Group of
Korean Society of Neurogastroenterology and Motility
1
Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea; 2Inje University College of Medicine, Busan, Korea;
3
Pusan National University School of Medicine, Busan, Korea; 4Seoul National University College of Medicine, Seoul, Korea; 5Dankook University
College of Medicine, Cheonan, Chungnam, Korea; 6Jeju National University School of Medicine, Jeju, Korea; 7Catholic University of Daegu
School of Medicine, Daegu, Korea; 8Wonkwang University School of Medicine, Iksan, Jeonbuk, Korea; 9Department of Internal Medicine and
Wonkwang Digestive Disease Research Institute, Wonkwang University Sanbon Hospital, Gunpo, Gyeonggi-do, Korea; 10Kyungpook National
University School of Medicine, Daegu, Korea; 11Soonchunhyang University College of Medicine, Seoul, Korea; 12Yeungnam University College of
Medicine, Daegu, Korea; 13National Medical Center, Seoul, Korea; 14Chungnam National University School of Medicine, Daejeon, Korea; 15Hallym
University College of Medicine, Chuncheon, Gangwon-do, Korea; 16Kosin University College of Medicine, Busan, Korea; 17Yonsei University
College of Medicine, Seoul, Korea; 18Chonnam National University Medical School, Gwangju, Korea; and 19Sungkyunkwan University School of
Medicine, Seoul, Korea
Background/Aims
In spite of increased concerns about the overlaps among the various functional gastrointestinal disorders (FGIDs), studies for the
overlap between constipation and other common FGIDs are rare. Therefore, we investigated the patterns of overlaps between
constipation and other common FGIDs.
Methods
This study was designed as a prospective nationwide multi-center questionnaire study using Rome III questionnaires for functional
dyspepsia (FD), irritable bowel syndrome (IBS), and functional constipation (FC), as well as various questionnaires about patients’
information, degree of symptoms, and quality of life. For the evaluation of gastroesophageal reflux disease (GERD), GERD-Q was used.
Results
From 19 centers, 759 patients with constipation were enrolled. The proportions of FC and IBS subtypes of constipation (IBS-C) were
59.4% and 40.6%, respectively. Among them, 492 (64.8%) showed no overlap. One hundred and thirty-six patients (17.9%) presented
overlapping GERD, and 80 patients (10.5%) presented overlapping FD. Fifty one (6.7%) of patients were overlapped by both GERD
and FD. Coincidental herniated nucleus pulposus (HNP) (P = 0.026) or pulmonary diseases (P = 0.034), reduced fiber intake (P =
0.013), and laxative use (P < 0.001) independently affected the rate of overlaps. These overlapping conditions negatively affected the
constipation-associated quality of life, general quality of life, and degree of constipation.
Conclusions
The overlap of GERD or FD was common in patients with constipation. Coincidental HNP or pulmonary diseases, reduced fiber intake,
and laxatives use were found to be independent associated factors for overlapping common FGIDs in Korean patients with constipation.
Key Words
Constipation; Dyspepsia; Gastroesophageal reflux; Overlapping
Received: March 1, 2017 Revised: May 5, 2017 Accepted: July 12, 2017
is properly cited.
*Correspondence: Suck Chei Choi, MD
Department of Gastroenterology, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Jeollabuk-do 54538, Korea
Tel: +82-63-859-2563, Fax: +82-63-855-2025, E-mail: medcsc@wku.ac.kr

www.jnmjournal.org
569
Kyung Sik Park, et al
Questionnaires
Introduction If patients agreed to participate in this study, they were re-
Functional gastrointestinal disorders (FGIDs) are vari- quested to sign the patient authorization form and to complete the
able combinations of chronic and recurrent gastrointestinal (GI) Korean version of the preliminary evaluation questionnaire, which
symptoms in which the identification of underlying mechanisms is consisted of 13 items. This questionnaire was conducted by the
not easy. Because there is no objective marker for the diagnosis of Korean Society of Neurogastroenterology and Motility (KSNM)
FGIDs, the diagnosis is usually based on the patients’ symptoms. based on Rome III criteria for IBS and functional constipation
In adults, FGIDs have been categorized into six groups on the as- (FC).12,13 The patients who fulfilled the Rome III criteria for IBS-
sumption that specific symptoms are related to specific anatomic constipation (IBS-C) or FC were enrolled in this study after the
regions.1,2 In Rome III and Rome IV classifications, each disorder exclusion of organic disorders such as acute abdomen, intestinal
is defined exclusively by specific criteria, and this clear definition of obstruction, intestinal pseudo-obstruction, and malignancy.
each disorder helps maintain homogeneity in research fields. How- Enrolled patients were requested to complete the case report
ever, in clinical situations, many patients complain of an overlap of 2 form, which included several demographic data, residence, smoking
or more disorders. Considering common pathophysiologic factors history, drinking history, history of present illness, history of medi-
such as dysmotility, visceral hypersensitivity, and gut-brain axis, cation, and preference of specific foods. The presence of diabetes
these overlaps are not strange.3,4 In fact, recently, some reports about mellitus (DM) or hypertension was assessed with closed questions
overlap among functional dyspepsia (FD), gastroesophageal reflux about each disease. However, the presence of other diseases, such as
disease (GERD), and irritable bowel syndrome (IBS) have been pulmonary disease, cerebrovascular accident (CVA), or herniated
published.5-11 Although there have been increased concerns about nucleus pulposus (HNP), were investigated with open questions.
the overlap among the various FGIDs, studies of overlap between The presence of GERD was assessed with diagnostic questionnaire
constipation and other common FGIDs are rare. Therefore, in this for gastro-esophageal reflux disease (GERD-Q) which consists
study, we investigated the overlap of constipation and other com- of 6 items.14 Furthermore, the presence of FD was evaluated with
mon FGIDs, as well as their associated risk factors. We then inves- the Korean version of questionnaire, which consists of 11 items
tigated how overlap of these conditions affects the quality of life in concerning upper GI symptoms. This questionnaire also was con-
patients with constipation. ducted by KSNM based on the Rome III criteria for FD.13,15
To evaluate the degree of constipation, the Patient-Assessment
of Constipation Symptoms (PAC-SYM) questionnaire16 was used.
Materials and Methods Three subscale scores for each domain (abdominal symptoms, rectal
symptoms, and stool symptoms) and total scores were investigated
Design according to the user guide. For the assessment of constipation-
This study was designed as a non-interventional, prospective, associated quality of life (QOL), the Patient-Assessment of Consti-
cross-sectional, nationwide multi-center questionnaire study. The pation Quality of Life (PAC-QOL) questionnaire17 was used. Four
protocol of this study was reviewed and approved by the institu- subscale scores for each domain (physical discomfort, psychosocial
tional review boards of each institution, including the Institutional discomfort, worry and concerns, and satisfaction) and total scores
Review Board of the Keimyung University Dongsan Medical Cen- were investigated according to the user guide. In addition, EQ-5D-
ter (IRB No. 2013-10-017-002). 3L (EuroQol group, Rotterdam, Netherlands) questionnaire18,19
was used for the assessment of general health-related QOL. Data
Subjects acquired from the descriptive system of EQ-5D-3L questionnaire
Consecutive adult patients (age of 20 or older) who visited were dichotomized into ‘no problems’ (ie, level 1) and ‘problems’
outpatient clinics in 19 hospitals complaining of constipation from (ie, levels 2 and 3), and proportions of patients with ‘problems’ were
January 2014 to February 2015 were considered as subjects. The assessed. EQ visual analogue scale (EQ VAS) was also evaluated to
list of 19 participated institutions is presented in the Supplementary measure overall self-rated health status.
Table. Korean versions of the above questionnaires were used after ob-
taining permission from their original copyright holders. For con-

Overlaps of Common FGIDs in Constipation
venience of presentation, the included patients were classified to 4

groups as follows according to the type of overlap: group I, patients Statistical Methods
with no overlap with other disorders; group II, patients presenting The SPSS statistical package version 20.0 (IBM Corp, Ar-
overlap with GERD; group III, patients presenting overlap with monk, NY, USA) was used for statistical analysis. All descriptive
FD; and group IV, patients presenting overlap with both GERD data are presented with the mean ± SD (standard deviation) for
and FD. continuous variables and with frequency or percentage for categori-
cal variables. Risk factors affecting the overlap disorders were as-
sessed by comparing group of patients with overlapping diseases
Table 1. Characteristics of Participants (N = 759)
with group of patients with non-overlapping diseases. Univariate
Gender analysis was performed with Student’s t test and chi-square test for
Male 245 (32.3%)
continuous and categorical variables, respectively. Logistic regres-
Female 514 (67.7%)
Age (mean ± SD, yr) 52.3 ± 17.9 (15-91) sion analysis was performed to identify the independent risk factors
Occupied area related with the presence of overlap. One-way analysis of variance
Capital area 164 (21.6%) (ANOVA) test was performed to compare the mean values in 3 or
Chungchung/Gangwon 93 (12.3%) more groups. After the ANOVA test, a Duncan test was performed
Honam 48 (6.3%) as a post hoc test. P -values less than 0.05 were considered statisti-
Kyeongbook 216 (28.5%)
cally significant.
Kyeongnam 183 (24.1%)
Jeju island 55 (7.2%)
Smoking history
Nonsmoker 568 (74.8%)
Results
Ex-smoker 118 (15.6%)
Smoker 73 (9.6%) Patient Demographics
Drinking history
From 19 centers, 759 eligible subjects among 947 patients with
Nondrinker 330 (43.5%)
Ex-drinker 117 (15.4%) constipation were included (Table 1). The proportion of males was
Drinker 312 (41.1%) 32.3% and the mean age was 52.3 ± 17.9 (range: 15-91) years.
Underlying diseases The residential areas of the subjects were relatively evenly distrib-
Hypertension 167 (22.0%) uted throughout South Korea. Among the participants, 9.6% and
DM 99 (13.0%) 41.1% were current smokers and drinkers, respectively. Further-
Diagnoses
more, 22% and 13% of the subjects suffered from hypertension
FC 451 (59.4%)
IBS-C 308 (40.6%)
and DM, respectively. Of the 759 subjects, 451 (59.4%) were
diagnosed with IBS-C, and the other 308 (40.6%) patients were
DM, diabetes mellitus; FC, functional constipation; IBS-C, irritable bowel
syndrome with constipation. diagnosed with FC.
Table 2. Prevalence of Overlaps
Groupa
Total
Ib II III IVb
FC
Frequency (n [%]) 314 (69.6) 72 (16.0) 43 (9.5) 22 (4.9) 451 (100.0)
IBS
Frequency (n [%]) 178 (57.8) 64 (20.8) 37 (12.0) 29 (9.4) 308 (100.0)
Total
Frequency (n [%]) 492 (64.8) 136 (17.9) 80 (10.5) 51 (6.7) 759 (100.0)
a
Grouping is as follows; group I, patients with no overlap with other disorders; group II, patients overlapped with gastroesophageal reflux disease (GERD); group
III, patients overlapped with functional dyspepsia (FD); group IV, patients overlapped with both GERD and FD.
b
Significant differences between functional constipation (FC) and irritable bowel syndrome (IBS) in the prevalence are found in group I (P = 0.001) and IV (P = 0.011).
IBS-C, IBS with constipation.
Vol. 23, No. 4 October, 2017 (569-577) 571

When analyzed in isolation, 178 (57.8%) of 308 C-IBS pa-

Prevalence of Overlaps tients and 314 (69.6%) of 451 FC patients did not show overlap-
Overall, 492 (64.8%) of the 759 subjects showed no overlap ping GERD or FD. Therefore, the proportion of non-overlapped
with GERD or FD (Group I). One hundred and thirty-six (17.9%) patients was higher in FC group (P = 0.001). Instead, 9.4% of
presented co-incidental GERD (Group II), and 80 (10.5%) pre- IBS patients and 4.9% of FC patients presented overlapping with
sented co-incidental FD (Group III). Fifty-one (6.7%) patients both GERD and FD, indicating higher prevalence of group IV in
presented both co-incidental GERD and FD (Group IV) (Table 2). the IBS-C than the FC group (P = 0.011) (Table 2).
Risk Factors Associated with Overlap

Table 3. Univariate Analysis Between Overlapped and Non-over- Of the various variables, the coincidence of HNP (P = 0.021)
lapped Groups
or pulmonary diseases (P = 0.021), reduced fiber intake (P =
Overlap (+) Overlap (-) 0.016), laxative use (P < 0.001), and old age (P = 0.009) were
Variables P -value
(n = 267) (n = 492) positively associated with overlap (Table 3). Of these variables, (1)
Male 81 (30.3%) 164 (33.3%) 0.417 coincidental HNP (P = 0.026) or pulmonary diseases (P = 0.034),
Smoking 23 (8.6%) 49 (10.0%) 0.546 (2) reduced fiber intake (P = 0.013), and (3) laxatives use (P <
Drinking 101 (37.8%) 211 (42.9%) 0.176
0.001) all independently affected the rate of overlap in multivariate
Hypertension 63 (23.6%) 104 (21.1%) 0.435
analysis (Table 4).
DM 37 (13.9%) 62 (12.6%) 0.624
HNP 9 (3.4%) 5 (1.0%) 0.021
CVA history 3 (1.1%) 5 (1.0%) 0.890 Degree of Symptoms Related to Constipation
Presence of pulmonary disease 8 (3.0%) 4 (0.8%) 0.021 In the analyses of data from the PAC-SYM questionnaire, all
Inadequate fiber intake 65 (24.3%) 84 (17.1%) 0.016 3 domains and the overall score showed significant differences in
Ingestion of laxatives 171 (64.0%) 243 (49.4%) < 0.001
the degree of symptoms (P < 0.001) (Table 5). Post hoc analyses
Age (mean ± SD, years) 54.6 ± 17.2 51.1 ± 18.2 0.009
with the Duncan test identified the patterns of these differences. In
BMI (mean ± SD, kg/m2) 22.6 ± 3.1 22.4 ± 2.9 0.428
the domain of “abdominal symptoms,” significant differences were
DM, diabetes mellitus; HNP, herniated nucleus pulposus; CVA, Cerebrovas-
cular accident; BMI, body mass index. noted among group I, group II and III, and group IV. There was
Table 4. Multivariate Analysis Between Overlapped and Non-overlapped Groups
Variables Crude OR Adjusted OR P -value

HNP 3.40 (1.13-10.24) 4.01 (1.18-13.70) 0.026
Presence of pulmonary disease 3.77 (1.12-12.63) 3.78 (1.11-12.86) 0.034
Inadequate fiber intake 1.57 (1.09-2.26) 1.61 (1.10-2.34) 0.013
Ingestion of laxatives 1.87 (1.38-2.55) 1.80 (1.31-2.47) < 0.001
Age 1.01 (1.00-1.02) 1.00 (0.99-1.01) 0.538
HNP, herniated nucleus pulposus.
Table 5. Degree of Symptoms Related to Constipation
Groupa
Domains P -valueb
I II III IV
Abdominal symptoms 1.01 ± 0.69 1.47 ± 0.78 1.42 ± 0.79 1.98 ± 0.84 < 0.001
Rectal symptoms 0.74 ± 0.82 0.94 ± 0.90 0.78 ± 0.80 1.24 ± 0.93 < 0.001
Stool symptoms 1.66 ± 0.99 2.02 ± 0.96 2.23 ± 0.86 2.54 ± 0.93 < 0.001
Total score 1.22 ± 0.70 1.57 ± 0.74 1.60 ± 0.67 2.01 ± 0.78 < 0.001
a
b
The P -value in each domain was derived from one-way ANOVA test.

Table 6. Constipation-associated Quality of Life According to Types of Overlap
Groupa
Domains P -valueb
I II III IV
Physical discomfort 1.74 ± 0.86 2.01 ± 0.87 2.34 ± 0.94 2.84 ± 0.87 < 0.001
Psychosocial discomfort 0.76 ± 0.70 1.21 ± 0.83 1.29 ± 0.86 1.85 ±1.04 < 0.001
Worries and concerns 1.32 ± 0.75 1.72 ± 0.85 1.88 ± 0.93 2.23 ± 1.02 < 0.001
Satisfaction 2.58 ± 0.76 2.67 ± 0.74 2.87 ± 0.77 2.98 ± 0.68 < 0.001
Total score 1.44 ± 0.59 1.80 ± 0.64 1.96 ± 0.72 2.36 ± 0.78 < 0.001
a
b
The P -value in each domain was derived from one-way ANOVA test.
Table 7. Dichotomized Data From the Descriptive System of EQ-5D-3L Questionnaire According to Types of Overlap
Groupa
Domains Problem (+) P -value
I (n = 474) II (n = 134) III (n = 80) IV (n = 51)
Exercise Frequency (n [%]) 66 (13.9) 19 (14.2) 13 (16.3) 17 (33.3) 0.004
Self care Frequency (n [%]) 19 (4.0) 12 (9.0) 6 (7.5) 11 (21.6) < 0.001
Usual activity Frequency (n [%]) 58 (12.2) 25 (18.7) 22 (27.5) 16 (31.4) < 0.001
Pain/discomfort Frequency (n [%]) 193 (40.7) 78 (58.2) 46 (57.5) 42 (82.4) < 0.001
Anxiety/depression Frequency (n [%]) 144 (30.4) 59 (44.0) 39 (48.8) 43 (84.3) < 0.001
a
The sample size of each group is slightly different from the original groups because of the missing values.
no difference between groups II and III. In the domain of “rectal 100
symptoms,” significant differences were noted only between group 90

IV and other groups. We noted no difference among groups I, II,
80
and III. In the domain of “stool symptoms” and “overall score,” the
EQ VAS
patterns of differences were the same in “abdominal symptoms.” 70
60
Constipation-associated Quality of Life
50
In the analyses of data from the PAC-QOL questionnaire, all
4 domains also showed significant differences in the degree of con- 40
stipation-associated QOL (P < 0.001) (Table 6). Post hoc analyses 30
with Duncan test also identified the patterns of these differences. In Group I Group II Group III Group IV
the domain of “physical discomfort,” significant differences were Figure. General health-related quality of life assessed with EQ visual
noted among each of the independent groups. Domains of “psycho- analogue scale (EQ VAS) scoring. Poor quality of live is noted in
social discomfort,” “worry and concerns,” “satisfaction,” and “total group IV compared to group I, II, and III. Significant differences are
noted only between group IV and other groups, while there are no dif-
score” showed the same patterns of differences. In this way, signifi-
ferences among group I, II, and III. Grouping is as follows: group I,
cant differences were noted among group I, groups II and III, and patients with no overlap with other disorders; group II, patients over-
group IV, and there were no differences between groups II and III. lapped with gastroesophageal reflux disease (GERD); group III, pa-
tients overlapped with functional dyspepsia (FD); group IV, patients
General Health-related Quality of Life overlapped with both GERD and FD.
In the analyses of dichotomized data from the descriptive
system of EQ-5D-3L questionnaire, proportions of patients with
Vol. 23, No. 4 October, 2017 (569-577) 573

“problem” were significantly higher in all 5 domains (exercise, self- review, it was found that most constipated patients meet the crite-
care, usual activity, pain/discomfort, and anxiety/depression) in ria for both IBS-C and FC, if the Rome III requirement for FC
groups of patients presenting overlapping conditions, especially in “Insufficient criteria for IBS” is suspended.26 Additionally, contrary
group IV (Table 7). The mean EQ-day scores in EQ VAS system to perceived expectations, IBS-C patients had more constipation-
from group I to group IV were 60.1, 57.1, 56.0, and 38.1, respec- associated symptoms rather than patients with FC. Since the clear-
tively. Therefore, significant differences were noted (P < 0.001) cut discrimination between IBS and FC is often difficult in real
(Figure). Post hoc analyses with the Duncan test identified that clinical situations, we enrolled and analyzed both FC and IBS-C
significant differences were noted only between group IV and other patients without dividing in our study. Discrimination between IBS
groups, while there were no differences among group I, II, and III. and FC was performed only to determine the prevalence of overlap-
ping conditions.
Although various FGIDs are structured to be diagnosed mu-
Discussion tually exclusively in the Rome III criteria, the possibility of overlap
In this study, the patterns of overlap of two common FGIDs among the FGIDs can be easily predicted considering the common
(ie, symptomatic GERD and FD) in patients with constipation pathophysiology of these disorders. There have been several origi-
were investigated. We also investigated how these overlaps affect the nal or review reports on the overlap of these FGIDs, particularly
quality of life in constipated patients. Our results show that more among common FGIDs such as FD, symptomatic GERD, and
than 30% of constipating patients present overlap of one or both IBS.3-8,10,11,27-29 According to a review article conducted by Fujiwara
investigated diseases, and that QOL of these patients is poorer than and Arakawa,5 up to 15.8% of the general population and 62.3%
that of patients who do not present overlapping diseases. of outpatients have been reported to have overlap between both
Constipation is a type of frequent GI symptom in which the subtypes of FD (ie, epigastric pain syndrome and postprandial
prevalence has been reported to be up to 20% depending on re- distress syndrome). Furthermore, the overlap of reflux symptoms
gions.20,21 “Constipation” as a symptom has comprehensive meaning in patients with uninvestigated dyspepsia has been reported to vary
depending on the person. It includes various states, such as a sense from 13.3% to 63.0% of prevalence.5 In another systematic review,
of insufficient defecation, propulsive force during defecation, sense the prevalence of IBS in patients with dyspepsia was reported to be
of barriers of defecation, longer stay in the bathroom, hard stool, 37.0% compared to 7.0% in those without dyspepsia.10 Therefore,
and decreased frequency of defecation.22 In our study, we consid- the odds ratio for IBS in patients with dyspepsia was about 8.00
ered patients who visited outpatient clinics complaining difficult, in- (95% CI, 5.74-11.16). As well as FGIDs, other functional disor-
frequent, or incomplete defecation as primary subjects of the study. ders including chronic fatigue syndrome, fibromyalgia, and hy-
The Korean version of the self-administered symptom ques- persensitive bladder are known to coexist with FD and IBS in the
tionnaire13 based on the Rome III criteria12 (Rome III-K) was same patient.30 Although there is a limitation that the sample size is
used in our study to define FC, IBS-C, and FD. Rome III-K is relatively small, the fact that overlap is common among FGIDs has
composed of 35 questions that assess the presence or frequency of also been reported in an Asian study.27
various GI symptoms. It was validated linguistically by KSNM in Our study shows that patients with constipation frequently
2013, and is useful for the diagnosis of functional heartburn, FD, overlap with GERD, FD, or both. However, the patterns of over-
IBS, FC, functional diarrhea, and functional bloating. laps are somewhat different from previous reports. Unlike other
We enrolled the patients in this study if he or she fulfilled the functional disorders, studies about overlap in patients with constipa-
Rome III criteria for FC or IBS-C and had no organic disorders. tion is rare. In a systematic review which analyzed 35 studies about
Although patients who had obvious organic disorders such as acute comorbid conditions in IBS-C and chronic idiopathic constipation,
abdomen, intestinal obstruction, intestinal pseudo-obstruction, FD and depression were reported as the most common comorbid
and malignancy were excluded, complete exclusion of secondary diseases in patients with IBS-C, whereas FD, DM, and depres-
constipation was impossible due to limitations of the observational sion were the most commonly overlapping diseases in patients with
questionnaire study. Although the Rome III and even Rome IV chronic idiopathic constipation.31 In another web-based, cross-
criteria for functional bowel disorders suggest that IBS-C and FC sectional study conducted in the United States, the impact of
are mutually exclusive, there are several studies reporting that these overlapping FD, GERD, IBS-C, and FC on symptom burden
conditions are not completely different.23-25 In a recent systematic and consulting behavior was assessed.32 Of the 2641 responders,

328 and 552 persons met the Rome III criteria for IBS-C or FC, and not a closed question, the reliability is low. Furthermore, fiber
respectively. In their study, only 17.4% of IBS and 37.6% of FC intake also was not quantitatively measured. Next, laxative use was
existed alone without overlapping GERD or FD (this group cor- more likely to be a result of severe symptoms in patients with over-
responds to group I in our study). These fractions were lower than lapping diseases rather than to be a risk factor itself. Therefore, to
our study which showed 57.8% and 69.6%, respectively. The por- obtain accurate independent risk factors associated with overlap,
tions of IBS and FC patients overlapping with GERD (corresponds well-designed questionnaires that consider various variables will be
to group II in our study) in their study were 7.3% and 10.1%, necessary.
respectively, which were also lower than our study of 20.8% and This study shows that the symptoms of patients with over-
16.0%, respectively. However, the portions of patients presenting laps are more severe than those of patients without overlap. It is
overlap with FD (corresponds to group III in our study) in IBS known from several reports that the symptom burdens of FGIDs
and FC were 40.8% and 33.5%, respectively. These values were are heavier when one disorder overlaps with one or more disor-
significantly higher than our study, which measured rates of 12.0% ders.5,6,9,10,29 This tendency also applies to patients with constipation,
and 9.5%, respectively. Similarly, the portions of patients present- as in previous study.32 In our study, we assessed the degree of con-
ing overlap with both GERD and FD (corresponds to group IV stipation using a well-known PAC-SYM questionnaire. This ques-
in our study) were 34.5% in IBS and 18.8% in FC. These values tionnaire contains 12 items assigned to 3 subscales: stool symptoms
were also higher than our study, which measured rates of only 9.4% (5 items), rectal symptoms (3 items), and abdominal symptoms (4
and 4.9%, respectively. The overall overlap frequency and overlap items). Each item is scored using a 5-point Likert scale (from 0 to 4),
frequency with FD were low; however, the overlap frequency with with lower scores meaning less symptom severity. Scores of 0, 1, 2, 3,
GERD was high in our study. There was a similar tendency in that and 4 mean absent, mild, moderate, severe, and very severe, respec-
the overall overlap frequency was higher in the IBS patients than in tively. As predicted, this study showed that symptoms of two (ab-
the FC patients. It is uncertain whether these differences are due to dominal symptoms and stool symptoms) domains as well as overall
regional differences (Eastern vs Western) or due to differences in symptoms were more severe in patients with overlapping diseases
the nature of participants (patients who visited hospital vs general with GERD or FD. Furthermore, the symptom severity was the
population who responded web-based questionnaire). highest in patients with all three combined disorders. Although
We found that the rate of overlap is associated with coincidental there was no difference in the symptom severity of rectal symptoms
HNP or pulmonary diseases, reduced fiber intake, and laxatives between the group without overlap and the group with overlap with
use. Several independent risk factors have been suggested in rela- one other disease, the symptom severity of this domain also was the
tion to overlapping FGIDs. Self-reported insomnia, frequent highest in patients with all three combined disorders.
abdominal pain, higher somatization score, and higher body mass As expected, poorer QOL was observed in patients with over-
index have been presented as risk factors for overlap of IBS and laps compared to patients without overlap in this study. It is not dif-
symptomatic GERD in a population study.33 Insomnia and so- ficult to predict that the quality of life will be lower with more severe
matization also have been suggested as risk factors for the overlap symptoms in the overlapping groups, and there are several reports
of FD and GERD in another study.7 Similarly, the presence of on this.3,5,6,31 In this study, we assessed both constipation-associated
depression has been reported to be a significant associated factor in QOL and general health-related QOL with PAC-QOL and EQ-
the overlap of FD and IBS.34 Therefore, a wide variety of variables 5D-3L questionnaires, respectively. PAC-QOL questionnaire
may act as risk factors for the overlap of several FGIDs, depending contains 28 items assigned to 4 domains: worries and concerns (11
on the variables to be considered. In this study, the co-incidence of items), physical discomfort (4 items), psychosocial discomfort (8
HNP or pulmonary diseases, reduced fiber intake, and laxatives items), and satisfaction (5 items). Each item was also scored using
use independently affected the overlap of constipation with disor- a 5-point Likert scale (from 0 to 4) with a lower score meaning a
ders discussed in this study. However, it is not appropriate to judge higher QOL although several items required a scoring revision.
these variables as independent risk factors based solely on these data This study showed that constipation-associated QOL of all do-
for several reasons. First, several variables that were considered as mains were lower in patients with overlapping diseases that included
risk factors for overlap in other studies were not included in the either GERD or FD. These scores were the lowest in patients com-
questionnaire used in this study. Second, because the presence of bined with all 3 disorders. The EQ-5D-3L questionnaire consisted
HNP or pulmonary diseases was investigated with open questions of the EQ-5D descriptive system and the EQ VAS. The EQ-5D-
Vol. 23, No. 4 October, 2017 (569-577) 575

3L descriptive system contains 5 dimensions: mobility, self-care, manuscript; Suck Chei Choi: study design, data acquisition, data
usual activities, pain/discomfort, and anxiety/depression. Although analysis, data interpretation, and drafting the manuscript; and Sam
each dimension is scored using 3 levels, we dichotomized them Ryong Jee, Bong Eun Lee, Kyoung Sup Hong, Jeong Eun Shin,
into ‘no problems’ and ‘problems’ for convenience according to the Soo-Young Na, Joong Goo Kwon, Yong Sung Kim, Hyun Seok
user guide. As expected, the proportion of patients with disability Lee, Tae Hee Lee, Kyeong Ok Kim, Jongkyoung Choi, Hee Seok
was significantly higher in the group of patients with overlapping Moon, Yeon Soo Kim, Moo In Park, Soo Jung Park, Seon-Young
diseases in all 5 dimensions. Similarly, EQ VAS revealed that lowest Park, and Sung Noh Hong: data acquisition and critical revision of
QOL in in patients combined with all three disorders. the manuscript.
There were several limitations to this study. First, despite vari-
ous medications and diseases that cause secondary constipation,
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Vol. 23, No. 4 October, 2017 (569-577) 577

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Alterations of Food-specific Serum IgG4 Titers to

Common Food Antigens in Patients With Irritable
Bowel Syndrome
Hong Sub Lee1,2 and Kwang Jae Lee1*

1
Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea; and 2Department of Gastroenterology, Myongji Hospital,
Goyang, Korea
Background/Aims
The role of dietary factors in the pathogenesis of irritable bowel syndrome (IBS) is still unclear. The aim of this study was to compare
IgG4 levels to common food antigens between patients with IBS and healthy controls.
Methods
Thirty-two patients diagnosed as IBS according to the Rome III criteria (12 diarrhea subgroup; 20 non-diarrhea subgroup) and 32 sex
and age-matched healthy controls participated in the study. Serum IgG4 titers to 90 common foods were measured in each subject.
The number of subjects with positivity defined as the cut-off value ≥ 0.7 U/mL was compared.
Results
Patients with IBS had significantly higher IgG4 titers to wheat, leek and taro compared to those of controls. Serum IgG4 titers to
ginger, cocoa, walnut, white radish, onion, and lettuce in IBS patients tended to be higher than controls. IgG4 titers to wheat,
gluten and gliadin in the diarrhea subgroup, and lettuce, leek and taro in the non-diarrhea subgroup tended to be higher compared
with controls. The number of subjects with positivity to apple, orange, lettuce, and leek was significantly higher in IBS patients than
controls. The number of subjects with positivity to apple, orange, gluten, and gliadin in the diarrhea subgroup, and egg white,
pineapple, soybean, lettuce, and leek in the non-diarrhea subgroup was significantly higher compared with controls.
Conclusions
Serum IgG4 antibody levels to some common foods are abnormally elevated in IBS patients. The type of foods with abnormally
elevated serum IgG4 titers in the diarrhea subgroup may be different from that in the non-diarrhea subgroup.
Key Words
Food; Immunoglobulin G; Irritable bowel syndrome
Received: April 19, 2017 Revised: June 26, 2017 Accepted: July 23, 2017
is properly cited.
*Correspondence: Kwang Jae Lee, MD
Department of Gastroenterology, Ajou University Hospital, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu,
Suwon 16499, Korea
Tel: +82-31-219-5102, Fax: +82-31-219-5999, E-mail: kjleemd@hotmail.com

www.jnmjournal.org
Food and Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a functional gastrointestinal
(GI) disorder that has been estimated to affect 1.1-29.2% of the Study Subjects and Design
global population.1,2 The pathophysiology of IBS is not completely IBS patients who visited the Gastroenterology Department of
known. However, several factors, including dietary factors, have Myongji Hospital were screened for the current study. All subjects
been suggested to play a role in the pathophysiology of IBS. About were given the list of symptoms of the validated Korean version of
50% of patients with IBS report postprandial exacerbations of the Rome III questionnaire (Rome III-K).15 In addition, blood tests
symptoms.3 It has been reported that perceived food intolerance is and colonoscopy were performed in all participants.
high (70%) in subjects with IBS.4 In addition, a prevalence rate of Exclusion criteria were (1) subjects with organic bowel diseases
perceived food intolerance is greater than 50% among subjects with including inflammatory bowel disease and infectious bowel disease;
IBS, which is a rate that is 2-fold greater than that reported by those (2) patients who have functional dyspepsia; (3) patients who have
without IBS.5 severe comorbidities such as cardiovascular diseases, chronic renal
It is common for IBS patients to avoid some foods, particularly diseases or chronic liver diseases, etc; (4) patients with mental ill-
fatty foods, milk products, carbohydrates, caffeine, alcohol, and nesses; and (5) history of GI surgery.
high protein.6 Moreover, they often seek information about dietary The healthy control group was recruited as the same manner.
modifications. However, because there is little evidence of dietary The control group included healthy subjects who did not have or-
factors in IBS, physicians usually have difficulty in providing appro- ganic diseases and recurrent abdominal symptoms. They were age
priate advice for diet. The estimates of food allergy prevalence were and sex matched with the patient group. They filled up the symp-
reported to be 8% of children and 5% of adults.7 Several mecha- tom questionnaire, and undertook blood tests and colonoscopy in
nisms including food hypersensitivity, direct stimulation by food order to check the presence of recurrent abdominal symptoms and
chemicals, and luminal distension have been suggested to explain organic diseases. All participants gave informed consent before they
GI symptoms induced by food.8 Among them, food hypersensitiv- participated in this study.
ity, classified in IgE-mediated and non-IgE mediated reactions, has This study was performed in a prospective, controlled design.
been a very controversial subject.9 Food-specific IgE antibodies are The study protocol and informed consent form was approved by
known to play a role in food allergy.7 However, the role of non-IgE the institutional review board of Myongji Hospital according to
mediated reaction remains poorly understood. the guidelines of the Declaration of Helsinki (MJH14-063). This
Among 4 subclasses of IgG antibodies, IgG4 reactions take trial was registered in http://cris.nih.go.kr (KCT0001774). All the
place in the gut during repeated exposure to food antigens. Studies participants completed the bowel disease symptom questionnaire
have reported raised serum IgG4 levels in patients with atopy.10,11 (Rome III-K). It was a validated Korean questionnaire of the Rome
Zar et al12 also reported elevated serum IgG4 levels to some foods III criteria.
in IBS patients. In that study, no significant differences in IgE
levels were observed between IBS patients and healthy controls. Measurement of Serum Food Antigen-specific IgG4
Moreover, it was reported that food elimination based on IgG4 Titers
levels improved symptoms in IBS patients.13 However, the role of The eligibility of the subjects was determined before the start
IgG4 antibodies against foods is controversial yet.14 Few studies of study. Serum food antigen-specific IgG4 titers were measured
have evaluated the role of IgG4 reaction to foods in IBS. with the Food Allergy Screening ELISA Kit (Metametrix Clinical
In the present study, we aim to compare food-specific IgG4 lev- Laboratory, 3425 Corporate Way, Duluth, GA, USA). Food al-
els to common food antigens between patients with IBS and healthy lergens are (derived from native foods) immobilized on solid phase
controls. (enzyme-linked immunosorbent assay plate), and IgG4 titers to 90
common foods were measured.
Food groups were classified into 6 categories: (1) dairy/meat/
poultry, (2) fruit, (3) fish/shellfish, (4) grains/legumes, (5) veg-
etables, and (6) nuts/seeds/miscellaneous (Table 1). The antibody
Vol. 23, No. 4 October, 2017 (578-584) 579

Table 1. The List of 90 Common Food Antigens Tested in the Current Study
Dairy, meat, Fish and shellfish Grains and legumes Vegetables Nuts, seeds, and
Fruit antigen
and poultry antigen antigen antigen antigen miscellaneous antigen
Cow's milk Apple Cod Rice White radish Almond
Casein Banana Salmon Wheat Cabbage Coconut
Chicken Grape Shrimp Corn Carrot Sesame
Egg white Grapefruit Tuna Oat Celery Walnut
Egg yolk Lemon Clam Millet Cucumber Cashew nut
Lamb Orange Crab Barley Garlic Sunflower
Pork Peach Lobster Buckwheat Mushroom Pepper
Beef Pear Mackerel Gluten Mustard seed Coffee
Yoghurt Pineapple Oyster Gliadin Olive Tea
Duck Strawberry Abalone Pea Onion Baker's yeast
Cheese Blueberry Scallop Soy bean Green pepper Ginger
Watermelon Cuttlefish Peanut Potato Brewer's yeast
Plum Eel Kidney bean Spinach Cocoa
Kiwi Tomato Honey
Mango Broccoli Aspergillus
Lettuce Kelp
Sweet potato
Leek
Taro
Bamboo shoots
Eggplant
Mugwort
titers were expressed as U/mL. The relative degree of IgG4 to Table 2. Demographic Features of the Study Subjects
each food is ranked in classes of 0 to +5 according to cutoff points Patients Controls
Characteristics P -value
established by the manufacturer. The cut off value in this study was (n = 32) (n = 32)
defined as +2 rank of 0.7 U/mL for each food antigen. The num- Age (age) 57.4 ± 11.2 56.8 ± 14.9 0.865
ber of subjects with positivity defined as cut-off value ≥ 0.7 U/mL Sex (male:female) 17:15 17:15
was compared using Pearson’s Chi-square test. History of postprandial 71.8 0
exacerbation (%)
Sample Size Calculation Body mass index (kg/m2) 24.1 ± 2.2 23.6 ± 3.8 0.463
History of diabetes 5 4 0.719
In a previous study, the mean IgG4 level to pork in IBS pa-
History of allergic disease 1 1 1.000
tients and controls was 31.54 U/mL (standard deviation 0.45)
Values are presented as mean ± standard deviation or numbers.
and 30.80 U/mL (standard deviation 0.59), respectively.16,17 The
number of participants in each arm of this study was calculated to
obtain results with an a of 0.05 and a power of 0.90. Therefore, we fidence intervals (CIs) were calculated. A P -value < 0.05 was con-
calculated that 54 subjects including 27 subjects and 27 controls sidered significant. SPSS for Windows version 11 software (IBM
were needed. We enrolled 70 subjects with the consideration of a Corp, Armonk, NY, USA) was used for all analyses.
15% drop out rate.
Statistical Methods Results

The statistical comparison between subjects with IBS and
healthy control was performed using the Pearson’s Chi-square test Subject Characteristics
and an independent sample t test. Odds ratios (ORs) and 95% con- From February 2015 through January 2016, 6 participants of

the 70 subjects screened were excluded because 1 had ulcerative

colitis and 5 subjects withdrew the consent. Among them, 32 pa- Serum IgG4 Titers
tients were diagnosed as IBS using a validated Korean questionnaire Patients with IBS had significantly higher IgG4 titers to wheat
of the Rome III criteria (12 diarrhea subgroup; 20 non-diarrhea (4.22 ± 7.67 U/mL vs 1.17 ± 3.06; P = 0.043), leek (0.13 ± 0.22
subgroup). Thirty-two sex and age-matched healthy individuals (15 U/mL vs 0.03 ± 0.10; P = 0.026), taro (1.00 ± 2.17 U/mL vs
women and 17 men; mean age, 56 years) without IBS symptoms 0.11 ± 0.26; P = 0.029), compared with healthy controls. Serum
and organic diseases participated in the study. The demographic IgG4 titers to ginger, cocoa, walnut, white radish, onion, and lettuce
features including age, sex, body mass index, and history of allergic in IBS patients tended to be higher than those in controls. IgG4 ti-
disease were comparable in both study groups (Table 2). ters to wheat, gluten and gliadin in the diarrhea subgroup tended to
be higher than those in controls. Patients in the non-diarrhea sub-
group tended to have higher IgG4 levels to lettuce, leek and taro,
Table 3. Food Antigens Showing Differences in IgG4 Titers (U/mL) Between Patients and Controls
Patients Controls Subgroups

Antigens P -value
(n = 32) (n = 32) Diarrhea P -value Non-diarrhea P -value
a
Wheat 4.22 ± 7.67 1.17 ± 3.06 0.043 5.45 ± 7.58 0.081 3.48 ± 7.81 0.219
Gluten 1.23 ± 2.78 0.47 ± 1.41 0.173 2.00 ± 2.64 0.079 0.77 ± 2.82 0.608
Gliadin 1.33 ± 3.12 0.36 ± 1.18 0.111 2.15 ± 2.76 0.050 0.83 ± 3.29 0.546
White radish 0.34 ± 0.83 0.04 ± 0.14 0.052 0.47 ± 1.16 0.234 0.27 ± 0.58 0.100
Onion 0.76 ± 1.90 0.08 ± 0.28 0.053 0.62 ± 1.49 0.237 0.84 ± 2.14 0.128
Lettuce 0.44 ± 1.10 0.07 ± 0.16 0.064 0.12 ± 0.22 0.396 0.64 ± 1.35 0.076
Leek 1.00 ± 2.17 0.11 ± 0.26 0.029a 0.86 ± 2.38 0.302 1.08 ± 2.10 0.054
Taro 0.13 ± 0.22 0.03 ± 0.10 0.026a 0.12 ± 0.23 0.218 0.13 ± 0.22 0.055
Walnut 0.16 ± 0.21 0.07 ± 0.16 0.064 0.16 ± 0.21 0.203 0.16 ± 0.21 0.124
Ginger 7.19 ± 2.16 0.59 ± 1.57 0.095 3.62 ± 1.07 0.349 9.33 ± 2.61 0.151
a
Statistically significant.
Values are mean ± standard deviation unless otherwise stated. Only the variables which have P < 0.1 was shown in the table.
Table 4. The Number of Subjects with a Positive Antigen Defined as Its IgG4 Titer ≥ 0.7 U/mL in Irritable Bowel Syndrome Patients and
Healthy Controls
Subgroups
Antigens Patients Controls OR (95% CI) P -value
Diarrhea P -value Non-diarrhea P -value
Egg white 11 5 2.829 (0.851-9.402) 0.083 3 0.473 8 0.048a
Apple 4 0 0.039a 3 0.003a 1 0.202
Orange 4 0 0.039a 2 0.018a 2 0.068
Pineapple 13 7 2.444 (0.817-7.308) 0.106 3 0.826 10 0.035a
Gluten 7 4 1.960 (0.512-7.498) 0.320 5 0.033a 2 0.784
Gliadin 6 3 2.231 (0.506-9.835) 0.281 5 0.013a 1 0.565
Soy bean 3 0 0.076 0 3 0.024a
White radish 3 0 0.076 1 0.099 2 0.068
Onion 5 1 5.741 (0.631-52.234) 0.086 2 0.112 3 0.118
Lettuce 4 0 0.039a 0 4 0.008a
Leek 7 1 8.680 (1.001-75.304) 0.023a 2 0.112 5 0.016a
Eggplant 4 1 4.429 (0.467-42.021) 0.162 0 0.536 4 0.045a
OR, odd ratio; CI, confidence interval.
a
Statistically significant.
Values are presented as numbers unless otherwise stated. Only the variables which have P < 0.1 was shown in the table.
Vol. 23, No. 4 October, 2017 (578-584) 581

compared with healthy controls (Table 3). food among countries, and this warrants further investigation.
The level of IgG4 antibodies against foods may just reflect the
The Number of Subjects With Positivity for Serum intake of the food. However, certain foods have frequently been
Food IgG4 Titers reported to generate or exacerbate IBS symptoms. These foods
The number of subjects with positivity for serum food IgG4 include wheat, milk products, egg, peanut, soy, sesame, tree nuts,
titers to apple, orange, lettuce, and leek was significantly higher in shellfish, spicy foods, coffee, vegetables, fatty foods and alcohol.7,16,17
IBS patients than that in healthy controls. The number of subjects Actually, IBS patients tend to think that specific foods are triggers.18
with positivity to apple, orange, gluten, and gliadin in the diarrhea Although many IBS patients mention that they avoid certain foods,
subgroup, and egg white, pineapple, soybean, lettuce, and leek in this does not seem to significantly affect their intake of nutrients.
the non-diarrhea subgroup was significantly higher, compared with According to a dietary survey, the real food intake in IBS patients
controls (Table 4). was not significantly different from that in healthy controls.19 The
observed minor differences show a tendency toward higher intake
of fruits and vegetables and a lower intake of meat and dairy prod-
Discussion ucts in IBS patients. Therefore, elevation of serum IgG4 titers to
In the present study, we demonstrated that serum IgG4 anti- some food antigens is more likely to be involved in the pathogenesis
body levels to some foods were abnormally elevated in IBS patients. or pathophysiology of IBS rather than just reflecting the intake of
Furthermore, the type of foods with abnormally elevated IgG4 titers the food. In the present study, the type of foods with abnormally
compared to normal controls in the diarrhea subgroup was different elevated IgG4 titers compared to normal controls in the diarrhea
from that in the non-diarrhea subgroup. Those findings suggest the subgroup was different from that in the non-diarrhea subgroup.
possibility that the IgG4-related immune reaction to some foods is This difference may be related to the involvement of IgG4-related
involved in the pathogenesis of IBS symptoms. immune reaction to specific food antigens in the generation of spe-
Previous studies showed that serum IgG4 antibodies to com- cific IBS symptoms. This speculation needs to be verified further.
mon foods are elevated in IBS patients.16,17 Like atopic conditions, Studies have shown the inflammatory components of IBS.20
those observations suggest the possibility of a role of IgG4-related The difference in the immune reaction to food antigens between
immune reaction in the pathophysiology of IBS. In a study from the individuals may be associated with different permeability to macro-
United Kingdom, IBS patients had significantly higher IgG4 titers molecules in the gut. Actually, increased intestinal mucosal perme-
to wheat, beef, pork, and lamb compared to controls.16 In contrast, a ability has been reported to be an important pathophysiologic factor
study from China showed that IBS patients had significantly higher in IBS.21 Increased intestinal mucosal permeability is associated with
levels of IgG antibody to crab, egg, shrimp, soybean, and wheat visceral and thermal hypersensitivity in a subset of IBS patients.21,22
than controls.17 In that study, patients with functional dyspepsia also Likewise, food hypersensitivity observed in IBS patients may be
had significantly higher titers of IgG antibody to egg and soybean, associated with increased intestinal mucosal permeability. Certain
compared with controls. Those studies suggest that symptoms as- food antigens and specific IgG antibodies may form immune com-
sociated with IBS or functional dyspepsia maybe related to food plexes that could cause an inflammatory cascade.23 Similarly, high
hypersensitivity. In the present study, IBS patients who overlapped levels of the IgG4 food antibodies are also observed in patients with
with functional dyspepsia were excluded, because we aimed to in- inflammatory bowel disease, where intestinal mucosal permeability
vestigate the relationship of IgG4-related immune reaction to food is known to be increased.24,25
antigens with IBS symptoms. We demonstrated that IBS patients Some studies have demonstrated that food-specific IgG4
had significantly higher IgG4 titers to wheat, leek, and taro com- antibody-guided exclusion diet may be effective in alleviating IBS
pared to controls. Moreover, serum IgG4 titers to ginger, cocoa, symptoms.26,27 The IgG4 antibody-guided exclusion diet affects
walnut, white radish, onion, and lettuce in IBS patients tended to various symptoms including abdominal pain or discomfort, stool
be higher than controls. Although higher levels of IgG4 to wheat shape, diarrhea frequency, and general feelings of distress. A previ-
antigen were also observed in previous studies, the type of foods ous systemic review of clinical trials regarding exclusion diet based
showing higher IgG4 titers in IBS patients in the present study was on IgG4 showed a 15-71% response rate.28 Immunological adverse
mostly different from that in other previous studies. This difference reactions by IgG appear to induce mucosal damage and further
may be related to the difference in ethnicity or the type of favorite increase of mucosal permeability that may be reversed by exclusion

diet. The positive effect of the IgG4 antibody-guided exclusion diet Financial support: None.
suggests that the IgG4-related immune reaction to some foods is
involved in the genesis of IBS symptoms. Conflicts of interest: None.
In the present study, IgG4 titers to wheat, gluten, and gliadin Author contributions: Kwang Jae Lee designed the protocol,
tended to be higher in the diarrhea subgroup, whereas those to let- conducted the study, collected and interpreted data, and drafted the
tuce, leek, and taro in the non-diarrhea subgroup, compared with manuscript; and Hong Sub Lee conducted the study, collected and
controls. The number of subjects with positivity to apple, orange, interpreted data, and drafted the manuscript.
gluten, and gliadin in the diarrhea subgroup, and egg white, pine-
apple, soybean, lettuce, and leek in the non-diarrhea subgroup
was significantly higher, compared with controls. Those findings References
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
Detecting the Non-physiological, Surgically

Tailored Ileocolic Anastomosis Using the Wireless
Motility Capsule. A Pre- and Post-operative,
Prospective, Within Subject Trial
Yngve Thorsen,1,2* Bojan V Stimec,3 Jens M Nesgaard,4 and Dejan Ignjatovic1,2

1
Department of Digestive Surgery, Akershus University Hospital, Lorenskog, Norway; 2Institute of Clinical Medicine, University of Oslo, Norway;
3
Faculty of Medicine, Department of Cellular Physiology and Metabolism, Anatomy Sector, University of Geneva, Switzerland; and 4Department
of Gastrointestinal Surgery, Vestfold Hospital Trust, Tonsberg, Norway
Background/Aims
Wireless motility capsule (WMC) detects the ileocolic junction (ICJ) in most non-operated patients. We find no data concerning this
examination in patients where the ileocolic valve is replaced by a per definition incompetent, surgically created ICJ. We wanted to see
if WMC could detect the ICJ after a right colectomy and assess the competency.
Methods
Prospective cohort study using a within-subject design to eliminate subject-subject variability. Selected patients operated with right
colectomy underwent 3 WMC examinations (pre-operatively, 3 weeks, and 6 months after surgery).
Results
Twenty patients (8 men) included, 7 (4 men) excluded due to poor recordings (4) and unforeseen events (3). Thirteen patients (4
men), median age 63 years completed 3 tests. Median bowel lengths removed were 11 cm for ileum and 21 cm for colon. Thirty-nine
examinations analyzed by 2 physicians who found all 13 ICJs at 3 examinations with high inter-rater reliability (intra-class correlation
coefficient: 0.99, 0.91, and 0.99 respectively), whereas the computer found 9, 8, and 10 out of the 13 ICJs, respectively. Computed
values significantly more often deviated from the 2 raters. Mean magnitude and duration of pH-drop at the ICJ (3 examinations) was
1.16-1.02-1.13 pH units and 3.15-4.78-3.75 minutes, respectively. pH-drop was smaller and duration longer at 3 weeks. We found
no differences between the pre-operative (competent ICJ) and post-operative 6-month examinations (incompetent ICJ). Highest
pressure immediately prior to ICJ was equal before and after surgery.
Conclusion
WMC can identify the non-physiological ICJ after right colectomy. Ileocolic competence cannot be assessed.
Key Words
Anastomosis, surgical; Colectomy; Gastrointestinal motility; Gastrointestinal transit; Ileocolic valve
Received: November 5, 2016 Revised: January 31, 2017 Accepted: March 12, 2017
is properly cited.
*Correspondence: Yngve Thorsen, MD
Department of Digestive Surgery, Akershus University Hospital, University of Oslo, Norway
Tel: +47-67969794, Fax: +47-67969040, E-mail: yngve.thorsen@gmail.com

www.jnmjournal.org
585
Yngve Thorsen, et al
als.gov/ct2/show/NCT01351714), and the “Comparison of bowel

function between D2 and D3 operated patients for right-sided co-
Introduction lon cancer” trial (Regional ethics committee sør-øst no. 2013/206).
Dealing with patients suffering from motility disorders is chal- Participation was voluntary; informed consent forms were signed.
lenging. Assessment of regional and whole gut transit times can
give the information needed for a correct therapeutic approach.1 Inclusion Criteria
A body of evidence has been built in the literature on the validity Patients under 75 years of age with right-sided colon cancer
of motility monitoring using the SmartPill wireless motility cap- planned to be operated on with the intent to cure.
sule (WMC).2-4 The pill measures both whole gut and segmental
(stomach, small bowel, and colon) transit times. Segmental transit Exclusion Criteria
times are defined as time intervals between important landmarks Patients excluded were those with denied participation, ob-
(pylorus and ileocolic junction [ICJ]) when the capsule moves structing tumor, post-operative complications, inflammatory bowel
from one bowel segment to another. Up to now, the WMC has disease, known motility disorders, previously performed bowel
mostly been applied in studies dealing with patients with functional resections, extended bowel resection, conditions causing motility
disturbances in an otherwise intact digestive tube. A few patients disorders (celiac disease, diabetes mellitus, scleroderma, Parkinson’s
who had undergone bowel resections were included by Arora et disease, and rheumatic conditions), and those using medication that
al5 but the precise localization of the bowel segment removed was can influence bowel motility.
not defined. Surgeons remove segments of bowel and suture them
together in order to maintain bowel continuity. It is, however, not Study Design
the same if an intestinal landmark (eg, ICJ) or a segment of bowel Data collection was prospective. To eliminate subject-subject
between these landmarks is removed. Unfortunately, no data can variability, a within-subject design was used, rendering patients as
be found in the literature on patients where one or more of these their own controls. Selected patients planned for operation with
landmarks has been surgically removed and an anastomosis created. right colectomy with extended D3 mesenterectomy (removal of
The surgically created ICJ is per definition incompetent. Through 10-15 cm of the terminal ileum, the ascending and proximal trans-
the years, many authors have described possible consequences of verse colon with an extended D3 mesenterectomy as previously
having an incompetent ileocolic valve without having a proper way described7,8) underwent three WMC examinations (pre-operatively,
to assess competence. Roland et al6 suggest that a low pressure prior 3 weeks after and 6 months after surgery).
to the ileocolic valve (defined as highest pressure over a 4-minute
window prior to the characteristic ileocecal pH drop) indicates that Instruments
the valve is incompetent. The WMC is an ambulatory non-invasive and non-radioactive
The aim of this study is to demonstrate the capacity of the diagnostic sensor that continuously measures pH, temperature, and
WMC to locate a surgically created (non-physiologic) ICJ after pressure as it passes through the gastrointestinal (GI) tract.9,10 The
right colectomy for cancer. A secondary aim is to investigate if com- sensor transfers data to a receiver that must be in the patient’s prox-
petence of the ICJ can be assessed by measuring the pressure prior imity.
to the ICJ.
Testing
Patients were required to ingest a standard meal (SmartBar a
Materials and Methods cereal bar, containing 260 kcal) after 8 hours of fasting and imme-
diately afterward swallow the WMC. After swallowing the capsule,
Patients they were asked to refrain from eating for 6 hours. Patients were
Patients in this study were included simultaneously in 2 trials, instructed to wear the receiver as close to the abdomen as possible
the “Safe Radical D3 Right Hemicolectomy for Cancer through except while bathing and showering. Furthermore, they were asked
Pre-operative Biphasic Multi-detector Computed Tomography to record all bowel movements and meals by pressing the receiver’s
(MDCT)” (Regional ethics committee Sør-Øst no. 2010/3354), event button as well as writing down the time displayed together
registered at ClinicalTrials.gov on May 9th 2011 (http://clinicaltri- with a brief description of the event/activity in a diary. The patients

SmartPill, Ileocolic Juncton, and Right Colectomy
were instructed to wait 3 minutes in the bathroom before flushing

the toilet after each bowel movement to ensure that the receiver cap- Physician-confirmed ileocolic junction
tured the fall in temperature as the capsule fell into the toilet bowl. Physician-confirmed ICJ is based on the validated stereotypical
Patients returned the receiver after 4 days, and the data were down- changes in the pH profile through the GI tract. An abrupt sus-
loaded to a computer. tained rise in pH of more than two units delineates the GE. After
the GE, a steady rise in the pH followed by a plateau represents
Analysis the passage through the small bowel. A drop of 0.5-2.0 pH units
Data analysis was performed using the MotiliGI version 3.0.20 usually occurs when the capsule enters the colon (due to bacterial
(Given Image, Yokneam Illit, Israel). The software presents a fermentation),11 thereby defining the ICJ. After the ICJ an erratic
graph visualizing the pH and pressure, as well as the temperature pH profile in the colon is characteristic. Inter-rater reliability was
throughout the GI tract. The physician is instructed to identify the assessed for 2 of the authors (Y.T. and D.I.) independently from
following physiological landmarks according to predefined criteria: each other, and the computer for identification of the ICJ (minutes
capsule ingestion, gastric emptying (GE), ICJ, and bowel exit. The elapsed from activation of the capsule) on all graphs. The authors
software compares the physician identified markers to those identi- were blinded for the bowel length removed, operation, and exami-
fied by the computer. If not equivalent, the software allows users nation.
to choose between marks defined by the program or previously The data on magnitude and duration of the pH drop within
identified landmarks. The process provides 2 sets of markers: the the ICJ were drawn from the graph produced by the software.
physician confirmed and the computed. Based on these physiologi-
cal landmarks the following values can be calculated: GE time, Pressure Prior to the Ileocolic Junction
small bowel transit time, colonic transit time, whole gut transit time, In the Statistics mode in MotiliGI a window over the last 4
and combined small and large bowel transit time. Furthermore, the minutes prior to the ICJ was selected. MotiliGI generates a report
software analyses the mean and maximum pressures as well as the for the selected window, including the highest pressure.
contractions per minute through the segments.
Histology
Identification of the Ileocolic Junction Data on the lengths of formol-fixed bowel resected were drawn
from the histopathology report. Due to shrinkage the fixed speci-
Computed ileocolic junction men is shorter than the natural length.12
The software selects the ICJ by finding the first and largest pH
drop between 30 minutes and 6 hours from GE. Statistical Methods
To determine the inter-rater reliability the intra-class correla-
tion coefficient (ICC) was calculated using the R-package psych.
Paired-Samples T-Test in SPSS version 22 (IBM Corp, Armonk,
Table 1. Independent Identification of the Ileocolic Junction by the
Computer and the 2 Raters NY, USA) was used to estimate the change in magnitude and dura-
tion of the pH fall. The same test was used to compare the pressure
ICJ (n)
Exams (n) prior to ICJ before and after surgery.
PC Y.T. D.I.
Pre-operative ICJa found: 9 13 13 13
ICJb deviation: 2 0 0
3 wk after surgery ICJa found: 8 13 13 13 Table 2. Correlation Between the Ileocolic Junctions Found by the 2
ICJb deviation: 1 1 1 Raters
6 mo after surgery ICJa found: 10 13 13 13 ICC Mean difference
ICJb deviation: 3 0 0 (Y.T.-D.I.) (min)
All exams ICJa found: 27 39 39 39
Pre-operative 0.99 1.58
ICJb deviation: 6 1 1
a
3 wk after surgery 0.91 6.30
Ileocolic junction (ICJ) found by: the computer (PC), Y.T., and D.I. 6 mo after surgery 0.99 -0.33
b
ICJ deviating more than 10 minutes from the other 2 raters.
Exams, examinations. ICC, intra class correlation.
Vol. 23, No. 4 October, 2017 (585-591) 587

600 Pre-operative 450 3 weeks after surgery

Minutes until ICJ defined by Y.T.

550 430
410
500
390
450
370
400
D.I. 350 D.I.
350 Computer Computer
Lineaer (D.I.) 330 Lineaer (D.I.)
300 310
300 400 500 600 310 360 410 460
Correlating ICJ (min) defined by D.I. and Computer Correlating ICJ (min) defined by D.I. and Computer
550 6 months after surgery

500
450
400
350
D.I. Figure 1. Time (minutes) from pill activation to the ileocolic junc-
300 Computer tion (ICJ) determined by Y.T. (x-axis) and the corresponding values
Lineaer (D.I.) determined by D.I. and the computer (y-axis). In both the first and
250 the last graph one outlier (due to gastroparesis) with a very long time
250 350 450 550 from activation to ICJ was excluded from the graph (but not from the
Correlating ICJ (min) defined by D.I. and Computer results).
Results 100
Between July 2013 and December 2015 a total of 20 patients 80

(8 men) were included in the study, 7 (4 men) were excluded: 4
due to poor recordings (major breaks around the expected location 60
mmHg
of the ICJ in 1 or more of the 3 recordings), 2 due to unforeseen

surgical events, and 1 patient could not swallow the second WMC. 40
Thirteen patients (4 men) with a median age of 63 years success-
fully completed all 3 tests. Median bowel lengths removed by the 20
procedure were 11 (4-20) cm for the terminal ileum and 21 (14-34)
cm for the colon. All 39 examinations were analyzed to identify the 0
Before surgery 3 weeks after 6 months after
ICJ. The physicians found all ICJs before and after surgery while surgery surgery
the computer did not; the results and equivalence between the raters Figure 2. Boxplot presenting the highest pressure (mmHg) over a
are presented in Table 1. 4-minute window prior to the characteristic pH-drop at the ileocolic
The inter-rater reliability between the 2 physicians was very junction.
high with only a mean difference of 0.33 minutes after 6 months
(Table 2).
Figure 1 graphically depicts the correlation between the ICJ

defined by Y.T., D.I., and the computer for each test. smaller, respectively.
The magnitude and duration of the pH drop for the 3 exami- The highest pressure during a 4-minute window prior to the
nations shows a tendency toward longer times and smaller falls 3 ICJ did not change significantly after the surgery. Compared to
weeks after surgery. Compared to the mean duration (3.15 minutes) the pre-operative pressure the mean pressure 3 weeks after surgery
before surgery, the duration 3 weeks and 6 months after surgery was 1.19 mmHg lower (-22.13, 19.75) P = 0.901, and the mean
were 1.63 minutes (P = 0.358) and 0.60 minutes (P = 0.584) pressure 6 months after surgery was 0.62 mmHg higher (-18.31,
longer, respectively. Compared to the pre-operative mean pH drop 19.54) P = 0.943 (Fig. 2).
(1.16 pH units), the pH drop 3 weeks and 6 months after surgery After the initial post-operative phase none of the patients had
were 0.14 pH units (P = 0.387) and 0.03 pH units (P = 0.683) diarrhea. Figure 3 displays a comparison of the 3 consecutive tests
Figure 3. The 3 consecutive examina-

tions in 1 patient. (A) The pre-operative
test demonstrating the stereotypical
pattern. After gastric emptying, the pH
rises abruptly for at least 2 pH-units
and continues to climb until it reaches
a plateau. At the end of the plateau, a
sudden pH-fall occurs when the capsule
C passes over from the ileum into the co-
lon. After the ileocolic junction, we see
an irregular pH-pattern, which is very
typical for the colon. (B) Three weeks
after surgery the same characteristic pat-
tern is present. In this patient, the pH-
drop is little affected. The colon transit
time is reduced by about one-third. The
small bowel transit time is only slightly
reduced. (C) Six months after surgery
the small bowel transit time is normal-
ized. The pH drop is still clearly visible
and the colon transit time is reduced.
Vol. 23, No. 4 October, 2017 (585-591) 589

with the WMC in 1 patient. Some authors emphasize that the anatomy and physiology of
the most terminal part of the ileum differ from the rest, rendering
it a sphincter.13 One can question if the “neoterminal” ileum cre-
Discussion ated after surgery is functionally comparable to the physiological
This article documents the ability of the WMC to identify the terminal ileum. Nevertheless, the limited small bowel resection
surgically created (non-physiological) ICJ after a right colectomy. (median length 11 cm) diminishes the importance of this question.
However, as already described by Wang et al. the automatic identi- One could also argue that the extended D3 mesenterectomy (which
fication of the ICJ by the computer seems to be too simplified and entails a more extensive mesenterectomy than at standard surgery7,8)
therefore often fails to recognize the ICJ.10 The number of ICJs could affect the contractility. The lack of a significant change in
identified by the computer is not higher prior to surgery than it is 6 mean and high pressure in the small bowel 6 months after surgery
months after, indicating that this is independent of the procedure. makes this explanation unlikely.
The physician confirmed values, though, based on the stereotypical The strength of this study is in the prospective data collection
changes in the pH-profile seem to be much more reliable. Even and the fact that every patient represents his own control, such a
after surgery, we find the same curve with the same pH-fall around paired design excludes personal variation, in this way providing a
the ileocolic region that Zarate et al11 described in their validation firm groundwork for the conclusions drawn. A potential weakness
of the WMC. This is clearly visible in Figure 3. In our study, the is the low number of patients, as well as the fact that one-third of the
inter-rater reliability between the 2 independent physicians is very patients were excluded from the analysis.
high, expressed by an ICC of 0.99 both before and 6 months after In conclusion, the WMC can identify the ICJ after a right col-
surgery. However, 3 weeks after surgery the stereotypical pH- ectomy. The accuracy is, however, somewhat reduced in the initial
profile (the graph displayed by the software) often is somewhat post-operative phase, due to a slightly disturbed pH-profile. ICJ
disturbed, making the identification of the ICJ more difficult. The valve competence cannot be assessed through the WMC.
duration of the pH-drop appears to be longer, and the magnitude
smaller. Even though the differences were too small to be significant
in our small sample, the trend is clear. The delicate mechanism of Financial support: Funding for the research and the publication
came from the Vestfold Hospital Trust (Grant No. B-2013/FoU-
the ICJ seems to be disrupted leading to longer times for chyme
05).
transit through the non-physiological and surgically created ICJ,
and in addition possible regurgitation. Nonetheless, the ICC be- Conflicts of interest: None.
tween the physicians on the examination 3 weeks after the operation
was still relatively high (0.91). The 6 month curve indicates similar Author contributions: Yngve Thorsen, Dejan Ignjatovic, and
function as before surgery implicating a possible compensatory Bojan V Stimec, designed the study; the data collection was per-
mechanism that is not valve related. formed by Yngve Thorsen and Jens M Nesgaard; the data were
It is known that up to 15% of subjects fail to show a character- analyzed by Yngve Thorsen and Dejan Ignjatovic and interpreted
istic sharp fall in pH at the ICJ.11 Zarate et al11 wondered if this is by the group; the article was written by Yngve Thorsen and Dejan
related to ileocolic valve competence. Roland et al6 found an asso- Ignjatovic; and Jens M Nesgaard and Bojan V Stimec contributed
ciation between a low pressure prior to the ICJ and small intestinal in writing parts of the manuscript and revising it.
bacterial overgrowth. They suggested that a low pressure indicates
lack of valve competence. These changes concerning the charac- References
teristic pH drop or the pressure prior to the ICJ when the ileocecal
valve is surgically removed are not confirmed in our study. Our 1. Rao SS, Camilleri M, Hasler WL, et al. Evaluation of gastrointestinal
present data indicate that the valve competence cannot be assessed transit in clinical practice: position paper of the American and European
using the WMC. The slightly altered pH-profile in the early post- Neurogastroenterology and Motility Societies. Neurogastroenterol Motil
2011;23:8-23.
operative period might also be related to a disturbance of the bacte-
2. Tran K, Brun R, Kuo B. Evaluation of regional and whole gut motility
rial colonization in the colon and possibly also to bacterial growth in using the wireless motility capsule: relevance in clinical practice. Therap
the small intestine due to stagnation of the chyme in the first days Adv Gastroenterol 2012;5:249-260.
after the operation. 3. Maqbool S, Parkman HP, Friedenberg FK. Wireless capsule motility:

comparison of the SmartPill GI monitoring system with scintigraphy for with D3 extended mesenterectomy. Tech Coloproctol 2016;20:445-453.
measuring whole gut transit. Dig Dis Sci 2009;54:2167-2174. 9. Saad RJ. The wireless motility capsule: a one-stop shop for the evaluation
4. Lee YY, Erdogan A, Rao SS. How to assess regional and whole gut of GI motility disorders. Curr Gastroenterol Rep 2016;18:14.
transit time with wireless motility capsule. J Neurogastroenterol Motil 10. Wang YT, Mohammed SD, Farmer AD, et al. Regional gastrointestinal
2014;20:265-270. transit and pH studied in 215 healthy volunteers using the wireless motil-
5. Arora Z, Parungao JM, Lopez R, Heinlein C, Santisi J, Birgisson S. ity capsule: influence of age, gender, study country and testing protocol.
Clinical utility of wireless motility capsule in patients with suspected mul- Aliment Pharmacol Ther 2015;42:761-772.
tiregional gastrointestinal dysmotility. Dig Dis Sci 2015;60:1350-1357. 11. Zarate N, Mohammed SD, O’Shaughnessy E, et al. Accurate localiza-
6. Roland BC, Ciarleglio MM, Clarke JO, et al. Low ileocecal valve pres- tion of a fall in pH within the ileocecal region: validation using a dual-
sure is significantly associated with small intestinal bacterial overgrowth scintigraphic technique. Am J Physiol Gastrointest Liver Physiol
(SIBO). Dig Dis Sci 2014;59:1269-1277. 2010;299:G1276-G1286.
7. Nesgaard JM, Stimec BV, Bakka AO, Edwin B, Ignjatovic D; RCC 12. Chen CH, Hsu MY, Jiang RS, Wu SH, Chen FJ, Liu SA. Shrinkage
study group. Navigating the mesentery. A comparative pre- and per-op- of head and neck cancer specimens after formalin fixation. J Chin Med
erative visualization of the vascular anatomy. Colorectal Dis 2015;17:810- Assoc 2012;75:109-113.
818. 13. Malbert CH. The ileocolonic sphincter. Neurogastroenterol Motil
8. Thorsen Y, Stimec B, Andersen SN, et al. Bowel function and quality of 2005;17(suppl 1):41-49.
life after superior mesenteric nerve plexus transection in right colectomy
Vol. 23, No. 4 October, 2017 (585-591) 591

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Comparison of Changes in the Interstitial Cells of

Cajal and Neuronal Nitric Oxide Synthase-positive
Neuronal Cells With Aging Between the Ascending
and Descending Colon of F344 Rats
Sun Min Lee,1 Nayoung Kim,1,2* Hyun Jin Jo,1 Ji Hyun Park,2 Ryoung Hee Nam,1 Hye Seung Lee,3 Hyun Jin Kim,4 Moon Young Lee,5
Yong Sung Kim,6 and Dong Ho Lee1
1
Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea; 2Department of Internal Medicine
and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea; 3Department of Pathology, Seoul National University
Bundang Hospital, Seongnam, Gyeonggi-do, Korea; 4Department of Internal Medicine, Gyeongsang National University Changwon Hospital,
Gyeongsang National University College of Medicine, Jinju, Gyeongsangnam-do, Korea; 5Department of Physiology and Institute of Wonkwang
Medical Science, Wonkwang University College of Medicine, Iksan, Jeollabuk-do, Korea; 6Division of Gastroenterology and Wonkwang Digestive
Disease Research Institute, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Gunpo, Gyeonggi-do, Korea
Background/Aims
Neuronal degeneration and changes in interstitial cells of Cajal (ICCs) are important mechanisms of age-related constipation. This
study aims to compare the distribution of ICCs and neuronal nitric oxide synthase (nNOS) with regard to age-related changes between
the ascending colon (AC) and descending colon (DC) in 6-, 31-, and 74-week old and 2-year old male Fischer-344 rats.
Methods
The amount of fecal pellet and the bead expulsion times were measured. Fat proportion in the muscle layer of the colon was analyzed
by hematoxylin and eosin staining. Proto-oncogene receptor tyrosine kinase (KIT) and neuronal nitric oxide synthase (nNOS) expression
were analyzed with Western blotting and immunohistochemistry. Isovolumetric contractile measurements and electrical field
stimulation were used to assess smooth muscle contractility.
Results
Colon transit and bead expulsion slowed with senescence. Fat in the muscle layer accumulated with age in the AC, but not in the
DC. The proportion of KIT-immunoreactive ICCs in the submucosal and myenteric plexus was higher in the DC than in the AC, and it
declined with age, especially in the AC. In contrast, the proportion of NOS-immunoreactive neurons in the myenteric plexus was higher
in the AC than in the DC, and both decreased in older rats. Nitric oxide levels declined with age in the DC. Muscle strip experiments
showed that the inhibitory response mediated by nitric oxide in the circular direction of the DC was reduced in 2-year old rats.
Conclusion
The AC and DC differ in their distribution of ICCs and nNOS, and age-related loss of nitrergic neurons more severely affects the DC
than the AC.
Key Words
Aging; Colon; Interstitial cells of Cajal; Nitric oxide synthase type I; Rats, inbred F344
Received: April 30, 2017 Revised: June 20, 2017 Accepted: July 9, 2017
is properly cited.
*Correspondence: Nayoung Kim, MD
Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam,
Gyeonggi-do 13620, Korea
Tel: +82-31-787-7008, Fax: +82-31-787-4051, E-mail: nayoungkim49@empas.com

www.jnmjournal.org
Effect of Age on Different Colonic Regions
region-specific neuronal change in DC remains to be investigated.

The colon has embryological and functional regional differ-
Introduction ences between the AC and DC. That is, the AC and DC come
Constipation is one of the most common digestive diseases. from different embryological origins and have distinct features in
The prevalence of constipation is 12-19%, and it increases with terms of development of ICCs at the end of the embryonic period
age.1,2 Among constipation patients over 65 years old, 65% reported in humans.31 Motor patterns also differ according to colonic re-
symptoms of straining during bowel movements and 40% reported gions.32 The velocity of fecal pellet propulsion is higher in the distal
symptoms of excessively solid stools.3 Furthermore, the prevalence colon than in the mid- and proximal colons in guinea pigs.32 These
of constipation was 26% in women and 16% in men 65 years of studies imply that there may be some distinctive features of ICCs
age or older in a study on self-reported constipation.4 Age-related and NOS associated with the differences in the decline of colonic
changes in the lower gastrointestinal tract include delayed colon motility that happens with age between the AC and DC. Several
transit time and reduction of the moisture content of stools.5 These studies have shown the distribution of ICCs and nNOS in the AC
changes can result from intestinal atrophy, reduced blood supply, and DC; however, the results varied possibly because of differences
and alterations in the enteric nervous system.6 in ages and species.33-37 Since there is loss or scathe of ICCs and
Interstitial cells of Cajal (ICCs) are the pacemaker cells in the neurons in the aging colon, we hypothesized that the distribution
colon; they induce spontaneous electrical and mechanical activity of ICCs and nNOS may change as animals age, and the functional
by acting as intermediaries of neurotransmission.7-9 A decline in the consequences could be different according to the colonic site. Given
number and volume of ICCs with age was reported in a study in this background, the aim of this study is to investigate the differ-
normal human colons.10 KIT protein, which is the receptor for stem ential distribution of ICCs and nNOS with regard to age-related
cell factor, is expressed in ICC and is an established immunohis- changes between the AC and DC in male Fischer-344 (F344) rats.
tological marker for ICCs.7,11 Kit mRNA and KIT protein levels In relation to these anatomical changes, functional studies were also
decline in the colons of patients with slow-transit constipation.12,13 In performed in the 6-, 31-, and 74-week old and 2-year old rats.
addition, stem cell factors and KIT protein activity is closely related
to the development and sustenance of ICCs, and their expression
levels decrease with age in the rat ascending colon (AC).14-16
Neuronal degeneration in the enteric nervous system is an
important mechanism of age-related functional changes in the guts Animals
of older animals.17 Dysfunction of intestinal muscles is associated Specific-pathogen-free, male F344 rats 6, 31, and 74 weeks,
with a reduction in enteric neuronal cells and an impaired response and 2 years of age were used in these studies (Orient Co Ltd, Seoul,
to direct stimuli in the myenteric plexus.18,19 Similar findings have Korea). The animals were bred under a specific-pathogen-free
been demonstrated in aging mice, rats, guinea pigs, and a non- condition, at 23°C and 12:12-hour light-dark cycles. They were
human primate model.20-23 The extent of age-related loss of enteric provided with unrestricted access to food and water. This study
neurons is controversial to date. In humans and rats, selective loss was performed in strict accordance with the recommendations in
of cholinergic neurons with sparing of nitrergic neurons has been the Guide for the Care and Use of Laboratory Animals of South
reported.24-26 In contrast, there was a report of a decrease of neuro- Korea. All experiments were approved by the Institutional Animal
nal nitric oxide synthase (nNOS) in old rats.27 On the other hand, Care and Use Committee (IACUC) of Seoul National University
restricting diet prevented age-related myenteric neuronal loss in the Bundang Hospital (Permission No. BA1304-27/033-04).
ileum of Sprague-Dawley rats.28 Nitrergic neurons generate nitric
oxide (NO) by nNOS to regulate the non-adrenergic non-cholin- Assessment of Constipation-like Phenotype in Rats’
ergic relaxation of smooth muscle that affects colonic motility.29 NO Defecation
enhances colonic transit by mediating descending relaxation and fa- Starting from 8-9 AM, the rats (in each age group, n = 8)
cilitates propulsion of the contents of the colon.30 Age-related loss of were fasted for 24 hours with free access to tap water. They were
nNOS in rats was reported in the AC and mid-colon;14,27 however, then allowed access to food for 2 hours, and were fasted again for 24
it has not been studied in the descending colon (DC) of the rat. hours in order to observe defecation.38 During fasting, we avoided
Although the extent of neuronal loss differed in human and rats, the the use of wire mesh in order to reduce stress. We recorded the
Vol. 23, No. 4 October, 2017 (592-605) 593

Sun Min Lee, et al
weight of the provided food before and after feeding. After feed- n = 6) were homogenized in lysis buffer and the supernant was
ing, we recorded the number of stools produced over the course of separated from the lysates. After SDS-PAGE, we transferred the
4 hours and 24 hours to investigate total fecal output including late proteins from gel to the PVDF membrane and blocked them with
defecation. To measure dry fecal weight, we collected the fecal sam- 5% skim milk. Starting with the blocking process, all procedures
ples that were excreted over the course of 24 hours and dried them were performed with Tris buffer (40 mM, pH 7.55) containing
for an additional 24 hours. The results are described as number of 0.3 M of NaCl and 0.05% Tween 20. After blocking, we blotted
defecations per rat and dry fecal weight per 300 g body weight. the membranes with antibodies for KIT (1:100 dilution, rabbit
polyclonal antibody; Santa Cruz Biotechnology, Santa Cruz, CA,
Bead Expulsion Study USA), nNOS (1:500 dilution, mouse monoclonal IgG2a antibody;
Each experiment started between 8 and 9 AM. Before the BD Biosciences, San Diego, CA, USA), and β-actin (1:1000 dilu-
experiment, rats (in each age group, n = 8) fasted for 24 hours but tion, rabbit polyclonal antibody; Biovision, Milpitas, CA, USA) at
given access to water. The fasted animals were then fed for 2 hours. 4°C overnight. Rabbit polyclonal antibodies (Santa Cruz Biotech-
We anesthetized the animals with isoflurane, eliminated stools in the nology) against KIT and β-actin and a mouse polyclonal antibody
rectum and inserted colored plastic beads to a depth of 3 cm past (Santa Cruz Biotechnology) against nNOS were used as secondary
the anus using a plastic rod. The diameter of the beads was 5 mm antibodies. For KIT data, the expression level was calculated by
for 6-week old rats and 6 mm for rats of other ages. After placing adding the band intensity of the mature and immature forms.
each rat in an individual cage, we observed the rats for 4 hours to
measure time until bead expulsion. Immunohistochemistry for KIT, Protein Gene
Product 9.5, and Neuronal Nitric Oxide Synthase
Tissue Preparation Immunohistochemistry (IHC) for KIT, protein gene product
After the defecation study and bead expulsion study, animals (PGP) 9.5, and nNOS was performed as previously described.14
were terminally anesthetized via inhalation of carbon dioxide to The tissue sections were treated with 3% hydrogen peroxide and
obtain colonic tissue samples. After discarding 1 cm from the ce- nonspecific binding sites were blocked. Then, the sections were
cum and anus, 5 cm of the proximal and distal parts of the colon incubated with primary antibodies. Anti-KIT (1:100 dilution, poly-
were collected from each.33,39 A part of each sample 1 cm in length clonal rabbit anti-human CD117; DAKO, Glostrup, Denmark),
was prepared for histological analysis by fixation in 10% buffered anti-PGP 9.5 (1:250 dilution, CM 329 AK; Biocare Medical,
formalin. The tissue specimens embedded in paraffin blocks were Concord, CA, USA), and anti-nNOS (1:500 dilution, AB5380;
cut perpendicularly to the lumen into 4 μm thick sections and then EMD Millipore, Billerica, MA, USA) were used as the primary
stained with hematoxylin and eosin. Western blot samples were im- antibodies. Since mast cells are known to express KIT, they were
mediately frozen in liquid nitrogen, and stored at –80°C until use. excluded from the counts after being identified by their round or
oval shape and deficiency of processes.7,10,40 For immunostaining,
Measurement of Histologic Fat Proportion an automatic immunostainer (BenchMark XT; Ventana Medical
A pathologist blinded to the experimental groups analyzed the Systems, Inc, Tucson, AZ, USA) and UltraView Universial DAB
histology of the samples. One slide per animal (in each age group, detection kit (Ventana Medical Systems) were used. Sections not
n = 10) and 2 fields per slide were selected at random. The fat pro- treated with primary antibodies were used as negative controls.
portion in the muscle layer was estimated as the area of fatty tissue
to total smooth muscle. The area was measured with the ImagePro Measurement of Nitric Oxide Levels
Plus analysis system (Media Cybernetics, Inc., San Diego, CA, NO was quantified using a microplate assay (G-7921, Thermo
USA) and described as mm2 per field of view. Fisher Scientific) following the manufacturer’s protocol. Briefly, the
colonic samples (in each age group, n = 4 or n = 5) were mixed
Western Blotting for KIT and Neuronal Nitric Oxide with a reagent containing equal volumes of N -(1-naphthyl)ethyl-
Synthase enediamine and sulfanilic acid, and then incubated for 30 minutes
We used AC and DC tissue after eliminating the mucosal at room temperature. The absorbance of the nitrite-containing
layer. The colonic specimens were prepared for protein analysis, samples was measured in a spectrophotometric microplate reader.
as previously described.14 Briefly, the samples (in each age group, Measurements were taken at a wavelength of 548 nm.

0.007, 31-week old rats vs 6-week old rats; P = 0.002, 74-week

Assessment of Smooth Muscle Contractility old rats vs 6-week old rats; P < 0.001, 2-year old rats vs 6-week
Change in smooth muscle contractility was evaluated by mea- old rats; and P = 0.003, 31-week old rats vs 2-year old rats) (Fig.
suring the contractile response with or without electrical field stimu- 1A). Then the weight of the total feces produced over the course of
lation (EFS) and neuronal inhibitors. We used standard organ-bath 24 hours was determined and adjusted to body weight. The fecal
techniques and methods for isovolumetric contractile measurement weight declined in older rats; that is, it was less in 31-week old, 74-
and EFS, as previously described.14 Five animals were used in each week old, and 2-year old rats than in 6-week old rats, and was also
age group. The muscle strips were allowed to equilibrate for up to less in 2-year old rats as compared to 31-week old rats (P < 0.001,
1-2 hours before the experiments. Contractile activity was quantified 31-week old rats vs 6-week old rats; P < 0.001, 74-week old rats vs
by calculating the area under the curve (AUC). It was first mea- 6-week old rats; P < 0.001, 2-year old rats vs 6-week old rats; and
sured in the resting state and then measured with EFS. EFS (320 P = 0.049, 2-year old rats vs 31-week old rats) (Fig. 1B). There
mA and 1 millisecond pulse-width for 5 seconds) was performed was no correlation between the amount of food intake and fecal
at various frequencies of 1, 2, 5, 10, and 20 Hz. The contractile weight, as determined with Pearson’s simple correlation coefficient
response to potassium chloride (KCl) was quantified to investigate (P = 0.073).
non-neuronally mediated smooth muscle contractility. Contraction
and relaxation of the colonic muscle induced by EFS was sequen- The Effect of Aging on Distal Colonic Transit
tially evaluated under atropine (10 μM). Moreover, we assessed the Following the evaluation of dysmotility in the whole colon,
EFS responses to apamin (1 μM) and L-NG-nitroarginine methyl we investigated dysmotility specifically in the DC and rectum by
ester (L-NAME, 100 μM) under non-adrenergic non-cholinergic measuring the time necessary for bead expulsion. The colonic bead
conditions by adding atropine, propranolol, and phentolamine expulsion time increased in 2-year old rats as compared to 6-week
(1 μM each). All data were obtained using the PowerLab data old rats (P = 0.043) (Fig. 1C), which indicates attenuation of distal
acquisition system, and the AUC was calculated using the values colonic transit in older rats.
acquired immediately before and after EFS. The value obtained
before drug treatment was defined as 100% when calculating the Fat Proportion in the Ascending Colon and
percent changes of EFS responses. Descending Colon
We analyzed fat deposition of the muscle layer on histology and
Statistical Methods compared the fat proportion between the AC and DC. Similar to
All statistical analyses were performed using the SPSS ver- what was found in a previous report,14 the proportion of fat in 74-
sion 18 (IBM Corp, Armonk, NY, USA). For comparison of two week old rats and 2-year old rats was significantly higher in the AC
means, Student’s t test or the Mann-Whitney test was used after than in DC (P = 0.031 and P = 0.004, respectively) (Fig. 2). On
normality evaluation with the Kolmogorov-Smirnov test. The cor- the other hand, the proportion of fat in the DC was extremely low;
relation between 2 factors was determined with Pearson’s simple cor- it was 0.00% in 74-week old and 0.81% in 2-year old rats (Fig. 2).
relation coefficient. Values are given as mean ± SEM. A P-value of
< 0.05 was taken to indicate statistically significance. Comparison of KIT Expression Between the
Ascending Colon and Descending Colon and the
Effect of Aging: Western Blot
Results KIT expression was higher in the DC than in the AC, and
there were statistically significant differences between 6-, 31-, and
The Effects of Aging on the Defecation 74-week old rats (P = 0.013 in 6-week old rats; P < 0.001 in 31-
The number of stools produced in 4 hours was less in 31-week week old rats; and P = 0.008 in 74-week old rats) (Fig. 3A). The
old, 74-week old, and 2-year old rats than in 6-week old rats (P = KIT protein level decreased in older ages; in the AC, it was lower
0.009, 31-week old rats vs 6-week old rats; P < 0.001, 74-week old in 31-week old, 74-week old, and 2-year old rats than in 6-week old
rats vs 6-week old rats; and P < 0.001, 2-year old rats vs 6-week rats (P = 0.034, 31-week old rats vs 6-week old rats; P = 0.048,
old rats) (Fig. 1A). Total fecal number in 24 hours also diminished 74-week old rats vs 6-week old rats; and P = 0.002, 2-year old rats
in older rats as compared to 6-week old and 31-week old rats (P = vs 6-week old rats) (Fig. 3A). Similarly, the KIT protein level in the
Vol. 23, No. 4 October, 2017 (592-605) 595

Sun Min Lee, et al
A 30
B 0.015
n=8 n=8
6-week old
25
Fecal weight/body weight

31-week old
74-week old
20 2-year old * 0.010
Fecal number
*
15
*,**
*
10 0.005 * *,**
5 *
* *
0 0.000
4 hr 24 hr 6 wk 31 wk 74 wk 2 yr
Defecation time Age
C 100 n=8
*
Bead expulsion time (min)
80
60
40
Figure 1. Assessment of constipation-like phenotype in rats’ defeca-
tion and distal colonic transit: bead expulsion time in 6-, 31-, 74-week
20 old, and 2-year old conscious rats. (A) Number of feces passed in 4
or 24 hours. (B) Total dry weight of feces defecated in 24 hours. (C)
0 Distal colonic transit time. The bars represent mean ± SEM (each
6 wk 31 wk 74 wk 2 yr group, n = 8). *P < 0.05 as compared with 6-week old rats; **P <
Age 0.05 as compared with 31-week old rats.
A AC DC
B
80 n = 10
Fat proportion of muscle layer (%)
AC *
DC 47.54
74 wk SMP 60
SMP
CM
CM
MP *
MP
LM LM 40 24.86
20
2 yr SMP SMP
CM CM
0.00 0.81
MP MP 0
LM 74 wk 2 yr
LM
50 um
Age
Figure 2. Proportion of fat in the muscle layer (%). Fat proportion was investigated with histological analysis. (A) Hematoxylin and eosin stain
(×200 magnifications) and (B) analysis of each measured area (mean ± SEM). The mean values are labeled on each column (each group, n =
10). *P < 0.05 between the ascending colon (AC) and descending colon (DC). SMP, submucosal plexus; CM, circular muscle; MP, myenteric
plexus; LM, longitudinal muscle.

A 1.5 n=6
B 2.0 n=6
AC AC
*** *** DC DC
*** 1.5
1.0
nNOS/actin
KIT/actin
*,**
* * 1.0 ***
*
**
0.5
0.5
*
0.0 0.0
6 wk 31 wk 74 wk 2 yr 6 wk 31 wk 74 wk 2 yr
Age Age
AC DC AC DC AC DC AC DC AC DC AC DC AC DC AC DC
Mature (145 kDa) nNOS (155 kDa)
Immature (120 kDa)
Actin (42 kDa)
Actin (42 kDa)
Figure 3. Expression of KIT protein and neuronal nitric oxide synthase (nNOS) in the rat ascending colon (AC) and descending colon (DC):
changes by age and difference according to colonic region. (A) KIT protein level. (B) nNOS protein level. The bars represent the mean ± SEM
(each group, n = 6). *P < 0.05 as compared with 6-week old rats; **P < 0.05 as compared with 31-week old rats; ***P < 0.05 between the AC
and DC.
DC was lower in 2-year old rats than in 6-week old and 31-week difference between the AC and DC in 74-week old and 2-year old
old rats (P = 0.018, 2-year old rats vs 6-week old rats; P = 0.011, rats in the submucosal plexus (P < 0.001 in both cases), and in 31-
2-year old rats vs 31-week old rats). week old and 2-year old rats in the myenteric plexus (P = 0.041 in
31-week old rats and P = 0.001 in 2-year old rats) (Fig. 4A and
Comparison of Neuronal Nitric Oxide Synthase 5A). This statistical difference of KIT expression levels between
Expression Between the Ascending Colon and the AC and DC in relation to age originated from slightly different
Descending Colon and the Effect of Aging: decreasing trends of KIT expression. That is, in the submucosal
Western Blot plexus, the KIT-positive area decreased with age specifically in the
Comparing between the AC and DC, in 74-week old rats, AC rather than in the DC (Fig. 4A and 5A). In the myenteric
nNOS protein expression level was significantly higher in the AC plexus, the KIT-immunoreactive area was reduced in both the AC
than in the DC (P = 0.043) (Fig. 3B). The nNOS protein levels and DC.
in the AC was significantly lower in 2-year old rats as compared to
31-week old rats (P < 0.001). The nNOS expression in the DC Comparison of Neuronal Nitric Oxide Synthase-
significantly decreased in 74-week old rats as compared to 6-week positive Area Between the Ascending Colon
old rats (P = 0.014); it also diminished in 2-year old rats but it was and Descending Colon and the Effect of Aging:
not statistically significant (P = 0.063) (Fig. 3B). Immunohistochemistry
There were differences in the nNOS-immunopositive area be-
Comparison of KIT-positive Area Between the tween the AC and DC, such that the proportion of nNOS-positive
Ascending Colon and Descending Colon and the neurons was higher in the AC than in the DC in the myenteric
Effect of Aging: Immunohistochemistry plexus in 31-week old and 74-week old rats, but this difference was
The KIT-positive area evident on IHC was higher in the DC not found in the submucosal plexus (Fig. 4B and 5B). A decrease
than in the AC in rats of all 4 ages. However, there was a significant in the proportion of nNOS-positive neuronal cells in the DC was
Vol. 23, No. 4 October, 2017 (592-605) 597

Sun Min Lee, et al
A AC DC
SMP SMP
SMP SMP
CM CM
CM CM
MP
MP
LM MP LM
LM MP
6 wk 31 wk 6 wk LM 31 wk
SMP SMP
SMP SMP
CM CM CM
CM
MP MP MP
LM LM LM MP
74 wk 2 yr 74 wk LM 2 yr
B AC DC
SMP SMP SMP

CM SMP
CM CM
CM
MP MP
LM LM MP
MP LM
6 wk 31 wk LM 6 wk 31 wk
SMP
SMP
CM
CM SMP SMP
MP CM CM
MP LM
LM MP MP
LM LM
74 wk 2 yr 74 wk 2 yr
C AC DC
SMP
SMP SMP
SMP
CM CM
CM CM
MP MP
LM MP MP
LM LM LM
6 wk 31 wk 6 wk 31 wk
SMP SMP SMP

SMP
CM CM CM
CM
MP MP
LM MP MP
LM LM LM
74 wk 2 yr 74 wk 2 yr
Figure 4. Photomicrography of KIT immunohistochemistry, neuronal nitric oxide synthase (nNOS), and protein gene product (PGP) 9.5 in the
rat colon: changes according to age and difference according to colonic region. Arrowheads indicate (A) KIT-, (B) nNOS-, and (C) PGP 9.5-im-
munoreactive cells (×200 magnification) in the ascending colon (AC) and descending colon (DC) of 6-, 31-, 74-week old, and 2-year old rats.
SMP, submucosal plexus; CM, circular muscle; MP, myenteric plexus; LM, longitudinal muscle.

A SMP MP
5 n=6 AC 5 n=6 AC
DC **** DC
4 4
KIT (+) %
KIT (+) %
3 3 ****
****
**** *,** *,**
2 2 *
*,**
1 *,** 1
*,**
0 0
Age Age
B SMP MP
8 n=6 AC 8 n=6 AC
DC **** DC
6 6 ****
nNOS (+) %
nNOS (+) %
4 *,** 4 *,**,***
* *,**,*** *
* *
2 *,** 2
0 0
Age Age
C SMP **** MP
20 n=6 AC 20 n=6 AC
*
DC DC
15 15
PGP 9.5 (+) %
PGP 9.5 (+) %
****
** **
10 10
**
5 * 5
** **
0 0
Age Age
D SMP MP
5 n=6 AC 5 n=6 AC
DC DC
nNOS/PGP 9.5 ratio
nNOS/PGP 9.5 ratio
4 4
3 3
*
2 * 2
****
*
1 * 1 **
*
0 0
Age Age
Figure 5. Immunohistochemical analysis of KIT, neuronal nitric oxide synthase (nNOS), and protein gene product (PGP) 9.5 in the rat colon:
changes according to age and differences according to colonic region. The proportion of (A) KIT-, (B) nNOS-, (C) PGP 9.5-immunoreactive
area, and (D) the nNOS/PGP 9.5 ratio in the submucosal plexus and myenteric plexus. The bars represents the mean ± SEM (each group, n =
6). *P < 0.05 compared to 6-week old rats; **P < 0.05 compared to 31-week old rats; ***P < 0.05 compared to 74-week old rats; ****P < 0.05
compared to ascending colon (AC). DC, descending colon; SMP, submucosal plexus; MP, myenteric plexus.
Vol. 23, No. 4 October, 2017 (592-605) 599

Sun Min Lee, et al
detected beginning at the age of 31 weeks, which was earlier than 5C). In addition, in the myenteric plexus of 31-week old and 74-
in the AC, especially in the myenteric plexus. In detail, in the my- week old rats, the proportion of PGP 9.5 immunoreactive area was
enteric plexus, the proportion of nNOS-immunopositive area was significantly higher in the AC than in the DC (P = 0.003 in 31-
lower in 31-week old and 74-week old rats than in 6-week old rats week old rats and P = 0.011 in 74-week old rats) (Fig. 4C and
(P < 0.001 for all comparisons) (Fig. 4B and 5B). In the submu- 5C), which is similar to the pattern of nNOS-positivity.
cosal plexus of the DC, the proportion of the nNOS-positive area
was lower in 74-week old rats than in 6-week old rats and in 2-year Comparison of Neuronal Nitric Oxide Synthase/
old rats, as compared to 6-week old rats and 31-week old rats (P = Protein Gene Product 9.5 Between the Ascending
0.001, 74-week old rats vs 6-week old rats; P < 0.001, 2-year old Colon and Descending Colon and the Effect of
rats vs 6-week old rats; and P = 0.009, 2-year old rats vs 31-week Aging: Immunohistochemistry
old rats) (Fig. 4B and 5B). The nNOS/PGP 9.5 ratio was calculated as the percent of
nNOS-positive area divided by the percent of PGP 9.5-positive
Comparison of the Protein Gene Product area for each animal. In this analysis, the change of nNOS/PGP 9.5
9.5-positive Neuronal Structure Between the ratio according to age was similar between the AC and DC (Fig.
Ascending Colon and Descending Colon and the 5D). A decrease with age was more prominent in the submucosal
Effect of Aging: Immunohistochemistry plexus than in the myenteric plexus. In the submucosal plexus of
The proportion of PGP 9.5 immunopositive area was higher the AC, the ratio was lower in 31-week, 74-week and 2-year old
in the myenteric plexus than in the submucosal plexus (Fig. 4C and rats as compared to 6-week old rats (P = 0.012, 31-week old rats
A 100 AC
B 800
KCI response
n=5 6-week old
ns DC
2-year old
80
**
600
NO (mol/g)
% Control
60
400
40 *
200
20
0 0
6 wk 2 yr AC- DC- AC- DC-
(n = 4) Age (n = 5) longitudinal longitudinal circular circular
4
C 140
L-NAME 10 (without EFS)
n=5 6-week old
2-year old Figure 6. Nitric oxide (NO) levels and spontaneous contraction in
6-week old and 2-year old rat colons. (A) Changes in NO level ac-
120 cording to age in the ascending colon (AC) and descending colon
(DC). (B) Contractile responses to potassium chloride (KCl) in the
% Control
longitudinal or circular muscle in the AC and DC of 6-week old and

100 * 2-year old rats. (C) Spontaneous contraction in 6-week old and 2-year
old rat colons after treatment with L-NG-nitroarginine methyl ester
(L-NAME). Area under the curve of baseline contractile response
during the contractile measurement. The bars represent the mean ±
80
70 SEM. The values shown are the differences in contraction before and
0
after treatment with L-NAME at the resting state without electrical
AC- DC- AC- DC- field stimulation (EFS). *P < 0.05 as compared with 6-week old rat
longitudinal longitudinal circular circular colon; **P < 0.05 between the AC and DC.

vs 6-week old rats; P = 0.028, 74-week old rats vs 6-week old rats; cally significant only in older animals (P < 0.001), not in younger
and P = 0.005, 2-year old rats vs 6-week old rats). It also decreased animals (P = 0.174).
in the submucosal plexus of the DC in 2-year old rats as compared
to 6-week old rats (P = 0.039). In the myenteric plexus of the AC, Isovolumetric Contractile Measurement and
the ratio decreased in 31-week old rats (P = 0.036) and then in- Electrical Field Stimulation
creased in 74-week old rats (P = 0.013). There was no statistically The response to KCl of 2-year old rats was analogous to that of
significant change according to age in the myenteric plexus of DC. 6-week old rats (Fig. 6B). The degree of spontaneous contraction
in the circular direction of 6-week old rats was over 100%, which
Nitric Oxide Levels means that it increased after treatment with L-NAME (Fig. 6C).
NO has been suggested as an important factor for regulation of On the other hand, in 2-year old rats, especially in the circular di-
descending relaxation in the rat colon.41,42 The NO level was signifi- rection in the DC, the contraction showed little discrepancy before
cantly decreased in 2-year old rats as compared to 6-week old rats and after treatment with L-NAME (Fig. 6C). The contractile
in the DC (P = 0.001), but not in the AC (P = 0.791) (Fig. 6A). response was lower in old rats than in young rats (P = 0.017) (Fig.
In addition, the discrepancy between the AC and DC was statisti- 6C).
A 140
AC-longitudinal B 250
DC-longitudinal
n=5 6-week old n=5 6-week old
2-year old 2-year old
*
120 200
% Control
% Control
100 150
80 100
60 50
50 40
0 0
No Atro- Apamin L-NAME No Atro- Apamin L-NAME
treatment phentol treatment phentol
C 140
AC-circular D 140
DC-circular
n=5 6-week old n=5 6-week old
2-year old 2-year old
*
120 120
% Control
% Control
100 100
80 80 * *
60 60
50 50
0 0
No Atro- Apamin L-NAME No Atro- Apamin L-NAME
treatment phentol treatment phentol
Figure 7. Electrical field stimulation (EFS) and contractile measurement with the colonic muscle strip in the ascending colon (AC) and descend-
ing colon (DC). EFS responses in the longitudinal direction in the AC (A) and DC (B), and in the circular direction in the AC (C) and DC (D).
The response to EFS with atropine-phentolamine, apamin, and L-NG-nitroarginine methyl ester (L-NAME) were measured in the colons of
6-week old and 2-year old rats. The value before drug treatment was defined as 100% in the calculation of percent changes of EFS responses. All
values are represented as mean ± SEM (each group, n = 5). *P < 0.05 as compared to 6-week old rats.
Vol. 23, No. 4 October, 2017 (592-605) 601

Sun Min Lee, et al
After electrical stimulation at 2 Hz for 5 seconds without any completely understood to date. From the postnatal to adult periods,
drug treatment, the contractile response significantly increased in ICCs emerge and develop in a proximal-to-distal manner in human
2-year old rats in the distal longitudinal function (P = 0.033) (Fig. colons.31 Ward et al34 suggested that the density of ICCs in all histo-
7B). In the distal circular function, the EFS response significantly logic layers was highest in the AC and dissipated in the proximal-to-
decreased in older rats, with treatment of atropine-phentolamine distal direction in 20-30 day old C57BL/6 mice, according to IHC
and L-NAME (P = 0.028 with atropine-phentolamine and P = data acquired with a confocal microscope.34 In the normal human
0.011 with L-NAME) (Fig. 7D). Degree of contraction barely colon and rectum, the transverse colon has the highest density of
increased after treatment with L-NAME, as compared to after ICCs amongst all colonic regions, as analyzed with IHC.35 Albertí
treatment with apamin (Fig. 7D). The increase of longitudinal et al33 suggested that there were no major differences in the density
function in DC was also observed in every frequency (Supplementary of KIT-positive ICCs between the AC, mid-colon, and DC in rats.
Figure). The tendency was similar but there was no significant dif- However, there have been reports of normal human colons that re-
ference between the 6-week old rats and 2-year old rats in the EFS veal a larger population of KIT-positive cells in the DC than in the
response at 1, 5, 10, and 20 Hz, except for the decrease of EFS AC.36,37 The present study showed that there are more KIT-positive
response with treatment of atropine-phentolamine in 2-year old rats ICCs in the submucosal plexus of F344 rats in the DC than in the
stimulated with EFS at 20 Hz (Supplementary Figure P). AC. These discrepancies in data may have resulted from differences
in ages and species of the animals used. In the study that performed
IHC in 8-10 weeks old Sprague-Dawley rats, nNOS expression
Discussion was greatest in the mid-colon.33 However, nNOS-positive cells
The aim of this study was to compare the AC and DC of rats were not observed in the submucosal plexus, and the distribution of
regarding the distribution and age-associated changes of ICCs and nNOS on whole mount showed no significant difference between
nNOS. Since we have reported age-related changes in the AC of the AC and DC.33 On the other hand, in the present study, the
Fisher rats in a previous study,14 the present study focused on in- distribution of nNOS in the submucosal plexus was observed not
vestigating the differences of AC and DC. The results of our study to differ between the AC and DC. According to a comparison of
demonstrate the following differences between the AC and DC: (1) nNOS expression in the myenteric plexus between the AC and DC,
fat deposition rarely occurred in the DC; (2) the expression of KIT the distribution of nNOS was not significantly different at 6-weeks
in the submucosal plexus was higher in the DC than the AC and of age, which was similar to the age examined in the previous study.
the expression of nNOS in the myenteric plexus was higher in the It seems notable that there was a significant difference in distribu-
AC than the DC, and both decreased with age; and (3) the reduction at ages of 31 weeks and above (Fig. 5B).
tion of NO and its functional effect was more severe in the DC. It is controversial whether age-related dysmotility is due to a
A reduction in colonic motility was confirmed by the experi- decrease in the amount of smooth muscle cells themselves or to
ments examining the amount that the rats defecated. Number of damage to intermediate cells such as neurons and ICCs.45-48 ICCs
stools produced over 4 hours and 24 hours and fecal weight had play an important part in colonic motility: propulsion is considered
similar results, revealing a constipation-like phenotype in older rats. to be induced by ICCs in the submucosal plexus, and the ICCs in
Next, the bead expulsion test, an in vivo experiment, was used to muscle layers are thought to mediate between the nerves and the
estimate propulsion in the DC.43,44 An increase in the time necessary smooth muscle cells.49 According to a previous human study and
for bead expulsion with age indicated a decrease in colonic transit in the present study, the concentration of ICCs seems to decrease in
the DC (Fig. 1C). old age.10 In addition, the number of ICCs was found to decline in
The present study demonstrated the fat proportion using histol- the colons of humans with slow-transit constipation.50 As analyzed
ogy in the DC. A previous report on fat deposition in the AC of old with IHC in this study, the area containing KIT-positive ICCs
F344 rats suggested that fat accumulation is one of the changes that diminished in old age and the rate of decrease was greatest in the
result in the colonic dysmotility seen in old age.14 In contrast to the myenteric plexus. Therefore, it is suggested that a decrease in KIT-
AC, fat deposition markedly decreased in the DC of 74-week old positive ICCs via senescence contributes to colonic dysmotility in
and 2-year old rats. Therefore, fat deposition may not be the cause old age.
of colonic dysmotility in the DC. Several studies using human or mouse colons have reported
Regional differences of ICCs and nNOS in the colon are not changes in the enteric nervous system with age. In humans, cholin-

ergic neurons are particularly vulnerable to neuronal loss in the my- this study, the contribution of NO to motility was more prominent
enteric plexus caused by aging.24 In mice, myenteric neurons were in 6-week old rats than in 2-year old rats, in the circulatory muscles
maintained in aging DC.51 In rats, there were no losses of nitrergic of the AC and DC. The contribution of NO in the longitudinal
neurons stained with nicotinamide adenine dinucleotide phosphate muscle seems to be relatively low.
diaphorase (NADPHd) in the stomach, small intestine, or large The functional consequences of declined nNOS expression
intestine.25 However, the total population of neurons stained with on colonic transit are incompletely understood. In the case of the
Cuprolinic Blue was reduced in both the aged small intestine and colonic pseudo-obstruction in patients with intractable constipation,
large intestine.25 On the other hand, decreased staining intensity for the reduced motility could be related to nNOS depletion especially
NADPHd-positive neurons and reduced nNOS expression in the in the transition zone close to the splenic flexure.55 These findings
myenteric plexus of aged F344BNF1 hybrid rats have been report- suggest that the changes in the nNOS-positive neurons may explain
ed.27,28 In our previous study on the AC of F344 rats, we showed the impaired motility due to senescence. In the present study, EFS
that the number of nNOS-positive neuronal cells declined with age, was conducted at frequencies of 1, 2, 5, 10, and 20 Hz. With EFS
as analyzed with the nNOS/PGP 9.5 ratio and the percentage of at and above 10 Hz, neuropeptides other than acetylcholines are
nNOS-positive neuronal cells per total neuronal cells in myenteric secreted, and their functions are not different from acetylcholines.56
ganglia.14 In the present study, in the AC and DC, neuronal areas Such neuropeptides include excitatory neuropeptides such as neu-
as indicated with PGP 9.5-immunoreactive areas increased in ado- rokinin A and B, substance P, and inhibitory neuropeptides such
lescence, and decreased to the level of young rats in old age; the loss as vasoactive intestinal peptides, gastric inhibitory polypeptides,
of myenteric neurons with age was consistent with previous reports neuropeptide S, and galanin.57 The response to EFS in the present
in aged mice and rats.51,52 In addition, nNOS expression visible on result can be interpreted by the balance between the excitatory and
Western blotting decreased according to age. However, there was inhibitory responses (Fig. 7). The excitatory response was predomi-
a slight increase in 2-year old rats compared to 74-week old rats. nant over the inhibitory response in older rats, while the inhibitory
Although the nNOS-positive areas in the submucosal plexus and response was superior to the excitatory response in younger rats,
myenteric plexus were reduced in old age, as analyzed with the especially in the distal circular function (Fig. 7D). Contractility
nNOS/PGP 9.5 ratio to exclude the effect of dilution with growth, was not increased in the older rats after treatment of L-NAME as
the decrease of nNOS in the myenteric plexus was not statistically compared to the point after treatment of apamin, which suggests
significant. Despite this limitation, age-related loss of nNOS in the a reduction of the contribution of NO to the distal circular func-
DC is supported by the decrease in colonic transit, nNOS protein tion. Thus, the decrease of the contribution of NO to the inhibitory
level, NO production and the EFS response. response was observed in the circular direction in the DC (Fig. 6C
The significant age-related decrease of NO level in the DC and 7D), and was consistent with the NO level. On the other hand,
described in this study was consistent with the results of previous the increase of EFS response in the distal longitudinal muscle of
studies that showed attenuation of nNOS expression in the colonic older rats may be a compensation for functional damage to the distal
myenteric plexus of aged rats (Fig. 6A).27 These results suggest that circular muscles (Fig. 7B). These results demonstrate that insuffi-
a reduction of nNOS-positive neurons may be associated to colonic cient production of NO may have influenced dysmotility in the DC
aging in the DC. This data also supports the previous results show- of old rats.
ing that colonic relaxation decreased particularly in the DC, which In conclusion, the AC and DC may differ in their distribution
caused the colon to be feasible to be susceptible to diverticulum, of ICCs and nNOS, and an age-related loss of nitrergic neurons af-
resulting in colonic dysmotility.53 fects more severely the DC than the AC.
The maintenance of KCl response in old age may reflect con-
servation of the function of the muscle cell itself.23,54 Figure 6C
shows a comparison of contraction before and after treatment with
Supplementary Material
L-NAME in the resting state without EFS. If NO majorly con- Note: To access the supplementary figure mentioned in this
tributes to the contraction in the resting state, spontaneous contrac- article, visit the online version of Journal of Neurogastroenterol-
tion is expected to increase after blocking NO. Inhibition by L- ogy and Motility at http://www.jnmjournal.org/, and at https://doi.
NAME will be altered if the activity of excitatory components such org/10.5056/jnm17061.
as tachykinin exceeds the inhibitory activity. According to results of
Vol. 23, No. 4 October, 2017 (592-605) 603

Sun Min Lee, et al
Financial support: This work was supported by the National lective labeling and isolation of functional classes of interstitial cells of
Research Foundation of Korea (NRF) grant for the Global Core Cajal of human and murine small intestine. Am J Physiol Cell Physiol
2007;292:C497-C507.
Research Center (GCRC) funded by the Korea government
12. Tong WD, Liu BH, Zhang LY, Xiong RP, Liu P, Zhang SB. Expres-
(MSIP) (No. 2011-0030001). The funders had no role in study sion of c-kit messenger ribonucleic acid and c-kit protein in sigmoid
design, data collection and analysis, decision to publish, or prepara- colon of patients with slow transit constipation. Int J Colorectal Dis
tion of the manuscript. 2005;20:363-367.
13. Yamamoto T, Watabe K, Nakahara M, et al. Disturbed gastrointestinal
Conflicts of Interest: None. motility and decreased interstitial cells of Cajal in diabetic db/db mice. J
Gastroenterol Hepatol 2008;23:660-667.
Author contributions: Sun Min Lee organized, analyzed, and 14. Jo HJ, Kim N, Nam RH, et al. Fat deposition in the tunica muscularis
interpreted the data, and wrote the manuscript; Nayoung Kim de- and decrease of interstitial cells of Cajal and nNOS-positive neuronal
signed, and mediated the present study, and supervised the manu- cells in the aged rat colon. Am J Physiol Gastrointest Liver Physiol
script; Hyun Jin Jo, Ji Hyun Park, Ryoung Hee Nam, Hye Seung 2014;306:G659-G669.
Lee, Hyun Jin Kim, and Moon Young Lee performed the experi- 15. Ordog T, Hayashi Y, Gibbons SJ. Cellular pathogenesis of diabetic gas-
troenteropathy. Minerva Gastroenterol Dietol 2009;55:315-343.
ments and interpreted the data; and Moon Young Lee, Yong Sung
16. Wu JJ, Rothman TP, Gershon MD. Development of the interstitial cell
Kim, and Dong Ho Lee advised design and supported preparing of Cajal: origin, kit dependence and neuronal and nonneuronal sources of
the manuscript including tables and the figures, and supervised the kit ligand. J Neurosci Res 2000;59:384-401.
manuscript. 17. Phillips RJ, Powley TL. Innervation of the gastrointestinal tract: patterns
of aging. Auton Neurosci 2007;136:1-19.
18. Camilleri M, Lee JS, Viramontes B, Bharucha AE, Tangalos EG. In-
sights into the pathophysiology and mechanisms of constipation, irritable
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JNM
pISSN: 2093-0879 eISSN: 2093-0887
The Effect of Deoxycholic Acid on Secretion and

Motility in the Rat and Guinea Pig Large Intestine
Nam Hee Kim,1 Jung Ho Park,1* Jae-soon Park,2 and Yeun-Ho Joung2
1
Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University College of Medicine, Seoul, Korea; and 2Department
of Electronics and Control Engineering, Hanbat National University, Daejeon, Korea
Background/Aims
Bile acid is an important luminal factor that affects gastrointestinal motility and secretion. We investigated the effect of bile acid on
secretion in the proximal and distal rat colon and coordination of bowel movements in the guinea pig colon.
Methods
The short-circuit current from the mucosal strip of the proximal and distal rat colon was compared under control conditions after
induction of secretion with deoxycholic acid (DCA) as well as after inhibition of secretion with indomethacin, 1,2-bis (o -aminophenoxy)
ethane-N ,N ,N′ ,N′ -tetra-acetic acid (an intracellular calcium chelator; BAPTA), and tetrodotoxin (TTX) using an Ussing chamber. Colonic
pressure patterns were also evaluated in the extracted guinea pig colon during resting, DCA stimulation, and inhibition by TTX using a
newly developed pressure-sensing artificial stool.
Results
The secretory response in the distal colon was proportionate to the concentration of DCA. Also, indomethacin, BAPTA, and TTX
inhibited chloride secretion in response to DCA significantly (P < 0.05). However, these changes were not detected in the proximal
colon. When we evaluated motility, we found that DCA induced an increase in luminal pressure at the proximal, middle, and distal
sensors of an artificial stool simultaneously during the non-peristaltic period (P < 0.05). In contrast, during peristalsis, DCA induced
an increase in luminal pressure at the proximal sensor and a decrease in pressure at the middle and distal sensors of the artificial stool
(P < 0.05).
Conclusions
DCA induced a clear segmental difference in electrogenic secretion. Also, DCA induced a more powerful peristaltic contraction only
during the peristaltic period.
Key Words
Colon; Deoxycholic acid; Gastrointestinal motility; Peristalsis; Secretion
Received: November 24, 2016 Revised: February 18, 2017 Accepted: March 12, 2017
is properly cited.
*Correspondence: Jung Ho Park, MD
Department of Internal Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, 29 Saemunan-ro,
Jongno-gu, Seoul 03181, Korea
Tel: +82-2-2001-2059, Fax: +82-2-2001-2485, E-mail: pjho3@hotmail.com

www.jnmjournal.org
Deoxycholic Acid in Secretion and Motility
solution (NaCl 125 mM, KCl 5.9 mM, CaCl2 2.5 mM, MgCl2
1.2 mM, NaHCO3 15.5 mM, NaH2PO4 1.2 mM, glucose 11.5
Introduction mM; pH 7.4). Then, the serosa and muscle were removed under
A high concentration of bile acids can induce watery diarrhea in light microscopy to obtain a stripped epithelium. To evaluate the se-
the human large colon. Chronic diarrhea is caused by unabsorbed cretory responses of the proximal and distal colon, colonic segments
bile acids in cases of ileal resection up to 100 cm,1 and agents that within 2-3 cm from the ileocecal valve and 4-5 cm from the anus
sequester bile acid cause a reduction in diarrhea without interfering were used, respectively.
with the metabolism of fat or bile acid.2 Several mechanisms are To evaluate peristalsis, guinea pigs were used instead of rats,
involved in the development of diarrhea secondary to unabsorbed since most experiments on intestinal peristalsis using artificial pel-
bile acids. Bile acids have a direct secretory effect on colonic en- lets and isolated colon were performed with guinea pig colon. Six
terocytes,3 and indirectly induce a secretory response by stimulating male guinea pigs (250-400 g) were used in this experiment. They
mast cells or intrinsic neural arcs.4,5 were sacrificed by CO2 inhalation overdose and exsanguination.
In addition, the introduction of bile acids into the human Then, the abdominal cavity was opened and an approximately 10
sigmoid colon and rectum stimulates colonic motility,6 and cheno- cm segment of the distal colon was removed. After removal of stools
deoxycholate significantly accelerates colon transit time in healthy inside the colon, the colonic segment was placed immediately in an
subjects.7 A failure to reabsorb bile acid was also suggested to be organ bath with Krebs solution. In our preliminary study, peristaltic
a cause of diarrhea owing to excess bile acids entering the colon.8 movement could rarely be seen in the proximal colon of guinea pigs.
Recently, bile acids have been suggested to play an important role in Therefore, the distal colon (where the proximal end of the colonic
irritable bowel syndrome with diarrhea. Idiopathic adult onset bile segment was defined as being 10 cm away from the anus) was used
acid malabsorption is not rare in irritable bowel syndrome with pre- to evaluate peristalsis.
dominant diarrhea (IBS-D),9 and increased bile acid biosynthesis is
associated with IBS-D.10,11 The role of bile acid in the development Secretion in the Proximal and Distal Colonic Mucosa
of gastrointestinal symptoms has become more important than ever. Using an Ussing Chamber
However, in previous studies, segmental heterogeneity12 has Stripped epithelium was mounted in a tissue holder with a
not been considered in bile acid induced secretion experiments, and window size of 2 mm. Because proximal and extracellular solutions
in terms of colonic motility, peristaltic movement was evaluated only were continuously perfused at a rate of 10-20 mL/min, the effects
by measuring muscular contractility, not by determining changes of various drugs could be evaluated sequentially in the same tissue.
in intracolonic pressure along a peristaltic wave.13 Therefore, in The pH was adjusted to 7.4 and the bath solution was heated with
the present study, we aim to evaluate the existence of segmental a water jacket. All experiments were performed at a temperature
heterogeneity of colonic secretion to deoxycholic acid (DCA), and of 37°C. The time between the removal of the epithelium and the
the actual influence of DCA on peristalsis using a newly-developed mounting in the Ussing chamber was about 30 minutes, during
sensor system. DCA is the most prominent secondary bile acid in which time it was maintained in a oxygenated phosphate buffered
human beings.14 solution at 4°C. The experiment was performed under open circuit
conditions and the transepithelial voltage (Vte) value, which refers to
the serum side of the epithelium, was used. The transepithelial re-
Materials and Methods sistance (Rte) was determined by the application of short (1 second)
current pulses (change [Δ] at I = 0.5 μA). The voltage deviation
Animals obtained when no tissue was present in the chamber was subtracted
Thirty-six female Sprague-Dawley rats (300-400 g) were used from the voltage deviation obtained when the chamber was present.
in the secretion study. Rats were euthanized by intravenous injec- After an equilibration period of 30 minutes, chloride secretion was
tion of sodium pentobarbital (45 mg/kg) and ketamine (15 mg/kg). evoked by treatment of DCA 0.5 mM on the luminal and baso-
All animal protocols were performed in accordance with Animal lateral sides. In the next step, to evaluate the secretory mechanism,
Experiment Guidelines of Kangbuk Samsung Hospital and ap- calcium-dependent chloride secretions were blocked by 1,2-bis(o -
proved by the Animal Care Committee. The colon was immediately aminophenoxy)ethane-N ,N ,N ′,N ′-tetra-acetic acid (BAPTA), and
removed, opened longitudinally, and washed with oxygenated Krebs cAMP and calcium-dependent chloride secretions were blocked
Vol. 23, No. 4 October, 2017 (606-615) 607

Nam Hee Kim, et al
by indomethacin, while secretion was stimulated by DCA. Lastly, A

secretion was measured after the addition of tetrodotoxin (TTX). (a) Polyamide film cleaning (f) Electroplating
Quantitative real-time polymerase chain reaction for

G protein-coupled bile acid receptor 1
(b) Titanium/Copper seed layer
G protein-coupled bile acid receptor 1 (GpBAR1) is the bile
acid receptor that is expressed in rat colonic epithelium, entero- (g) Photoresister remove
chromaffin cells, and myenteric neurons in the colon.14,16 The

polymerase chain reaction (PCR) amplification was performed
(c) Photoresister coating
in a LightCycler 480 Real-Time PCR System (Roche Applied
Science, Indianapolis, IN, USA) in 96 well plates. PCR mix
(h) Seed layer etching
contained 2 μL cDNA template, 2 μL of primer mix and 10 μL
of LC480 SYBR Green I Master Mix from the LC480 SYBR
Green I Master kit (Roche). Plate layout design was maintained (d) Ultraviolet exposure
for triplicates of the samples according to rat GpBAR1 (forward

5’-cactgcccttctctctgtcc-3’; reverse 5’-agttcaggtccagttacgc-3’) and rat
(i) Adhesive bonding
glyceraldehyde-3-phosphate dehydrogenase (GAPDH) (forward
5’-ggtgctgagtatgtcgtgga-3’; reverse 5’-gtggttcacacccatcacaa-3’),
3 wells for negative. The PCR protocol included 1 cycle of poly- (e) Photolithography
merase activation for 10 minutes at 95˚C, 45 cycles of amplification
with 10 seconds denaturation at 95˚C, 1 minute annealing at 55˚C,
and 5 seconds extension at 72˚C in each cycle and 1 cycle for melt-
ing curve analysis with 10 seconds denaturation at 95˚C, 1 minute
annealing at 60˚C and a melting step at 98˚C at 0.2˚C/sec ramp B
rate. Each sample was run in triplicate.
Proximal sensor
Peristaltic Evaluation of Guinea Pig Large Intestine
Using an Artificial Stool with Serial Capacitive
Distal sensor
Sensors
Development of a pressure-sensing artificial stool

To mimic real guinea pig excrement, we designed an artificial
pellet (4 × 9 mm in size and the surface area of the proximal and
distal segments was 4.7 mm2, while that of the middle segment was Middle sensor
5.05 mm2) and attached it to the packaged sensor. The artificial pel-
let was made of polylactic acid and formed by 3-dimensional print- Figure 1. Fabrication sequence for the sensor and schematic of
pressure-sensing artificial stool. (A) [a] Polyamide was chosen for the
ing (Fig. 1A). The proposed pressure sensor was designed with substrate with consideration of microfabrication and biocompatibility.
careful consideration of the structure and motility mechanism of the [b] The surface was covered by titanium/copper (Ti/Cu, 20/300 nm)
films by sputtering for seed layer in the electroplating process. The
guinea pig large intestine. Three pressure sensors were mounted, electrode for capacitor sensors was then shaped by photolithography
one each on the proximal, middle, and distal portions of the artificial and formed by Cu electroplating as shown in [c] and [e]. Then, the
pellet, in order to provide some redundancy in the size and shape unnecessary photoresister and seed layer was removed by a solvent and
a metal etchant ([f] to [h]). Those electrode formation processes were
of the artificial guinea pig feces. The capacitance of a prototype done on the bottom and upper substrates. [i] To achieve hermeticity
sensor was recorded as 2.5-3.0 pF. This capacitance value was later of the pressure sensors, the bottom and upper substrates were directly
bonded by the assistance of an adhesive film (OCA film; Shin-Chang,
converted to a count value using a lab-fabricated data conversion Dongducheon, Korea). (B) Location of proximal, middle, and distal
system. The sensitivity of the pressure sensor was recorded as below sensors on the ovoid shaped artificial stool.

1 mmHg per atmospheric pressure (Fig. 1B). Finally, tests for the
reproducibility and accuracy of measurements were done using an
evaluation system (High precision pressure regulator CPC3000; Results
Mensor San Marcos, Texas, USA), vacuum chamber, network
analyzer (HP, 8753E; Palo Alto, CA, USA), and switch module Secretory Responses of the Proximal and Distal
(PXIe-1082; National Instruments; Austin, Texas, USA). Colon to Bile Acids
In vitro experiments using pressure-sensing artificial Electrical properties following luminal and basolateral
stool addition of deoxycholic acid
After an equilibration period of 30 minutes in an organ bath, In the distal colon, the luminal addition of DCA induced an
artificial stool was inserted into the oral side of the colonic segment increase in short-circuit current (Isc ) values in a concentration-
(10 cm in length), and then 1, 10, and 100 μM DCA were added dependent manner. However, the increase in delta Isc after the addi-
to the tissue bath. Changes in intraluminal pressure and frequency tion of DCA 0.5 mM on the basolateral side was more significant
of colonic contraction were analyzed for 10-15 minutes after the as compared to the secretory responses on the luminal side (Δ Isc =
introduction of the drugs. Frequency was calculated using a Fourier 49.76 ± 43.83 and 4.62 ± 6.83 μA·cm–2 for the proximal and dis-
series (MATLAB program; MathWorks, Natick, MA, USA) and tal colon, respectively; P < 0.001, n = 8) (Fig. 2A). When DCA
is expressed in Hertz. In addition, 100 μM DCA and 1 μM TTX was added to the luminal and basolateral sides of the proximal co-
were applied to the tissue bath and motor responses were recorded. lon, no significant changes in Isc were seen (n = 8) (Fig. 2B).
The distal colon was used for the study of peristalsis since peristalsis
rarely occurs in the proximal colon. All measured values are ex- Segmental differences of secretory responses following
pressed as the change in pressure from baseline (pressure at rest). basolateral addition of deoxycholic acid
When we compared secretory responses between segments, sig-
Statistical Methods nificant differences were detected in Isc after the basolateral addition
All data are expressed as means ± standard deviations. Two- of 0.5 mM DCA between the values measured in the proximal and
tailed Student’s t tests and ANOVA tests were utilized for the distal colon (Δ Isc = 49.76 ± 43.83 and 11.45 ± 15.38 μA·cm-2
comparison of statistical differences. A P -value of < 0.05 was con- for the proximal and distal colon, respectively; P < 0.05, n = 8).
sidered to be significant.
P < 0.05
A P < 0.05
B
100 30 P > 0.05
P > 0.05
short circuit current (mA)
80
20
60
40
10
20
0 0
0.5 mM 0.5 mM 5 mM 50 mM 0.5 mM 0.5 mM 5 mM 50 mM
(basolateral) (basolateral)
DCA DCA
Figure 2. Secretory response to the luminal and basolateral addition of deoxycholic acid (DCA). (A) In the distal colon, the luminal addition of
DCA induced an increase in short-circuit current (Isc ) values in a concentration dependent manner (n = 8), and the increase in secretion after the
basolateral addition of DCA 0.5 mM was more significant than the secretory responses on the luminal side. (B) When DCA was added to the lu-
minal and basolateral side in the proximal colon, only slight increase of Isc was noted (n = 8).
Vol. 23, No. 4 October, 2017 (606-615) 609

Nam Hee Kim, et al
A P < 0.05
B
100 150
P > 0.05

80
100
60
40
50
20
0 0
in
TA
in
TA
X
M
M
TT
TT
c
c
m
m
P
P
ha
ha
BA
BA
+
+
5
5
et
et
0.
0.
m
m
+
+
CA
CA
do
do
D
D
In
In
+
+
Figure 3. Effect of pretreatment with indomethacin, 1,2-bis(o -aminophenoxy) ethane-N ,N ,N ′,N ′-tetra-acetic acid (BAPTA) and tetrodotoxin
(TTX) on secretory response of the proximal and distal colon. (A) The basolateral addition of indomethacin, BAPTA and TTX resulted in the
abolition of responses to deoxycholic acid (DCA) in the distal colon (n = 6), (B) but not in the proximal colon.
Effects of indomethacin, BAPTA, and tetrodotoxin 2.5 P > 0.05

after addition of deoxycholic acid in the proximal and
mRNA relative expression
distal colon 2.0
In the distal colon, the basolateral addition of indomethacin,

1.5
BAPTA, and TTX resulted in an abolition of responses to DCA.
This decrease in delta Isc values was found to be significant (P <
1.0
0.05 for the application of indomethacin, BAPTA, and TTX, n =
6) (Fig. 3A). However, in the proximal colon, pretreatment with
0.5
indomethacin, BAPTA, and TTX did not have an effect on the
secretory responses to DCA (P > 0.05) (Fig. 3B). 0.0
Proximal colon Distal colon
Quantitative real-time polymerase chain reaction Figure 4. Expression levels of G protein-coupled bile acid receptor 1
analysis of G protein-coupled bile acid receptor 1 (GpBAR1) between proximal and distal colon. The distribution of
The levels of GpBAR1 expression in the proximal and distal GpBAR1 was similar in both colon segments (n = 5).
colon were determined using qRT-PCR, with the values normalized
to the corresponding GAPDH gene transcription values. The dis- the proximal or middle sensors (n = 5, P < 0.01) (Fig. 5A). The
tribution of GpBAR1 was similar in both colonic segments (Fig. 4). increase in pressure at all sensors on an artificial stool was concen-
tration-dependent (Fig. 5B). However, DCA had no effect on the
Motor Effects of Bile Acid on the Distal Colon frequency of contraction at the proximal, middle, and distal sensors
(Fig. 5C).
Changes in contractility and frequency: during peristal- However, during the peristaltic period, 1 μmol DCA caused
tic and non-peristaltic period a significant increase in pressure only at the proximal sensor of an
During the non-peristaltic period, the addition of 1 μmol DCA artificial stool (Fig. 6A), while a notable decrease in pressure at the
into the colonic lumen induced a significant increase in pressure at middle and distal sensors was detected (n = 4, P < 0.05) (Fig. 6B
the proximal, middle, and distal sensors of the artificial stool, and and 6C). There was no change in the frequency of contraction at
the pressure change at the distal sensor was greater than that at any of the sensors on the artificial stool (n = 4, P > 0.05).

A Proximal colon
C Proximal colon
Middle colon
3000 Middle colon P < 0.01 0.25
Distal colon
Distal colon P > 0.05
0.20
2000
0.15
mmHg
Hz
1000
0.10
0
100 200 300 400 500 0.05
Seconds
1000 0.00
1 10 100
DCA (mol)
B P < 0.01 P < 0.01 P < 0.01

1500 1500 2500
2000
1000 1000
mmHg
mmHg
mmHg
1500
1000
500 500
500
0 0 0
1 10 100 1 10 100 1 10 100
Proximal sensor (mol) Middle sensor (mol) Distal sensor (mol)
Figure 5. Pressure changes after the addition of deoxycholic acid (DCA) during non-peristaltic period. (A) The addition of DCA 1 µmol into the
colonic lumen induced a significant increase in pressure at all sensors of an artificial stool, and pressure change at the distal sensor was greater than
those in the proximal and middle sensors (n = 5). (B) Increase in pressure at all sensors was concentration dependent. (C) DCA had no effect on
the frequency of contraction at the proximal, middle, and distal sensors of an artificial stool.
Change in contractility with the addition of tetrodotoxin the non-peristaltic period, application of DCA induced a concen-
during 100 µmol deoxycholic acid-induced contraction tration-dependent increase in pressure at the proximal, middle and
At first, pretreatment with TTX significantly increased pres- distal parts of an artificial stool. However, when DCA was added
sure at the proximal and distal sensors of an artificial stool (n = 5, during peristalsis, pressure at the proximal part was significantly
P < 0.01) (Fig. 7). However, this change gradually disappeared increased while pressure at the distal and middle parts was notably
over time. decreased compared with control pressure. Addition of TTX did
not inhibit colonic contractility at first, but colonic contractility
tended to decrease slowly as time passed.
Discussion We also observed that the secretory response induced by baso-
In this study, we showed that DCA induced a significant secre- lateral addition of DCA was 10 to 100 times more prominent than
tory response in the distal colon, and secretion was inhibited by in- that caused by luminal addition of DCA in the distal colon; this
domethacin, BAPTA, and TTX. However, in the proximal colon, result is consistent with that of previous reports.17 Actually, efficient
DCA caused only a slight secretory response and secretion was not ileal conservation, together with rapid bacterial modification of bile
inhibited by indomethacin, BAPTA, or TTX. Furthermore, during acids entering the colon, results in the aqueous concentration of
Vol. 23, No. 4 October, 2017 (606-615) 611

Nam Hee Kim, et al
A 1000
B 0
P < 0.01
500 1000
mmHg
mmHg
0 2000
P < 0.01
500 3000
Control DCA 1 mol Control DCA 1 mol
Proximal sensor Middle sensor
C 0
1000
mmHg
2000 P < 0.01

Figure 6. Pressure changes after the addition of deoxycholic acid
(DCA) during the peristaltic period. (A) DCA 1 µmol caused a
3000 significant increase in pressure at the proximal sensor of an artificial
Control DCA 1 mol stool, and (B and C) a notable decrease of pressure at the middle and
Distal sensor distal sensors (n = 4).
A B
1500 P < 0.01 4000 P < 0.01
3000
1000
mmHg
mmHg
2000
500
1000
0 0
DCA 100 mol + TTX DCA 100 mol + TTX
Proximal sensor Distal sensor
Figure 7. Pressure changes on the distal sensors (deoxycholic acid [DCA] 100 µmol + tetrodotoxin [TTX]). At first, pretreatment of TTX signifi-
cantly increased pressure at the proximal (A) and distal sensors (B) of an artificial stool. However, this change gradually disappeared over time (n = 5).

bile acids in the colon being quite low, < 1 mM.18 The circulating This pattern of increased contractility did not accelerate propulsion
DCA pool is only about 0.66 g (1.7 mM).19 Therefore, the physi- of the artificial stool. However, during the peristaltic period, DCA
ologic concentration of luminal DCA might not have an effect on caused faster movement of an artificial stool by increasing pushing
the secretory response at all. Alternatively, if DCA could enter the strength and decreasing resistance at the distal part of the artifi-
basolateral side of the colonic epithelium, perhaps because of in- cial stool. This result was not dependent upon the way DCA was
flammation or mucosal breakage, the possibility of inducing a secre- administered (intraluminally or extraluminally). These results are
tory response would be much higher.17 partly consistent with a previous report that mucosal application of
Application of DCA induced a marked increase in Isc in the DCA stimulated ascending contraction and descending relaxation
proximal and distal colon, and the increase in Isc in the distal colon of the colonic circular muscle, thus inducing peristalsis.14 Bile acids
was greater than that in the proximal colon. This segmental het- are known to activate GpBAR1, which is expressed by enterochro-
erogeneity in the secretory responses is consistent with the results maffin cells and intrinsic primary afferent neurons, and the release
of previous reports. The distal segments of the rat colon were more of 5-hydroxytryptamine and calcitonin gene-related peptide, the
sensitive to both carbachol and forskolin than were the proximal major transmitters of the afferent limb of the peristaltic reflex.13
segments20 and similar results were reported in the human ascend- In terms of the efficacy of DCA on the peristaltic reflex, DCA
ing colon and rectum.12 In terms of secretory mechanisms, our was suggested to stimulate migrating action potential complexes
results are in line with those of previous studies; stimulation of a (MAPC) in the colon, and the increase in MAPC activity is de-
colonic mucosal cAMP system is strongly implicated in mediating pendent on intact cholinergic and alpha adrenergic neurons.24 Also,
DCA-induced colonic secretion,21 and DCA probably activates full-thickness segments of mouse colon stimulated by various Gp-
Ca2+-regulated K+ conductance and acts on non-epithelial cells BAR1 agonists induced peristalsis in mice.14 However, an increase
to activate Cl– secretion indirectly17 However, some of our results in the peristaltic reflex in previous reports was estimated by whole-
appear to contradict those of previous reports. Activation of Gp- gut transit time and defecation frequency, not by the actual number
BAR1 rapidly decreased basal chloride secretion and attenuated of peristaltic movements. Shortened whole-gut transit time does
the chloride-mediated secretory response to a cholinergic agent.16 not necessarily indicate an increased frequency of the peristaltic
This discrepancy may be due to differences in agonist action on reflex. In the present study, DCA did not increase the frequency of
GpBAR1. Ursodeoxycholic acid and lithocholic acid attenuate peristaltic movements, and instead only strengthened the propulsive
colonic epithelial secretory function22,23 In contrast, DCA activates power on the artificial stool. Considering these results, the decreased
ion channels in colonocytes and acts on non-epithelial cells to acti- transit times seen in a previous study might be caused by faster
vate chloride secretion indirectly.17 Furthermore, pretreatment with movement of an artificial stool instead of by increased frequency of
TTX changed the secretory responses to DCA, confirming that the peristaltic reflex.
the nervous system is associated with secretion induced by DCA. Luminal bile acids exert region-specific actions in the intestine.
Considering that the effects of GpBAR1 activation are independent They inhibit motility of the small intestine,25 while stimulating mo-
of the ENS,16 DCA may induce secretory responses in the colon by tility in the large intestine.26 Segmental heterogeneity also exists in-
a dual mechanism consisting of GpBAR1 activation and neuronal side the large intestine. The peristaltic reflex could be easily induced
activity. In the proximal colon, addition of basolateral DCA only only in the distal colon of the guinea pig, but not in the proximal
induced a slight increase in Isc and pretreatment with indomethacin, colon. This heterogeneity may be caused by differences in neuronal
BAPTA, or TTX did not change the electrical properties. This innervation rather than by differences in the distribution of Gp-
indicates that the proximal colon is not responsible for the secre- BAR1, because the distribution of GpBAR1 was similar in both
tory response to DCA. A similar result was found in the human colonic segments. Furthermore, rat colon was not suitable for the
proximal colon.12 However, there is also a possibility that the lack of evaluation of peristalsis, since artificial stools rarely induce the peri-
secretory response to DCA in the proximal colon might lead to low staltic reflex in the rat colon. For that reason, guinea pig colon was
sensitivity of proximal colon to the BAPTA and TTX. used in the present study. Thus, species diversity was also shown
DCA had a different effect on colonic contractility according to through our experiments.
whether peristalsis did or did not occur. During the non-peristaltic One interesting finding of this study is that DCA induced in-
period, DCA induced a significant increase in pressure at the proxi- creased contractility after pretreatment with TTX. This result was
mal, middle, and distal parts of an artificial stool simultaneously. contrary to our expectations. Possible explanations are as follows.
Vol. 23, No. 4 October, 2017 (606-615) 613

Nam Hee Kim, et al
First, rhythmic phasic contractions of the human sigmoid colon 8. Walters JR, Tasleem AM, Omer OS, Brydon WG, Dew T, le Roux
are not affected by TTX. This lack of effect of TTX demonstrated CW. A new mechanism for bile acid diarrhea: defective feedback inhibi-
the non-neuronal origin of rhythmic phasic contractions27 and an tion of bile acid biosynthesis. Clin Gastroenterol Hepatol 2009;7:1189-
1194.
unbalanced effect of TTX on excitatory and inhibitory enteric mo-
9. Wedlake L, A’Hern R, Russell D, Thomas K, Walters JR, Andreyev HJ.
tor neurons could increase colonic contractility for a short time. Systematic review: the prevalence of idiopathic bile acid malabsorption as
Actually, first-stage gastrointestinal symptoms after TTX intoxica- diagnosed by SeHCAT scanning in patients with diarrhoea-predominant
tion include nausea, vomiting, diarrhea, and abdominal pain, rather irritable bowel syndrome. Aliment Pharmacol Ther 2009;30:707-717.
than paralytic ileus. Secondly, the experiment was not long enough 10. Wong BS, Camilleri M, Carlson P, et al. Increased bile acid biosynthesis
to identify a relaxation response after pretreatment with TTX. Ow- is associated with irritable bowel syndrome with diarrhea. Clin Gastroen-
terol Hepatol 2012;10:1009-1015, e3.
ing to the viability of a resected colon, 2 hours was the maximum
11. Bajor A, Gillberg PG, Abrahamsson H. Bile acids: short and long term
experimental time. effects in the intestine. Scan J Gastroenterol 2010;45:645-664.
In conclusion, DCA induced a clear segmental difference in 12. Park JH, Rhee PL, Lee JH, et al. Segmental heterogeneity of electro-
electrogenic secretion. Also, DCA caused a general increase in genic secretions in human ascending colon and rectum. Int J Colorectal
the pressure of spontaneous colonic contractions during the non- Dis 2006;21:357-364.
peristaltic period. However, during the peristaltic period, DCA 13. Alemi F, Poole DP, Chiu J, et al. The receptor TGR5 mediates the proki-
netic actions of intestinal bile acids and is required for normal defecation
induced a more powerful peristaltic movement in the distal colon.
in mice. Gastroenterology 2013;144:145-154.
14. Keating N, Mroz MS, Scharl MM, et al. Physiological concentrations
of bile acids down-regulate agonist induced secretion in colonic epithelial
Financial support: None. cells. J Cell Mol Med 2009;13:2293-2303.
15. Barcelo A, Claustre J, Toumi F, et al. Effect of bile salts on colonic
Conflicts of interest: None. mucus secretion in isolated vascularly perfused rat colon. Dig Dis Sci
2001;46:1223-1231.
Author contributions: Nam Hee Kim: wrote the manuscript;
16. Ward JB, Mroz MS, Keely SJ. The bile acid receptor, TGR5, regulates
Jung Ho Park: planned the study; and Jae-soon Park and Yeun-
basal and cholinergic-induced secretory responses in rat colon. Neurogas-
Ho Joung: made sensors. troenterol Motil 2013;25:708-711.
17. Mauricio AC, Slawik M, Heitzmann D, et al. Deoxycholic acid
(DOC) affects the transport properties of distal colon. Pflugers Arch
References 2000;439:532-540.
18. Hofmann AF. Bile acids: the good, the bad, and the ugly. News Physiol
1. Aldini R, Roda A, Festi D, et al. Bile acid malabsorption and bile acid Sci 1999;14:24-29.
diarrhea in intestinal resection. Dig Dis Sci 1982;27:495-502. 19. Marcus SN, Heaton KW. Intestinal transit, deoxycholic acid and the cho-
2. Jacobsen O, Højgaard L, Hylander Møller E, et al. Effect of entero- lesterol saturation of bile—three inter-related factors. Gut 1986;27:550-
coated cholestyramine on bowel habit after ileal resection: a double blind 558.
crossover study. Br Med Jr (Clin Res Ed) 1985;290:1315-1318. 20. Nobles M, Diener M, Mestres P, Rummel W. Segmental heterogeneity
3. Huang X, Heyman M, Nath S, Castagna M, Desjeux J. Distinct signal- of the rat colon in the response to activators of secretion on the cAMP-,
ing mediates chloride secretion induced by tumor promoter bile-salts and the cGMP- and the Ca2+-pathway. Acta Physiol Scand. 1991;142:375-
phorbol esters in human colonic cells. Int J Oncol 1995;6:1159-1163. 386.
4. Gelbmann CM, Schteingart CD, Thompson SM, Hofmann AF, Bar- 21. Conley DR, Coyne MJ, Bonorris GG, Chung A, Schoenfield LJ. Bile
rett KE. Mast cells and histamine contribute to bile acid-stimulated secre- acid stimulation of colonic adenylate cyclase and secretion in the rabbit.
tion in the mouse colon. J Clin Invest 1995;95:2831-2839. AM J Dig Dis 1976;21:453-458.
5. Sun Y, Fihn BM, Sjövall H, Jodal M. Enteric neurones modulate the 22. Kelly OB, Mroz MS, Ward JB, et al. Ursodeoxycholic acid attenuates
colonic permeability response to luminal bile acids in rat colon in vivo. colonic epithelial secretory function. J Physiol 2013;591:2307-2318.
Gut 2004;53:362-367. 23. Ao M, Domingue JC, Khan N, et al. Lithocholic acid attenuates cAMP-
6. Kirwan WO, Smith AN, Mitchell WD, Falconer JD, Eastwood dependent Cl- secretion in human colonic epithelial T84 cells. Am J
MA. Bile acids and colonic motility in the rabbit and the human. Gut Physiol Cell Physiol 2016;310:C1010-C1023.
1975;16:894-902. 24. Shiff SJ, Soloway RD, Snape WJ Jr. Mechanism of deoxycholic acid
7. Odunsi-Shiyanbade ST, Camilleri M, McKinzie S, et al. Effects of stimulation of the rabbit colon. J Clin Invest 1982;69:985-992.
chenodeoxycholate and a bile acid sequestrant, colesevelam, on intestinal 25. Penagini R, Misiewicz JJ, Frost PG. Effect of jejunal infusion of bile
transit and bowel function. Clin Gastroenterol Hepatol 2010;8:159-165. acids on small bowel transit and fasting jejunal motility in man. Gut

1988;29:789-794. 27. Aulí M, Martínez E, Gallego D, et al. Effects of excitatory and inhibitory
26. Snape WJ Jr, Shiff S, Cohen S. Effect of deoxycholic acid on colonic mo- neurotransmission on motor patterns of human sigmoid colon in vitro. Br
tility in the rabbit. Am J Physiol 1980;238:G321-G325. J Pharmacol 2008;155:1043-1055.
Vol. 23, No. 4 October, 2017 (606-615) 615

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Letter to the Editor
A Rare Cause of Acute Colonic Pseudo-obstruction:

Ogilvie’s Syndrome Caused by Herpes Zoster
TO THE EDITOR: Acute colonic pseudo-obstruction (ACPO, disease that could cause ACPO. She was treated with intravenous
also called Ogilvie’s syndrome) is a rare disorder characterized by fluids, oral valaciclovir, bisacodyl, and polyethylene glycol. After 3
colonic dilatation in the absence of a mechanical cause.1 Although days, she had a small bowel movement with gas passing. However,
ACPO is an important cause of morbidity and mortality, the patho- colonic dilatation was still present. Her bowel symptoms gradually
physiology is not completely understood. Predisposing factors improved after conservative management and the colonic dilatation
for ACPO are non-operative trauma, infection (pneumonia and disappeared after 10 days (Fig. 2C and 2D).
sepsis), cardiac disease (myocardial infarction and heart failure), ob- Herpes zoster mainly involves the sensory neurons. However,
stetric/gynecological abdominal/pelvic surgery, neurological disor- motor nerve involvement occurs in about 5% of cases, resulting in
ders (Parkinson’s disease, spinal cord injury, multiple sclerosis, and diaphragmatic and bladder paralysis.3 Unilateral abdominal wall
Alzheimer’s disease), orthopedic surgery, and various other medical paralysis due to motor nerve involvement by herpes has rarely been
and surgical conditions.2 reported.4 Gastrointestinal manifestations of herpes zoster such as
We recently experienced a rare case of ACPO caused by her- colonic pseudo-obstruction and gastroparesis are extremely rare.
pes zoster. A 75-year-old female was admitted for right back pain The mechanism of colonic pseudo-obstruction in herpes zoster
for 4 days. She also complained of a sudden onset of constipation is not known. However, extrinsic autonomic or motor neuron in-
with abdominal distension and discomfort. Physical examination volvement has been suggested.5 In addition, direct invasion of the
revealed erythematous vesicles involving the right L4 dermatome intestinal muscularis propria and myenteric plexus by varicella-
and marked abdominal distension without tenderness (Fig. 1). zoster virus was reported in an HIV-positive patient with Burkitt
Laboratory test results showed no overwhelming abnormalities ex- lymphoma.5 The interval between onset of the herpes zoster rash
cept sodium 132 (normal: 136-147) mEq/L, chloride 97 (normal: and bowel symptom in patients with zoster-associated ACPO is
98-110) mEq/L, and C-reactive protein 1.76 (normal: 0.0-0.3) variable. A literature review reported that rashes developed 1 day to
mg/dL. Abdominal radiography showed diffuse colonic dilatation several weeks after bowel symptom onset in 48%, 2 days to 1 month
(Fig. 2A and 2B), however abdominopelvic computed tomography before bowel symptom onset in 28%, and simultaneously in 24%.6
revealed no definite obstructive lesion in the colon. ACPO associ- Zoster is not uncommon and is generally self-limited. However,
ated with herpes zoster was diagnosed. There was no underlying it is a rare cause of ACPO, which has a high mortality rate if isch-
A B
Figure 1. Physical examination. (A) Ve-

sicular eruptions involving the right L4
dermatome and (B) marked abdominal
distension were noted.

www.jnmjournal.org
Letter to the Editor
A B
C D
Figure 2. Radiographic findings. (A, B)

Abdominal X-ray on admission shows
diffuse colonic dilatation. (C, D) Co-
lonic dilatation disappears after 10 days
of conservative management.
emia or perforation occurs. Therefore, early recognition and appro- ter pseudohernia or zoster lumbar hernia? Hernia 2014;18:145-146.
priate management of unusual gastrointestinal presentations such 5. Pui JC, Furth EE, Minda J, Montone KT. Demonstration of varicella-
zoster virus infection in the muscularis propria and myenteric plexi of the
as ACPO in patients with zoster is important to prevent potential
colon in an HIV-positive patient with herpes zoster and small bowel pseu-
serious outcomes. do-obstruction (Ogilvie’s syndrome). Am J Gastroenterol 2001;96:1627-
1630.
Jae Yoon Chung,1 Jong Seol Park,2 and Yong Sung Kim2
1
Department of Anesthesiology, Wonkwang University Sanbon Hospital, 6. Edelman DA, Antaki F, Basson MD, Salwen WA, Gruber SA, Los-
Gunpo, Gyeonggi-do, Korea; and 2 Department of Internal Medicine and anoff JE. Ogilvie syndrome and herpes zoster: case report and review of
Wonkwang Digestive Disease Research Institute, Wonkwang University the literature. J Emerg Med 2010;39:696-700.
Sanbon Hospital, Gunpo, Gyeonggi-do, Korea
1. Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo-

Financial support: This work was supported by Wonkwang Uni-
obstruction. Aliment Pharmacol Ther 2005;22:917-925.
versity 2017 (Jae Yoon Chung).
2. Vanek VW, Al-Salti M. Acute pseudo-obstruction of the colon (Ogilvie’s
Conflicts of interest: None.
syndrome). An analysis of 400 cases. Dis Colon Rectum 1986;29:203-
Author contributions: Concept: Jae Yoon Chung and Yong Sung
210. Kim; data collection and/or processing: Jae Yoon Chung and Jong
3. Jellinek EH, Tulloch WS. Herpes zoster with dysfunction of bladder and Seol Park; analysis and/or interpretation, literature search, and writ-
anus. Lancet 1976;2:1219-1222. ing: Jae Yoon Chung, Jong Seol Park, and Yong Sung Kim; and critical
4. Chernev I, Dado DN. Segmental zoster abdominal paresis/paralysis, zos- review: Yong Sung Kim.
Vol. 23, No. 4 October, 2017 (616-617) 617

JNM
pISSN: 2093-0879 eISSN: 2093-0887
Journal of Neurogastroenterology and Motility Letter to the Editor
Gastroesophageal Reflux Disease Could Progress

to Achalasia
TO THE EDITOR: We read with interest the article entitled “Is patients had smooth muscle hypertrophy and enteric ganglionitis at
Gastroesophageal Reflux Disease and Achalasia Coincident or Not” the gastroesophageal junction, and they suggested that these mor-
published in January 2017, by Jung and Park.1 The title raises a phological changes might result in various functional esophageal
very interesting question, however, in the end, the question remains diseases. Based on these findings we assume that in certain cases
unanswered and the paper mostly focuses on the overlapping symp- GERD may progress to achalasia.
toms between gastroesophageal reflux disease (GERD) and acha-
lasia, thus leading to diagnostic delay in many achlasia patients. The Laura Bognar, Andras Vereczkei, and Ors Peter Horvath
arguments for and against whether the coexistence of the 2 diseases Department of Surgery, University of Pécs, Hungary
is accidental or not, are poorly supported. We have previously put 1. Jung DH, Park H. Is gastroesophageal reflux disease and achalasia coin-
the question to ourselves as well, and based on our own experience cident or not? J Neurogastroenterol Motil 2017;23:5-8.
and thorough review of the literature, we believe that the develop- 2. Király A, Illés A, Undi S, Varga G, Kalmár K, Horváth PO. Gas-
ment of achalasia in certain GERD patients is not a coincidence, troesophageal reflux disease progressing to achalasia. Dis Esophagus
but that there may be a cause-and-effect relationship between the 2 2005;18:355-358.
diseases.2 Our surgical work team have operated on over 40 patients 3. Bognar L, Horvath OP, Jancso G, Vereczkei A. GERD: a debated
background of achalasia. J Gastrointest Dig Syst 2016;6:432.
with achalasia in the past 15 years and in 10% of them, the etiologi-
4. Dua K, Surapaneni SN, Kuribayashi S, Hafeezullah M, Shaker R. Pro-
cal role of reflux arose.3 Similar to the fact that the human body tective role of aerodigestive reflexes against aspiration: study on subjects
has developed several aero-digestive reflexes to protect the airways with impaired and preserved reflexes. Gastroenterology 2011;140:1927-
from aspiration,4 we suggest that chronic acid exposure may lead to 1933.
structural and functional changes in the esophagus, as, for example, 5. Guo JP, Gilman PB, Thomas RM, Fisher RS, Parkman HP. Barrett’s
to the development of achalasia. By this means, the narrowing of the esophagus and achalasia. J Clin Gastroenterol 2002;34:439-443.
distal lumen of the esophagus could be interpreted as another kind 6. Cantù P, Savojardo D, Baldoli D, Bonavina L, Penagini R. Barrett’s
esophagus in untreated achalasia: ‘guess who’s coming to dinner’ first.
of protective mechanism of the body aiming at preventing the re-
Dis Esophagus 2008;21:473.
fluxate entering the esophagus or beyond. A convincing argument 7. Kotidis KN, Rogers ML, Knowles KR, Beggs FD. Coexisting acha-
for the chronological order, and presumably, the casual relation- lasia and paraoesophageal hiatal hernia. Eur J Cardiothorac Surg
ship between reflux and achalasia is that several reports have been 2002;21:130-132.
published describing the presence of Barrett’s esophagus among 8. Altorjay A, Szilagyi A, Arato G, et al. Morphological changes in the
untreated achalasia patients.5,6 The most plausible explanation for lower esophageal sphincter influencing the result of antireflux surgical
interventions in chronic gastroesophageal reflux disease. Hepatogastroen-
this is that these patients had long-standing reflux disease before the
terology 2006;53:342-347.
development of achalasia. Also, several cases have been described 9. Altorjay A, Juhasz A, Kellner V, Sohar G, Fekete M. Metabolic changes
where achalasia occured with concomitant hiatal hernia7 and it is in the lower esophageal sphincter influencing the result of anti-reflux
well-known that hiatal hernia induces the development of GERD. surgical interventions in chronic gastroesophageal reflux disease. World J
Among our own untreated achalasia cases we also had one patient Gastroenterol 2005;11:1623-1628.
with concomitant Barrett’s esophagus and one with hiatal hernia.
Altorjay et al8,9 reported an interesting observation after compar-
ing muscle samples taken from the lower esophageal sphincter of Conflicts of interest: None.
reflux patients and those of a control group. They found that reflux

www.jnmjournal.org
JNM Journal of Neurogastroenterology and Motility
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lication of the Journal and related papers (original articles, duplicate publication allegations for published papers and
review articles, and others). brings the results to the Executive Committee of KSNM.
Article 5 (Administration of Research Ethics Violation)

1. When research ethics violations occur, the chair of the fied time or exclude the violator permanently.
Council should call a meeting immediately to review the 4. The Council keeps a record of the investigation and the re-
situation, and report the results to the executive committee. sults of ethical misconduct.
2. The Council should keep any investigation of ethics viola- 5. If the Council confirms ethical misconduct in a paper, the
tions confidential, and should not oppose the interests of the executive committee announces the case and disapproves
Journal. the publication of the paper in the Journal. If the paper is
3. Upon completion of the investigation, the Council decides already published in the Journal, the paper will be deleted
the level of punishment appropriate for the violator (author from the paper list of the Journal and this will be announced
or corresponding author) based on the level of violation - the to the members of the Journal, as well as to related academic
Council can prohibit publication to the Journal for a speci- institutions.
Article 6
Any other cases that are not indicated in this regulation should to Biomedical Journals: Writing and Editing for Biomedical
follow the Uniform Requirements for Manuscripts Submitted Publication (http://www.icmje.org).
Abbreviation, Acronyms and Short Names

Journal of Neurogastroenterology and Motility provides a list of the official abbreviations. Otherwise, any unofficial abbreviation
should be used where they appear in the text at least three times, and be explained in parentheses at the first time in the text.
Do not use abbreviation(s) in the title.
ACTH adrenocorticotropic hormone HCV hepatitis C virus

(adrenocorticotropin) HDV hepatitis D (delta) virus
ADP adenosine diphosphate H&E hematoxylin and eosin
ADPase adenosine diphosphatase HIV human immunodeficiency virus
ALT alanine aminotransferase HLA histocompatibility leukocyte antigen
AMP adenosine monophosphate Ig immunoglobulin
anti-HAV antibody to hepatitis A virus IL interleukin
anti-HBc antibody to hepatitis B core antigen IFN interferon
anti-HBe antibody to hepatitis B e antigen Km Michaelis constant
anti-HBs antibody to hepatitis B surface antigen MHC major histocompatibility complex
anti-HDV antibody to hepatitis D (delta) virus MRI magnetic resonance imaging
AST aspartate aminotransferase mRNA messenger RNA
ATP adenosine triphosphate NANB non-A, non-B (hepatitis)
ATPase adenosine triphosphatase NSAID nonsteroidal anti-inflammatory drug
BUN blood urea nitrogen PG prostaglandin
cAMP adenosine 3’,5’-cyclic monophosphate PGI prostacyclin
cDNA complementary DNA PNS peripheral nervous system
cGMP guanosine 3’,5’-cyclic monophosphate RNA ribonucleic acid
CNS central nervous system TGF transforming growth factor
CT computed tomography TNF tumor necrosis factor
DNA deoxyribonucleic acid (deoxyribonucleate) TXA2 thromboxane A2
EDTA ethylenediaminetetraacetic acid UDCA ursodeoxycholic acid
HAV hepatitis A virus VIP vasoactive intestinal polypeptide
HBcAg hepatitis B core antigen vol volume
HBeAg hepatitis B e antigen vs versus
HBsAg hepatitis B surface antigen wt weight
HBV hepatitis B virus
Measurements and Units of Measure

Combining Prefixes cal calorie(s)
T tera- (1012) CFU colony-forming unit(s)
G giga- (109) C coulomb(s)
M mega- (106) cpm counts per minute
k kilo- (103) cps counts per second
h hecto- (102) cm3 cubic centimeter(s) (not cc)
da deca- (101) Ci Curie(s)
d deci- (10-1) cycle/min cycles per minute
c centi- (10-2) cycle/sec cycles per second
m milli- (10-3) Da dalton(s)
m micro- (10-6) day(s) day(s) (do not abbreviate)
n nano- (10-9) dL deciliter
p pico- (10-12) oC degree(s) Celsius
f femto- (10-15) d density
a atto- (10-18) dpm disintegrations per minute
dps disintegrations per second
Units eV electron volt(s)
A ampere(s) Eq equivalent(s)
Å angstrom(s) oF degree(s) Fahrenheit
F farad Ω ohm(s)
ft foot osm osmole(s)
G gauss oz ounces(s)
g gram(s) Pa pascal(s)
t1/2 half-life lb pound(s)
H henry(ies) psi pound-force per square inch
Hz hertz rpm revolutions per minute
hr hour(s) rps revolutions per second
in inch(es) sec second(s)
IU international unit(s) U unit(s)
J joule(s) V volts(s)
K kelvin W watt(s)
kcal kilocalorie(s) wk week(s)
kDa kilodalton(s) yr year(s)
kg kilogram(s)
L liter(s) Statistical Terms
× magnification ANOVA analysis of variance
m meter(s) CI confidence interval
mg microgram(s) r correlation coefficient
mL microliter(s) df degrees of freedom
mm micrometers (do not use microns) x̄ mean
msec microsecond(s) NS not significant
mL milliliter(s) n number of observations
mmHg millimeter(s) of mercury OR odds ratio
min minute(s) p probability
mo month(s) SD standard deviation
mol/L molar SE standard error
mol mole(s) SEM standard error of the mean
msec millisecond(s) F variance ratio
General Information
Drug names. Please use generic names wherever possible. If a trade name drug was used in the study being reported, please cite
the trade name in parentheses, along with the manufacturer’s name and location.
Chemical names. Chemical names should be spelled and styled according to the Merck Index, 10th edition.
Manufacturers. When the use of specific scientific equipment or other products is cited in the manuscript, the manufacturer’s full
name, city, and state (or country) should be given in parentheses immediately after the citation. If other equipment or products from
the same manufacturer are cited later in the paper, the manufacturer’s name only should be given in parentheses.
Instructions to Authors
Journal of Neurogastroenterology and Motility is a joint official make formal changes to ensure compliance with this journal.
journal of the Korean Society of Neurogastroenterology and
Manuscripts should be submitted via online through website
Motility, the Thai Neurogastroenterology and Motility Soci-
(http://www.jnmjournal.org). Authors can also find the Copy-
ety, the Japanese Society of Neurogastroenterology and Motil-
right Assignment Form and Author’s Checklist at website.
ity, the Indian Motility and Functional Disease Association,
The Journal follows the Uniform Requirements for Manu-
the Chinese Society of Gastrointestinal Motility, the South
scripts Submitted to Biomedical Journals: Writing and Editing
East Asia Gastro-Neuro Motility Association, the Taiwan
for Biomedical Publication (http://www.icmje.org/) and Good
Neurogastroenterology and Motility Society and the Asian
Publication Practice Guidelines for Medical Journals (http://
Neurogastroenterology and Motility Association. The Journal
kamje.or.kr/data/guidelines.pdf). Authors are recommended
publishes Editorials, Reviews, Technique Review, Original
to consult the Medical Terminology Book (http://term.kma.
Articles, and Letters to the Editor in the field of neurogastro-
org/). So far there is no article processing charge. However,
enterology and motility. Submissions are accepted only on the
this policy could be changed in the future.
understanding that they have not been submitted elsewhere
and have not been and will not be published elsewhere. All The Editorial Office
submitted papers are peer-reviewed before it is decided wheth- Journal of Neurogastroenterology and Motility, Room 305,
er they could be accepted, rejected, or returned for revision. Lotte Gold Rose Vill II, 31 Seolleung-ro 86-gil, Gangnam-gu,
The Journal reserves the right to edit the language of papers Seoul 06193, Korea
accepted for publication for clarity and correctness, and to
Research Ethics Regulations

1. Researchers should be honest about their research. Resear (1) Researchers should fully explain the purpose and
chers need to have a high ethical standard at all times during methods of research as well as any possible mental and
the research, in areas such as receiving funds for research, physical harm that could occur during research par-
publishing research results, and fairly compensating participation. If he/she is to publish the research results,
ticipants. More specifically, research papers that are forged, he/she has to indicate that on the paper.
altered, plagiarized, overlapped, and/or dishonest cannot be (2) Researchers cannot write down participants’ names or
published either online or in journals and are not eligible for initials. In case of possible disclosure of participants’
research funds. identification through pictures of face or anything
1) Forgery, Alteration, Plagiarism similar, researchers should receive written informed
(1) Forgery: making up data or research results that do consent from the participants or their guardians.
not exist. (3) Researchers should receive an approval from Institu-
(2) Alteration: fabricating research materials, equipment, tional Review Board and indicate it on the paper if one
or processes, or changing/deleting research results wishes to publish the research results.
intentionally to distort research contents or results. (4) Any research that deals with clinical trials should be
(3) Plagiarism: using others’ ideas, research (process and registered to the primary national clinical trial regis-
contents), and/or results without proper authorization tration site such as http://ncrc.cdc.go.kr/cris, or other
or citation. sites accredited by the WHO or the International
2) Overlap Publication and Dishonest Research Committee of Medical Journal Editors.
(1) Publishing research papers that contain the same or 3. If a research object is animal, researchers should follow these
similar contents to that which were/are published in general rules:
other journals or books in the Society’s memoir, or (1) Researchers should indicate what he/she did to mini-
publishing research papers that are/were published in mize the pain or discomfort that experiment subjects
the Society’s memoir in other journals or books. went through.
(2) Multiple or duplicate publication can be allowed after (2) Researchers should indicate that he/she did not violate
a review from the Publication Council, if it is qualified NIH guideline (NIH Guide for the Care and Use of
under the Uniform Requirements for Manuscripts Sub- Laboratory Animals).
mitted to Biomedical Journals (http://www.icmje.org). (3) When necessary, the Society can ask for a written con-
(3) Wrongful Research Paper Author Indication: either sent and an approval letter issued by Animal Ethics
refusing to grant a qualification to publish (without Committee.
proper reasons) to a person who contributed to science 4. Conflicts of interest or financial support should be indicated
and/or technology with his/her research contents or on the paper.
results, or granting qualification to publish to a person 5. Corrections of Errors
who did not contribute to science and/or technology The Journal will publish corrections when errors could
because of a wish to express appreciation or honor. affect the interpretation of data or information. When the
2. If a research object is human, researchers should follow the error is made by the author, the term “Corrigendum” will
Declaration of Helsinki (http://www.wma.net). Details are be used; when the error is made by the Publisher, the term
as follows: “Erratum” will be used.
JNM
Submission Checklists
COVER LETTER more than 6 figures or tables with 100 or less references.
The corresponding author must give written assurance that 4) Technique Reviews: It highlights a practical approach
neither the submitted material nor its portions thereof have to perform and interpret tests, both current and advanced,
been published previously or are under consideration for pub- in the area of neurogastroenterology and motility. It can
lication by this or other journals. be a review or mini-review.
5) Original Articles: ① Abstract, ② a list of key words
AUTHORSHIP
(5 or less) using MeSH terms from Index Medicus, ③
All authors must have made a significant intellectual contribu-
Introduction, ④ Materials and Methods, ⑤ Results, ⑥
tion to the manuscript according to the criteria formulated by
Discussion, ⑦ Acknowledgements, ⑧ References, ⑨
the International Committee of Medical Journal Editors. Each
Tables (each table completed with title and footnotes), ⑩
author should have participated sufficiently in the work to take
Figure legends.
public responsibility for the content. Authorship credits should
6) Letters to the Editor: A letter containing comment(s)
be based only on substantial contributions to: (a) conception
on an article in the Journal must be submitted within 6
and design, or analysis and interpretation of data; (b) drafting
months of its publication, should not exceed 400 words,
the article or revising it critically for important intellectual con-
must cite the subject article as a reference and should
tent; and (c) final approval of the version to be published.
include no more than 10 references. The letter will be
Participation solely in the acquisition of funds or the collec-
sent to the corresponding author of the article for a re-
tion of data does not justify authorship. General supervision
sponse. The author’s reply to the posed letter also follows
of the research group is not sufficient for authorship. The role
the same format. If a letter contains a brief case report, it
played by each author should be described on the cover page
should contain no more than 600 words, 2 figures and 10
(eg, in planning and/or conducting the study, collecting and/
or less references. The Editorial Board has the right to
or interpreting data, and/or drafting the manuscript). The cor-
accept or reject any letter and may edit the accepted letters
responding author is responsible for all aspects of the manu-
as long as the writers’ views are not misrepresented.
script.
PREPARATION OF THE MANUSCRIPT Title page
Submissions should be uploaded as Word or rich text format The title page should contain the title of the paper, the full
(rtf) documents. The entire article (including tables) should be names of the authors, the addresses of the institutions at
supplied as a single file; only the electronic figures should be which the work was carried out together, and the full postal
supplied as separate files. The manuscript must be written with address, e-mail address, facsimile, and telephone number
double-line spacing and 3 cm margins on A4 sized format of the corresponding author.
consecutively, beginning from the title page. Please include line The title should be short and informative. A running title
numbers in your MS word manuscript to help reviewers refer (not to exceed 45 characters and spaces) should be added
to specific lines of the paper when they make their comments. if the complete title exceeds 12 words.
All measurements should be in metric units.
Abstract
Manuscripts should be in the following order: Abstract should be described continuously under subhead-
1) Editorials: Editorials will be paired with the most impor- ings of Background/Aims, Methods, Results, and Con-
tant articles of each issue and will be solicited at the pro- clusions within 250 words or less. The abstract should not
visional acceptance of an article. They should not exceed contain abbreviations or references.
1000 words excluding references and not be divided into Five, or at least three, key words should be supplied below
sections and limited to 20 references and 2 or less tables/ the abstract and should be taken from those recommended
figures. by the Index Medicus (MeSH) browser list (http://www.
2) Reviews and Meta-analyses: Reviews and meta- nlm.nih. gov/mesh/meshhome.html).
analyses should contain an abstract of not more than 250
words. Manuscript length must not exceed 6000 words Text
excluding references, figure legends or tables. The reviews 1) Original Articles
and meta-analyses should contain at least 2 and not more All original manuscripts should be divided into Abstract,
than 8 figures or tables with 150 or less references. If the Introduction, Materials and Methods, Results, Discus-
length and number of references exceed the limit allowed, sion, Acknowledgments and References.
then consent from the Editor-in-Chief is required. (1) Introduction
3) Mini-Reviews: Mini-reviews should contain an abstract The rationale for the study should be summarized and
of not more than 250 words. Manuscript length must not pertinent background material should be outlined.
exceed 4000 words excluding references, figure legends or The introduction should not contain either results or
tables. The mini-reviews should contain at least 2 and not conclusions.
JNM
(2) Materials and Methods first identification of the table or figure in the text.
Materials and Methods should be described in suffi- In the reference list, the references should be numbered
cient detail so that another investigator could repeat the and listed in order of appearance in the text. List all au-
work. The location of a manufacturer (manufacture thors if the number of authors is less than 7. List first 3
name, city, state, country) listed in the text should be authors followed by et al., if the number of authors is 7 or
included. Statistical methods used should be outlined. more. Names of journals should be abbreviated in the style
Ethical guidelines for human or animal study should used in Index Medicus.
be described and approval of institutional human re- Reference to unpublished data and personal communica-
search review committee or animal welfare committee tions should appear in the text only.
should be cited. Describe in detail hazardous proce-
dures or chemicals involved, including precautions References should be listed in the following forms:
observed. • Journal articles
(3) Results 1. Shim SG, Rhee JC, Rhee PL, et al. Mechanism of mo-
Results should be presented in logical sequence in the tilin action on smooth muscle of the human stomach.
text, tables and illustrations, and repetitive presentation Korean J Gastroenterol 2002;39:4-12.
of the same data in different forms should be avoided. 2. Meltzer SJ, Abnen DJ, Battifour A, Yokokota J, Cline
The results should not include material appropriate for MJ. Protooncogene abnormalities in colon cancer and ad-
the discussion. enomatous polyps. Gastroenterology 1987;92:1174-1180.
(4) Discussion • Books
Discussion considers the results in relation to any Day RA. How to write and publish a scientific paper. 3rd
hypotheses advanced in the introduction. This may ed. Phoenix: Oryx 1988:163-196.
include an evaluation of the methodology and of the • Book chapter
relationship of new information to the existing corpus Costa M, Furness JB, Llewellyn-Smith IF. Histochem-
of knowledge in that field. Data given in the results istry of the enteric nervous system. In: Johnson LR, ed.
section should not be reiterated here. Physiology of the gastrointestinal tract. Volume 1. 2nd ed.
2) Reviews and Meta-analyses New York: Raven 1987:1-40.
Substantive systematic reviews in basic and clinical topics • Abstract/supplement
of neurogastroenterology and motility will be considered Roxburgh J, Cooke RA, Deverall P, et al. Haemodynamic
for publication. They will be evaluated by peer review function of the carbomedics bileaflet prosthesis [abstract].
of the manuscript prior to consideration of publication. Br Heart J 1995;73(suppl 2):37.
An abstract must be included. Meta-analyses of genetic • Electronic citations
studies are required to follow the Human Genome Epi- Basically, websites are referenced with their URL and
demiology Network (HuGENet) guidelines, available at access date, and as much other information is given as is
http://www.cdc. gov/genomics/hugenet. available. Access date is important, as websites can be up-
3) Mini-Reviews and Technique Reviews dated and URLs change. The “date accessed” can be later
Mini-reviews are invited articles that inform the point of than the acceptance date of the paper, and it can be just the
view about basic and clinical topics of neurogastroenter- month accessed.
ology and motility in which there have been recent and • Electronic journal articles
important advances. They bring to a focus on one spe- Morse SS. Factors in the emergency of infectious diseases.
cific subject, and can be controversial, briefly discussing Emerg Infect Dis 1995 Jan-Mar;1(1). www.cdc.gov/
opposing viewpoints. Technique reviews are a review or nciod/ EID/vol 1 no 1morse.htm (accessed 5 Jun 1998).
mini-review that inform the recent knowledge and details • Online first
about functional or motility tests. Before the article has appeared in an issue
Use the citation format:
Acknowledgements Sabin MA, Ford AL, Holly JMP, Hunt LP, Crowne
The source of financial grants and other funding should EC, Shield JPH. Characterization of morbidity in a UK,
be acknowledged, including a frank declaration of the hospital based, obesity clinic. Arch Dis Child Published
authors’ industrial links and affiliations. The contribution Online First: 24 Oct 2005. doi:10.1136/adc.2005.083485.
of colleagues or institutions should also be acknowledged.
Thanks to anonymous reviewers are not allowed. Tables
Each table must be simple and typed on a separate page
References with its heading above it. Explanatory matter is placed in
The Journal style of referencing should be used. In the footnotes below the tabular matter and not included in the
text, references should be cited using superscript Arabic heading. All non-standard abbreviations are explained in
numerals in the order in which they appear. If cited only the footnotes.
in tables or figure legends, number them according to the Footnotes should be indicated by superscripts a, b and c
JNM
etc. The word “number” should be abbreviated as “n” to relevant to the conclusion of an article that is not included
express the number of samples or subjects. For example, in the printed version owing to space or format constraints.
it should be written as (n=24). Statistical measures such It is posted on the journal’s website and linked to the ar-
as SD or SE(M) should be identified. Vertical rules and ticle when the article is published, and may consist of data
horizontal rules between entries should be omitted. Each files, figures, videos or extensive tables. The printed article
table is referred in the text consecutively and numbered must be complete and self-explanatory without the supple-
according to order of citation. The tables and its legend/ mentary information. Supplementary material enhances a
footnotes should be understandable without reference to reader’s understanding of the paper but may not be essen-
the text. The order of footnotes is as follows; after it is in- tial to the reader’s understanding.
dicated by superscript a, b and c etc, then the abbreviation When submitting supplementary material, ensure that
is explained. For example, IBS, irritable bowel syndrome; you upload them using the “Supplemental File Upload.”
CNSD, chronic non-specific diarrhea. The last one is used Supplementary material should be cited in the article text
for statistics. as “Supplementary Fig. 1, Supplementary Table 1 or
Supplementary Materials and Methods etc.” A legend for
Figure legends each figure, table, video, or other data should be included
Figure legends should be typed double-spaced on a within the submitted file. All video files submitted must
separate sheet following Figure 1 or Figure 2. Symbols, be of the highest quality possible. Any editing of the video
arrows and letters indicating parts of illustrations should is the responsibility of the author(s). Acceptable video file
be explained in the legend. Each figure should be referred formats are: MPEG-1 or MPEG-2 (.mpg), Quicktime
in the text consecutively as Fig. 1 or Fig. 2 in parenthesis (.mov), Microsoft (.avi), or CompuServe GIF (.gif).
and should be numbered according to order of citation. If Maximum video length is 5 minutes, and maximum file
figure is indicated in the sentence without the parenthesis, size is 160 MB. Concise legends must accompany each
then it should be described as Figure 1. video in the text file.
Figures Photographs of patients

If a figure consisted of at least 2 sections, each figure If photographs of patients are used, they should not be
should be listed as A, B or C in the upper left corner of identifiable and should be accompanied by written permis-
each figure. The statistical difference (P-value) should sion to use them.
be expressed as three digits below zero. If direct indica-
tion is difficult to express in the figure, then *, **, *** Units of measurement
may be used. Theses asterisks should be explained in the Authors should express all measurements in conventional
figure legend. Figure format is individualized as follows: units, with Système International (SI) units given in pa-
photographic images should be submitted in TIFF, JPG rentheses throughout the text. Figures and tables should
(JPEG), PNG, and GIF format with the original high- use conventional units, with conversion factors given in
resolution. It should have a minimum width of 100 mm legends or footnotes.
and a minimum resolution of 300 dpi. Neither compres-
sion nor change of the color mode should be made. Line- Abbreviations
arts (graphs and illustrations) should be submitted in The Journal provides a list of the official abbreviations. It
native PPT (preferred) including editable figure elements, appears in the Journal and its website. Otherwise, any un-
vector files, or TIFF files (at least 300 dpi with a mini- official abbreviation should be used where they appear in
mum width of 100 mm). the text at least three times, and be explained in parenthe-
ses at the first time in the text. Do not use abbreviation(s)
Supplementary materials in the title.
Supplementary material is peer reviewed material directly
April 30, 2016
Volume 22 Number 2
Editorials
Yu Kyung Cho
485 The Clinical Implications of Overlap Between Constipation and Common Functional Gastrointestinal Disorders
Kang Nyeong Lee

Yeon-Ji Kim, Woo Chul Chung, Byung Wook Kim, Sung Soo Kim, Jin Il Kim, Na Jin Kim, Jinho Yoo, and Soo Hwan Kim
Original Articles
517 Relationship Between Salivary Pepsin Concentration and Esophageal Mucosal Integrity in Patients With Gastroesophageal
Reflux Disease
526 Intravenous Corticotropin-releasing Hormone Administration Increases Esophageal Electrical Sensitivity in Healthy
Individuals
Takahisa Yamasaki, Toshihiko Tomita, Mayu Takimoto, Takashi Kondo, Katsuyuki Tozawa, Yoshio Ohda, Tadayuki Oshima, Hirokazu Fukui, Jiro Watari,
and Hiroto Miwa
533 Severe Delayed Gastric Emptying Induces Non-acid Reflux up to Proximal Esophagus in Neurologically Impaired Patients
Shinji Ishii, Suguru Fukahori, Kimio Asagiri, Yoshiaki Tanaka, Nobuyuki Saikusa, Naoki Hashizume, Motomu Yoshida, Daisuke Masui,
Naoko Komatsuzaki, Naruki Higashidate, Saki Sakamoto, Tomohiro Kurahachi, Shiori Tsuruhisa, Hirotomo Nakahara, and Minoru Yagi
541 Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting
550 The Ability of the Eating Assessment Tool-10 to Detect Aspiration in Patients With Neurological Disorders
555 Psychiatric Co-morbidity in Patients With Irritable Bowel Syndrome at a Tertiary Care Center in Northern India
Yuman Kawoos, Zaid A Wani, Showkat A Kadla, Irfan A Shah, Arshad Hussain, M Maqbool Dar, Mushtaq A Margoob, and Kouser Sideeq
561 Prediction of Delayed Colonic Transit Using Bristol Stool Form and Stool Frequency in Eastern Constipated Patients:
A Difference From the West
569 Nationwide Multicenter Study for Overlaps of Common Functional Gastrointestinal Disorders in Korean Patients With
Vol. 23, No. 4 October 2017

Constipation
Kyung Sik Park, Sam Ryong Jee, Bong Eun Lee, Kyoung Sup Hong, Jeong Eun Shin, Soo-Young Na, Joong Goo Kwon, Suck Chei Choi,
Yong Sung Kim, Hyun Seok Lee, Tae Hee Lee, Kyeong Ok Kim, Jongkyoung Choi, Hee Seok Moon, Yeon Soo Kim, Moo In Park, Soo Jung Park,
Seon-Young Park, Sung Noh Hong, and Constipation Research Group of Korean Society of Neurogastroenterology and Motility
578 Alterations of Food-specific Serum IgG4 Titers to Common Food Antigens in Patients With Irritable Bowel Syndrome
585 Detecting the Non-physiological, Surgically Tailored Ileocolic Anastomosis Using the Wireless Motility Capsule. A Pre- and
Post-operative, Prospective, Within Subject Trial
592 Comparison of Changes in the Interstitial Cells of Cajal and Neuronal Nitric Oxide Synthase-positive Neuronal Cells With
Aging Between the Ascending and Descending Colon of F344 Rats
Sun Min Lee, Nayoung Kim, Hyun Jin Jo, Ji Hyun Park, Ryoung Hee Nam, Hye Seung Lee, Hyun Jin Kim, Moon Young Lee, Yong Sung Kim,
Pages 483-618
and Dong Ho Lee

606 The Effect of Deoxycholic Acid on Secretion and Motility in the Rat and Guinea Pig Large Intestine

2017
618 Gastroesophageal Reflux Disease Could Progress to Achalasia October Volume 23 Number 4

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April 30, 2016

Reviews and Meta-analyses

Vol. 23, No. 4 October 2017

and Dong Ho Lee

Letters to the Editor

Editorial Board Members

Statistical Editor Manuscript Editor Illustrator

Committee of Asian Neurogastroenterology and Motility Association

Board Members of the Korean Society of Neurogastroenterology and Motility

Publication Committee of the Korean Society of Neurogastroenterology and Motility

Reviews and Meta-analyses

495 Reflux Hypersensitivity: A New Functional Esophageal Disorder

504 Is Helicobacter pylori Associated Functional Dyspepsia Correlated With Dysbiosis?

526 Intravenous Corticotropin-releasing Hormone Administration Increases Esophageal Electrical

Letters to the Editor

618 Gastroesophageal Reflux Disease Could Progress to Achalasia

Can Acute Stress Cause Esophageal Hypersensitivity

ⓒ 2017 The Korean Society of Neurogastroenterology and Motility

cal distension, increased esophageal contractility, and decreased

484 Journal of Neurogastroenterology and Motility

The Clinical Implications of Overlap Between

Kang Nyeong Lee

ⓒ 2017 The Korean Society of Neurogastroenterology and Motility

486 Journal of Neurogastroenterology and Motility

Understanding the Chicago Classification:

Francisco Schlottmann,1* Fernando A Herbella,2 and Marco G Patti1

scheme for the diagnosis of esophageal motility disorders in esopha-

ⓒ 2017 The Korean Society of Neurogastroenterology and Motility

Figure 1. Normal high-resolution

Contraction vigour Peristalsis

488 Journal of Neurogastroenterology and Motility

Lower Esophageal Sphincter mmHg

Failed DCI < 100 mmHg ∙ sec ∙ cm 40

Type I Type II Type III

Vol. 23, No. 4 October, 2017 (487-494) 489

ation in a 10 seconds gap, triggered at the beginning of a swallow mmHg

during LES relaxation, and eliminates pseudo-relaxation due to 130

Intrabolus Pressure Pattern

Abnormal intrabolus pressure corresponds to regions of 70

(whole esophageal body), compartmentalized (from the contractile 40

Esophageal Motility Disorders

490 Journal of Neurogastroenterology and Motility

subtypes (Fig. 5). 190

Type I: incomplete LES relaxation, aperistalsis and absence of 160

Type II: incomplete LES relaxation, aperistalsis and panesoph-

ageal pressurization in at least 20% of swallows. 110

tions (DL < 4.5 seconds) in at least 20% of swal- 80

Esophagogastric Junction Outflow Obstruction

Hypercontractile esophagus Minor Disorders of Peristalsis

Vol. 23, No. 4 October, 2017 (487-494) 491

Esophagogastric Junction Outflow Obstruction

492 Journal of Neurogastroenterology and Motility

Vol. 23, No. 4 October, 2017 (487-494) 493

494 Journal of Neurogastroenterology and Motility

Reflux Hypersensitivity: A New Functional

Takahisa Yamasaki and Ronnie Fass*

geal mucosa on upper endoscopy. Rome II suggested that patients

Received: August 23, 2017 Revised: None Accepted: September 8, 2017

ⓒ 2017 The Korean Society of Neurogastroenterology and Motility

A Rome II B Rome III

NERD Functional heartburn NERD Functional heartburn

Normal endoscopy and biopsies

Normal acid exposure Normal acid exposure Abnormal acid exposure

Functional heartburn Reflux hypersensitivity NERD