Trending Topics in Gastroenterology | GastroAGI

IBS Pharmacotherapy Safety: AMJ, March 2026

Introduction Choosing drug therapy for irritable bowel syndrome (IBS) requires balancing symptom benefit against treatment-related adverse effects. While clinicians often use the number needed to treat (NNT) to compare efficacy, the number needed to harm (NNH) offers an equally important perspective by estimating how many patients need to be treated before one stops therapy because of an adverse event. This systematic review and meta-analysis evaluated the safety of commonly used IBS medications by focusing on discontinuation due to adverse events, a pragmatic marker of tolerability. Summary This meta-analysis included 54 placebo-controlled clinical trials involving 33,538 patients and assessed IBS-C, IBS-D, and global symptom therapies. The primary outcome was NNH, derived from treatment discontinuation due to adverse events. Among IBS-C therapies, the NNH was 35 for linaclotide, 53 for lubiprostone, 59 for plecanatide, 58 for tegaserod, and 16 for tenapanor. For IBS-D therapies, the NNH was 14 for alosetron and 32 for eluxadoline, while rifaximin and ramosetron had negative, nonsignificant NNH values, meaning placebo groups had numerically higher discontinuation rates than active treatment groups. For global IBS symptom therapy, tricyclic antidepressants had an NNH of 24. Overall, tenapanor, alosetron, and tricyclics had the greatest risk of treatment discontinuation due to adverse events, whereas rifaximin appeared to be the safest pharmacotherapy studied. The most common adverse effects reflected mechanism of action: diarrhea and nausea for IBS-C drugs, constipation for IBS-D drugs, and anticholinergic or sedative effects for tricyclics. Importantly, many adverse events were transient and nonserious. This study emphasizes that IBS treatment decisions should not rely on efficacy alone. Safety, tolerability, and patient preference should be central when selecting among multiple reasonable drug options.

Global Dietary Patterns Influence Severity of IBS: CGH, March 2026

The role of habitual diet in the global epidemiology of irritable bowel syndrome (IBS) remains incompletely understood. In this large international analysis from the Rome Foundation Global Epidemiology Study, investigators evaluated whether regional dietary patterns are associated with variations in IBS prevalence and symptom severity. A total of 54,127 participants from 26 countries completed questionnaires assessing Rome IV IBS criteria and frequency of intake of 10 food groups. Using latent class analysis, researchers identified four distinct dietary pattern clusters. These clusters demonstrated significant differences in both IBS prevalence and symptom severity. Clusters A (5.6%) and B (4.5%) had the highest IBS prevalence and symptom severity, and were largely represented by countries such as Egypt, Brazil, Colombia, Argentina, Germany, Poland, and the United States. In contrast, clusters C (3.4%) and D (2.6%), predominantly from Europe and Asian countries, showed lower IBS prevalence and milder symptoms. These findings suggest that regional dietary habits may contribute to global variations in IBS burden. Understanding population-specific dietary patterns may help design culturally appropriate dietary interventions for IBS management worldwide.

Mucus Brushing and SIBO: Frontline Gastroenterology, March 2026

Introduction Upper small intestinal bacterial overgrowth (USIBO) is characterised by excessive bacterial colonisation in the duodenum or proximal jejunum, often leading to symptoms such as bloating, abdominal distension, and dyspepsia. Diagnosing USIBO remains challenging. Current methods include breath tests (glucose or lactulose hydrogen testing) and duodenal fluid aspiration, but both have important limitations. Breath tests have variable sensitivity and specificity, while aspirate cultures can be difficult to obtain and are prone to contamination and dilution, resulting in false-positive rates of up to 20%. These challenges have prompted exploration of alternative diagnostic techniques. Summary This study revisits the duodenal mucus brushing technique, an older but largely overlooked method for detecting bacterial overgrowth. During endoscopy, a cytology brush is used to collect mucus directly from the duodenal or proximal jejunal mucosa, targeting bacteria adherent to the mucosal surface rather than bacteria suspended in luminal fluid. In a cohort of 92 patients with suspected USIBO, bacterial growth was detected in 24% of cases using this technique. Streptococcus species were the most commonly identified organisms, followed by coliform bacteria. Importantly, contamination testing demonstrated a false-positive rate of only 8%, significantly lower than that reported with traditional duodenal aspiration. The authors propose that bacteria involved in USIBO preferentially adhere to the mucosal mucus layer, making mucus sampling a more accurate diagnostic source. The brushing technique is simple, reproducible, and can be performed during routine endoscopy, potentially improving the detection of small intestinal bacterial overgrowth in patients lacking duodenal fluid samples.

Defecography Metrics in Chronic Constipation: Gastroenterology | March 2026

Introduction Chronic constipation is frequently evaluated using physiologic testing such as fluoroscopic defecography and high-resolution anorectal manometry to identify pelvic floor dysfunction and evacuation disorders. A recent study combined these techniques to define a synchronous “proctomanometric” signature of constipation. However, concerns have been raised about the methodological assumptions used to classify evacuation patterns. Accurate definitions and patient phenotyping are crucial because diagnostic thresholds and analytic models can strongly influence the interpretation of anorectal physiology and the clinical diagnosis of pelvic floor dyssynergia. Summary The correspondence highlights three methodological issues. First, the study defined “successful evacuation” as expelling ≥25% of rectal barium within three attempts lasting ≤17 seconds, a threshold that may be overly restrictive and physiologically unrealistic. Prior studies demonstrate that even healthy individuals may take >30 seconds to evacuate similar volumes, suggesting that strict time limits could generate false-positive diagnoses of impaired evacuation. Second, the study combined functional constipation (FC) and constipation-predominant IBS (IBS-C) using older Rome III criteria, despite Rome IV guidelines recognizing important pathophysiologic differences between these conditions. Pooling them may confound interpretation of anorectal pressure patterns. Third, the study applied machine-learning models with many predictors but limited sample size, raising concerns about overfitting and lack of reproducibility. The author proposes more physiologic evacuation metrics, Rome IV–based patient stratification, and more robust statistical validation to improve translation of these findings into clinical practice.

Colonoscopy is the Best for CRC Screening: Gastroenterology | March 26

Introduction Colonoscopy has become the dominant colorectal cancer (CRC) screening test in the United States, credited with major reductions in CRC incidence and mortality through detection and polypectomy. Yet CRC screening uptake targets remain unmet, alternative tests (especially FIT) have strong evidence, and health systems are increasingly shifting from opportunistic to programmatic screening—raising an uncomfortable but necessary question: should colonoscopy still be promoted as “the best” screening choice? Summary This commentary argues that while colonoscopy is the most comprehensive colorectal examination and the “final common pathway” for all screening strategies, it cannot be automatically crowned the best population-wide screening test. The authors highlight that real-world effectiveness is not only about test efficacy, but also about participation, feasibility, adherence over time, and colonoscopy quality (which is operator dependent). In many countries, organised screening programs favour FIT because it is inexpensive, noninvasive, scalable, and can achieve high participation, with colonoscopy reserved for positive tests. The authors emphasise that programmatic stool-based screening—when repeated and paired with reliable follow-up colonoscopy—can deliver prevention benefits comparable to colonoscopy-based strategies. They point to recent randomised evidence, including COLONPREV, showing that invitations to FIT can achieve CRC incidence and mortality outcomes comparable to invitations to colonoscopy, while requiring fewer colonoscopies due to higher participation and triage. The piece also addresses the financial realities in US gastroenterology and the potential conflict of interest when colonoscopy is preferentially promoted. The conclusion is clear: gastroenterologists should champion CRC screening broadly, simplify choices where needed (often to colonoscopy vs stool-based testing), and align messaging with population-level effectiveness rather than defending colonoscopy as universally “best.”

SAPP Defines “Gut Health”: Nature Reviews Gastro & Hepatol | Feb. 2026

“Gut health” is widely used by clinicians, researchers, industry, and the public—but until now lacked a unified, clinically usable definition. This ISAPP consensus statement convened an interdisciplinary expert panel to clarify what “gut health” should mean and how it should be measured, particularly in the context of diet, fermented foods, probiotics, prebiotics, and microbiome research. The panel proposes a pragmatic definition: gut health is “a state of normal gastrointestinal function without active gastrointestinal disease and gut-related symptoms that affect quality of life.” Crucially, the definition is not limited to absence of diagnosis: a patient with IBD or coeliac disease may still have gut health during remission. Equally, poor gut health can exist without obvious symptoms or without measurable abnormalities—highlighting the gap between patient experience and current objective testing. The statement emphasizes that gut health is multidimensional, spanning functional physiology (motility, secretion, absorption), microbiome-related functions, barrier integrity, immune homeostasis, gut endocrine function, and the gut–brain axis. The authors also review clinically accessible metrics and caution that many emerging “gut health tests” lack validated normal ranges or correlate poorly with meaningful outcomes. This consensus provides a needed foundation for consistent clinical communication and for designing dietary/biotic intervention trials with clearer endpoints and more defensible claims. 20 Key Takeaways Gut health needed a standard definition—the term has been used inconsistently across science, medicine, and marketing. ISAPP defines gut health as normal GI function without active GI disease and symptoms that impair quality of life. Disease diagnosis ≠ absence of gut health: remission states (e.g., IBD in remission) can meet gut health criteria. Conversely, poor gut health can exist without symptoms (subclinical dysfunction) or without measurable abnormalities. The framework integrates subjective experience + objective function—both matter. The concept applies to the entire GI tract, from mouth to anus. “Gut health” is considered broadly synonymous with gastrointestinal health, and includes digestive health. Transient symptoms from normal physiology (stress diarrhea, travel constipation) should be distinguished from persistent QOL-impacting symptoms. Quality of life impact is central—symptoms become “clinically important” when they are bothersome and impair daily living. The statement organizes gut health into six functional domains: digestion/physiology, microbiome, barrier, immunity, endocrine, gut–brain axis. Many objective measures (e.g., permeability tests, microbiome indices) lack validated normal ranges and have variable reproducibility. Microbiome testing currently cannot define an individual’s gut health reliably in clinical practice. “Dysbiosis” is a problematic term—microbiome patterns vary widely by geography, age, and context. Barrier function (“leaky gut”) is often overinterpreted; all guts are selectively permeable, and many claims exceed evidence. Stool tools like Bristol stool form scale and symptom frequency/duration remain highly practical clinical metrics. Inflammation assessment is best supported by histology when needed; noninvasive markers (CRP, fecal calprotectin) are helpful but not definitive. Diet is a major determinant, but responses are highly individualized; “one diet fits all” is unsupported. Research outcomes labeled “gut health” are often heterogeneous—this consensus encourages clarity about which domain is being targeted. The panel argues for development of core outcome sets to standardize gut health research and reduce reporting bias. This document is a starting point: future work must refine validated biomarkers, normal ranges, and determinants of future gut health risk.

The Fiesole Consensus report

The Fiesole Consensus Report refers to an international set of guidelines and recommendations on the diagnosis, management, and prevention of diverticular disease. This consensus was developed by a group of 32 experts from 14 countries, employing a structured Delphi process that adheres to the PICO (Population, Intervention, Comparison, Outcome) framework and GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. The report is designed to standardize care and provide evidence-based guidance for clinicians dealing with this increasingly prevalent condition. ### Key Highlights of the Fiesole Consensus Report: #### 1. **Definitions and Epidemiology** - **Diverticulosis**: The presence of colonic diverticula (small pouches in the colon wall) without associated symptoms. - **Diverticular disease**: When diverticula are associated with symptoms or complications such as inflammation or infection. - Diverticulosis is the most common structural abnormality of the colon in developed countries, with an increasing prevalence worldwide. - Approximately 20–25% of individuals with diverticulosis develop symptoms that fall under diverticular disease. #### 2. **Risk Factors** - High dietary fiber intake is protective against diverticular disease. - Risk factors include: - Smoking - Obesity - Use of certain medications such as non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, opioids, and immunotherapy agents. #### 3. **Diagnosis** - Imaging is critical for diagnosing suspected acute diverticulitis. - **Ultrasound**: May be appropriate when performed by experienced clinicians. - **CT Scans**: Preferred for diagnosing complicated cases of diverticulitis. - Diverticulosis itself does not require any specific treatment or imaging unless symptoms or complications arise. #### 4. **Management of Diverticular Disease** - **Symptomatic Uncomplicated Diverticular Disease (SUDD)**: - Dietary fiber, selected probiotics, mesalazine, and rifaximin may help alleviate symptoms. - **Acute Uncomplicated Diverticulitis**: - Routine antibiotic use is *not* recommended. - **Complicated Diverticulitis**: - Imaging is essential to guide management. - **Elective Surgery**: - Should be individualized based on the patient's quality of life rather than the number of episodes of diverticulitis. #### 5. **Surgical Management** - Surgery is reserved for cases where complications arise or when symptoms significantly impair quality of life. - Decisions should prioritize the patient's preferences and overall well-being. #### 6. **Research Priorities** - The report emphasizes the need for further research into: - Microbiome characterization in diverticular disease. - Genetic risk profiling to better understand individual susceptibility. - Long-term outcomes of selective antimicrobial and surgical strategies. ### Conclusion The Fiesole Consensus Report aims to provide a comprehensive and standardized approach to the diagnosis, treatment, and prevention of diverticular disease. By integrating the latest evidence and expert opinions, the report seeks to optimize patient outcomes across diverse healthcare systems. It also identifies critical gaps in knowledge and highlights areas for future research, ensuring that the management of diverticular disease continues to evolve in alignment with emerging scientific insights.

Rome III vs Rome IV Criteria for IBS Diagnosis in Southeast Asia - J of JGH - Jan,26

The study published in the *Journal of Gastroenterology and Hepatology* (JGH) on January 26, titled "Rome III vs Rome IV Criteria for IBS Diagnosis in Southeast Asia," investigates how the adoption of the Rome IV diagnostic criteria has impacted the reported prevalence, demographic, and clinical characteristics of irritable bowel syndrome (IBS) in Southeast Asia, specifically in Malaysia and Indonesia. ### Key Findings of the Study: 1. **Prevalence Differences**: - The Rome IV criteria identified significantly fewer individuals with IBS compared to the Rome III criteria. - A substantial number of individuals previously diagnosed with IBS under Rome III were reclassified into other functional bowel disorder categories when Rome IV was applied. 2. **Demographic Shifts**: - IBS cases identified under Rome IV criteria were more likely to be younger and female, suggesting a notable shift in the demographic profile of those diagnosed. - This indicates that the Rome IV criteria may be more selective in identifying a narrower and more specific subgroup of IBS cases. 3. **Clinical and Psychological Characteristics**: - Individuals diagnosed with IBS under Rome IV experienced more severe gastrointestinal symptoms compared to those identified under Rome III. - Despite having more severe symptoms, these individuals reported lower levels of anxiety but poorer mental health-related quality of life. - This suggests that the Rome IV criteria may capture individuals with greater overall symptom burden and a more pronounced impact on quality of life. 4. **Healthcare Utilization**: - Patterns of healthcare utilization remained consistent between individuals diagnosed using the Rome III and Rome IV criteria, indicating that the shift in diagnostic criteria does not significantly affect healthcare-seeking behavior. 5. **Dietary Patterns**: - Participants diagnosed with IBS under the Rome IV criteria followed a more restricted diet, with lower intake across several major food groups. - This dietary restriction may reflect efforts to manage more severe symptoms or could be a consequence of the narrower diagnostic criteria. ### Implications: - The reduced sensitivity of the Rome IV criteria for diagnosing IBS in Southeast Asia highlights its limitations in identifying the broader spectrum of IBS cases that were previously captured under Rome III. - The Rome IV criteria appear to focus on a narrower subset of individuals with more pronounced symptoms and distinct demographic features, potentially underestimating the true prevalence of IBS in the population. - The findings underscore the importance of considering regional and cultural factors when applying global diagnostic criteria, as dietary habits, healthcare access, and symptom reporting can vary widely across populations. ### Conclusion: The transition from Rome III to Rome IV criteria has led to a significant reduction in IBS prevalence in Southeast Asia and has shifted the demographic and clinical profile of diagnosed cases. While Rome IV identifies individuals with greater symptom severity and reduced mental well-being, its lower sensitivity may overlook many individuals with milder or atypical forms of IBS. This raises questions about the appropriateness of the Rome IV criteria for diverse populations and highlights the need for region-specific adaptations or complementary diagnostic approaches in Southeast Asia.

Advances in Gut Microbiome and Metabolomics in IBD–Depression Comorbidity - J of JGH Jan,26

As of my training cutoff in October 2023, I cannot access or summarize the specific contents of the "Journal of Gastroenterology and Hepatology (JGH)" article dated January 26. However, based on the context provided, I can offer a detailed overview of advances in gut microbiome and metabolomics research related to IBD–depression comorbidity: ### Advances in Gut Microbiome and Metabolomics in IBD–Depression Comorbidity #### 1. **Microbiome Dysbiosis in IBD and Depression** - **IBD-Associated Dysbiosis**: Inflammatory bowel disease (IBD) is marked by reduced microbial diversity and depletion of beneficial taxa such as *Firmicutes* and *Faecalibacterium*. These changes exacerbate intestinal inflammation and compromise gut health. - **Depression-Associated Dysbiosis**: Depressive disorder similarly involves altered gut microbial composition, with reductions in microbial richness and beneficial bacteria such as *Bifidobacterium*. - **Shared Microbial Alterations**: IBD patients with comorbid depression exhibit more severe dysbiosis compared to those without depression. This highlights the bidirectional relationship between gut health and mental health. #### 2. **Key Microbial Metabolites and Their Roles** - **Short-Chain Fatty Acids (SCFAs)**: SCFAs like butyrate are critical for maintaining intestinal barrier integrity and regulating immune responses. Deficiencies in SCFAs are linked to worsened intestinal inflammation and depressive symptoms. - **Bile Acid Dysregulation**: Altered bile acid metabolism disrupts gut–brain communication, contributing to both mood disturbances and intestinal inflammation. - **Tryptophan Metabolism**: Enhanced tryptophan degradation in IBD affects serotonin synthesis, directly linking gut inflammation to depressive symptoms. Serotonin is a key neurotransmitter in mood regulation. #### 3. **Gut–Brain Axis as a Communication Pathway** - The microbiota–gut–brain axis integrates neural, immune, and endocrine signaling. Dysbiosis and inflammation in IBD can lead to neuroimmune crosstalk, where cytokines like TNF-α and IL-6 cross the blood–brain barrier, contributing to neuroinflammation and depressive symptoms. - Chronic stress and cytokine signaling overstimulate the hypothalamic-pituitary-adrenal (HPA) axis, increasing gut permeability and amplifying intestinal inflammation. #### 4. **Therapeutic Advances** - **Probiotics**: Strains like *Lactobacillus* and *Bifidobacterium* show promise in reducing inflammation and improving both gastrointestinal and psychological outcomes. These probiotics may help restore microbial balance and enhance SCFA production. - **Fecal Microbiota Transplantation (FMT)**: FMT is emerging as a potential therapy to alleviate intestinal inflammation and depressive symptoms by restoring microbial diversity and balance. - **Dietary Interventions**: Diets rich in fiber, such as Mediterranean-style diets, support microbial diversity, promote SCFA production, and reduce systemic inflammation. These diets may benefit both gut health and mental health in IBD patients. - **Personalized Microbiome-Based Therapies**: Advances in microbiome and metabolomics research pave the way for individualized treatments targeting specific microbial and metabolic profiles in IBD patients with comorbid depression. #### 5. **Future Directions** - **Integrative Research**: Combining microbiome, metabolomics, and neuroimmune studies will provide deeper insights into the complex interplay between gut health and mental health in IBD–depression comorbidity. - **Biomarker Development**: Identifying specific microbial and metabolic biomarkers may enable early diagnosis and targeted interventions for IBD patients at risk of depression. - **Precision Medicine**: Personalized approaches based on an individual's microbiome composition and metabolic profile could optimize treatment outcomes for both IBD and depression. If you are looking for specific findings or experimental data from the JGH article, I recommend accessing the publication directly through academic databases or institutional subscriptions.

Prevention of Acute Diverticulitis and DICA Score -Eur.J.Gastroenterol.Hepatol Jan 26

The prevention of acute diverticulitis (AD) based on the DICA (Diverticular Inflammation and Complication Assessment) score offers several key insights and takeaways for individualized management strategies. Below is a detailed summary: ### 1. **Introduction to the Problem** Acute diverticulitis (AD) is a common complication in patients with colonic diverticulosis, and its prevention remains a significant unmet clinical need. The DICA score provides an endoscopic stratification system to assess the risk of developing AD, enabling tailored interventions for patients based on their individual risk profiles. This study investigated the effectiveness of various preventive strategies, including no treatment, high-fibre diet, mesalamine, rifaximin, and a combination of mesalamine and rifaximin, in reducing the risk of AD over a 3-year period. --- ### 2. **Key Findings from the Study** #### **Overall Risk of Acute Diverticulitis** - During the 3-year follow-up, 140 cases of acute diverticulitis were documented. - The **lowest crude 3-year AD risk** was observed in the **no-treatment group (3.3%)**, followed by: - **High-fibre diet (5.9%)** - **Mesalamine alone (9.5%)** - **Rifaximin alone (11.8%)** - **Combination therapy (mesalamine + rifaximin) (17.1%)** #### **Effectiveness of Preventive Strategies** - **Mesalamine** showed a significant benefit in reducing the risk of AD compared to rifaximin and combination therapy: - Mesalamine reduced the hazard of AD by **58%** compared to rifaximin (HR 0.42; 95% CI 0.19–0.94). - Mesalamine reduced the hazard of AD by **63%** compared to combination therapy (HR 0.37; 95% CI 0.15–0.88). - **Rifaximin** was associated with a **higher hazard of AD** compared to no treatment, suggesting it lacks preventive benefits. - **Combination therapy** (mesalamine + rifaximin) showed the **highest crude incidence** of AD, indicating no synergistic benefit. #### **DICA Score-Based Stratification** - Treatment effects varied according to the DICA classification, emphasizing the importance of endoscopic risk stratification: - **DICA 2 Patients** derived the greatest benefit from mesalamine therapy. - Mesalamine reduced AD risk by **77%** compared with rifaximin (HR 0.23; 95% CI 0.08–0.62). - Mesalamine reduced AD risk by **84%** compared with combination therapy (HR 0.16; 95% CI 0.05–0.53). - In DICA 2 patients, mesalamine emerged as the most effective preventive strategy. - The benefit of mesalamine over no treatment was not clearly established across all DICA scores. --- ### 3. **Conclusion: DICA-Guided Individualized Approach** The findings support the use of a **DICA-guided individualized approach** to AD prevention rather than a uniform pharmacologic prophylaxis strategy. Key conclusions include: - Mesalamine demonstrates significant preventive benefits, particularly for patients with intermediate-risk disease (DICA 2 classification). - Rifaximin and combination therapy (mesalamine + rifaximin) are not effective and may even increase the risk of AD. - The no-treatment strategy showed the lowest crude risk of AD, raising questions about the necessity of pharmacologic interventions in certain patient groups. - Endoscopic risk stratification using the DICA score is essential for identifying patients who may benefit from targeted preventive measures, optimizing outcomes, and avoiding unnecessary treatments. In summary, **mesalamine therapy tailored to DICA 2 patients** is the most effective strategy for reducing AD risk, highlighting the importance of individualized, risk-based management approaches in clinical practice.