LAUSR

The beginning of a new year and 10th volume of the United European Gastroenterology (UEG) Journal marks the end of a year with publications in scientific advances and clinical strategies for the management of gastrointestinal (GI) conditions. In 2021, the UEG and European Society for Neurogastroenterology and Motility (ESNM) consensus on functional dyspepsia (FD) and gastroparesis were published as attempts to address the lack of guidance in recognizing, diagnosing and treating these GI conditions. Following a Delphi consensus with 41 experts from 22 European countries, a total of 87 (FD) and 89 (gastroparesis) statements were voted for agreement with evaluation of the quality of evidence. The importance of the 36 (FD) and 25 (gastroparesis) statements reaching consensus (>80% agreement) is illustrated here for the definition, diagnosis and management of these conditions and in relation to other important publications of the past year. While the cardinal symptoms of FD allow subdivision into epigastric pain (epigastric pain and burning) and postprandial distress syndrome (early satiation, postprandial fullness), the latter may overlap with nausea and vomiting in gastroparesis and in the presence of delayed gastric emptying. Apart from the need of a gastroduodenoscopy for establishing a firm diagnosis of FD, endoscopy is also mandatory and useful to exclude a mechanical obstruction in gastroparesis, with a potential role for food stasis. Although dyspepsia may be managed without endoscopy in primary care patients without alarm symptoms or risk factors, the presence of H. pylori needs to assessed and eradicated if positive (Figure 1). Guidance for the C‐urea (UBT) and gastric emptying breath tests (GEBT) is also provided by the European guideline on the use of C‐breath tests from the European Association for Gastroenterology, Endoscopy and Nutrition, ESNM and European Society for Pediatric Gastroenterology Hepatology and Nutrition, among many other tests. In this Delphi consensus with 43 experts from 18 European countries, the test‐and‐treat strategy for uninvestigated dyspepsia using the UBT received a high grade of recommendation. Also, the GEBT is an established alternative to scintigraphy, which were both endorsed in the dedicated gastroparesis‐consensus. Of note, readers are provided with all practical measures for the performance and interpretation of these tests, including the monitoring of pancreatic exocrine and liver function (Figure 1). In addition, the European guideline on hydrogen (H2) and methane (CH4) breath tests was recently published by a separate working group. While their use for common abdominal symptoms (e.g., bloating, flatulence, pain, and diarrhea) is increasing, the lack of standardization among centers in different countries is hampering comparisons. Besides the need for validated symptom evaluation to establish carbohydrate intolerance, the importance of confounding factors is highlighted when testing oro‐cecal transit time and suspected small bowel bacterial overgrowth (SIBO) (Figure 1). As rapid transit with early colonic fermentation of ingested sugars results in false‐positive diagnoses, this can be minimized with concomitant scintigraphy or glucose rather than lactulose. In a French monocentric and retrospective study, rotating rather than single antibiotics (quinolone or azole) were more effective for remission of SIBO using the glucose breath test, regardless of underlying disorders (including FD in up to 20%), which may be related to the use of proton pump inhibitors (PPI). Indeed, only PPI were endorsed as an effective therapy for FD, with consensus for only two classes of prokinetics in gastroparesis. In the absence of currently approved treatments in Europe, these consensus papers identify the need for novel therapeutic approaches in FD and gastroparesis. Similar gaps have been found in the management of lower GI tract disorders, including microscopic colitis (MC) for which the UEG and European MC Group developed guidelines based on the agreement of 32 experts and researchers from 14 European countries. The consensus established the undisputed role of ileocolonoscopy as a primary diagnostic tool, including the proper biopsy performance. Importantly, experts defined the histologic criteria for incomplete MC form. However, in the monitoring process, recommendations were against the repeated histology evaluation. Finally, in the therapeutic strategy, despite the moderate level of evidence, oral budesonide was recommended as a cornerstone for the induction and maintenance treatment of both MC forms without increased risk of serious adverse events (Figure 1).