Strenuous exercise can be associated with “Exercise Induced Gastrointestinal Syndrome” (Ex-GIS), a clinical condition characterized by a series of gastrointestinal (GI) disturbances that may impact the physical and psychological performance of athletes. The pathophysiology comprises multi-factorial interactions between the GI tract and the circulatory, immune, enteric, and central nervous systems. There is considerable evidence for increases in the indices of intestinal damage, permeability, and endotoxemia associated with impaired gastric emptying, slowing of small intestinal transit, and malabsorption of nutrients. Heat stress and racing mode seem to exacerbate these GI disturbances. GI symptomatology that derives from strenuous exercise is similar to that of IBS and other GI functional disorders defined in the Rome IV Criteria. To manage Ex-GIS, the exercise modality, state of dehydration, environmental temperature, concomitant therapies, and self-managed diet should be evaluated, and if risk elements are present, an attempt should be made to modify them. Multiple strategies can be successively adopted to manage Ex-GIS. Nutritional and behavioral interventions appear to be the principal ones to avoid symptoms during the exercise. The aim of this review will be to explore the pathophysiology, clinical aspect, and current literature on behavioral and nutritional strategies to manage Ex-GIS, regarding a gluten-free diet and low-fermentable oligo-, di-, and mono-saccharides and polyols (FODMAP) diet.

Lactose malabsorption (LM) refers to the incomplete absorption of lactose in the small intestine, resulting in the arrival of ingested lactose in the colon, which can give rise to symptoms defined as lactose intolerance (LI). The lactose breath test (LBT), thanks to its low cost, availability, and noninvasiveness, is the most used diagnostic method. However, the LBT is a tedious tool, requiring prolonged involvement of patients, qualified staff, and infrastructure, of which the most time-consuming factor is the frequency and number of breath samples needed. Objectives: To simplify the current LBT methodology, compliant with the current guidelines’ statements, by reducing the test duration or the number of breath samples, without compromising the test’s accuracy. Methods: The results of the standard LBT were compared with two simplified tests: a “shortened” test, lasting three hours, with samples taken every 30 min; and a “five-sample” test, lasting four hours, with samples taken every hour. Patients were stratified into three grades of malabsorption (mild, moderate, severe) based on the amount of gas exhaled. A clinical severity score was introduced to assess the clinical relevance of LI using a specific questionnaire. Results: Among the 543 patients enrolled (F 71.5%, mean age 43.7 ± 17.6 yrs), 60.4% (328/543) tested positive for LM. A total of 70.5% (383/543) presented LI, with 32.1% of those being true intolerants (LI without LM). The shortened test demonstrated an accuracy of 93.9%, with a sensitivity of 89.9% and a false negative rate of 10.1% (33/328). The five-sample test showed higher accuracy and sensitivity than the shortened test (96.5% and 94.2%, respectively; p = 0.03) with a false negative rate of 5.8% (19/328). Of the 19 false negatives in the five-sample test, 95% (18/19) were categorized as mild malabsorbents. No statistical correlation was found between the clinical severity score and LBT results. Conclusions: The five-sample test, involving hourly breath measurements, is a reliable option for simplifying the LBT without significantly reducing the procedure’s sensitivity.

Achalasia is a rare esophageal motility disorder that affects both sexes and all ages. Peroral endoscopic myotomy (POEM) has been reported as an optional treatment since 2010 [1]. Frequently associated adverse events include pneumoperitoneum, pneumomediastinum, and pneumothorax, which are usually asymptomatic and managed conservatively [2] [3]. Perforation, bleeding, mediastinitis, and peritonitis rarely occur and are often symptomatic. Mucosal injuries (including dehiscence, ulcer, and ischemia) do not alter the post-procedural course [4]. A 31-year-old man, affected by idiopathic achalasia, was admitted as an outpatient to our Gastroenterological Unit owing to symptom recurrence and weight loss (Eckardt score 8). Two years before, he had undergone POEM, which was complicated by pneumomediastinum and ischemic damage of the distal esophagus with residual fibrosis. An esophagogram revealed a dilated esophagus (maximum diameter 60 mm) and supracardial stricture extending 15 mm above ([Video 1]). His dysphagia was most likely worsened by post-POEM complications. We planned to place a fully covered removable metal stent (SEMS; 60 × 27 mm) to achieve progressive, effective dilation of the distal esophagus ([Video 1]). The SEMS would be firmly fixed by means of an over-the-scope (OTS) clip. This novel OTS clip device has demonstrated success in reducing SEMS migration even in benign diseases [5]. Video 1 Placement of a self-expandable metal stent secured by an over-the-scope clip for comprehensive treatment of achalasia after failed peroral endoscopic myotomy with fibrosis complications. The SEMS was released 10 mm above the post-POEM stricture, 25 mm above the cardia, and fixed by means of the OTS clip. The patient was discharged uneventfully on the same day. An alternative approach (Heller myotomy) was ready to be employed in case of failure. At the 4-week follow-up, dysphagia had improved and the patient had gained weight. Both the OTS clip and the SEMS were removed using the remOVE device (Ovesco Endoscopy AG, Tübingen, Germany) ([Video 1]). The patient was discharged uneventfully 12 hours later. After a further 4 weeks, an esophagogram revealed a significant reduction in the esophagus dilation and the patient’s clinical condition had significantly improved (Eckardt score 0) ([Video 1]). Endoscopy_UCTN_Code_CPL_1AH_2AD Article published online: 21 October 2022 © 2022. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

Background/Objectives: Small intestinal microbial overgrowth (SIMO), including both small intestinal bacterial overgrowth (SIBO) and intestinal methanogen overgrowth (IMO), is commonly diagnosed using non-invasive breath tests, whose diagnostic performance and criteria remain inconsistent. This study aimed to assess SIMO prevalence using lactulose (LBT) and glucose breath tests (GBT), compare their diagnostic yields for SIBO and IMO, analyze associated gas profiles, clinical features, risk factors, and evaluate the diagnostic accuracy of a simplified fasting methane criterion for IMO. Methods: Cross-sectional study conducted on 564 outpatients (75.7% female) with suspected SIMO. Patients underwent LBT (n = 275), GBT (n = 289), or both (n = 47). Results: SIMO was diagnosed in 26.8% of patients. LBT identified significantly more SIMO than GBT (37.5% vs. 16.6%, p < 0.01), particularly for SIBO (24.4% vs. 4.8%, p < 0.01), while IMO detection was comparable (9.8% vs. 10.7%). Mixed overgrowth (dual SIBO/IMO positivity) showed a borderline trend favoring LBT. Methane peaks occurred significantly earlier than hydrogen in both BTs. Clinical symptoms did not significantly differ between SIMO subtypes or between test-positive and test-negative groups. The simplified fasting methane criterion showed limited diagnostic accuracy for IMO making it inadequate as a standalone diagnostic tool, requiring further validation before clinical implementation. Conclusions: GBT is the more reliable test for SIMO diagnosis due to LBT’s lower specificity. Clinical symptoms alone were not predictive of SIMO subtypes, while the different gas profile suggests a distinct spatial distribution of microbial populations with a higher proximal concentration of methanogenic Archaea.

Introduction and aims: Esophageal achalasia (EA) is a rare motility disorder. Symptoms often impair quality of life (QoL) and lead to restrictive, self-managed diets with potential nutritional deficiencies. The study aimed to assess dietary patterns and nutritional status in EA patients. Materials and methods: EA patients, retrospectively recruited from January 2018 to August 2024, filled out a 15-day diary to record ingested food and relative symptoms onset for each meal. Estimated caloric intake and macronutrient composition were compared to those recommended by the Italian Society of Human Nutrition (SINU). EA activity was assessed with Eckardt Symptoms Score (ESS) and QoL with the MD Anderson Dysphagia Inventory (MDADI). Results: Of 44 patients (24M, 20F; 56.9 ± 15.7 years), 79% had active disease (ESS ≥3). The mean daily caloric intake was 1,573 ± 368 kcal/die, significantly lower than the estimated needs ( p < 0.0001). Macronutrients distribution was unbalanced with an increase in fats (37.8%), a decrease in carbohydrates (43.2%), and insufficient fiber intake (14 g). The most common symptom-triggering foods were bread, pasta, pizza (50–60%). Additionally, 60% reported worsened symptoms with cold foods, while 53% found relief with hot foods. Conclusion: This study highlights the pivotal role of dietary factors, particularly food consistency and temperature, in the management of EA, supporting the incorporation of individualized dietary counseling into standard EA care.