Category Archives: Gastroenterology

Global Evidence of Gastric Cancer Prevention with Helicobacter pylori Eradication

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Several recent articles have confirmed the benefits of H pylori eradication on reducing the risk of gastric cancer. This is in both Western and Eastern populations.

In this retrospective study from Nordic countries (Denmark, Sweden, Norway, Finland, and Iceland), researchers followed outcomes among ~700,000 people treated for H. pylori infection. The incidence of gastric adenocarcinoma was twice that of the general population in the first 5 years after treatment, likely reflecting H. pylori–related carcinogenesis that already was underway, but after 11 years, the incidence fell to that of the general population and remained there.

Discussion points:

  • The results of this study from 5 entire Western countries are in line with systematic reviews from Asian populations, indicating that H pylori eradication reduces the risk of gastric cancer
  • In addition, it has been proposed that eradication of H pylori might increase the risk of esophageal adenocarcinoma, but our recent study based on the NordHePEP found no such increase (Ref: Gastroenterology. 2024; 167:485-492.e3)

In this population-based study with more than 900,000 individuals, gastric cancer incidence and mortality rates were significantly lower in H pylori-treated individuals than in the general population.

In this meta-analysis of 11 randomized trials and 13 cohort studies researchers compared outcomes in treated and untreated H. pylori–positive adults. In both groups of studies, gastric cancer incidence was 40% lower in people who underwent H. pylori eradication. All but two of these studies were from eastern Asia.

 “In 2025, the IARC Working Group has issued a new report reaffirming H pylori eradication as a globally actionable and cost-effective intervention for the primary prevention of GC.18…Also, addressing the global public health challenge of antibiotic resistance remains essential, necessitating the development of susceptibility-guided or empirically optimized regimens tailored to local resistance patterns.

My take (borrowed from the commentary): “Despite the challenges, collectively, the emerging evidence from diverse populations reinforces the significant benefits of H pylori eradication in reducing GC incidence and mortality. These findings continuously support that H pylori eradication remains an effective preventive strategy across demographic settings, highlighting its relevance as a critical public health measure globally.”

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IBS Impact: Survey Reveals Daily Life Struggles

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AGA GastroNews, AGA IBS in America survey reveals IBS major burden despite advances in treatment (8/7/25):

Methods: The Harris Poll on behalf of AGA in 2024, among 2,013 U.S. adults age 18+ who have been diagnosed by a health care provider with IBS-C (1,005) or IBS-D (1,008). In addition, U.S. health care provider research was conducted online among 600 health care providers including gastroenterologists (n=200), primary care physicians (PCPs, n=200), gastroenterology nurse practitioners (NP)/physician assistants (PA) (n=100), and PCP NP/PAs (n=100)

Key findings:

  • IBS symptoms interfere with patients’ productivity at work/school for nearly 11 days per month on average
  • IBS symptoms disrupt personal activities eight days per month on average
  • 69% say their symptoms make them feel like they’re not “normal”
  • 77% avoid situations where bathroom access is limited.
  • 72% find it difficult to plan activities due to unpredictable symptoms.
  • 72% stay home more often because of their symptoms

My take: This sample of patients with IBS likely has more severe symptoms than a more general population of patients with IBS. Nevertheless, it highlights the impact of IBS symptoms on daily living.

Link: AGA IBS Toolkit

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Westminster Abbey, London


“Are Marathons and Extreme Running Linked to Colon Cancer?”

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NY Times 8/19/25: Are Marathons and Extreme Running Linked to Colon Cancer?

An excerpt:

A small, preliminary study found that marathoners were much more likely to have precancerous growths. Experts aren’t sure why…

Dr. Cannon, an oncologist with Inova Schar Cancer in Fairfax, Va., launched a study, recruiting 100 marathon and ultramarathon runners aged 35 to 50 to undergo a colonoscopy.

The results were staggering. Almost half the participants had polyps, and 15 percent had advanced adenomas likely to become cancerous. The rate of advanced adenomas was much higher than that seen among adults in their late 40s in the general population, which ranges from 4.5 percent to 6 percent, according to recent studies.

The research was presented at an American Society of Clinical Oncology conference but has not yet been published in a medical journal…

Dr. David Rubin, chief of gastroenterology and director of the Inflammatory Bowel Disease Center at the University of Chicago, said the study was important but limited. It lacked a control arm consisting of similar young adults who were not long-distance runners, he noted, and the family histories of colon cancer among the marathoners were not entirely known…

Runners often develop gastrointestinal symptoms that they dismiss as benign — so-called runner’s trots, for example. The symptoms can be caused by ischemic colitis, a condition that develops when blood flow to the colon is temporarily reduced as it is redirected to muscles in other parts of body (like a runner’s legs).

My take: While this is a small study, it indicates that extreme runners could have an increased risk of colonic polyps and cancer. If there are symptoms (especially rectal bleeding and weight loss), a low threshold for further evaluation is needed.

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View of Statue of Liberty from Governor’s Island

IBD Management in Pregnancy: Global Consensus

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U Mahadevan et al. Clinical Gastroenterology and Hepatology 2025 (published ahead of print). Open Access! Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease

Addendum -updated reference: U Mahadevan et al. Clinical Gastroenterology and Hepatology 2025; 23: S1-S60. Open Access! Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease

This is a 60 page open access article. Table 1 lists 34 “GRADE” statements and Table 2 lists 35 consensus statements. This article is also jointly published in the following:

  • Gut
  • Am J Gastroenterol
  • Inflammatory Bowel Diseases
  • Journal of Crohn’s and Colitis
  • Aliment Pharmacol Ther

For Moms:

For Babies:

My take: This is a useful reference –mainly helpful for gastroenterologists rather than pediatric providers.

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Can Smartphone Use Increase the Risk of Hemorrhoids?

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There are many reasons NOT to use a phone while you are on the toilet. Now a small study indicates that smartphone use is associated with longer time on the toilet and increased rate of endoscopically-detected hemorrhoids.

An excerpt from the NBC summary:

“The longer you sit on the toilet, the worse it is for you,” said Dr. Trisha Pasricha, director of the Beth Israel Deaconess Medical Center’s Institute for Gut-Brain Research Institute in Boston. Pasricha is also an author of the study, which was published Wednesday in PLOS One…

Pasricha and colleagues surveyed 125 adults just before they were about to have a routine colonoscopy to screen for colorectal cancer. Eighty-three (66%) of the participants admitted to using their phones in the bathroom — mostly to catch up on news of the day and scroll through social media.

Gastroenterologists performing the colonoscopies looked for evidence of inflamed veins, or hemorrhoids. People who said they took their phone into the bathroom were 46% more likely to have hemorrhoids compared to the others…

The experts agreed that business on the toilet should take no longer than 5 minutes. More than 37% of study participants who used a smartphone in the bathroom stayed for longer than that, compared to 7% of people who kept their phones out of the bathroom.

My take: This study has a number of limitations; so, a definite link between smartphones and hemorrhoids has not been established. For example, there could be reverse causation. In this case, individuals who expected to be on the toilet longer may be more likely to use their smartphones rather than the smartphones making them stay longer. Nevertheless, I think multitasking on the toilet is generally not a good idea.

Brooklyn Bridge, August 2025

Expert Advice for GI Manifestations of Hypermobile Ehlers-Danlos Syndrome Including Association with POTS and Mast Cell Activation Syndrome (MCAS)

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Q Aziz et al. Clinical Gastroenterology and Hepatology, Volume 23, Issue 8, 1291 – 1302. Open Access! AGA Clinical Practice Update on GI Manifestations and Autonomic or Immune Dysfunction in Hypermobile Ehlers-Danlos Syndrome: Expert Review

This review and practice update includes 16 “best practice advice” statements. Here are nine of them:

  • #1: Clinicians should be aware of the observed associations between hEDS or HSDs and POTS and/or MCAS and their overlapping gastrointestinal (GI) manifestations; while theoretical explanations exist, experimental evidence of the biological mechanisms that explain relationships is limited and evolving.
  • #2: Testing for POTS/MCAS should be targeted to patients presenting with clinical manifestations of POTS/MCAS, but universal testing for POTS/MCAS in all patients with hEDS/HSDs is not supported by the current evidence.
  • #3: Gastroenterologists seeing patients with DGBI should inquire about joint hypermobility and strongly consider incorporating the Beighton score for assessing joint hypermobility into their practice as a screening tool; if the screen is positive, gastroenterologists may consider applying 2017 diagnostic criteria to diagnose hEDS (https://www.ehlers-danlos.com/wp-content/uploads/2017/05/hEDS-Dx-Criteria-checklist-1.pdf) or offer appropriate referral to a specialist where resources are available.
  • #4: Testing for POTS through postural vital signs (eg, symptomatic increase in heart rate of 30 beats/min [40 beats/min for 12-19 yo] or more with 10 minutes of standing during an active stand or head-up tilt table test in the absence of orthostasis) and referral to specialty practices (eg, cardiology or neurology) for autonomic testing should be considered in patients with hEDS/HSDs and refractory GI symptoms who also report orthostatic intolerance after exclusion of medication side effects and appropriate lifestyle or behavioral modifications (eg, adequate hydration and physical exercise) have been attempted but is not required for all patients with hEDS/HSDs who report GI symptoms alone.
  • #5: In patients presenting to gastroenterology providers, testing for mast cell disorders including MCAS should be considered in patients with hEDS/HSDs and DGBI who also present with episodic symptoms that suggest a more generalized mast cell disorder (eg, visceral and somatic pain, pruritus, flushing, sweating, urticaria, angioedema, wheezing, tachycardia, abdominal cramping, vomiting, nausea, diarrhea, urogynecological and neurological complaints) involving 2 or more physiological systems (eg, cutaneous, GI, cardiac, respiratory, and neuropsychiatric), but current data do not support the use of these tests for routine evaluation of GI symptoms in all patients with hEDS/HSDs without clinical or laboratory evidence of a primary or secondary mast cell disorder.
  • #6: If MCAS is suspected, diagnostic testing with serum tryptase levels collected at baseline and 1–4 hours following symptom flares may be considered by the gastroenterologist; increases of 20% above baseline plus 2 ng/mL are necessary to demonstrate evidence of mast cell activation.
  • #12: Medical management of GI symptoms in hEDS/HSDs and POTS/MCAS should focus on treating the most prominent GI symptoms and abnormal GI function test results. In addition to general DGBIs and GI motility disorder treatment, management should also include treating any symptoms attributable to POTS and/or MCAS.
  • #13: Treatment of POTS may include increasing fluid and salt intake, exercise training, and use of compression garments. Special pharmacological treatments for volume expansion, heart rate control, and vasoconstriction with integrated care from multiple specialties (eg, cardiology, neurology) should be considered in patients who do not respond to conservative lifestyle measures.
  • #14: When MCAS is suspected, patients can benefit from treatment with histamine receptor antagonists and/or mast cell stabilizers, in addition to avoiding triggers such as certain foods, alcohol, strong smells, temperature changes, mechanical stimuli (eg, friction), emotional distress (eg, pollen, mold), or specific medications (eg, opioids, nonsteroidal anti-inflammatory agents, iodinated contrast).

Background: “Clinical gastroenterologists are encountering an increasing number of patients with chronic GI symptoms who also appear to experience comorbid hEDS/HSDs, POTS, and/or MCAS.15,16 Recognizing and treating GI symptoms in patients with hEDS/HSDs and comorbid POTS or MCAS present major challenges for clinicians, who often feel under equipped to address their needs.”

The article provides guidance on measuring hypermobility (Beighton Scoring System), Diagnosis/classification of mast cell activation (Table 1) and treatments for these disorders (Table 2)

My take: This is a useful reference for the overlap of DGBIs with hypermobile Ehlers-Danlos, POTS and Mast cell Activation. Nevertheless, the relationship between these disorders is unclear. In fact, there have been some studies indicating that joint mobility is not associated with an increase in functional GI disorders. Some of the association may be related to a surveillance bias.

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Impact of GLP-1 Agonists on IBD and Obesity

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P Sehgal et al. Clin Gastroenterol Hepatol 2025; 23: 1453-1454.Safety and Clinical Effectiveness of GLP1 Receptor Agonists in Inflammatory Bowel Disease Patients

Background: “The prevalence of obesity among patients with inflammatory bowel disease (IBD) is estimated at 15-40%, and continues to rise. Obesity has been associated with a more severe phenotype of IBD.”

Methods: Retrospective cohort with 244 patients. Semaglutide was the most commonly prescribed agent (54%).

Key findings:

  • GLP-1RA use led to weight loss from 102 kg to 97.6 kg at 12-24 weeks postinitiation
  • GLP-1RA was associated with a significant drop in CRP from 10.1 mg/dL to 3 mg/dL
  • In a subset of 32, fecal calprotectin values decreased from 825 mcg/kg to 235 mcg/kg (P= 0.13)

Limitations: Retrospective study with a short duration, lack of a control group for this study, and lack of endoscopic data.

My take: As with the broader population, GLP-1 RAs help with weight loss in patients with IBD. Many patients may derive health benefits from weight loss alone. This study, though with numerous limitations, indicates the potential beneficial effects on the activity of IBD based on improvements in biomarkers.

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Old Mill on the Cherokee Trail at Stone Mtn Park. Stone Mtn, GA

Pharmacologic Neuromodulation for Bloating Symptoms

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Briefy noted: EN Madva et al. Scand J Gastroenterol 2025 Aug 8:1-5. doi: 10.1080/00365521.2025.2544306. Online ahead of print. Pharmacologic neuromodulation for bloating.

This was a small retrospective study of consecutively referred patients with a DGBI (N = 77; ages 18-74, 87% female) to a tertiary neurogastroenterology clinic who were prescribed a neuromodulator for a primary complaint of bloating in 2016-2022.  Duloxetine was the most commonly prescribed neuromodulator (n = 52, 67.5%).

My take: This study shows that neuromodulators are likely beneficial for bloating symptoms. Dr. Garza () previously noted that in patients with bloating “the typical increase in excess gas during bloating symptoms is only 22 mL.” Thus, “A lot of bloating symptoms are due to increased sensitivity and ‘weird gas handling.’ The latter could include compression of diaphragm rather than elevation.”

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How to Diagnose Celiac Disease in Patients Already Receiving a Gluten Free Diet

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Open Access: Evaluating for Celiac Disease in Patients on a Gluten-Free Diet: A Practical Approach

Algorithm -Figure 2:

Figure 3 lists the content of several common foods -some noted below

While gluten exposure increases the diagnostic yield of currently available tests, there are novel tests being developed “which may aid in the diagnosis of CeD regardless of diet, with a particular focus on immune-based assays. One such innovation involves the use of tetramer-based assays, which enable the direct detection of gluten-specific T cells in the blood. These tetramers, designed to bind to HLA-DQ2 molecules, can help identify T cells that have been activated by gluten exposure. This presents a highly specific immune marker for CeD. Even for those on a GFD, sensitivity (97%) and specificity (95%) have been impressive.”

My take: This article provides practical advice for evaluating whether celiac disease is present in those already consuming a GFD.

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And news from The Onion 8/26/25: Hummingbird Feels Like Fucking Idiot After Seeing Other Bird Gliding

Celiac Risk Among First-Degree Relatives of Index Case

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S Karimzadhagh, et al. The American Journal of Gastroenterology 2025; 120(7):p 1488-1501. Global Prevalence and Clinical Manifestations of Celiac Disease Among First-Degree Relatives: A Systematic Review and Meta-Analysis

Methods: Of 8,764 studies screened, 34 studies involving 10,016 first-degree relatives (FDRs) of patients with Celiac Disease (CeD) were included

Key findings:

  • The pooled estimates for seroprevalence and the biopsy-confirmed CeD prevalence in FDRs were 11% and 7%, respectively
  • Daughters and sisters had the highest prevalence rates at 23% and 14%, compared with sons and brothers at 6% and 9%, respectively. Mothers/fathers prevalence rates were 5%. It is noted, however, that the stud only included 32 daughters and 41 sons, making these estimates less reliable
  • Abdominal pain (42%), bloating (39%), and flatulence (38%) were the most common gastrointestinal symptoms, while 34% of FDRs with CeD were asymptomatic

Discussion points:

Discrepancy between serology and biopsy: “First, not all individuals who tested positive through serological screening underwent a confirmatory duodenal biopsy. Second, some individuals with positive anti-tTG Ab may have false-positive results, or the disease process is still in the early stages of the disease, where intestinal damage is not yet detectable. This highlights that relying solely on serological screening without follow-up evaluations and intestinal biopsy can lead to overestimating the true prevalence of CeD.”

Limitations: “Some included studies only screened the siblings of indexed patients with CeD. For example, one study reported a prevalence of 22% among siblings. Given that genetic factors play a pivotal role in the pathogenesis of CeD and that the prevalence of CeD among siblings is often higher than that of other FDRs, this selective screening approach could potentially introduce selection bias into the overall prevalence of CeD in FDRs.”

My take: This study supports routine screening of first-degree relatives of patients with Celiac Disease, especially as many are asymptomatic.

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