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Background/Aims The prevalence of irritable bowel syndrome (IBS) has risen considerably over the past decade in Singapore. We aim to explore the contribution of changes in diet, lifestyle and habits that may contribute to the increased prevalence and development of IBS. Methods This is a survey-based cross-sectional population study aimed to gather demographic, socio-economical, lifestyle, dietary, antibiotic usage and other related information. Subjects were adult male or female Singaporeans aged 21 years or above. Association of the factors gathered with the presence or absence of IBS (by Rome III criteria) was assessed using chi-square or Fisher’s exact test. Variables with a level of statistical significance of 0.1 or less in the univariate analysis were entered into a stepwise logistic regression model. Results A total of 297 subjects participated in the study (female 60.3%). Overall, 20.9% subjects fulfilled the Rome III IBS criteria. Univariate analysis showed that IBS was associated with pet ownership, antibiotic usage, late dinner, (> 9 PM) and consumption of Western meals, coffee, and bread. The multivariate logistic regression analyses showed that IBS was independently associated with being a pet owner (P = 0.008; OR, 2.5; 95% CI, 1.278–5.037). Conclusions The prevalence of IBS was 20.9% using the Rome III criteria in our study. The association between IBS and pet ownership will need further investigation.

Background The current study aimed to model the moment-to-moment relationship between daily life stress, negative emotions and bowel symptoms among patients with irritable bowel syndrome – diarrhoea subtype (IBS-D) in the flow of daily life using a smartphone-based experience-sampling method (ESM). Methods Patients with IBS-D (n=27) and healthy controls (HC) (n=30) completed ESM ratings of their real-time daily life stress, which was defined as the subjective stress related to daily activities, negative emotion and bowel symptoms 8 times a day for 14 consecutive days, following a baseline interview measuring bowel and mood symptoms. Moment-to-moment association between ESM variables was tested within and between groups using multilevel regression modelling. Results Patients with IBS-D reported more severe bowel symptoms (ps 0.05). Time-lagged analysis of ESM data revealed that, among patients with IBS-D, daily life stress predicted a decrease in abdominal pain and urgency to defecation at a subsequent time point (ps Conclusions ESM unveiled the dynamic relationship between bowel symptoms, stress and emotionality. Patients with IBS-D responded to bowel symptoms with more stress and distress momentarily. Counter-intuitively, daily life activity stress served as a protective factor for bowel symptoms. Our data informed the psychological understanding of IBS.

The concept of consuming microorganisms in the treatment of a medical condition and in health maintenance has gained much attraction, giving rise to an abundance of medical claims and of health supplements. This study identified relevant clinical questions on the therapeutic use of probiotics and reviewed the literature in irritable bowel syndrome, inflammatory bowel disease, impaired intestinal immunity, liver disease, intestinal infections, and common childhood digestive disorders. Statements were developed to address these clinical questions. A panel of experienced clinicians was tasked to critically evaluate and debate the available data. Both consensus and contentious statements are presented to provide to clinicians a perspective on the potential of probiotics and importantly their limitations.

There are limited studies on incidence rates of metachronous neoplastic lesions after resecting large colorectal polyps. In the present study, we analyzed metachronous lesions after endoscopic resection of colorectal polyps ≥20 mm in size.We retrospectively analyzed consecutive patients who underwent endoscopic resection of polyps from 2006 to 2013 at two affiliated hospitals. All patients underwent at least two total colonoscopies before follow up to ensure minimal missed polyps. Only patients who had follow-up colonoscopy annually after resection were recruited. We separated patients according to size of polyp resected; there were 239 patients in the ≥20-mm group and 330 patients in the20-mm group. Clinical characteristics and cumulative rates of metachronous advanced adenoma and cancer in both groups were analyzed. Advanced adenoma was defined as a neoplastic lesion ≥10 mm in size and adenoma with a villous component.Cumulative rate of development of metachronous advanced adenoma and cancer in the ≥20-mm group was significantly higher than in the20-mm group (22.9% vs. 9.5%, P 0.001) at 36 months. There was also more development of small polyps 5-9 mm in the ≥20-mm group than in the20-mm group (45.2% vs. 28.8%, P 0.001). With respect to metachronous lesions, there were more right-sided colonic lesions in the ≥20-mm group than in the20-mm group (78.8% vs. 50.0%, P = 0.015).High incidence rates of development of metachronous neoplastic lesions were detected after resection of colorectal polyps ≥20 mm in size.

Poor handovers contribute to medical near misses, adverse events and waste of healthcare resources. To improve handover communication, public hospitals in Singapore are among the pioneers in Asia to develop standardized handover protocols and handover training courses. This study aimed to examine junior residents’ experience and perception on clinical handovers and discuss the implications on developing a standard handover protocol and handover training. Two survey studies with 47 junior residents were conducted at the Department of Internal Medicine, National University Hospital (NUH) of Singapore in Nov 2008 and from Jan to Mar 2010 respectively. Overall, junior residents supported handover standardization. Specifically, with respect to content standardization, junior residents demonstrated a good awareness of essential topics that should be communicated during a handover, and yet follow up action and non-modifiable identifiers were poorly covered in their current practices; with respect to method standardization, they showed a strong preference for an interactive handover channel. To our surprises, the recommended verbal communication plus text message method was not highly accepted, largely due to the high workload of preparing text messages. Moreover, handover training was advocated by junior residents and they considered the early stage of physicians’ medical training to be the proper time to learn handover skills.

Background and Aim Generally, colorectal endoscopic submucosal dissection (ESD) cannot be carried out with severe lens cloudiness. We examined the occurrence of lens cloudiness during ESD as well as the efficacy of a novel cleaner for it. Methods This study was a prospective study compared to historical control. First, we analyzed 103 ESD cases using standard cleaner at the Kyoto Prefectural University of Medicine in 2012. Relationship between lens cloudiness and clinical characteristics of lesions was analyzed. Lens cloudiness was recorded as grade 0 (clear) to grade 2 (very unclear). Then, we recruited 92 consecutive patients who underwent colorectal ESD using the novel cleaner from August 2013 to July 2014. The cleaner was applied on top of the lens before procedure and ability to prevent lens cloudiness was tested. Additionally, the novel cleaner was injected from endoscopic channel into a space created by endoscopic hood and colonic wall in seven cases with grade 1 or 2 of lens cloudiness and the ability to clean lens cloudiness inside the colon was tested. Results Rate of severe lens cloudiness was 8.7%. Multivariate analysis showed that severe lens cloudiness was related with severe submucosal fatty tissue (P

Background/Aims The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria. Methods After EAR3Q was developed by Asian experts by consensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean, and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations. Results Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700–1.000) except in Korean (0.300–0.500) and Indonesian (0.100–0.400) languages at the initial and 2-week follow-up visit. Conclusions Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.

Background/study aim Linked color imaging (LCI) by a laser endoscope (Fujifilm Co, Tokyo, Japan) is a novel narrow band light observation. In this study, we aimed to investigate whether LCI could improve the visibility of colorectal polyps using endoscopic videos. Patients and methods We prospectively recorded videos of consecutive polyps 2 – 20 mm in size diagnosed as neoplastic polyps. Three videos, white light (WL), blue laser imaging (BLI)-bright, and LCI, were recorded for each polyp by one expert. After excluding inappropriate videos, all videos were evaluated in random order by two experts and two non-experts according to a published polyp visibility score from four (excellent visibility) to one (poor visibility). Additionally, the relationship between polyp visibility scores in LCI and various clinical characteristics including location, size, histology, morphology, and preparation were analyzed compared to WL and BLI-bright. Results We analyzed 101 colorectal polyps (94 neoplastic) in 66 patients (303 videos). The mean polyp size was 9.0 ± 8.1 mm and 54 polyps were non-polypoid. The mean polyp visibility scores for LCI (2.86 ± 1.08) were significantly higher than for WL and BLI-bright (2.53 ± 1.15, P Conclusions LCI improved polyp visibility compared to WL for both expert and non-expert endoscopists. It is useful for improving polyp visibility in any location, any size, any morphology, any histology, and any preparation level.Study registration: UMIN000013770

Surgery and other non-pharmacological treatments such as sacral nerve stimulation are used for the treatment of difficult-to-treat chronic constipation. Novel pharmacological therapeutic agents are also being introduced. To evaluate the efficacy of these treatments, it is imperative to have a consistent definition of pharmacologically refractory constipation. A systematic review of studies on refractory, difficult-to-treat or surgically treated constipation was carried out to determine the criteria that various authors used to define this group of patients.A systematic review was performed for literature published from June 2005 to June 2015 using PubMed, Cochrane, and Scopus databases, as well as manual searches. Studies on patients with refractory or intractable constipation were extracted. Criteria used for defining refractory constipation, as well as pharmacological agents tried including dosage, frequency, and duration, were reviewed.Sixty-one studies were included in this review. Forty-eight involved surgical treatment of constipation, while 13 examined non-surgical therapies for refractory constipation. There is no generally accepted definition of refractory constipation. Authors consider constipation to be refractory when response to management is suboptimal, but there is no consensus on the choice of drug, order of usage, and dosage or treatment duration. Prior medical therapy was not mentioned at all in five studies.There is need for a detailed definition of pharmacologically refractory constipation before submitting patients to invasive treatments and to evaluate new pharmacological agents.

Information on real world treatment experiences of patients with functional bowel disorders is lacking from Asia. This study aimed to describe the medication exposure and treatment satisfaction of patients presenting to gastroenterology clinics across a sampling of Asian cities.From March 2011 to October 2013, adult patients presenting to hospital-based gastroenterology outpatient clinics in 11 cities across Asia, who fulfilled screening criteria for any functional gastrointestinal disorder, were asked to complete a validated culturally adapted translation of the Rome III diagnostic questionnaire, a checklist of medications received in the preceding 3 months and questions on treatment satisfaction.A total of 1376 patients (female 755, male 621, 41.36 ± 13.25 years) comprising irritable bowel (621, 45.1%), unspecified functional bowel disorder (372, 27.8%), functional constipation (202, 14.7%), functional bloating (144, 10.5%), and functional diarrhea (56, 4.1%) completed the study. Of 1105 patients with a previous consultation, 509 (46.1%) were dissatisfied with their treatment, with ineffective treatment being the commonest reason. Satisfaction with previous consultation was lowest by diagnosis for functional constipation (29.2%), and the most bothersome symptom was straining (37.5%). Of 1046 patients who had taken medications for their gastrointestinal symptoms in the last 3 months, 793 (75.8%) had received two or more drugs. For irritable bowel syndrome patients, treatment with proton pump inhibitors and antispasmodics was recorded in 57% and 31%, with overlapping epigastric pain and heartburn predicting proton pump inhibitors use.More attention should be given to treatment gaps with regards to possible under-treatment with antispasmodics in irritable bowel syndrome and to critically evaluating the efficacy of constipation management.

A same-day low-volume 1 L polyethylene glycol (PEG) for bowel preparation before colonoscopy was developed to improve patients' compliance. We aimed to evaluate the efficacy and safety of this regimen especially for the elderly and patients with renal dysfunction.All consecutive patients who underwent colonoscopy in our center from November 2014 to September 2015 were included. Patients undertook a low-residue diet with 10 mL sodium picosulfate 1 day before colonoscopy. Subsequently, they had 1 L low-volume PEG (MoviPrep) and 0.5 L water 4 h before the examination. Clinical outcomes, including cleansing level using the Boston bowel preparation score (BBPS), in the elderly and special-elderly (65-79 and ≥80 years old) were analyzed and compared with the non-elderly (18-64 years old). Additionally, patients with renal dysfunction were analyzed with respect to both complications and changes in blood parameters.A total of 5427 patients (mean age: 64.5 ± 13.8) were analyzed. The rate of BBPS ≥ 6 in the elderly (2761 patients), special-elderly (565 patients), and non-elderly (2101 patients) was 94.1, 91.8, and 94.6 %, respectively. In the special-elderly, the rate of renal dysfunction was 14.8 %, and no severe complications were detected after colonoscopy. Additionally, there were no severe complications in 86 patients with renal dysfunction, though elevation of hematocrit was shown after intake of 1 L PEG (before, 36.7 ± 6.1 vs. after, 39.0 ± 5.7, P = 0.006).Our study shows the safety and efficacy of same-day low-volume 1 L PEG bowel preparation in colonoscopy for the elderly and patients with renal dysfunction.

Dear Editor: Endoscopic submucosal dissection (ESD) is useful for resecting large early colorectal cancers. Postoperative hemorrhage is one of the complications for colorectal ESD. Patients with antithrombotic drug such as antiplatelet and anticoagulant are not uncommonly encountered during colorectal ESD because the number of silver generation grows; patients with multiple co-morbidities and polypharmacy also become more prevalent. Due to the importance of antithrombotic drug, many countries had developed their own clinical guidelines advising whether to continue or withhold antithrombotic drug during a certain procedure. To our knowledge, there are no detail reports about postoperative hemorrhage after colorectal ESD in patients with anticoagulant. In this report, we aimed to compare the status of postoperative hemorrhage for colorectal ESD cases with antithrombotic (anticoagulant or antiplatelet) and those without. Consecutive patients who underwent colorectal ESD at the Kyoto Prefectural University of Medicine from November 2008 to April 2015 were retrospectively reviewed. Indication for ESD included (1) tumors that cannot be resected with EMR, as well as those that are diagnosed as (2) intramucosal cancer (Tis) and part of T1 cancer without risk of lymph node metastasis by magnifying endoscopic examination. We analyzed various clinicopathological outcomes in all ESD cases and all included cases were divided into three groups: group A, cases with antiplatelet; group B, cases with anticoagulant (±antiplatelet); and group C, cases without antithrombotic drug. Characteristics of patients and tumors (age, sex, tumor size, location) as well as procedural record and complications (en bloc resection, procedure time, postoperative hemorrhage, perforation, blood transfusion, thrombosis and etc.) were also examined. We followed the Japanese Gastroenterological Endoscopy Society (JGES) on the management of patients on antithrombotic drugs during endoscopy published in 2005 and 2010. Regularly, antiplatelet drugs including aspirin were withdrawn for 1 to 7 days and restarted 1–3 days after ESD. In patients with high embolic risk, aspirin was continued before and after ESD. With respect to anticoagulants, warfarin was regularly replaced with subcutaneous heparin (20,000 units/day) 3 days before ESD. Heparin was stopped 6 h before ESD. Both heparin and warfarin were re-prescribed 1 day after ESD and were continued 4–14 days until the prothrombin times-international normalized ratio (PT-INR) was recovered. However, in some patients, warfarin was withdrawn 3 days before ESD without heparin replacement and was restarted 2 days after ESD until 2010. Dabigatran was withdrawn 1 day before ESD and restarted 1 day after ESD. This study was approved by the ethics committees of Kyoto Prefectural University of Medicine. This study was carried out in accordance with the World Medical Association Helsinki Declaration and was a part of sub-analysis of the study registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) as number UMIN000013772. With respect to overall 678 ESD cases, mean age of patients was 68.2 ± 10.3 years. Three hundred fifty-three * Naohisa Yoshida naohisa@koto.kpu-m.ac.jp

A review of relevant publications revealed that the criteria for defining refractory constipation were ill-defined. Common treatment for constipation includes osmotic, stimulant, and enterokinetic agents. Prucalopride is a new enterokinetic agent that has been shown in clinical trials to produce significant improvements in bowel functions, gastrointestinal symptoms, and quality of life. Patients who fail pharmacological treatment should be referred to specialized centers for physiological laboratory evaluation like transit studies, balloon expulsion, anorectal manometry, and defecography. Potential pathophysiology of refractory constipation include physiological disturbances like pelvic floor dyssynergia and slow transit constipation. Physical defects such as rectocoele and internal prolapse are uncommon. Psychological disturbances have been linked to persistent GI symptoms. Non-pharmacological treatments to consider include biofeedback and behavioral therapy. More studies are needed before surgery can be recommended. There is the possibility that a wider acceptance of the use of laxatives may substantially reduce the number of patients with refractory constipation.

Background and Aim Chronic constipation is usually associated with young women, and urinary and sexual dysfunction has been reported as co-morbidity. Elderly men also appear to suffer from chronic constipation, as well as lower urinary tract symptoms and erectile dysfunction, but their association as co-morbidity has not been studied in the community. The aim of the present study was to determine the prevalence of bowel symptoms in our community with particular reference to the association with urinary and sexual dysfunction in the male population. Methods A population-based cross–sectional survey involving 2276 subjects (1143 male, 1133 female) representative of the Singapore population demographics was conducted to evaluate the prevalence of chronic bowel disturbances, lower urinary tract symptoms (LUTS), and erectile dysfunction (ED). Results The prevalence of chronic constipation was 25.1% overall, with the highest in men aged ≥ 70 years (35.8%) followed by women aged 20–29 years (30.5%). The commonest symptoms reported in chronic constipation were hard stool (95.1%), straining (90.9%) and incomplete evacuation (53.8%). Bloating was often experienced by 25.5% of the community, among whom 61.1% had some form of bowel disturbance. In men aged ≥ 30 years, LUTS (7.8% v 3.1%) and ED (60.5% v 48.6%) were more common in men with than without chronic constipation; constipation was an independent predictor of ED. Conclusions In this Asian urban community, chronic constipation was more common than previously suspected, and urinary and erectile dysfunction were found to be co-morbidity in men.

A clinical shift handoff can be considered as a three-phase process, consisting of pre-handoff, handoff communication, and post-handoff. The majority of studies on clinical handoffs focused on the handoff communication. There is limited literature on how pre-handoff and post-handoff activities are conducted. This study aims to understand the handoff practice in a public hospital in Singapore from the three-phase process’ point of view, to identify potential problems that may occur in such a setting, and to discuss potential interventions to enhance clinical shift handoffs.

Background The current study aimed to model the moment-to-moment relationship between daily life stress, emotions, and bowel symptoms among patients with irritable bowel syndrome-diarrhea subtype (IBS-D) in the flow of daily life using a smartphone-based experience sampling method (ESM). Methods Patients with IBS-D (N = 27) and healthy controls (HC; N = 30) completed ESM ratings of their real-time daily life stress, which was defined as subjective stress related to daily activities, both positive and negative emotions, as well as bowel symptoms eight times a day for 14 consecutive days, following a baseline interview measuring bowel and mood symptoms. Moment-to-moment association between ESM variables was tested within and between groups using multilevel regression modeling. Key results Patients with IBS-D reported more severe bowel symptoms and lower positive affect than HCs, but levels of daily life stress and negative affect were comparable between groups. Time-lagged analysis of ESM data revealed that, among patients with IBS-D, daily life stress predicted a decrease in abdominal pain and urgency to defecation at a subsequent time point, whereas severity of bowel symptoms and occurrence of diarrhea predicted a subsequent increase in negative affect and daily life stress. The above associations were not found among HCs. Conclusions and inferences ESM unveiled the dynamic relationship between bowel symptoms, stress, and emotionality. Patients with IBS-D responded to bowel symptoms with more stress and distress momentarily. Counter-intuitively, daily life activity stress appeared to ameliorate bowel symptoms, although a more rigorous study design is required to testify this claim. Psychological understanding of IBS-D is discussed.

Generally, colorectal endoscopic submucosal dissection (ESD) cannot be carried out with severe lens cloudiness. We examined the occurrence of lens cloudiness during ESD as well as the efficacy of a novel cleaner for it.This study was a prospective study compared to historical control. First, we analyzed 103 ESD cases using standard cleaner at the Kyoto Prefectural University of Medicine in 2012. Relationship between lens cloudiness and clinical characteristics of lesions was analyzed. Lens cloudiness was recorded as grade 0 (clear) to grade 2 (very unclear). Then, we recruited 92 consecutive patients who underwent colorectal ESD using the novel cleaner from August 2013 to July 2014. The cleaner was applied on top of the lens before procedure and ability to prevent lens cloudiness was tested. Additionally, the novel cleaner was injected from endoscopic channel into a space created by endoscopic hood and colonic wall in seven cases with grade 1 or 2 of lens cloudiness and the ability to clean lens cloudiness inside the colon was tested.Rate of severe lens cloudiness was 8.7%. Multivariate analysis showed that severe lens cloudiness was related with severe submucosal fatty tissue (P 0.001). The novel cleaner had significantly less cloudiness cases compared to the standard cleaner (14.1% vs 33.0%, P = 0.002). Additionally, the novel cleaner enabled us to clean lens cloudiness in all seven cases.Lens cloudiness during ESD was associated with submucosal fatty tissue. Effective lens cleaner should be used to prevent and clean lens cloudiness.

Background/aims Non-celiac gluten sensitivity has been increasingly recognized as a predisposing factor for irritable bowel syndrome (IBS)-like symptoms in Western populations where celiac disease (CD) is relatively common. In Asia where CD is rare, we wish to de-termine the prevalence of gluten protein associated serology in IBS patients, which has not been formally studied, and its rela-tion to histological and human leukocyte antigen (HLA) markers. Methods We reviewed a consecutive cohort of Asian patients with IBS, who had undergone serologic testing for IgA against deamidated gliadin peptide antibodies (IgA DGP) and IgA anti-endomysium antibodies, and who also had duodenal biopsies during clinical workup. In addition, a subset of Chinese patients with positive serology was further tested for HLA-DQ2 and HLA-DQ8. Results Of 186 patients, 34 (18%) were positive for IgA DGP; bloating, abdominal pain, belching and diarrhea were the most com-monly reported symptoms but diarrhea as the most bothersome symptom was significantly more common in IgA DGP positive patients. Mildly increased intra-epithelial lymphocytes on duodenal biopsy was also more common (29% vs. 9%, P = 0.001). Nine of 21 Chinese patients tested as IgA DGP positive undertook HLA-DQ2/DQ8 testing, with only 2 being positive for HLA-DQ8. All patients with positive IgA DGP reported symptom improvement with gluten withdrawal. Conclusions We have described a series of Asian, mainly Chinese, patients with IBS who were tested positive for IgA DGP, and improved on a gluten exclusion diet. We believe this is the first report of non-celiac gluten sensitivity in Asia, a region where CD is uncommon.

Background: Kiwifruit is high in pectic polysaccharides and dietary fiber. This study aimed to find out how the ingestion of kiwifruit will affect intestinal microbiota populations, namely Lactobacillus, Bacteroides, Clostridium, Bifidobacterium , and Enterococcus . Methods: Freeze dried kiwifruit (equivalent of two fresh kiwifruits) was given to each of the six subjects daily for four days. Faecal samples were collected before, during and after kiwifruit consumption. The faecal bacteria were enumerated by qPCR and RT qPCR methods. Results: The effect of the kiwifruit on intestinal microbiota profile varied between individuals; in general, the kiwifruit demonstrated a prebiotic effect of promoting the content of faecal lactobacilli and bifidobacteria (as compared to the baselines of the same individual before consumption) for as long as the fruit was consumed. The effect was however transient, the levels of the two bacteria returned near to that of the baselines upon cessation of consumption. Conclusion: Kiwifruit is a prebiotic in selectively enhancing the growth of intestinal lactic acid bacteria. Keywords: kiwifruit; polysaccharides; gastrointestinal microflora; faecal lactobacilli; faecal bifidobacteria (Published: 18 June 2012) Citation: Microbial Ecology in Health & Disease 2012, 23 : 18572 - http://dx.doi.org/10.3402/mehd.v23i0.18572

Irritable bowel syndrome (IBS) is a common disorder characterized by recurrent abdominal pain or discomfort, in combination with disturbed bowel habits in the absence of identifiable organic cause. Melatonin (N-acetyl-5-methoxytryptamine) is a hormone produced by the pineal gland and also large number by enterochromaffin cells of the digestive mucosa. Melatonin plays an important part in gastrointestinal physiology which includes regulation of gastrointestinal motility, local anti-inflammatory reaction as well as moderation of visceral sensation. Melatonin is commonly given orally. It is categorized by the United States Food and Drug Administration as a dietary supplement. Melatonin treatment has an extremely wide margin of safety though it may cause minor adverse effects, such as headache, rash and nightmares. Melatonin was touted as a potential effective candidate for IBS treatment. Putative role of melatonin in IBS treatment include analgesic effects, regulator of gastrointestinal motility and sensation to sleep promoter. Placebo-controlled studies in melatonin suffered from heterogeneity in methodology. Most studies utilized 3 mg at bedtime as the standard dose of trial. However, all studies had consistently showed improvement in abdominal pain, some showed improvement in quality of life of IBS patients. Melatonin is a relatively safe drug that possesses potential in treating IBS. Future studies should focus on melatonin effect on gut mobility as well as its central nervous system effect to elucidate its role in IBS patients.

Introduction: Pharyngeal High Resolution Manometry (HRM) has been increasingly used in research studies. The utility of this technique for clinical purposes requires a better understanding of the effects of variables on the recorded pressure signature. Some of these variables such as neck position and volume of swallowed material may not have appreciable effect on esophageal pressure measurements but could affect the pharynx significantly. Therefore, our AIM was to determine the effect of the bolus volume, several neck positions, and posture on the pharyngeal and Upper Esophageal Sphincter (UES)pressure phenomenon using HRM technique. Methods: We studied 16 healthy young volunteers (8 F, age 20-30 years) with HRM in four neck positions (neck neutral, neck 15" extension, neck 30° and 45° flexion) and 2 body postures (sitting and supine), four volumes (dry and 5 ml, 10 ml and 20 ml). Each swallow volume was repeated three times. We measured amplitude (mmHg) duration (s) and velocity (cm/s). Results: A total of 1536 swallows were evaluated. Pharyngeal pressure phenomenon exhibited larger duration in the proximal pharynx compared to distal, while they exhibited higher amplitude in the distal pharynx compared to the proximal pharynx but not velopharyngeal region(P7-P6) (figure 1a and 1b). These parameters were not affected by posture, neck position or volume of swallowed liquid. Intrabolus hypopharyngeal pressure (IBP) increased with increased swallowed volume significantly (P,0.05). There was no effect by posture or neck position on the IBP. Resting UES pressure was not affected by the posture, however it showed significant change due to neck position P,0.05 (Table) ConclusionDuring pharyngeal HRM, neck position or posture has no appreciable effect on recorded pharyngeal peristalsis; however it affects the UES pressure significantly. This effect needs to be considered during pharyngeal HRM. Table. Effect of neck position on pharyngo-UES HRM variables