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Neurogastroenterology and motility disorders of the gastrointestinal (GI) tract encompass a broad spectrum of diseases involving the GI tract and central nervous system. They have varied pathophysiology, clinical presentation and management, and make up a substantial proportion of outpatient clinic visits. Typically, patients experience persistent symptoms referable to the GI tract despite normal endoscopic and radiologic findings. An appropriate evaluation is thus important in the patient's care. Advances in technology and understanding of the disease pathophysiology have provided better insight into the physiological basis of disease and a more rational approach to patient management. While technological advances serve to explain patients' persistent symptoms, they should be balanced against the costs of diagnostic tests. This review highlights the GI investigative modalities employed to evaluate patients with persistent GI symptoms in the absence of a structural lesion, with particular emphasis on investigative modalities available locally and the clinical impact of such tools. [ABSTRACT FROM AUTHOR]

Gastric cancer is the second leading cause of cancer-related mortality and the fourth most common cancer globally. There are, however, distinct differences in incidence rates in different geographic regions. While the incidence rate of gastric cancer has been falling, that of gastric cardia cancers is reportedly on the rise in some regions. Helicobacter pylori (H. pylori) infection is a major risk factor of non-cardia gastric cancer, and data has emerged concerning the role of H. pylori eradication for primary prevention of gastric cancer. Dietary, lifestyle and metabolic factors have also been implicated. Although addressing these other factors may contribute to health, the actual impact in terms of cancer prevention is unclear. Once irreversible histological changes have occurred, endoscopic surveillance would be necessary. A molecular classification system offers hope for molecularly tailored, personalised therapies for gastric cancer, which may improve the prognosis for patients. [ABSTRACT FROM AUTHOR]

Chronic pancreatitis is associated with varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. In addition, extracorporeal shockwave lithotripsy improves the success rate of endoscopic clearance of intraductal stones. However, recent data from randomised trials have shown better long-term outcomes with surgical drainage for obstructive pancreatic ductal disease. In patients with distal biliary strictures, stent insertion leads to good immediate drainage, but after stent removal, recurrent narrowing is common. Endoscopic drainage of pancreatic pseudocysts has excellent outcome and should be accompanied by pancreatic ductal stenting when a ductal communication is evident. In those who remain symptomatic, endoscopic ultrasonography-guided coeliac plexus block may provide effective but short-term pain relief. In this review, we present the current evidence for the role of endotherapy in the management of patients with chronic pancreatitis. [ABSTRACT FROM AUTHOR]

An editorial is presented on the collaboration with Wolters Kluwer Medknow. Wolters Kluwer Medknow is a leading global publishing services provider that provides publishing services to more than 400 medical society journals in over 40 specialties.. It focuses on what matters to our community: the timely publication of quality papers. An overview of the testament to the quality of submissions by authors and the efforts of reviewers is presented.

In this issue of the Singapore Medical Journal, Norman et al performed a retrospective analysis of the outcomes of cases handled by SMC DTs regarding unprofessional behaviour of junior doctors. Singapore Med J 2021; 62(3): 107-108 https://doi.org/10.11622/smedj.2021025 107 Editorial 1 Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, 3 Yong Loo Lin School of Medicine, National University of Singapore, Singapore Correspondence: Prof Ang Tiing Leong, Senior Consultant, Department of Gastroenterology and Hepatology, Changi General Hospital, 2 Simei Street 3, Singapore 529889. ang.tiing.leong@singhealth.com.sg T he concept of professionalism for doctors has been present since antiquity. Norman NBM, Soo JMP, Lam MYK, Thirumoorthy T. Unprofessional behaviour of junior doctors: a retrospective analysis of outcomes by the Singapore Medical Council disciplinary tribunals. (4) The SMC is empowered to regulate the ethical behaviour and professional conduct of registered doctors. [Extracted from the article]

INTRODUCTION Endoscopic transenteric stenting is the standard treatment for pseudocysts, but it may be inadequate for treating infected collections with solid debris. Surgical necrosectomy results in significant morbidity. Direct endoscopic necrosectomy (DEN), a minimally invasive treatment, may be a viable option. This study examined the efficacy and safety of DEN for the treatment of infected walled-off pancreatic necrosis and infected pseudocysts with solid debris. METHODS This study was a retrospective analysis of data collected from a prospective database of patients who underwent DEN in the presence of infected walled-off pancreatic necrosis or infected pseudocysts with solid debris from April 2007 to October 2011. DEN was performed as a staged procedure. Endoscopic ultrasonography-guided transgastric stenting was performed during the first session for initial drainage and to establish endoscopic access to the infected collection. In the second session, the drainage tract was dilated endoscopically to allow transgastric passage of an endoscope for endoscopic necrosectomy. Outcome data included technical success, clinical success and complication rates. RESULTS Eight patients with infected walled-off pancreatic necrosis or infected pseudocysts with solid debris (mean size 12.5 cm; range 7.8-17.2 cm) underwent DEN. Underlying aetiologies included severe acute pancreatitis (n = 6) and post-pancreatic surgery (n = 2). DEN was technically successful in all patients. Clinical resolution was achieved in seven patients. One patient with recurrent collection opted for surgery instead of repeat endotherapy. No procedural complications were encountered. CONCLUSION DEN is a safe and effective minimally invasive treatment for infected walled-off pancreatic necrosis and infected pseudocysts. [ABSTRACT FROM AUTHOR]

Background and aims: Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced procedure with significant complication rate of 5 to 10%. Scant data is available on quality indicators for trainee-involved ERCP. In our study, we evaluated the outcome of trainee-involved ERCPs in which a protocol-based strategy to minimize complications during selective biliary cannulation was adopted. Patients and methods: Hands-on training was excluded if patients had ASA grade > 3. The trainee's attempts at selective biliary cannulation were stopped and the procedure taken over by the supervising expert endoscopist if the following factors were encountered: (1) failed cannulation after 5 attempts; (2) unsuccessful cannulation after 10 minutes; (3) edematous papilla; (4) pancreatic duct cannulation ≥ 2 times. After successful ductal cannulation, the trainee was allowed to continue additional hands on training in other aspects such as stone extraction and stenting. Results: During the study period, 331 patients underwent ERCP. Trainee group (TG) consisted of 85 patients; mean age 70 (range 27-99). Expert group (EG) consisted of 246 patients; mean age 65 (range 19-98). The overall technical success rate was 97.9% and there was no significant difference between TG (98.8%) and EG (97.6%). The overall complication rate was 3.9% and there was no difference between TG (3.5%) and EG (4%). In TG, although inadvertent pancreatic duct cannulation occurred in 12/85 (14.1%), acute pancreatitis developed only in 3/85 (3.5%). Conclusion: The high success and low complication rates in trainee-involved and expert-only ERCP procedures were similar. While using a protocol-based strategy, good clinical outcome during the provision of hands-on training for ERCP was observed. [ABSTRACT FROM AUTHOR]

Background/Aims Environmental factors such as food, lifestyle and prevalence of Helicobacter pylori infection are widely different in Asian countries compared to the West, and physiological functions and genetic factors of Asians may also be different from those of Westerners. Establishing an Asian consensus for functional dyspepsia is crucial in order to attract attention to such data from Asian countries, to articulate the experience and views of Asian experts, and to provide a relevant guide on management of functional dyspepsia for primary care physicians working in Asia. Methods Consensus team members were selected from Asian experts and consensus development was carried out using a modified Delphi method. Consensus teams collected published papers on functional dyspepsia especially from Asia and developed candidate consensus statements based on the generated clinical questions. At the first face-to-face meeting, each statement was reviewed and e-mail voting was done twice. At the second face-to-face meeting, final voting on each statement was done using keypad voting system. A grade of evidence and a strength of recommendation were applied to each statement according to the method of the GRADE Working Group. Results Twenty-nine consensus statements were finalized, including 7 for definition and diagnosis, 5 for epidemiology, 9 for pathophysiology and 8 for management. Algorithms for diagnosis and management of functional dyspepsia were added. Conclusions This consensus developed by Asian experts shows distinctive features of functional dyspepsia in Asia and will provide a guide to the diagnosis and management of functional dyspepsia for Asian primary care physicians. [ABSTRACT FROM AUTHOR]

Barrett's esophagus (BE) is defined as a metaplastic change of the distal esophageal epithelium from squamous to columnar type epithelium with the presence of intestinal metaplasia. There is a striking geographic variation in the prevalence rates of BE. Most epidemiological data on BE are derived from patients undergoing endoscopy and do not reflect prevalence rates in the general population. BE is much more common in the West when compared with Asia and Africa. Although BE is less common in Asia, the demographics are similar to the West, being predominantly found in older men with longer duration of reflux symptoms. Some studies from the West have suggested an increase in prevalence rates of BE. An increase in prevalence rates will have significant implications for health resource utilization and costs, due to the small but significant risk of developing esophageal adenocarcinoma. Endoscopic surveillance with the aim of detecting early lesions has been advocated. Compared with conventional white-light endoscopy with blind four-quadrant biopsies, the use of image-enhanced endoscopy, including chromoendoscopy, may improve detection of subtle mucosal irregularities and facilitate targeted biopsies. However, a truly cost-effective surveillance strategy remains to be determined. [ABSTRACT FROM AUTHOR]

In Asia, the prevalence of Helicobacter pylori ( H. pylori) infection varies markedly in different countries. Higher prevalence rates are found in developing Asian countries while lower rates have been reported in more industrialized and developed countries. Within a country, the seroprevalence rates may vary between distinct geographic regions. H. pylori infection is an important etiological factor for the occurrence of non-cardia gastric adenocarcinoma. The incidence rate of gastric adenocarcinoma in Asia tends to mirror the seroprevalence rate of H. pylori infection; however, there are populations with high seroprevalence rates of H. pylori infection that paradoxically have low incidence rates of gastric adenocarcinoma. These diverse clinical outcomes are related to bacterial virulence factors, concomitant environmental factors, host susceptibility and immune response. This review summarizes the current epidemiology of H. pylori infection in Asia and analyzes these data in the context of gastric cancer epidemiology. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Non-erosive reflux disease (NERD) constitutes the majority of patients with gastroesophageal reflux disease (GERD). Esophageal pH monitoring is useful in distinguishing patients with NERD from functional heartburn. The gastroenterologist often faces the dilemma of choosing the most appropriate investigative modality. The wireless Bravo® capsule allows prolonged 48 hour monitoring with improved patient tolerance, but concerns regarding its reduced sensitivity compared to conventional pH catheter have been raised. We compared the prevalence of high esophageal acid exposure and positive symptom correlation profiles (using the symptom index [SI] and symptom association probability [SAP]) in patients who underwent Bravo® compared to patients who underwent conventional pH catheter, and evaluated the efficacy of Bravo® monitoring in a multiracial Asian cohort. METHODS: Retrospective analysis of all pH studies performed between January 2004 and February 2009 for patients with persistent reflux symptoms and a normal gastroscopy. RESULTS: 66 (27 Male, 42.4 ± 13.4 years) and 55 (24 Male, 47.1 ± 13.3 years) patients underwent wireless and pH catheter evaluation respectively. “True NERD” (abnormal acid exposure) was diagnosed in 26 (39.4%) and 20 (36.4%) patients (pNS) while “acid-sensitive esophagus” (SI ≥ 50% and/or SAP ≥ 95%) occurred in 14 (21.2%) and 12 (21.8%) patients (pNS) using the wireless and pH catheter respectively. Extended recording time with Bravo® led to an incremental diagnostic yield of 30%. CONCLUSION: The wireless capsule was well tolerated. The diagnostic yield was similar using both modalities. With the increasing availability of impedance-pH technology, it is uncertain if devices that detect only acid-reflux events will be surpassed. [ABSTRACT FROM AUTHOR]

The Asia–Pacific Consensus Conference was convened to review and synthesize the most current information on Helicobacter pylori management so as to update the previously published regional guidelines. The group recognized that in addition to long-established indications, such as peptic ulcer disease, early mucosa-associated lymphoid tissue (MALT) type lymphoma and family history of gastric cancer, H. pylori eradication was also indicated for H. pylori infected patients with functional dyspepsia, in those receiving long-term maintenance proton pump inhibitor (PPI) for gastroesophageal reflux disease, and in cases of unexplained iron deficiency anemia or idiopathic thrombocytopenic purpura. In addition, a population ‘test and treat’ strategy for H. pylori infection in communities with high incidence of gastric cancer was considered to be an effective strategy for gastric cancer prevention. It was recommended that H. pylori infection should be tested for and eradicated prior to long-term aspirin or non-steroidal anti-inflammatory drug therapy in patients at high risk for ulcers and ulcer-related complications. In Asia, the currently recommended first-line therapy for H. pylori infection is PPI-based triple therapy with amoxicillin/metronidazole and clarithromycin for 7 days, while bismuth-based quadruple therapy is an effective alternative. There appears to be an increasing rate of resistance to clarithromycin and metronidazole in parts of Asia, leading to reduced efficacy of PPI-based triple therapy. There are insufficient data to recommend sequential therapy as an alternative first-line therapy in Asia. Salvage therapies that can be used include: (i) standard triple therapy that has not been previously used; (ii) bismuth-based quadruple therapy; (iii) levofloxacin-based triple therapy; and (iv) rifabutin-based triple therapy. Both CYP2C19 genetic polymorphisms and cigarette smoking can influence future H. pylori eradication rates. [ABSTRACT FROM AUTHOR]

OBJECTIVE:  To evaluate the role of endoscopic drainage and endoscopic necrosectomy in the management of symptomatic pancreatic fluid collection. METHODS:  The clinical data of patients with symptomatic pancreatic fluid collection referred for endoscopic drainage were captured prospectively and analyzed. Pancreatic duct disruption was treated with stenting. Endosonography-guided transmural drainage and endoscopic necrosectomy were performed when indicated. RESULTS:  Fifteen consecutive patients (mean age 53.7 years; range 23–82 years) underwent endoscopic management of pancreatic fluid collections (pseudocysts: six; abscesses: six; infected walled-off necrosis: three). Pancreatic duct fistulas were present in 13 patients. The drainage techniques used were: (i) transpapillary drainage; five; (ii) transmural drainage; two (these two patients had no pancreatic duct fistulas); and (iii) combined transpapillary and transmural drainage; eight. An additional transgastric endoscopic necrosectomy was performed in five patients. The endoscopic treatment was successful in all cases. The only complication was asymptomatic pneumo-peritoneum that occurred in one patient. Combined transpapillary and transmural drainage led to the faster resolution of the fluid collection compared to transpapillary drainage (75.6 vs 147 days, P = 0.03). No recurrence occurred over a mean follow up of 486 days. CONCLUSION:  Endoscopic drainage and endoscopic necrosectomy are safe and effective techniques for the treatment of symptomatic pancreatic fluid collection. [ABSTRACT FROM AUTHOR]

An editorial is presented on international medical journal that accepts quality academic submissions from across the world with topics such as mentoring and competency, medical professionalism, responding to the challenges of COVID-19. Topics include COVID-19 vaccine-related concerns and colon cancer screening at a younger age; and needs of trainees and generalists in the hospital setting, as a Problem-Solving for Acute and Critical Care (PACC), will be launched in 2022.

Acid-related disorders are common management problems in clinical practice. The key to effective management is successful suppression of gastric acid production. Proton pump inhibitors (PPIs) are the most potent acid suppressants available and are significantly more effective than histamine H2 receptor antagonists. Although PPIs are highly effective as a class, differences in their pharmacokinetics, such as bioavailability, elimination half-life and metabolism, may translate into differences in clinical outcomes. A new immediate-release omeprazole has been introduced, which allows rapid absorption. This has been shown to produce significantly better nocturnal gastric acid control than delayed-release tablets. The bioavailability of rabeprazole on day 1 is greater than with other PPIs, and this may translate into faster onset of symptom relief for patients with gastrooesophageal reflux disease. On the other hand, the bioavailability of esomeprazole increases 3-fold at day 5, and it has been shown that on day 5, esomeprazole provided significantly more effective control of gastric acid than other PPIs. The exact clinical significance of these observations remains to be determined. There is genetic polymorphism in PPI metabolism via cytochrome P450 2C19. In Helicobacter pylori eradication, a significantly lower eradication rate was seen in extensive metabolisers with omeprazole and lansoprazole but not with rabeprazole. The oesophagitis healing rate was lower in extensive metabolisers with lansoprazole but not with rabeprazole. The currently available PPIs have short elimination half-lives ranging from 1 to 1.5 hours. Tenatoprazole is a new PPI that has a 5- to 7-fold longer elimination half-life than current PPIs. It could be potentially more useful for the treatment of gastro-esophageal reflux disease and nocturnal acid breakthrough than other PPIs. [ABSTRACT FROM AUTHOR]

Background and Aims: Since the publication of the Asia-Pacific GERD consensus in 2004, more data concerning the epidemiology and management of gastroesophageal reflux disease (GERD) have emerged. An evidence based review and update was needed. Methods: A multidisciplinary group developed consensus statements using the Delphi approach. Relevant data were presented, and the quality of evidence, strength of recommendation, and level of consensus were graded. Results: GERD is increasing in frequency in Asia. Risk factors include older age, male sex, race, family history, higher socioeconomic status, increased body mass index, and smoking. Symptomatic response to a proton pump inhibitor (PPI) test is diagnostic in patients with typical symptoms if alarm symptoms are absent. A negative pH study off therapy excludes GERD if a PPI test fails. The role for narrow band imaging, capsule endoscopy, and wireless pH monitoring has not yet been undefined. Diagnostic strategies in Asia must consider coexistent gastric cancer and peptic ulcer. Weight loss and elevation of head of bed improve reflux symptoms. PPIs are the most effective medical treatment. On-demand therapy is appropriate for nonerosive reflux disease (NERD) patients. Patients with chronic cough, laryngitis, and typical GERD symptoms should be offered twice daily PPI therapy after excluding non-GERD etiologies. Fundoplication could be offered to GERD patients when an experienced surgeon is available. Endoscopic treatment of GERD should not be offered outside clinical trials. Conclusions: Further studies are needed to clarify the role of newer diagnostic modalities and endoscopic therapy. Diagnostic strategies for GERD in Asia must consider coexistent gastric cancer and peptic ulcer. PPIs remain the cornerstone of therapy. [ABSTRACT FROM AUTHOR]

Nocturnal acid breakthrough is seen in more than 70% of Helicobacter pylori-negative patients taking long-term proton pump inhibitors (PPI). It is defined as an intragastric pH of less than 4 for at least 60 consecutive minutes during the overnight period in patients on PPI therapy. It occurs as a result of the recovery of intragastric acidity. Nocturnal acid breakthrough can be clinically significant in patients with complicated gastroesophageal reflux disease, Barrett’s esophagus and esophageal motility disorders because of the potential for continued esophageal mucosal injury. To decrease nocturnal acid breakthrough, for patients on once daily PPI, treatment should be stepped up to twice daily. For patients already on twice daily PPI, nocturnal histamine-2 receptor antagonists may be added, but the long-term effectiveness remains debatable as patients may develop tolerance over the course of time. New PPI with a longer half-life may decrease nocturnal acid breakthrough. [ABSTRACT FROM AUTHOR]

Background: In Singapore, the highest incidence of gastric cancer occurs in the Chinese (C), with lower rates among Malay (M) and Indian (I) subjects. The purpose of the present paper was to examine whether racial differences in the prevalence of Helicobacter pylori and serum pepsinogen (PG) could account for this difference. Methods: A randomized community health survey involving 7000 asymptomatic healthy individuals was conducted. Among the Chinese, Malay and Indian respondents, subjects were matched for age, gender and race and a total of 595 sera were obtained. The H. pylori seropositivity and serum PG levels were determined by ELISA. The dependency of the cumulative gastric incidence rate on H. pylori seroprevalence was evaluated by linear regression. The racial difference in the seroprevalence of H. pylori and low serum PG was determined. Results: The H. pylori seroprevalence was similar between Chinese and Indian subjects, but significantly lower among Malay subjects (C, 46.3%; M, 27.9%; I, 48.1%). The gastric cancer incidence rates correlated with H. pylori seropositivity for the Chinese and Malay subjects, but not for the Indian subjects. The prevalence of low PG was highest in Indian subjects (PG I low: C, 2.1%; M, 5.4%; I, 14.2%; P < 0.0001; PG I:II ratio low: C, 5.3%; M, 5.9%; I, 12.6%; P = 0.012), even when adjusted for gender and the presence of H. pylori. Conclusions: The difference in gastric cancer incidence correlated with H. pylori seroprevalence for Chinese and Malay subjects. The lower incidence of gastric cancer among Indian subjects cannot be explained by differences in H. pylori or serum PG. Other modifying factors such as host and environmental factors may be important. © 2005 Blackwell Publishing Asia Pty Ltd [ABSTRACT FROM AUTHOR]

The article presents author's views on ‘Professionalism in Medical Practice', with the importance of examining the entire healthcare ecosystem addressing the issue of medical professionalism. Topics include the lapses of the individual also consider the healthcare environment; and how the organization of health systems may impose psychological strain on individuals and result in errors in professionalism.

An editorial is presented on adapting and embracing change in the new normal. Topics include the COVID-19 has had a tremendous impact on all aspects of our lives, the adjustments were made to both work-related activities and our personal spheres, and the important work at the editorial office of the Singapore Medical Journal (SMJ) has continued unbated and albeit with necessary adjustments in line with health directives.

The article presents case studies of symptomatic advanced sigmoid-type achalasia, successfully treated by additional proximal curve myotomy during peroral endoscopy myotomy.

The article presents a case study of a 38-year-old man diagnosed with chronic pancreatitis developed because of access alcohol consumption, and was performed with endoscopic cholangiopancreatography (ERCP), and plastic stents insertion.

The article presents a case study of a 46-year-old man with segment 8 hepatocellular carcinoma (HCC) from hepatitis was admitted to a hospital for issues of postoperative bilioma, abdominal pain and cholestasis. The patient underwent a computed tomography (CT) of the liver and magnetic resonance imaging for its postcholecystectomy status and bile ducts. The article also discusses the use of SpyGlass DS Direct Visualization System in cholangioscopy.