Despite of the widespread use of hydrogen and methane breath test, the variability in testing protocols, gas measurement techniques, and interpretation criteria continues to challenge the reproducibility and comparability across centers, especially in the Asia-Pacific region. The Asian Neurogastroenterology and Motility Association hence presents the first Asian monograph guiding application and interpretation of breath test. The monograph was formulated according to the framework of indications, preparatory process, performance, and interpretation of results, as well as future direction for research.

Background/Aims: Belching can occur either independently or concurrently with reflux symptoms. This study aims to explore the relationship between belching and reflux and explore the underlying mechanisms involved. Methods: Firstly, patients with isolated belching symptoms or concurrent belching and reflux symptoms were retrospectively enrolled. High-resolution esophageal impedance manometry (HRIM) and 24-hour pH impedance monitoring were used to assess belching types and temporal relationship between belching and reflux. Secondly, subjects with belching disorder were prospectively recruited. Postprandial HRIM monitoring was used to clarify the relationship and underlying mechanisms between belching and reflux. Results: In the initial phase, 139 subjects were enrolled. Regardless of patients' symptom spectrum (with or without gastroesophageal reflux symptoms), the proportion of preceding-reflux belching was significantly higher in those with objective evidence of gastroesophageal reflux disease, compared to those without (both P < 0.05), which indicated that belching could trigger reflux events and led to more severe reflux burden. To clarify the potential mechanisms involved, 44 belching subjects were prospectively enrolled in the second phase of this study. HRIM analysis demonstrated that maximum intragastric pressure, gastric–lower esophageal sphincter pressure gradient and gastric–esophageal pressure gradient were significantly higher in preceding-reflux belching than those in independent belching. Conclusions This study demonstrated that belching might trigger reflux by increasing intragastric pressure, elevating the gastric-sphincter pressure gradient, which enables gastric contents to pass through the esophagogastric junction.These findings have crucial clinical significance, suggesting that reducing the occurrence of belching might be a potential treatment for refractory reflux.

Background/Aims: Chronic constipation is prevalent yet under-diagnosed across Asia, compromising quality of life and burdening healthcare systems. Cultural stigma, varied diets, and limited access to standardized diagnostic tools delay timely care. Methods: The Bali Chronic Constipation Roundtable in November 2024, brought together experts from 11 Asian countries. The group reviewed epidemiological data, analyzed multinational questionnaire on clinical practice pattern, and conducted structured discussions to identify key barriers and propose region-specific recommendations. Results: Chronic constipation prevalence varies across Asia, ranging from 1.8% in India to 16.6% in Japan, with women and the elderly disproportionately affected. Under-reporting persists owing to cultural taboos and widespread self treatment with laxatives and traditional medications. Although the Rome IV criteria remains the global standard, they may not fully reflect Asian symptom profiles, and diagnosis is limited by scarce motility laboratories. First line therapies such as dietary-fiber optimization and osmotic laxatives are widely available, but newer pharmacotherapies (prucalopride, linaclotide, lubiprostone, and elobixibat) remain costly and unevenly accessible. Biofeedback for dyssynergic defecation is underutilized due to limited availability. Experts recommend expanded regional research on to refine diagnostic criteria, coupled with enhanced physician education and public awareness. They advocate accessibility to second-line and novel therapies that incorporate culturally attuned regional guidelines, and improved access to gastrointestinal motility testing. Conclusions The Bali Chronic Constipation Roundtable highlighted Asia’s need for region specific diagnostics and management. Addressing diagnostic and treatment gaps will improve outcomes, while ongoing researcher clinician policy collaboration must standardize guidelines, advance research, and ensure equitable care across Asia.

Background/Aims: Reflux symptoms frequently present in patients diagnosed with functional dyspepsia (FD). This investigation sought to elucidate the contribution of gastroesophageal reflux in the overlap relationship. Methods: Consecutive patients presenting with reflux symptoms and/or FD symptoms were prospectively included. Comprehensive assessments, including symptoms evaluation, endoscopy, esophageal functional examinations (high-resolution manometry and reflux monitoring), and proton pump inhibitor (PPI) treatment efficacy evaluation, were conducted in these patients. Results: The study enrolled 315 patients, 43.2% of which had concurrent FD symptoms and overlapping reflux symptoms. Notably, a mere 28.7% of patients in the overlap symptoms group had objective gastroesophageal reflux disease evidences (the grade of esophagitis≥ B or the acid exposure time ≥ 4.2%). Functional heartburn was demonstrated to be the main cause of overlapping reflux symptoms(55.1%). Reflux parameters analysis revealed that the reflux burden in the overlap symptoms group paralleled that of the FD symptoms group, with both registering lower levels than the reflux symptoms group (P < 0.05). Furthermore, PPI response rates were notably diminished in the overlap symptoms group (P < 0.001), even for those with objective gastroesophageal reflux disease evidences. Conclusions The study illuminated that overlapping reflux symptoms in FD was common. Strikingly, these symptoms primarily diverged from reflux etiology and exhibited suboptimal responses to PPI intervention. These findings challenge prevailing paradigms and accentuate the imperative for nuanced therapeutic approaches tailored to the distinctive characteristics of overlapping reflux symptoms in the context of FD.

Gastroesophageal reflux disease (GERD) is characterized by significant clinical heterogeneity. Conventional diagnostic approaches, including symptom-based questionnaires, empirical acid suppression trials, and single-modality objective tests, demonstrate limited sensitivity and specificity, often resulting in diagnostic inaccuracies and inefficient resource utilization. To overcome these diagnostic challenges, this article provides a systematic review of recent advancements and ongoing debates in GERD diagnostics, with a focus on the diagnostic value of multimodal parameters as outlined in the Lyon Consensus 2.0. It also explores the clinical relevance of emerging auxiliary diagnostic metrics. We emphasize that integrating clinical symptomatology, endoscopic findings, esophageal physiological measurements, and psychosocial factors (augmented by composite scoring systems and artificial intelligence), offers a promising strategy for accurate diagnosis and personalized treatment of GERD.

Objective:This study aims to conduct a systematic review and network meta-analysis comparing the safety and efficacy of endoscopic versus surgical treatments for gastroesophageal reflux disease (GERD).Methods:Randomized controlled trials were identified through systematic searches of MEDLINE, Embase, Web of Science, and CNKI. Both direct effect models and Bayesian random-effects network meta-analysis were used to compare treatments directly and indirectly. The following types of studies were included : (1) RCTs involving endoscopic or surgical treatment for adult GERD patients aged ≥18 years with no previous history of gastroesophageal surgery; (2) studies comparing two or more treatment methods, including different endoscopic or surgical procedures, proton pump inhibitor (PPI) therapy, and/or sham surgery; and (3) articles published in Chinese or English. Review articles and conference abstracts were excluded.Results:A total of 47 randomized controlled trials were enrolled, and 43 studies were network meta-analyzed. Both endoscopic and surgical treatments significantly reduced postoperative PPI use compared to PPI therapy ( P <0.05). Among all treatment modalities, laparoscopic Nissen fundoplication (LNF, SUCRA=0.84) demonstrated the highest efficacy, followed by laparoscopic Toupet fundoplication (LTF, SUCRA=0.71) and anterior partial fundoplication (APF, SUCRA=0.70). Transoral incisionless fundoplication (TIF) demonstrated the best outcomes in relieving heartburn (SUCRA=0.87) and bloating (SUCRA=0.86) symptoms. The overall safety of surgical treatment was comparable to that of PPI therapy. However, LNF was associated with a higher incidence of postoperative dysphagia and gas-related symptoms, whereas TIF had a lower risk of postoperative complications. Conclusions:Both endoscopic and surgical treatments are effective for GERD. LNF provides the highest rate of medication discontinuation but carries a higher risk of postoperative complications. TIF offers better relief of heartburn and bloating with fewer complications.

Background/Aims: Reflux symptoms frequently present in patients diagnosed with functional dyspepsia (FD). This investigation sought to elucidate the contribution of gastroesophageal reflux in the overlap relationship. Methods: Consecutive patients presenting with reflux symptoms and/or FD symptoms were prospectively included. Comprehensive assessments, including symptoms evaluation, endoscopy, esophageal functional examinations (high-resolution manometry and reflux monitoring), and proton pump inhibitor (PPI) treatment efficacy evaluation, were conducted in these patients. Results: The study enrolled 315 patients, 43.2% of which had concurrent FD symptoms and overlapping reflux symptoms. Notably, a mere 28.7% of patients in the overlap symptoms group had objective gastroesophageal reflux disease evidences (the grade of esophagitis≥ B or the acid exposure time ≥ 4.2%). Functional heartburn was demonstrated to be the main cause of overlapping reflux symptoms(55.1%). Reflux parameters analysis revealed that the reflux burden in the overlap symptoms group paralleled that of the FD symptoms group, with both registering lower levels than the reflux symptoms group (P < 0.05). Furthermore, PPI response rates were notably diminished in the overlap symptoms group (P < 0.001), even for those with objective gastroesophageal reflux disease evidences. Conclusions The study illuminated that overlapping reflux symptoms in FD was common. Strikingly, these symptoms primarily diverged from reflux etiology and exhibited suboptimal responses to PPI intervention. These findings challenge prevailing paradigms and accentuate the imperative for nuanced therapeutic approaches tailored to the distinctive characteristics of overlapping reflux symptoms in the context of FD.

Background/Aims: Reflux symptoms frequently present in patients diagnosed with functional dyspepsia (FD). This investigation sought to elucidate the contribution of gastroesophageal reflux in the overlap relationship. Methods: Consecutive patients presenting with reflux symptoms and/or FD symptoms were prospectively included. Comprehensive assessments, including symptoms evaluation, endoscopy, esophageal functional examinations (high-resolution manometry and reflux monitoring), and proton pump inhibitor (PPI) treatment efficacy evaluation, were conducted in these patients. Results: The study enrolled 315 patients, 43.2% of which had concurrent FD symptoms and overlapping reflux symptoms. Notably, a mere 28.7% of patients in the overlap symptoms group had objective gastroesophageal reflux disease evidences (the grade of esophagitis≥ B or the acid exposure time ≥ 4.2%). Functional heartburn was demonstrated to be the main cause of overlapping reflux symptoms(55.1%). Reflux parameters analysis revealed that the reflux burden in the overlap symptoms group paralleled that of the FD symptoms group, with both registering lower levels than the reflux symptoms group (P < 0.05). Furthermore, PPI response rates were notably diminished in the overlap symptoms group (P < 0.001), even for those with objective gastroesophageal reflux disease evidences. Conclusions The study illuminated that overlapping reflux symptoms in FD was common. Strikingly, these symptoms primarily diverged from reflux etiology and exhibited suboptimal responses to PPI intervention. These findings challenge prevailing paradigms and accentuate the imperative for nuanced therapeutic approaches tailored to the distinctive characteristics of overlapping reflux symptoms in the context of FD.

Objective:To investigate the current level of awareness among Chinese gastroenterologists regarding small intestinal bacterial overgrowth (SIBO).Methods:From March 7th to April 14th, 2024, an online survey questionnaire was sent to qualified clinical physicians specializing in gastroenterology in various levels of general hospitals across the country through the official channels of national academic organizations such as the Gastroenterology Branch of the Chinese Medical Association, the Gastrointestinal Motility Group of the Gastroenterology Branch of the Chinese Medical Association, and the Functional Gastrointestinal Disorders Collaborative Group of the Gastroenterology Branch of the Chinese Medical Association, as well as through the national medical continuing education project cooperation platform. The questionnaire content includes basic information, awareness of consensus guidelines on functional gastrointestinal disorders (FGID) and SIBO, understanding of SIBO and its diagnosis and treatment strategies, et al. The influencing factors of physicians′ cognitive level regarding SIBO were analyzed based on the questionnaire results. Statistical methods employed descriptive statistical method and partial correlation analysis.Results:A total of 511 valid questionnaires were collected, among them, 78.1% (399/511) of the respondents practiced in tertiary hospitals, and 90.2% (461/511) of the respondents were aware of the definition of SIBO. However, only 9.0% (46/511) could accurately identify all the key points of the relevant consensus guidelines. Educational background (undergraduate and master′s degree vs. doctor degree, OR=0.265, 0.528, 95% confidence interval(95% CI): 0.155 to 0.454, 0.322 to 0.865), professional title (junior title vs. senior title, OR=0.577, 95% CI: 0.344 to 0.968), and the number of SIBO cases handled per year (less than 50 cases vs. more than 200 cases, OR=0.144, 95% CI: 0.043 to 0.479) were independent influencing factors that affect the cognitive level of specialist physicians regarding SIBO and the guidelines (all P<0.05). The results of hydrogen and methane breath test (HMBT) was the main reference indicator for diagnosing SIBO in the respondents (79.8%, 408/511), but only 8.4%(43/511) of the specialists were familiar with the principle of HMBT, and 65.9% (337/511) were not clear about the differences in diagnostic thresholds among different consensus or guidelines. Rifaximin was the most commonly used therapy (87.5%, 447/511), but there was significant heterogeneity in the selection of dosage and treatment course. According to the survey, 17.6% (90/511) of the clinicians believed that comprehensive assessment of the patient′s clinical condition was not necessary for the diagnosis and treatment of FGID. Conclusion:Gastroenterologists are familiar with the basic concepts of SIBO, but their understanding of the diagnostic criteria application and the latest research progress is limited.

Objective:This study aims to conduct a systematic review and network meta-analysis comparing the safety and efficacy of endoscopic versus surgical treatments for gastroesophageal reflux disease (GERD).Methods:Randomized controlled trials were identified through systematic searches of MEDLINE, Embase, Web of Science, and CNKI. Both direct effect models and Bayesian random-effects network meta-analysis were used to compare treatments directly and indirectly. The following types of studies were included : (1) RCTs involving endoscopic or surgical treatment for adult GERD patients aged ≥18 years with no previous history of gastroesophageal surgery; (2) studies comparing two or more treatment methods, including different endoscopic or surgical procedures, proton pump inhibitor (PPI) therapy, and/or sham surgery; and (3) articles published in Chinese or English. Review articles and conference abstracts were excluded.Results:A total of 47 randomized controlled trials were enrolled, and 43 studies were network meta-analyzed. Both endoscopic and surgical treatments significantly reduced postoperative PPI use compared to PPI therapy ( P <0.05). Among all treatment modalities, laparoscopic Nissen fundoplication (LNF, SUCRA=0.84) demonstrated the highest efficacy, followed by laparoscopic Toupet fundoplication (LTF, SUCRA=0.71) and anterior partial fundoplication (APF, SUCRA=0.70). Transoral incisionless fundoplication (TIF) demonstrated the best outcomes in relieving heartburn (SUCRA=0.87) and bloating (SUCRA=0.86) symptoms. The overall safety of surgical treatment was comparable to that of PPI therapy. However, LNF was associated with a higher incidence of postoperative dysphagia and gas-related symptoms, whereas TIF had a lower risk of postoperative complications. Conclusions:Both endoscopic and surgical treatments are effective for GERD. LNF provides the highest rate of medication discontinuation but carries a higher risk of postoperative complications. TIF offers better relief of heartburn and bloating with fewer complications.