Mistakes in clinical investigation of gastrointestinal motility and function and how to avoid them

or a urea breath test should be considered if Helicobacter pylori infection is suspected. Additionally, stool calprotectin levels are used to screen for inflammatory bowel disease (IBD) and are also raised in many cases of advanced neoplasia. Prospective trials and meta-analyses indicate that the presence of alarm symptoms is associated with a 5–10% risk of serious disease, compared with a 1–2% risk in patients without alarm symptoms. 4 Early endoscopy is indicated to exclude ‘organic’ pathology in this Mistake 1 Failing to perform endoscopy and/or imaging in the presence of alarm features The initial assessment of patients with gastrointestinal symptoms must identify ‘alarm features’ that could indicate the presence of neoplasia, ulceration or inflammation in the digestive tract and require urgent endoscopy and/or imaging (see list in figure 1). In practice, identification is based on clinical history and the results of laboratory investigations, including a full blood count, clinical chemistry for renal and liver function, calcium, thyroid Symptoms related to abnormal gastrointestinal motility and function can occur from the moment food is swallowed to the time stool is passed into the toilet. A recent UEG survey indicated that dysphagia, heartburn, bloating, abdominal pain and changes to bowel habit are each reported by 5–15% of the general population.1 These symptoms are frequent reasons for seeking medical attention from general physicians and for referral to specialist gastroenterologists. Most patients with these symptoms do not have neoplasia, infection or inflammation on initial investigation, but rather so-called functional gastrointestinal symptoms.2, 3 For patients with mild symptoms, negative tests provide reassurance and simple, symptomatic management might be all that is required (e.g. acid suppression, stool regulation). However, for those with severe symptoms that persist on therapy, ruling out life-threatening disease is not sufficient, and referral to the neurogastroenterology and motility (NGM) laboratory for physiological measurements is often indicated. Clinical investigations aim to explain the cause of symptoms and establish a diagnosis that can guide rational treatment. Until recently, it could be argued that manometry, scintigraphy, breath tests and related tests rarely provided this information. As a result, only patients with suspected major motility disorders (e.g. achalasia, severe reflux disease or faecal incontinence) were routinely referred to the NGM laboratory for tests. Technological advances, such as high-resolution manometry (HRM), now provide objective measurements not only of motility, but also of function in terms of the movement (and digestion) of ingested material within the gastrointestinal tract. Furthermore, the ability to associate events (such as bolus retention, reflux or gas production) with symptoms provides an indication of visceral sensitivity and can identify what is causing patient complaints. Here, I discuss frequent mistakes in clinical investigation of gastrointestinal motility and function based on a series of consensus documents published by members of the International Working Group for Disorders of Gastrointestinal Motility and Function. group and also in patients who have raised stool calprotectin levels. Endoscopy should also be performed in patients who have an existing functional gastrointestinal disease (FGID) diagnosis if alarm features develop, in patients who have severe symptoms that fail to respond to therapy and if there is a persistent change in symptoms during follow up. If endoscopy is performed, biopsy samples should be acquired to test for infection (e.g. H. pylori) or inflammation (e.g. coeliac disease, microscopic colitis). This is appropriate even if appearances are normal. Abdominal ultrasound to exclude gallbladder stones and other abdominal pathology is part of the routine evaluation in many European countries; however, CT should not be performed routinely, especially in young females, to avoid unnecessary exposure to radiation. In patients with negative test results who have ongoing symptoms, it is not appropriate to repeat endoscopic or other investigations without a clear indication because the costs are significant and the