Feature Papers in Gastrointestinal Disorders in 2025–2026

Background/Objectives: The role of the intestinal microbiota in gastroenterological diseases has gained increasing relevance in general medicine. The study aimed to evaluate the knowledge and awareness of Italian general practitioners regarding gut microbiota, as well as the clinical applications of probiotics and prebiotics. Methods: The survey research involved 457 Italian general practitioners, who anonymously filled an online structured questionnaire. Results: Most respondents identified antibiotics, diet, gastrointestinal infections, and stress as factors that can modulate the gut microbiota, while a smaller proportion recognized the role of physical activity. A comparable number acknowledged the influence of obesity, smoking, and immunosuppressant drugs. Although most participants correctly defined probiotics, the concept of prebiotics was less widely understood. Probiotics were primarily prescribed for irritable bowel syndrome, suspected dysbiosis, or during antibiotic therapy, and only a portion of physicians reported routinely combining them with prebiotics. The selection of probiotic strains was mainly based on personal experience, while fecal microbiota analysis was seldom used in clinical practice. Conclusions: These findings provide an updated snapshot of current knowledge and practices regarding the microbiota in Italian general medicine and highlight critical gaps, particularly in the understanding of prebiotics and less recognized modulatory factors. Full article

Background: Achalasia is a rare primary esophageal motility disorder characterized by impaired lower esophageal sphincter relaxation and progressive loss of peristalsis. Although its pathogenesis remains incompletely understood, autoimmune mechanisms have been repeatedly proposed. Thyroid disorders, particularly autoimmune thyroiditis and Graves’ disease, have been reported as frequent comorbidities, suggesting a shared autoimmune background. Methods: We conducted a narrative review of PubMed, Scopus, and Web of Science from January 2005 to August 2025. Eligible studies included observational cohorts, case–control analyses, and case reports describing thyroid disease in achalasia. Mechanistic and immunological studies relevant to thyroid autoimmunity were also considered. Data were synthesized narratively and summarized in tables and figures. Results: Despite heterogeneity, evidence consistently indicates an increased prevalence of thyroid disease in achalasia. Early reports described dysfunction in up to one quarter of cases, while Romero-Hernández et al. demonstrated a threefold higher risk of autoimmune thyroid disease. Multicenter data confirmed thyroid autoimmunity in about one fifth of patients. Although thyroid disease did not alter short-term procedural outcomes, unrecognized dysfunction may complicate postoperative evaluation. Immunological findings, including human leukocyte antigen (HLA) susceptibility and lymphocytic infiltration of myenteric plexus, further support a shared autoimmune predisposition. Conclusions: Thyroid disorders, particularly autoimmune hypothyroidism, are more common in achalasia than in the general population. Although the evidence remains limited, the consistent signal suggests a non-random association. Early recognition may improve patient management, while prospective multicenter studies are needed to clarify causality and to determine whether achalasia should be considered part of a broader autoimmune spectrum. Full article

Background: The human gut microbiome—a diverse ecosystem of trillions of microorganisms—plays an essential role in metabolic, immune, and neurological regulation. However, modern lifestyle factors such as antibiotic overuse, cesarean delivery, reduced breastfeeding, processed and high-sodium diets, alcohol intake, smoking, and exposure to environmental toxins (e.g., glyphosate) significantly reduce microbial diversity. Loss of keystone species like Bifidobacterium infantis (B. infantis) and Lactobacillus reuteri (L. reuteri) contributes to gut dysbiosis, which has been implicated in chronic metabolic, autoimmune, cardiovascular, and neurodegenerative conditions. Materials and Methods: This Qualitative Systematic Review (QualSR) synthesized data from over 547 studies involving human participants and standardized microbiome analysis techniques, including 16S rRNA sequencing and metagenomics. Studies were reviewed for microbial composition, immune and metabolic biomarkers, and clinical outcomes related to microbiome restoration strategies. Results: Multiple cohort studies have consistently reported a 40–60% reduction in microbial diversity among Western populations compared to traditional societies, particularly affecting short-chain fatty acid (SCFA)-producing bacteria. Supplementation with B. infantis is associated with a significant reduction in systemic inflammation—including a 50% decrease in C-reactive protein (CRP) and reduced tumor necrosis factor-alpha (TNF-α) levels—alongside increases in regulatory T cells and anti-inflammatory cytokines interleukin-10 (IL-10) and transforming growth factor-beta 1 (TGF-β1). L. reuteri demonstrates immunomodulatory and neurobehavioral benefits in preclinical models, while both probiotics enhance epithelial barrier integrity in a strain- and context-specific manner. In murine colitis, B. infantis increases ZO-1 expression by ~35%, and L. reuteri improves occludin and claudin-1 localization, suggesting that keystone restoration strengthens barrier function through tight-junction modulation. Conclusions: Together, these findings support keystone species restoration with B. infantis and L. reuteri as a promising adjunctive strategy to reduce systemic inflammation, reinforce gut barrier integrity, and modulate gut–brain axis (GBA) signaling, indicating translational potential in metabolic and neuroimmune disorders. Future research should emphasize personalized microbiome profiling, long-term outcomes, and transgenerational effects of early-life microbial disruption. Full article

Background: Spontaneous intragastric balloon hyperinflation (SIBH) is a rare and concerning complication of intragastric balloons (IGBs). The mechanisms underlying SIBH remain unclear. This systematic review aims to synthesise the current evidence regarding the clinical presentation, management, complications, and hypothesised aetiologies of SIBH. Methods: A comprehensive literature search was conducted using PubMed, EMBASE, MEDLINE, and Ebsco databases. Studies reporting on cases of SIBH were identified and reviewed. Data points were extracted on patient presentation, management strategies, complications, outcomes, and proposed mechanisms. Results: Eighteen publications describing 29 patients with SIBH were included. The most common clinical presentation was gastric outlet obstruction (86%). Emergency endoscopy was required in 96% of cases, with balloon removal performed in 82%. Reported complications included acute pancreatitis and mucosal erosions; however, neither long-term morbidity nor mortality was observed. Microbial colonisation was hypothesised as the underlying cause in 62% of publications, supported by culture findings from balloon contents in 90% of cases, most commonly isolating gas-producing organisms such as Candida (80%) and anaerobic bacteria (40%). Conclusions: SIBH most frequently presents with gastric outlet obstruction and typically necessitates emergency endoscopic intervention. Gas-producing microbial colonisation of the balloon is the predominant hypothesised aetiology. Preventive strategies targeting microbial colonisation may be crucial in reducing the incidence of SIBH. Full article