Background

Gastrointestinal (GI) motility disorders such as gastroparesis, functional dyspepsia, enteric dysmotility, irritable bowel syndrome, and constipation have a substantial global impact, reducing quality of life and imposing significant burdens on health insurance systems [1, 2].

GI motility disorders manifest as unexplained symptoms affecting various parts of the GI tract. These include the upper oesophagal sphincter, oesophagal peristalsis, lower oesophagal sphincter, gastric emptying, small intestinal motility, colonic transit, colonic dysbiosis, and anorectal issues such as dyssynergia and anal sphincter defects. Distinguishing GI motility disorders from organic conditions (such as inflammatory or malignant diseases) heavily relies on patient history, which poses diagnostic challenges [3, 4].

GI motility disorders pose a diagnostic challenge. They manifest as unexplained symptoms affecting various parts of the GI tract, including the upper oesophagal sphincter, oesophagal peristalsis, lower oesophagal sphincter, gastric emptying, small intestinal motility, colonic transit, colonic dysbiosis, and anorectal issues such as dyssynergia and anal sphincter defects [3]. In clinical practice, the first step to assess GI symptoms is to exclude organic diseases, mainly if there are any concerning signs such as weight loss, bloody stool, abdominal masses, lymphadenopathy, or anemia [5]. Motility tests are usually performed for patients with persistent complaints associated with GI motility disorders, significantly affecting their quality of life, nutrition, social functioning, and work productivity, or occasionally elevating mortality risk [6, 7]. Furthermore, distinguishing GI motility disorders from organic conditions (such as inflammatory or malignant diseases) relies heavily on patient history [4].

Recent progress has brought forth sophisticated diagnostic instruments to evaluate GI motility and function [8, 9]. The International Working Group on Disorders of GI and Function strongly encourages the consistent use of these diagnostic tests to detect clinically relevant problems and guide treatment decisions [10, 11]. Despite advancements in this particular area, there remains a lack of overall agreement on the proper protocols for diagnosing and treating extremely severe gastrointestinal motility disorders. This absence of agreement has triggered debates among experts globally, leading to considerable variability in clinical practice [12]. Unfortunately, this circumstance may have increased the number of intestinal failures as a result of severe GI motility disorders [13].

In Egypt, similarly, despite numerous global publications, there is a limited emphasis on GI motility research. We hypothesized that insufficient awareness, ambiguity, and inconsistencies in defining and investigating GI motility disorders might contribute to physicians’ hesitancy in ordering GI motility studies. Consequently, Egyptian patients with such disorders are likely to be underdiagnosed. To comprehensively address this issue, we interviewed Egyptian physicians to explore their attitudes toward adult patients with GI motility disorders, evaluate their clinical practices, and pinpoint specific knowledge gaps in this domain.

Methods

An observational cross-sectional study was conducted in Egypt to examine physicians’ knowledge, practice, and attitudes towards adult patients with GI motility disorders.

Data collection

Physicians were invited to answer a questionnaire. The questionnaire was uploaded online (Microsoft Forms or Google Forms) to be self-employed for physicians to answer. They were invited through several social media platforms (Facebook, Twitter, and Whatsapp).

Questionnaire structure

The questionnaire administered in this study comprised two primary sections. Part I gathered data related to socio-demographic characters of the study participant, including age, gender, residence, educational qualifications, specialty, and workplace details. Part II inquired into assessing participants’ knowledge, practices, and attitudes about GI motility disorders. It included questions about understanding and preferences regarding motility disorders, exploration of clinical practices, and evaluation of attitudes towards these conditions.

Questionnaire validation

We ensured that our questionnaire achieved content validity and was well-prepared for further assessment in real-world settings. The following steps were taken: (1) Content Validation Form Preparation: The content validation form was developed to ensure the review panel understood their task clearly. This form served as a guide for evaluating the questionnaire. (2) Expert Review Group Selection: A review group of experts with specific knowledge of the subject matter was meticulously formed. The committee comprised seven professors: two gastroenterologists (MA and MAG), one public health expert (SWE), one specialist in endemic medicine (ME), and three tropical medicine professors (HMA, MAS, and IFM). (3) Pilot Testing and Cognitive Interviewing: Trained team members (EAS) administered the translated questionnaire to 20 participants. Participants’ understanding, readability, language usage, wording, cultural appropriateness of items, and clarity of response instructions were assessed during these interviews. Some interviewees encountered difficulties comprehending certain modified items. Additionally, participants provided valuable feedback on specific questions. (4) Final Version Approval: The questionnaire was refined based on insights from pilot testing and cognitive interviews. Subsequently, the researchers approved the final version, preparing it for field testing.

Statistical analysis

Data were presented as mean ± SD for quantitative variables and percentages and frequencies for qualitative variables. Statistical tools from the Epi website were utilized to determine the sample size. The sample size calculation considered a 5% margin of error, a 95% confidence interval, and an estimated design effect (DEFF) of one (n = [DEFF*Np(1-p)]/[(d2/Z21-α/2*(N-1) + p*(1-p)]). Initially, the estimated minimum sample size was 384 participants. However, the actual collected sample size was 462 participants.

Ethical consideration

The study obtained approval from the Ethics Committee of the National Liver Institute, Menoufia University, Egypt (IRB No: 00416/2022). It adhered to the International Ethical Guidelines for Epidemiological and Descriptive Studies.

Results

Study’s demographics and participant characteristics

Our study had a diverse pool of physicians. All Egyptians, the majority from Greater Cairo (35%). Males participated more than female physicians (56.9% to 43.1%). Physicians aged 30 to 34 were more than any other age group (37.2%). Most study participants held master’s degrees (30.3%) or MDs (33.3%), indicating high education and expertise. Participants averaged 8.45 years of specialty field experience, with 40.3% having fewer than five years. Most participants had diagnostic (52.4%) and therapeutic (29.7%) upper GI endoscopic experience (Table 1).

Table 1 Demographic data of the participants
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Participants’ knowledge of GI motility studies and symptoms

Approximately 67.1% of participants indicated familiarity with GI motility studies, while 31.6% responded that they did not know, and only a small percentage (1.3%) were unsure. Dysphagia, odynophagia, reflux symptoms, non-cardiac chest pain, vomiting, eructation, and epigastric pain were recognized as symptoms of upper GI motility disorders by the majority of participants, with percentages ranging from 48.7% to 84.2%. Although not typically associated with upper GI motility disorders, hematemesis was identified as such by a small percentage (13.4%) of participants (Table 2, Fig. 1).

Table 2 Participants’ knowledge of GI motility studies
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Fig. 1
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Participants’ knowledge of GI motility studies

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Symptoms such as constipation, bloating, diarrhea, bloody diarrhea, incontinence, the need to strain, a sense of obstruction, and long periods between motions were identified as symptoms of lower GI motility disorders. Notably, while constipation was recognized as a symptom by the majority (85.1%) of participants, bloody diarrhea, which is not typically associated with lower GI motility disorders, was acknowledged by 21.6% of participants (Table 2, Fig. 2).

Fig. 2
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Participants’ knowledge of GI motility symptoms

*Not a GI motility disorder.*Long period between motions = constipation

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Participants’ knowledge of GI motility diagnostic methods

A significant portion of participants (63.8%) emphasized the importance of endoscopy as a primary investigative tool for diagnosing various GI motility disorders. The study also revealed overwhelming agreement among participants (84.9%) regarding the indispensable nature of manometry in diagnosing GI motility disorders. Furthermore, participants collectively acknowledged other investigative modalities relevant to diagnosing GI motility disorders. Most (59.1%) recognized pH studies as crucial for assessing acid reflux and esophageal motility. Similarly, a notable percentage (67.1%) affirmed the importance of the barium study, indicating its value in highlighting structural abnormalities and functional issues within the GI tract. Scintigraphy garnered significant recognition, with 74.7% of participants acknowledging its relevance in diagnosing motility disorders and emphasizing its utility in evaluating gastric emptying and transit times. However, opinions regarding the utility of computed tomography (CT) were more diverse, with 65% agreeing or strongly agreeing on its importance, while 34.8% expressed neutral or disagreeing perspectives. This divergence suggests varying participant interpretations regarding CT’s role in diagnosing GI motility disorders. Additionally, endoscopic ultrasound emerged as a priority investigation modality, with 63.2% of participants recognizing its significance (Table 3).

Table 3 Knowledge about investigations, modalities, and diagnosis of different GI motility disorders
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Participants practice for GI motility disorders

Many participants saw GI motility problems, with 24.7% seeing 1–5 and 24.7% seeing 6–10. This highlights the substantial caseload and the importance of effective diagnostic and management strategies. Also, most doctors (34.0%) who think a patient has a GI motility disorder first do endoscopy and imaging, then manometry. This demonstrates a standard, step-by-step method for diagnosing GI motility disorder in clinical practice.

The data demonstrates varying physician practices in referrals and interventions. Most participants refer patients to endoscopy (58.0%), whereas 6.8% and 7.4% suggest surgery and psychiatry. Similarly, 78.5% and 67.2% of physicians commonly manage achalasia and gastroparesis medically, while GERD and constipation receive more diverse management frequencies (Table 4, Fig. 3).

Table 4 Participants’ practice for GI motility disorders
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Fig. 3
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a GI motility disorder investigation referral frequency; b management frequency of GI motility disorders; and c frequency of suspected GI motility disorders investigations referral

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Attitude of the participants about motility disorder

A significant proportion of hospitals lack dedicated motility units or machines, with 56.9% of participants reporting their absence. The reasons cited for this absence vary, including financial constraints, lack of expertise, and perceived lack of necessity due to nearby units. Despite these challenges, participants are strongly inclined to participate in research studies on motility disorders, with 71.2% expressing interest. Additionally, the overwhelming majority (77.9%) of participants affirm the importance of diagnosing GI motility disorders, highlighting the recognition of these conditions as significant health concerns. Furthermore, the belief in the benefits of early diagnosis is prevalent, with 79.7% of participants acknowledging the potential benefits to patients. However, perceived barriers to motility practice, including the complexity of the branch, lack of experts, and expensive investigations, suggest ongoing challenges in effectively addressing GI motility disorders (Table 5).

Table 5 Attitude of the participants about motility disorder
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Discussion

The field of GI tract motility is dynamic and promising, with significant progress made over the past century, particularly in the last five decades. This progress is attributed to integrating various aspects, including electrophysiology, smooth muscle physiology, flow dynamics, neurohormonal physiology, and pharmaceutical research [14]. Interest in GI motility science surged in Egypt after adopting third-space endoscopic techniques in 2019, following the introduction of manometry devices in the 1990s [15].

This study represents a pioneering effort in Egypt and the broader Middle East to assess physicians’ knowledge, attitudes, and practices regarding GI motility studies. A total of 462 Egyptian physicians participated actively by answering the study questionnaire. The participant characteristics revealed a diverse demographic profile. According to the Association of American Medical Colleges, 56.9% of the participants were male, consistent with global trends, as males constitute over 80% of gastroenterologists [16]. Our study also underscores the diverse expertise and backgrounds of the participants, enriching the study’s insights and perspectives. One-third of the participants belonged to the 35–39 age group, with a significant portion falling within the 25–29- and 35–39-year brackets. Gastroenterologists dominated the study, constituting nearly two-thirds of the participants, while most were affiliated with university hospitals. Qualification-wise, around a third held either an MD, with a similar proportion possessing diplomas or fellowships. Specialty experience ranged widely from 0 to 50 years, with a mean of 8.45 ± 6.6, with 40% having less than 5 years of experience. Conversely, endoscopy experience ranged from 0 to 35 years, with a mean of 5.43 ± 5.25 (Table 1).

Our study indicates varying levels of knowledge and recognition among participants regarding GI motility studies and symptoms associated with upper and lower GI motility disorders. Dysphagia, a distressing oesophagal symptom, poses diagnostic challenges, particularly when functional causes are implicated after excluding organic factors [17]. Notably, vomiting is a hallmark symptom of gastroparesis [18], underlining the intricate relationship between GI motility and symptomatology. Moreover, gastroesophageal reflux disease (GERD) manifests through a spectrum of symptoms, including chest pain, dysphagia, odynophagia, epigastric pain, and nausea [19], mirroring a broader spectrum of motility disorders [20]. In our study, nearly 84.2% identified dysphagia as an essential symptom indicating an upper GI motility disorder, followed by 77.1% for non-cardiac chest pain, 72.5% for odynophagia, and 69% for vomiting as an upper GI motility disorder symptom.

Primary constipation is a significant subset of chronic constipation, often resulting from neuromuscular incoordination and frequently overlapped by dyssynergic defecation [21]. Regarding diarrhea, after excluding the presence of alarm symptoms such as bleeding, malnutrition, nocturnal diarrhea, and positive family history of colorectal cancer, dysmotility and functional causes should be investigated to diagnose irritable bowel disease with diarrhea and functional diarrhea [22]. In our study, 85.1% identified chronic constipation as an essential symptom indicating a lower GI motility disorder, followed by 74.5% for the need to strain, 70.6% for diarrhea, and 86.8% for bloating as lower GI motility disorder symptoms (Fig. 2).

GIT bleeding is a red flag of organic causes like inflammation, ulcers, varices, arteriovenous malformations, or malignancy [3]. Surprisingly, 13.4% said hematemesis is a sign of upper GI motility problems, while 16.7% didn’t know. While 16% didn’t know, 21.6% mistakenly replied that reduced GI motility problems cause bloody diarrhea. Nearly one-third of interviewees were unfamiliar with GI motility disorders (Table 2).

High-resolution manometry is well-known as the gold standard for diagnosing oesophagal motor dysfunction [23], especially when combined with impedance sensors [24]. pH studies are the most suitable, advanced method to diagnose GERD and are considered the gold standard [25]. Barium studies remain an essential diagnostic test in patients with motility disorders since they can identify structural lesions such as strictures and help identify significant motility disorders [26]. Gastric scintigraphy is a standard diagnostic tool for gastric dysmotility [27]. Our study findings suggest that participants generally recognize the importance of various investigation modalities in diagnosing GI motility disorders, with endoscopy, manometry, pH study, and scintigraphy particularly emphasized. Nearly two-thirds strongly agreed, and an additional 29.7% agreed that manometry is very important in the diagnosis of different GI motility disorders. However, a lesser percentage showed agreement for other investigations. One third strongly agreed, and an additional 28.8% agreed that pH studies are important in diagnosis, with nearly the same percent for barium studies. Unfortunately, due to wrong beliefs or lack of scientific basis, one-third strongly agreed that CT and abdominal ultrasound play a role in diagnosing GI motility disorders (Table 3, Fig. 3).

Our study findings shed light on physicians’ clinical practices and decision-making processes regarding GI motility disorders in Egypt; nearly half of the participants saw few patients with any GI motility disorders, less than 5 per week, or may not see one weekly. About one-third of them perform endoscopy, imaging at first, and then manometry when suspecting a GI motility disorder. About 24% may even try to treat and re-evaluate before imaging. More than 50% of them very frequently or consistently referred their suspected patient for endoscopy, and 47.9% for manometry. Unfortunately, only 26.9% of studied participants very frequently or consistently referred their suspected GI motility disorder patient to undergo a barium study, and only 13.8% were referred to psychiatry ((Table 4). The most frequent disorders that the participating physicians managed in their clinics were GERD and constipation, which is consistent with the global prevalence of constipation at fourteen percent [28], and the estimated global prevalence of GERD at 15%–25% [29].

When asked about having a motility unit/machine in their hospitals, more than half of the participants stated that they didn’t, in addition to 9.5% who didn’t know. They said this is due to financial problems or non-availability of experts. More than two-thirds of the studied participants paid attention. They were interested in participating in research concerning motility fields, stating that it is essential to diagnose GI motility disorders early. It is worth mentioning that most of the participants had a positive attitude towards GI motility practice. However, only 22.1% felt comfortable when dealing with a patient with a motility disorder. Most of the participating physicians were willing to attend training about motility disorders (96% for how to manage motility disorders medically, 94.6% for how to read a manometry report/topography, and 89.5% for investigations) rather than manometry [e.g., radiological] training (Table 5). This indicates potential gaps in resources and expertise within the healthcare infrastructure, suggesting a need for investment and capacity building to address GI motility disorders in Egypt better.

Standardized guidelines and improved coordination among healthcare providers are highlighted for patient care optimization. Training must be enhanced for suspecting, diagnosing, and managing motility disorders. Resource limitations, expertise boosts, and research initiatives are crucial in managing GI motility disorders in Egypt. The study reveals a lack of knowledge among Egyptian physicians about GI motility disorders, including symptom awareness and understanding of diagnostic modalities. Despite the lack of knowledge, most participants believe early diagnosis of GI motility disorders is important. Addressing knowledge deficits and improving physicians’ practice is essential for better patient outcomes in managing GI motility disorders. Training programs are needed to enhance physicians' knowledge and practice, covering the importance of medical and endoscopic management, early diagnosis, and various investigative modalities. Further research is required to evaluate training programs' effectiveness and identify barriers to GI motility practice in different regions. Studies should be conducted in other countries to understand physicians’ knowledge and practices regarding GI motility disorders.

Limitations

Self-reported questionnaires may cause recall bias. The study had a diverse pool of physicians with different clinical backgrounds, expertise, and specialties, which can affect the level of data interpretation. Despite these challenges, the study aimed to study various responses, reflecting Egyptian physicians’ knowledge, attitudes, and practices about GI motility disorders.

Conclusions

This study provides important insights into the current state of knowledge, practice, and attitudes of physicians regarding GI motility disorders in Egypt. The study highlights the urge for more training and educational programs to improve awareness among physicians regarding GI motility disorders. To achieve proper diagnosis and management of patients with GI motility disorders.