Relationship between anxiety and gastric sensorimotor function in functional dyspepsia

Efficacy of buspirone, a fundus-relaxing drug, in patients with functional dyspepsia

BACKGROUND & AIMS

Impaired accommodation and hypersensitivity to gastric distention are believed to be involved in the development of functional dyspepsia (FD). Buspirone, a 5-hydroxytryptamine 1A receptor agonist, relaxes the proximal stomach in healthy individuals. We studied the effects of buspirone on symptoms and mechanisms of FD.

METHODS

We performed a randomized, double-blind, placebo-controlled, crossover study of 17 patients (13 women; mean age, 38.5 ± 2.4 years). The study included 2 treatment periods of 4 weeks each, separated by a 2-week washout period. In the first period, 7 participants were given buspirone (10 mg, 3 times daily for 4 weeks) and 10 were given placebo 15 minutes before meals; patients switched groups for the second period. We assessed meal-related symptoms and severity, along with gastric sensitivity, accommodation, and emptying (by using barostat and breath tests) before and after 4 weeks of treatment.

RESULTS

Buspirone significantly reduced the overall severity of symptoms of dyspepsia (7.5 ± 1.3 vs 11.5 ± 1.2 for placebo; P < .005) and individual symptoms of postprandial fullness, early satiation, and upper abdominal bloating, whereas placebo had no significant effect (all P < .05). Buspirone did not alter the rate of gastric emptying of solids or sensitivity to gastric distention, but it significantly increased gastric accommodation, compared with placebo (229 ± 28 vs 141 ± 32 mL, respectively; P < .05), and delayed gastric emptying of liquids (half-life = 64 ± 5 vs 119 ± 24 minutes, respectively). Adverse events were similar when patients were given buspirone or placebo.

CONCLUSIONS

In patients with FD, 4 weeks of administration of buspirone significantly improved symptoms and gastric accommodation, compared with placebo, whereas gastric emptying of liquids was delayed.

Dyspepsia is strongly associated with major depression and generalised anxiety disorder - a community study

BACKGROUND

The relationship between dyspepsia and psychiatric comorbidity such as anxiety and depression is poorly defined. Previous studies have been limited by lack of standardised diagnostic criteria.

AIM

To examine the prevalence and comorbidity of dyspepsia as defined by Rome III (6-month duration) with DSM-IV-TR generalised anxiety disorder (GAD) and major depressive episodes (MDE) in the general population.

METHODS

A random population-based telephone survey was done using a questionnaire on symptoms of Rome III Dyspepsia, DSM-IV-TR GAD and MDE and their chronological relationship.

RESULTS

Of the 2011 respondents 8.0% currently had Rome III Dyspepsia, 3.8% reported GAD and 12.4% reported MDE respectively. Dyspeptic subjects had a twofold increased risk of GAD (OR = 2.03, 95% CI: 1.06-3.89, P < 0.001) and a threefold increased risk of MDE (OR = 3.56, 95% CI: 2.33-5.43, P < 0.001). MDE and GAD most often coincided with dyspepsia in onset. Dyspepsia (OR = 2.48, 95% CI: 1.65-3.72 P < 0.001), MDE (OR = 2.39, 95% CI: 1.64-3.46, P < 0.001) and female sex (OR = 1.65, 95% CI: 1.21-2.23, P < 0.001) independently predicted frequent medical consultations. GAD independently predicted high investigation expenditure (OR = 4.65, 95% CI: 1.15-18.70, P = 0.03).

CONCLUSIONS

With stringently adopted Rome III and DSM-IV-TR criteria, dyspepsia was strongly associated and often coincident in onset with generalised anxiety disorder and major depressive episodes in the community. Excessive healthcare utilisation should alert clinicians to risk of psychiatric comorbidity.

Relationship between Symptoms and Gastric Emptying of Solids in Functional Dyspepsia

Objective:

Functional dyspepsia is a heterogeneous disorder and different pathophysiological mechanisms underlie its symptom patterns. This study investigated the relationship between dyspepsia symptoms and overall and proximal gastric emptying in patients with functional dyspepsia.

Methods:

A total of 93 patients with functional dyspepsia and 32 healthy subjects were enrolled in this cross-sectional study. Prevalence and severity of eight dyspepsia symptoms were recorded. Gastric emptying was measured using single photon emission computed tomography scanning.

Results:

Overall and proximal gastric emptying were delayed in 47.3% (44/93) and 46.2% (43/93) of the patients, respectively. Logistic regression analyses showed that presence of nausea was associated with delayed proximal gastric emptying (odds ratio 4.951; 95% confidence interval 1.321, 18.558). There were no significant differences between normal and delayed overall gastric emptying according to presence of symptoms.

Conclusions:

Presence of nausea might indicate delayed gastric emptying of the proximal stomach. Promotion of proximal gastric emptying may constitute an effective therapy for patients with functional dyspepsia who report nausea as the dominant symptom.

Relationship between symptoms and proximal stomach function in patients with functional dyspepsia

AIM: To investigate the prevalence of impaired proximal stomach function and its relationship to symptoms in patients with functional dyspepsia (FD).

METHODS: Fifty-nine patients with FD and 32 healthy subjects (HS) were enrolled in this study. After an overnight fast of at least 12 h, a double-lumen polyvinyl tube with an adherent plastic bag that was finely folded was introduced through the patient's mouth. A gastric barostat was used to evaluate proximal stomach function (sensitivity, accommodation and compliance). After an overnight fast, gastric emptying was measured by single photon emission computerized tomography (SPECT). The gastric emptying curve was plotted to calculate the gastric emptying half-time. Individual dyspepsia symptom scores were obtained for all patients and their relationship with proximal stomach function was assessed. Logistic regression analysis and χ² statistics were used to identify the association between proximal stomach function and symptoms.

RESULTS: Visceral hypersensitivity to gastric distention was found in 44.07% of the patients, and their gastric emptying half-time did not significantly differ from that of patients with normal sensitivity. Epigastric pain was significantly more prevalent in patients with visceral hypersensitivity than in those with normal sensitivity (P < 0.01). Epigastric pain was independently and significantly associated with hypersensitivity to gastric distention (OR = 4.430, P < 0.05). Impaired gastric accommodation was found in 37.29% of the patients, and their gastric emptying half-time did not differ from that of other patients. Impaired gastric accommodation to gastric distention was associated with a higher prevalence of early satiety (P < 0.05). The presence of early satiety was the only symptom that was independently associated with impaired accommodation to gastric distention (OR = 3.231, P < 0.05). Reduced compliance was found in 54.24% of the patients; however, no relationship was found between reduced compliance and dyspeptic symptoms.

CONCLUSION: Symptoms are associated with impaired proximal stomach function in patients with FD. Epigastric pain and early satiety can be used to predict the presence of hypersensitivity and impaired accommodation, respectively.

A placebo-controlled trial of an oral capsaicin load in patients with functional dyspepsia

BACKGROUND

The pathophysiology of functional dyspepsia is poorly understood. Visceral hypersensitivity may play a key role. We studied a previously validated test to assess chemical hypersensitivity in functional dyspepsia by applying an oral capsaicin load.

METHODS

A total of 116 outpatients with upper gastrointestinal (GI) symptoms participated in this double-blind, placebo-controlled trial of which 73 patients received a final diagnosis of functional dyspepsia. Patients swallowed a capsule containing 0.75 mg capsaicin or placebo. A graded questionnaire evaluated the severity of nine upper GI symptoms before and after capsule ingestion and an aggregate symptom score was calculated. A final score of >9 was considered as a positive test.

KEY RESULTS

In functional dyspepsia, median perception scores were 10.8 (interquartile range: 4.5-18.8) after ingestion of capsaicin and 0.5 (0.0-2.5) after placebo (P < 0.001). Thirty-seven functional dyspepsia patients (54%) had a positive test after capsaicin ingestion, whereas only four (11%) patients with upper GI symptoms but without functional dyspepsia were capsaicin positive [median perception score: 1.5 (0.0-5.0)]. After placebo, symptom scores were low and not significantly different among patient groups (P > 0.05). Clinical characteristics, age, and gender distribution was similar in capsaicin positive and capsaicin negative functional dyspepsia patients (P > 0.05). The value of patient blinding was good.

CONCLUSIONS & INFERENCES

Half of functional dyspepsia patients had chemical hypersensitivity, determined with an oral capsaicin load. Placebo response was negligible. The results of the capsaicin test were not associated with specific dyspepsia symptoms or Rome subgroups.

Abuse history, depression, and somatization are associated with gastric sensitivity and gastric emptying in functional dyspepsia

OBJECTIVE

Gastric sensitivity testing relies on subjective reporting and may therefore be influenced by psychosocial factors and somatization. Furthermore, psychological processes may affect gastric motor function (accommodation to a meal emptying) through efferent brain-gut pathways. This study sought to determine the association of abuse history, psychiatric comorbidity, and somatization with gastric sensorimotor function.

METHODS

In 201 patients with functional dyspepsia, gastric sensitivity and accommodation were studied with a barostat. Gastric emptying of solids was studied using a breath test. Sexual and physical abuse history, psychiatric comorbidity (depression and panic disorder), and somatization were assessed using validated questionnaires. Multiple linear regression models were used to identify patient characteristics independently associated with gastric sensitivity and emptying.

RESULTS

Age (p = .02), sexual abuse history (p < .001), physical abuse history (p = .004), and somatization (p < .001) were independently associated with gastric discomfort threshold (R(2) = 0.30); a significant depression-by-sexual abuse interaction effect was also found (p = .003). None of the factors studied were associated with gastric accommodation to a meal. Physical abuse history (p = .003) and somatization (p = .048) were independently associated with gastric emptying (R(2) = 0.19).

CONCLUSIONS

These results demonstrate the complex relationship among abuse history, psychiatric comorbidity, somatization, and gastric sensorimotor (dys)function. Although the psychobiological mechanisms underlying these relationships remain to be determined, the autonomic nervous, stress hormone, and immune systems may be involved.

Do we have an alternative for the Rome III gastroduodenal symptom-based subgroups in functional gastroduodenal disorders? A cluster analysis approach

BACKGROUND

Functional dyspepsia (FD) is a heterogeneous biopsychosocial disorder. The Rome III consensus proposed a subdivision into epigastric pain syndrome and postprandial distress syndrome, based on gastroduodenal symptom pattern only; nausea/vomiting- and belching disorders were classified as separate functional gastroduodenal disorders (FGD). We aimed to investigate an alternative subdivision of FGD, taking into account gastric sensorimotor function, anxiety & depression and 'somatization', besides gastroduodenal symptoms.

METHODS

Gastroduodenal symptom data were available for 857 consecutive FGD patients (Rome II criteria). In a subsample (n=259), additional data were obtained on gastric sensitivity, anxiety, depression and 'somatization'. Two separate cluster analyses were performed. In analysis 1, clustering was based on individual gastroduodenal symptom scores. In analysis 2, gastric sensitivity, anxiety & depression and 'somatization', besides total gastroduodenal symptoms score, were used for clustering.

KEY RESULTS

Analysis 1 identified four clusters, largely supporting the Rome III classification, with early satiation, pain and nausea/vomiting clusters, besides a limited severity cluster (R(2) = 0.32). Analysis 2 suggested a five-cluster solution (R(2) = 0.48). Anxiety, depression and 'somatization' were the most important variables separating the clusters. 'Primary somatization' (with low psychiatric symptom levels) as well as 'secondary somatization' (with high anxiety & depression scores) subgroups were identified, besides three other subgroups characterized by psychiatric/gastroduodenal symptoms, mild anxiety symptoms and limited overall severity, respectively.

CONCLUSIONS & INFERENCES

We propose an alternative to the current subgrouping in FGD that is exclusively based on gastroduodenal symptoms. This may have consequences for future classification of FGD, as well as broader relevance towards the debate on subgrouping 'functional somatic syndromes'.

Factors associated with co-morbid irritable bowel syndrome and chronic fatigue-like symptoms in functional dyspepsia

BACKGROUND

It is unclear which factors explain the high co-morbidity between functional dyspepsia (FD) and other functional somatic syndromes. The aim of this study is to investigate the association between gastric sensorimotor function, psychosocial factors and 'somatization' on the one hand, and co-morbid irritable bowel syndrome (IBS) and chronic fatigue (CF)-like symptoms on the other, in FD.

METHODS

In 259 tertiary care FD patients, we studied gastric sensorimotor function with barostat (sensitivity, accommodation). We measured psychosocial factors (abuse history, alexithymia, trait anxiety, depression, panic disorder) and 'somatization' using self-report questionnaires, and presence of IBS and CF-like symptoms. Hierarchical multiple logistic regression was used to determine which of these factors were independently associated with co-morbid IBS and CF-like symptoms, including testing of potential mediator effects.

KEY RESULTS

Co-morbid IBS or CF-like symptoms respectively were found in 142 (56.8%) and 102 (39.4%) patients; both co-morbidities were not significantly associated (P=0.27). Gastric accommodation (β=0.003, P=0.04) and 'somatization' (β=0.17, P= 0.0003) were independent risk factors for IBS (c=0.74, P<0.0001); the effect of adult abuse (β=0.72, P=0.20) was mediated by 'somatization'. Depression (β=0.16, P=0.008) and 'somatization' (β=0.18, P=0.004) were overlapping risk factors for CF-like symptoms (c=0.83, P<0.0001); the effects of alexithymia and lifetime abuse were mediated by depression and 'somatization', respectively.

CONCLUSIONS & INFERENCES

'Somatization' is a common risk factor for co-morbid IBS and CF-like symptoms in FD and mediates the effect of abuse. Gastric sensorimotor function and depression are specific risk factors for co-morbid IBS and CF-like symptoms, respectively.

The HTR3A polymorphism c. -42C>T is associated with amygdala responsiveness in patients with irritable bowel syndrome

BACKGROUND & AIMS

5-Hydroxytryptamine (5-HT)3 receptor (5-HT3R) antagonists are effective in treating patients with irritable bowel syndrome (IBS) and have anxiolytic effects. Their therapeutic effects are related, in part, to reducing amygdala engagement during expected visceral pain. A single nucleotide polymorphism in HTR3A, c.-42C>T;(C178T; rs1062613), is associated with altered reactivity of the amygdala during emotional face processing in healthy subjects (controls). We evaluated the influence of this single nucleotide polymorphism on amygdala reactivity to emotional faces and nonemotional stimuli in female patients with IBS and controls.

METHODS

We measured brain responses during an affect-matching paradigm in 54 women (26 with IBS, 29 controls) using functional magnetic resonance imaging. We examined associations between HTR3A c.-42C>T genotype (C/C vs T carrier) and responses in amygdala and other regions of brain that expressed high levels of 5-HT3R.

RESULTS

The C/C genotype was associated with greater anxiety symptoms in patients with IBS and controls and increased activation of the amygdala under emotional and nonemotional conditions. Among patients with IBS, C/C genotype was associated with greater symptom ratings. A subset of IBS patients with the C/C genotype had increased amygdala responses to nonemotional stimuli, compared with other subjects with C/C genotype.

CONCLUSIONS

Regardless of diagnosis, the C/C genotype of the c.-42C>T polymorphism in HTR3A, compared with T carrier status, is associated with increased anxiety and amygdala responsiveness during emotional and nonemotional tasks. This polymorphism was associated with severity of IBS symptoms. Although this genotype is not sufficient for diagnosis of IBS, it is associated with severity of symptoms.

Effect of mianserin on gastric sensorimotor function and gastric emptying: a randomized, placebo-controlled, double-blind, crossover study in healthy volunteers

BACKGROUND

Antidepressants such as mianserin can improve symptoms in some functional dyspeptic patients but their mechanism of action remains unclear. We aimed to assess the effects of mianserin on gastric sensorimotor function in man.

METHODS

In this randomized, placebo-controlled, double-blind, crossover study 12 healthy subjects (six men) underwent a gastric barostat study and a gastric emptying breath test after 7 days pretreatment with placebo or mianserin (20 mg; p.o.). Graded isobaric and isovolumetric distentions were performed to determine gastric compliance and sensitivity. Subsequently, intrabag pressure was held constant and the volume increase after administration of a liquid meal (200 mL; 300 kcal) was studied. Breath was sampled before and after ingestion of a test meal and half-emptying times for solids and liquids were determined from the breath samples. Mianserin was compared to placebo using t-tests and mixed model analysis (mean ± SD).

KEY RESULTS

Mianserin did not affect pressures or volumes needed to induce first perception or discomfort. During isovolumetric distensions compliance was decreased after mianserin treatment (1.8 ± 0.4 vs 2.0 ± 0.3 mmHg 100 mL(-1); P < 0.05). Premeal volumes were comparable in both treatment arms (221 ± 99 vs 220 ± 88 mL), but meal-induced relaxation during the first 30 min was significantly inhibited after mianserin treatment (F(6,40) = 2.58, P < 0.05). Mianserin did not affect either solid or liquid gastric emptying.

CONCLUSIONS & INFERENCES

Mianserin does not alter gastric emptying rate or sensitivity to gastric distension, but inhibits gastric accommodation to a meal in its early phase. These observations provide no explanation for the effects of mianserin in functional dyspeptic patients.

Longitudinal and cross-sectional factors associated with long-term clinical course in functional dyspepsia: a 5-year follow-up study

OBJECTIVES

Functional dyspepsia (FD) is a heterogeneous disorder with different pathophysiological mechanisms underlying the symptom pattern, but little is known about its clinical course. The aims of this study were to study the long-term evolution of symptoms in a clinical FD population and to identify factors associated with outcome.

METHODS

FD patients who previously underwent gastric function testing and filled out a dyspepsia symptom score (DSS) were contacted. At follow-up, patients indicated whether symptoms had worsened, remained unchanged, improved, or disappeared. Anxiety and depression, DSS, chronic fatigue symptoms, irritable bowel syndrome (IBS) comorbidity, and FD-specific quality of life (QoL) were assessed using mailed questionnaires. Bivariate associations between different patient characteristics and DSS and QoL at follow-up were tested; multiple linear regression was used to identify factors associated with the outcomes, both longitudinally and cross-sectionally.

RESULTS

Data were obtained from 253 patients (84.9% of the eligible and consenting population (n=298) and 53.2% of the original population (n=476)). The mean duration of follow-up was 68±2 months. Disappeared, improved, unchanged, and worsened symptoms were reported by 17.4, 38.3, 30.8, and 13.4% of the patients, respectively. Correlations between dyspepsia symptoms at initial visit and follow-up were small to moderate in magnitude. DSS at initial visit and trait anxiety were longitudinally associated with DSS at follow-up, with a trend found for weight loss; depression, chronic fatigue, and IBS at follow-up were cross-sectionally associated with DSS. Trait anxiety, weight loss, and DSS at initial visit were independently associated with QoL at follow-up; depression as well as DSS and chronic fatigue at follow-up were cross-sectionally associated.

CONCLUSIONS

About half of FD patients reported disappeared or improved symptoms after a mean follow-up of 5 years. Although stability of symptom levels is low to moderate, DSS at initial visit, trait anxiety, and initial weight loss are more strongly associated with outcome than gastric sensorimotor function.

Risk factors for impaired health-related quality of life in functional dyspepsia

BACKGROUND

The influence of patient characteristics on HRQoL in functional dyspepsia is poorly understood.

AIM

To determine the contribution of gastric sensorimotor function, psychosocial factors & 'somatization' to HRQoL in functional dyspepsia.

METHODS

In 259 tertiary care functional dyspepsia patients, we studied gastric sensorimotor function with barostat. We measured psychosocial factors and 'somatization' using self-report questionnaires. HRQoL was assessed using the SF-36 physical and mental composite scores (PCS, MCS). Bivariate associations between gastric sensorimotor function, psychosocial factors and 'somatization' on the one hand and PCS and MCS on the other were estimated. Variables significantly associated with PCS or MCS in bivariate analysis were entered into hierarchical multiple linear regression models.

RESULTS

Mean PCS was 40.1 ± 9.5; mean MCS was 45.1 ± 10.8. 'Somatization' (P < 0.0001) and chronic fatigue (P = 0.002) were significantly associated with impaired PCS (R² = 0.52, P < 0.0001). The effects of abuse history and depression were 'mediated' by 'somatization'. Trait anxiety (P = 0.02), alexithymia (P = 0.06), depression (P = 0.06), positive affect (P < 0.0001), negative affect (P = 0.002) and generalised anxiety disorder (P = 0.01) were significantly associated with impaired MCS (R² = 0.67, P < 0.0001).

CONCLUSIONS

'Somatization' is the most important risk factor for impaired physical HRQoL in functional dyspepsia; it 'mediates' the effect of abuse history and depression. Mental HRQoL is mainly explained by psychosocial factors.

Association of serotonin transporter gene polymorphisms with the development of functional dyspepsia and accompanying psychiatric symptoms

AIM: To investigate the association of serotonin transporter (SERT) gene polymorphisms with the development of functional dyspepsia (FD) and accompanying psychiatric symptoms.

METHODS: Polymerase chain reaction (PCR) was used to detect the SERT gene-linked polymorphic region (5-HTTLPR) and the variable number tandem repeats (VNTRs) in intron 2 of the SERT gene in 60 patients with FD and 80 healthy subjects.

RESULTS: There are significant differences in 5-HTTLPR S allele frequencies among groups classified according to FD subtype and those according to psychiatric symptoms (all P < 0.05). No significant differences were noted in genotype distribution or allele frequency of VNTRs between controls and FD patient.

CONCLUSION: The S allele of 5-HTTLPR may be associated with the development of FD-PDS subtype and FD-associated psychiatric symptoms.

Psychological dysfunction is associated with symptom severity but not disease etiology or degree of gastric retention in patients with gastroparesis

OBJECTIVES

Gastroparesis patients may have associated psychological distress. This study aimed to measure depression and anxiety in gastroparesis in relation to disease severity, etiology, and gastric retention.

METHODS

Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) scores for state (Y1) and trait (Y2) anxiety were obtained from 299 gastroparesis patients from 6 centers of the National Institute of Diabetes and Digestive and Kidney Diseases Gastroparesis Clinical Research Consortium. Severity was investigator graded as grades 1, 2, or 3 and patient reported by Gastroparesis Cardinal Symptom Index (GCSI) scores. Antiemetic/prokinetic medication use, anxiolytic and antidepressant medication use, supplemental feedings, and hospitalizations were recorded. BDI, Y1, and Y2 scores were compared in diabetic vs. idiopathic etiologies and mild (≤20%) vs. moderate (>20-35%) vs. severe (>35-50%) vs. very severe (>50%) gastric retention at 4 h.

RESULTS

BDI, Y1, and Y2 scores were greater with increasing degrees of investigator-rated gastroparesis severity (P<0.05). BDI, Y1, and Y2 scores were higher for GCSI >3.1 vs. ≤3.1 (P<0.05). Antiemetic and prokinetic use and ≥6 hospitalizations/year were more common with BDI ≥20 vs. <20 (P<0.05). Anxiolytic use was more common with Y1≥46; antidepressant use and ≥6 hospitalizations/year were more common with Y2≥44 (P<0.05). BDI, Y1, and Y2 scores were not different in diabetic and idiopathic gastroparesis and did not relate to degree of gastric retention. On logistic regression, GCSI >3.1 was associated with BDI ≥20 and Y1≥46; antiemetic/prokinetic use was associated with BDI≥20; anxiolytic use was associated with Y1≥46; and antidepressant use was associated with Y2≥44.

CONCLUSIONS

Higher depression and anxiety scores are associated with gastroparesis severity on investigator- and patient-reported assessments. Psychological dysfunction does not vary by etiology or degree of gastric retention. Psychological features should be considered in managing gastroparesis.

Anxiety increases acid-induced esophageal hyperalgesia

OBJECTIVE

Anxiety at the time of gastrointestinal injury or inflammation increases the risk of developing visceral hyperalgesia. Distal esophageal acidification induces hyperalgesia in the non-acid exposed proximal esophagus, due to the sensitization of spinal dorsal horn neurones. The objective was to determine whether anxiety influences acid-induced hyperalgesia.

METHODS

A total of 19 healthy volunteers (n = 12 females; age, 22-57 years; mean, 35.7 years) completed a 10-minute mood induction paradigm (anxiety or neutral) with autonomic monitoring (visit 1). On visits 2 and 3, pain thresholds to electrical stimulation, in milliamperes (mA), were determined in the proximal esophagus and foot (control) before and after a 30-minute infusion of 0.15 M of hydrochloric acid. During esophageal acid infusion, the subjects randomly received anxiety or neutral mood induction with autonomic monitoring, in a crossover design. Anxiety and pain ratings were recorded pre and post infusion.

RESULTS

Visit 1: Anxiety induction increased anxiety scores (p < .001), mean arterial pressure (p < .001), and cardiac sympathetic index (p = .007), and reduced parasympathetic measures (cardiac vagal tone [p = .05] and cardiac sensitivity to baroreflex [p = .006)]). Visit 2: Anxiety induction conferred greater acid-induced hyperalgesia compared with neutral (-4.9 mA versus 2.7 mA, p = .009, analysis of covariance). No differences in autonomic measures were found during acid infusion with anxiety or neutral mood induction.

CONCLUSIONS

Anxiety induction increases acid-induced esophageal hyperalgesia; anxiety, thus, facilitates central sensitization in the esophagus. Our studies provide a new model for studying the effects of anxiety on esophageal hyperalgesia and may allow testing of therapeutic strategies to reduce this effect.

Depressive mood and quality of life in functional gastrointestinal disorders: differences between functional dyspepsia, irritable bowel syndrome and overlap syndrome

OBJECTIVE

To investigate the differences in depressive mood and quality of life in patients with between functional dyspepsia (FD), irritable bowel syndrome (IBS), and FD-IBS overlap as diagnosed based on Rome III criteria.

METHODS

The subjects completed a questionnaire based on Rome III criteria, the Beck Depressive Inventory (BDI) including Cognitive Depression Index (CDI) for depressive mood evaluation and the 36-item Short Form general health survey (SF-36) for quality of life assessment. Upper gastrointestinal endoscopy and colonoscopy were performed to exclude organic disease.

RESULTS

Of 279 subjects, 70 and 124 subjects were diagnosed as FD and IBS, respectively. FD-IBS overlap patients (n=42) and FD alone patients (n=28) showed higher BDI scores than normal subjects (n=127) (P<.001 and P=.02, respectively), whereas that of IBS alone patients (n=82) did not show difference (P=.17). All the SF-36 subscores of the FD-IBS overlap patients were significantly lower than normal subjects (P<.05).

CONCLUSIONS

Depressive mood was significantly related to FD and FD-IBS overlap but not to IBS based on Rome III criteria. FD-IBS overlap patients have worse quality of life than FD-alone and IBS-alone patients.

Pathophysiological and psychosocial study in patients with functional vomiting

Background/Aims

To explore clinical patterns, predisposing factors, psychosocial aspects and the possible pathogenesis in Functional Vomiting (FV) patients.

Methods

Ten healthy subjects and 19 FV patients participated in this study. Gastrointestinal symptoms and psychological state were evaluated by questionnaires, including Zung self-rating anxiety and depression scale and Eysenck personality questionnaire. Cutaneous electrogastrography, perfusion nutrition load test and intragastric pressure were performed in patients. Perfusion nutrition load test and intragastric pressure were also performed in healthy subjects.

Results

FV involved young female predominantly (4 male, 15 female; age 25.8 ± 8.4 years). Postprandial vomiting soon after meal without self-induced maneuver was the most common pattern of FV. Prevalence for overlaps between FV and functional dyspepsia was high (84.2%). Emotional changes and stress contributed to the development of FV. Prevalence of abnormal psychological status and personality in patients with FV was high (83.3% and 47.1%). Patients with FV had significant postprandial gastric dysrhythmia, impaired gastric accommodation and enhanced gastric sensitivity. There were significant correlations between clinical presentations, gastric function and psychological states.

Conclusions

Patients with FV had abnormal psychological status, gastric dysmotility and hypersensitivity, which indicated that both of peripheral and central abnormalities could contribute to the pathogenesis of FV.

Regional brain activity in functional dyspepsia: a H(2)(15)O-PET study on the role of gastric sensitivity and abuse history

BACKGROUND & AIMS

Differences in brain activity between health and functional dyspepsia (FD) have been reported; it is unclear whether this is influenced by gastric hypersensitivity or abuse history. Therefore, we aimed to determine the influence of gastric sensitivity and abuse history on gastric sensation scores and brain activity in homeostatic-afferent, emotional-arousal, and cortical-modulatory brain regions in FD.

METHODS

Abuse history was assessed using a validated self-report questionnaire. H(2)(15)O positron emission tomography was performed in 25 FD patients (13 hypersensitive and 8 abused) during 3 conditions, that is, no distension, gastric distension at discomfort threshold, and sham distension. Data were analyzed in SPM2. Region of interest analysis was used to confirm differences in prehypothesized regions.

RESULTS

No association between hypersensitivity and abuse history was found. Gastric hypersensitivity was associated with significantly higher gastric sensation scores during baseline and sham. A condition-independent difference in ventral posterior cingulate activity was found between groups, as well as distension and sham-specific differences in brainstem and cingulate areas. Abuse history was associated with higher gastric sensation scores in all conditions and with differences in insular, prefrontal, and hippocampus/amygdala activity.

CONCLUSIONS

Gastric sensitivity and abuse history independently influence gastric sensation as well as brain activity in FD.

Abnormal regional brain activity during rest and (anticipated) gastric distension in functional dyspepsia and the role of anxiety: a H(2)(15)O-PET study

OBJECTIVES

During gastric distension in hypersensitive functional dyspepsia (FD), activation was found in somatosensory cortex (SI/SII) and ventrolateral prefrontal cortex (vlPFC) but, contrary to controls, not in pregenual anterior cingulate (pACC). The aims of this article were to study (i) cortical activations and deactivations during distension and sham compared with baseline in FD, regardless of sensitivity status; (ii) differences in brain activity between health and FD during "no distension" conditions; and (iii) the relationship between anxiety and brain activity in FD.

METHODS

Brain H(2)(15)O-PET was performed in 25 FD patients (13 hypersensitive) during three conditions: baseline, distension at discomfort threshold, and sham. Brain activity was compared against healthy controls using SPM2.

RESULTS

Discomfort threshold was lower; sensation scores in all conditions were higher in patients than controls. (i) Activations were similar to controls, except for a lack of pACC activation during distension in FD. Patients showed no dorsal pons and amygdala deactivation during distension and sham, respectively. (ii) Comparing baseline or sham activity showed the following differences: higher activity in SII/SI, insula, midcingulate (MCC), dorsolateral and ventrolateral PFC in controls; and higher activity in occipital cortex in FD. Differences in left lateral PFC were specific to sham. (iii) Anxiety correlated negatively with pACC and MCC and positively with dorsal pons activity.

CONCLUSIONS

FD patients failed to activate pACC, to deactivate dorsal pons during distension, and to deactivate amygdala during sham; this may represent arousal-anxiety-driven failure of pain modulation. During baseline and sham, differences between patients and controls were found in sensory as well as affective-cognitive areas.

Stress profile, coping style, anxiety, depression, and gastric emptying as predictors of functional dyspepsia: a case-control study

OBJECTIVE

To determine whether gastric emptying, stomach peristaltic frequencies, stress profile, depressive symptoms, anxiety, and salivary cortisol levels could predict functional dyspepsia (FD).

METHODS

Magnetogastrography (MGG) was used to measure gastric emptying time and the gastric peristaltic frequencies in 15 patients with FD diagnosis and in 17 healthy volunteers. In all the participants, stress profile, anxiety, and depressive symptoms were evaluated by means of standardized questionnaires, and morning salivary samples were collected for the measurement of cortisol levels. A univariate logistic regression model was used to examine the probability of the measured variables to predict the presence of FD.

RESULTS

The univariate logistic regression model showed that the half-time of gastric emptying (OR=1.16 P=.01); the subscale of stress items (OR=1.08, P=.003); negative appraisal of subscale coping strategies (OR=1.03, P=0.007); anxiety (OR=1.05, P=.01); and depression (OR=1.23, P=.02) had a significant predictive value for the presence of FD. However, by applying the stricter multiple comparison criteria, only stress, negative appraisal, and anxiety arose as predictors of FD. The FD patients compared with healthy volunteers showed significantly elevated half-time of gastric emptying (P<.0006), high scores in the subscales of stress (P<.000003), in behavior type "A" (P<.04), in coping styles (P<.008), in depression (P<.0004), and in anxiety (P<.0002).

CONCLUSIONS

These findings indicate that psychosocial stress, mood symptoms, and coping style are predictors of FD. The stress shows high sensibility and specificity in the patients with FD, indicating a contribution in the etiopathogenesis of dyspepsia.

Altered rectal sensory response induced by balloon distention in patients with functional abdominal pain syndrome

Background

Functional abdominal pain syndrome (FAPS) has chronic unexplained abdominal pain and is similar to the psychiatric diagnosis of somatoform pain disorder. A patient with irritable bowel syndrome (IBS) also has chronic unexplained abdominal pain, and rectal hypersensitivity is observed in a majority of the patients. However, no reports have evaluated the visceral sensory function of FAPS precisely. We aimed to test the hypothesis that FAPS would show altered visceral sensation compared to healthy controls or IBS. The present study determined the rectal perceptual threshold, intensity of sensation using visual analogue scale (VAS), and rectal compliance in response to rectal balloon distention by a barostat in FAPS, IBS, and healthy controls.

Methods

First, the ramp distention of 40 ml/min was induced and the thresholds of discomfort, pain, and maximum tolerance (mmHg) were measured. Next, three phasic distentions (60-sec duration separated by 30-sec intervals) of 10, 15 and 20 mmHg were randomly loaded. The subjects were asked to mark the VAS in reference to subjective intensity of sensation immediately after each distention. A pressure-volume relationship was determined by plotting corresponding pressures and volumes during ramp distention, and the compliance was calculated over the linear part of the curve by calculating from the slope of the curve using simple regression.

Results

Rectal thresholds were significantly reduced in IBS but not in FAPS. The VAS ratings of intensity induced by phasic distention (around the discomfort threshold of the controls) were increased in IBS but significantly decreased in FAPS. Rectal compliance was reduced in IBS but not in FAPS.

Conclusion

An inconsistency of visceral sensitivity between lower and higher pressure distention might be a key feature for understanding the pathogenesis of FAPS.

Recent insights on central processing and psychological processes in functional gastrointestinal disorders

There is increasing evidence for a key role of psychological processes and their central nervous system substrates in functional gastrointestinal disorders, although the exact nature of the relationship remains only partially understood. However, progress in this key area of psychosomatic medicine is rapidly being made. In this review article, we will give an overview of recent advances in understanding the complex mechanisms by which psychological processes and functional gastrointestinal disorder symptoms reciprocally influence each other. Various lines of evidence from different branches of biomedical and psychological science will be discussed, particularly epidemiology, patho- and psychophysiology and functional brain imaging, focusing on the most recent and novel findings. We will conclude this paper with a paragraph on new insights into treatment.

Psychopathology and personality trait in subgroups of functional dyspepsia based on Rome III criteria

OBJECTIVES

Functional dyspepsia is a heterogeneous symptom complex that may be subdivided into postprandial distress syndrome and epigastric pain syndrome. We aimed to investigate differences among these subgroups in psychopathological factors and personality traits.

METHODS

We enrolled 187 consecutive outpatients (72.2% female patients, mean age 42.6 years) with functional dyspepsia based on the Rome III criteria. Patients were interviewed and evaluated by the Brief Symptom Rating Scale and the short-form Maudsley personality inventory for severity of psychopathology and personality traits. Multiple linear regression models were built for each psychopathological dimension and personality trait to assess the independent association with each subclass diagnosis of functional dyspepsia.

RESULTS

There was an overlap (n=64, 34.2%) between the patients diagnosed with epigastric pain syndrome (n=157, 84.0%) and those with postprandial distress syndrome (n=94, 50.3%). Patients with symptoms compatible with both syndromes were psychopathologically more severe than either subgroup without overlapping. Multiple linear regression analysis demonstrated that the diagnosis of postprandial distress syndrome was independently associated with higher scores in overall psychopathological stress, and specifically in somatization (P=0.034), depression (P=0.028), phobia (P=0.044), and additional symptoms (P<0.001). However, epigastric pain syndrome was not associated with psychopathology. Postprandial distress was univariately associated with neuroticism, but the association was insignificant in the multivariate analysis (P=0.136).

CONCLUSIONS

The Rome III subgroups of functional dyspepsia significantly overlap. Patients fulfilling criteria for both subgroups had symptoms that were psychopathologically more severe than those of patients without overlapping. Diagnosis of postprandial distress syndrome, but not epigastric pain syndrome, is independently associated with psychopathological factors.

Tests of gastric neuromuscular function

Tests of gastric neuromuscular function are used to evaluate patients with symptoms referable to the upper digestive tract. These symptoms can be associated with alterations in the rates of gastric emptying, impaired accommodation, heightened gastric sensation, or alterations in gastric myoelectrical function and contractility. Management of gastric neuromuscular disorders requires an understanding of pathophysiology and treatment options as well as the appropriate use and interpretation of diagnostic tests. These tests include measures of gastric emptying; contractility; electrical activity; regional gastric motility of the fundus, antrum, and pylorus; and tests of sensation and compliance. Tests are also being developed to improve our understanding of the afferent sensory pathways from the stomach to the central nervous system that mediate gastric sensation in health and gastric disorders. This article reviews tests of gastric function and provides a basic description of the tests, the methodologies behind them, descriptions of the physiology that they assess, and their clinical utility.

Relationship between symptoms and dietary patterns in patients with functional dyspepsia

BACKGROUND & AIMS

Patients with functional dyspepsia (FD) often report that their symptoms are related to food ingestion. However, there is a lack of information about differences in eating patterns and nutrient intake between these patients and healthy individuals or the association with specific symptoms. We performed a prospective trial to evaluate the relationship between FD symptoms and dietary factors.

METHODS

Twenty patients with FD (17 women) and 21 healthy subjects (18 women) completed detailed diet diaries, recording all foods eaten, drinks consumed, and times of consumption, as well as the occurrence, timing, and severity of dyspeptic symptoms (ie, nausea, discomfort, fullness, bloating, upper-abdominal/epigastric pain) for 7 days. Data from the diet diaries were analyzed for the number of meals, light meals, snacks and drinks, energy intake, and macronutrient distribution.

RESULTS

Patients with FD ate fewer meals (P < .01) and consumed less total energy (P = .1) and fat (P = .1) than healthy subjects. Their symptoms were modest in severity (score out of 10; 5 [range, 3-8]) and occurred within 31 minutes (range, 8-64 min) of eating. Fullness was related directly to the amount of fat ingested (z, 1.91; P < .05) and overall energy intake (z, 2.12; P < .05) and related inversely to the amount of carbohydrate ingested (z, -1.9; P = .05). Similarly, bloating was related to the amount of fat ingested (z, 1.68; P = .09). There was no significant relationship between symptom severity and any of the dietary variables measured.

CONCLUSIONS

Management of patients with FD might be improved by instructing them to consume smaller meals with reduced fat content.

Cortical deactivations during gastric fundus distension in health: visceral pain-specific response or attenuation of 'default mode' brain function? A H2 15O-PET study

Gastric distension activates a cerebral network including brainstem, thalamus, insula, perigenual anterior cingulate, cerebellum, ventrolateral prefrontal cortex and potentially somatosensory regions. Cortical deactivations during gastric distension have hardly been reported. To describe brain areas of decreased activity during gastric fundus distension compared to baseline, using data from our previously published study (Gastroenterology, 128, 2005 and 564). H(2) (15)O-brain positron emission tomography was performed in 11 healthy volunteers during five conditions (random order): (C(1)) no distension (baseline); isobaric distension to individual thresholds for (C(2)) first, (C(3)) marked, (C(4)) unpleasant sensation and (C(5)) sham distension. Subtraction analyses were performed (in SPM2) to determine deactivated areas during distension compared to baseline, with a threshold of P(uncorrected_voxel_level) < 0.001 and P(corrected_cluster_level) < 0.05. Baseline-maximal distension (C(1)-C(4)) yielded significant deactivations in: (i) bilateral occipital, lateral parietal and temporal cortex as well as medial parietal lobe (posterior cingulate and precuneus) and medial temporal lobe (hippocampus and amygdala), (ii) right dorsolateral and dorso- and ventromedial PFC, (iii) left subgenual ACC and bilateral caudate head. Intragastric pressure and epigastric sensation score correlated negatively with brain activity in similar regions. The right hippocampus/amygdala deactivation was specific to sham. Gastric fundus distension in health is associated with extensive cortical deactivations, besides the activations described before. Whether this represents task-independent suspension of 'default mode' activity (as described in various cognitive tasks) or an visceral pain/interoception-specific process remains to be elucidated.

Is the antidepressant venlafaxine effective for the treatment of functional dyspepsia?

Several studies have suggested that antidepressants might be beneficial in the treatment of patients with functional gastrointestinal disorders. This commentary discusses the results of a high-quality, multicenter, randomized, double-blind, placebo-controlled trial that showed no benefit of the antidepressant venlafaxine over placebo in the treatment of a large group of patients with functional dyspepsia. Moreover, venlafaxine was poorly tolerated by a considerable number of patients. The routine use of venlafaxine and other serotonin and norepinephrine reuptake-inhibitor antidepressants to treat patients with functional dyspepsia is, therefore, not recommended. Whether certain subgroups of patients, particularly those with anxious or depressive psychiatric comorbidities, might benefit from treatment with this class of antidepressants, however, remains to be elucidated. Antidepressants with different mechanisms of actions, for example mirtazapine, might still prove beneficial for the treatment of functional dyspepsia, but no clinical studies have yet investigated the efficacy of these drugs in this setting.

The frequency of the psychiatric symptoms in the patients with dyspepsia at a university hospital

OBJECTIVE

According to the psychiatric hypothesis, the symptoms of dyspepsia may be due to depression, anxiety or a somatization disorder. We investigated the frequency of psychiatric symptoms in patients undergoing endoscopic procedures with dyspepsia, either with or without pathological findings, and compared this with control subjects without dyspeptic symptoms.

METHODS

Ninety patients with dyspeptic symptoms and 90 control subjects participated in the study. Both the patients and the controls were asked to complete a questionnaire about socio-demographic characteristics, the Turkish version of the Spielberger State-Trait Anxiety Inventory (STAI) and the Symptom Check List-90 (SCL-90). In order for us to determine whether the criteria for any of the conditions listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) were met, the patients were asked to take part in the Structured Clinical Interview for DSM-IV disorders.

RESULTS

Of the participants, 47.8% had a psychiatric disorder according to DSM-IV criteria, somatoform disorder (44.2%) being the most common. While 42.2% patients were determined to have a pathological finding using endoscopic evaluation, 57.8% had no findings. Together with the somatization and obsessive-compulsive disorder subscale scores, the total SCL-90 score and the mean trait anxiety score were statistically significantly higher in participants with no pathological findings. There were trends for anxiety (13.2% vs. 7.7%) and mood (2.6% vs. 0.0%) disorders to be more frequent in patients with pathological findings, while somatoform disorder+depressive disorder (17.3% vs. 5.2%) was more frequent in patients with no findings, although the differences were not statistically significant (Z=0.7, P>.05). The scores of state-trait anxiety, somatization, obsession-compulsion, depression, anxiety, phobic anxiety and psychotism subscales, and the total SCL-90 score were statistically significantly higher in those participants without a pathological finding than in the controls.

CONCLUSIONS

Regarding the high frequency of psychiatric disorders in patients with dyspeptic symptoms, we think that such patients should be evaluated by two separate departments, gastroenterology and psychiatry.

The role of somatosensory cortical regions in the processing of painful gastric fundic distension: an update of brain imaging findings

Painful gastric distension is processed in a network consisting of brainstem, thalamus, insula, anterior cingulate cortex, (lateral) orbitofrontal and prefrontal cortex, superior temporal cortex and cerebellum. However, the role of primary and secondary somatosensory cortical regions (SI/SII) in the processing of visceral sensation or pain in general and gastric sensation in particular remains unclear. The aim of this study was to localize activations in the SI/SII area from our previously published functional brain imaging studies on gastric distension more precisely, using newly available cytoarchitectonic probability maps of SI/SII, implemented in the SPM Anatomy toolbox. In healthy volunteers, we found two clusters to be overlapping with SII (mainly the OP4 subregion) and, to a lesser extent, SI, although this overlap was small in size. In functional dyspepsia patients, we found two clusters to be overlapping with SII (mainly OP4), of which the cluster in the right hemisphere also overlapped with SI. These findings were confirmed in a conjunction analysis of both groups. Activation in right SI/SII was significantly higher in healthy volunteers when formally compared to patients. These results provide more detailed information on the brain processing of gastric sensation, supporting the hypothesis that SI/SII are involved. This is in line with some previously published studies on visceral sensation, but at variance with some other studies. Methodological differences between the brain imaging studies on gastric distension may account for these somewhat discrepant findings.

Functional brain imaging of gastrointestinal sensation in health and disease

It has since long been known, from everyday experience as well as from animal and human studies, that psychological processes-both affective and cognitive-exert an influence on gastrointestinal sensorimotor function. More specifically, a link between psychological factors and visceral hypersensitivity has been suggested, mainly based on research in functional gastrointestinal disorder patients. However, until recently, the exact nature of this putative relationship remained unclear, mainly due to a lack of non-invasive methods to study the (neurobiological) mechanisms underlying this relationship in non-sleeping humans. As functional brain imaging, introduced in visceral sensory neuroscience some 10 years ago, does provide a method for in vivo study of brain-gut interactions, insight into the neurobiological mechanisms underlying visceral sensation in general and the influence of psychological factors more particularly, has rapidly grown. In this article, an overview of brain imaging evidence on gastrointestinal sensation will be given, with special emphasis on the brain mechanisms underlying the interaction between affective & cognitive processes and visceral sensation. First, the reciprocal neural pathways between the brain and the gut (brain-gut axis) will be briefly outlined, including brain imaging evidence in healthy volunteers. Second, functional brain imaging studies assessing the influence of psychological factors on brain processing of visceral sensation in healthy humans will be discussed in more detail. Finally, brain imaging work investigating differences in brain responses to visceral distension between healthy volunteers and functional gastrointestinal disorder patients will be highlighted.

Regional cerebral blood flow during gastric balloon distention in functional dyspepsia

BACKGROUND & AIMS

Hypersensitivity to proximal gastric distention as a result of abnormal central nervous system processing of visceral stimuli is a possible pathophysiologic mechanism in functional dyspepsia (FD). Increasing evidence suggests involvement of both lateral and medial pain systems in normal visceral sensitivity and aberrant brain activation patterns in visceral hypersensitivity. We hypothesized that there is involvement of aberrant brain activation in FD with hypersensitivity to gastric distention. Our aim was to investigate regional cerebral blood flow during painful proximal gastric distention in hypersensitive FD.

METHODS

Brain (15)O-water positron emission tomography was performed in 13 FD patients with symptoms of gastric hypersensitivity during 3 conditions: no distention, sham distention, and isobaric distention to unpleasant or painful sensation. Pain, discomfort, nausea, and bloating during maximal distention were rated on visual analogue scales. Data were analyzed using statistical parametric mapping.

RESULTS

The threshold for painful distention was 6.6 +/- 3.8 mm Hg greater than the minimal distending pressure. At the corrected P level of less than .05, subtraction analysis (painful distention - no distention) showed activations in bilateral gyrus precentralis, bilateral gyrus frontalis inferior, bilateral gyrus frontalis medialis, bilateral gyrus temporalis superior, bilateral cerebellar hemisphere, and left gyrus temporalis inferior. Sham distention minus no distention showed no activations.

CONCLUSIONS

Similar to healthy volunteers, proximal stomach distention in FD activates components of the lateral pain system and bilateral frontal inferior gyri, putatively involved in regulation of hunger and satiety. In hypersensitive FD, these activations occur at significantly lower distention pressures. In contrast to findings in normosensitivity, none of the components of the medial pain system were significantly activated.