The management of common gastrointestinal disorders in general practice A survey by the European Society for Primary Care Gastroenterology (ESPCG) in six European countries

Evaluating the Utility of a Large Language Model in Answering Common Patients' Gastrointestinal Health-Related Questions: Are We There Yet?

BACKGROUND AND AIMS

Patients frequently have concerns about their disease and find it challenging to obtain accurate Information. OpenAI's ChatGPT chatbot (ChatGPT) is a new large language model developed to provide answers to a wide range of questions in various fields. Our aim is to evaluate the performance of ChatGPT in answering patients' questions regarding gastrointestinal health.

METHODS

To evaluate the performance of ChatGPT in answering patients' questions, we used a representative sample of 110 real-life questions. The answers provided by ChatGPT were rated in consensus by three experienced gastroenterologists. The accuracy, clarity, and efficacy of the answers provided by ChatGPT were assessed.

RESULTS

ChatGPT was able to provide accurate and clear answers to patients' questions in some cases, but not in others. For questions about treatments, the average accuracy, clarity, and efficacy scores (1 to 5) were 3.9 ± 0.8, 3.9 ± 0.9, and 3.3 ± 0.9, respectively. For symptoms questions, the average accuracy, clarity, and efficacy scores were 3.4 ± 0.8, 3.7 ± 0.7, and 3.2 ± 0.7, respectively. For diagnostic test questions, the average accuracy, clarity, and efficacy scores were 3.7 ± 1.7, 3.7 ± 1.8, and 3.5 ± 1.7, respectively.

CONCLUSIONS

While ChatGPT has potential as a source of information, further development is needed. The quality of information is contingent upon the quality of the online information provided. These findings may be useful for healthcare providers and patients alike in understanding the capabilities and limitations of ChatGPT.

[Irritable bowel syndrome in the Russian Federation: results of the ROMERUS multicenter observational study]

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most common functional disorders of the gastrointestinal tract. According to Russian guidelines, a standard examination using laboratory and instrumental evaluation methods, including colonoscopy, should be performed to establish the diagnosis of IBS.

AIM

To characterize the Russian population of IBS patients.

MATERIALS AND METHODS

A multicenter observational prospective study ROMERUS was conducted at 35 clinical centers in the Russian Federation. The study included male and female patients aged 18 to 50 with a diagnosis of IBS based on the Rome IV criteria, with no signs of structural gastrointestinal disease. The follow-up duration was 6 months and included three patients' visits to the study site. During the study, data were collected on patients' demographic and clinical characteristics, medical history, and drug therapy. The secondary parameters included the assessment of the proportion of patients with a diagnosis of IBS confirmed by a standard examination among all patients meeting the Rome IV criteria, the evaluation of the change over time of the IBS symptoms, quality of life (QoL), and adherence to therapy. Characterization of the population was performed using descriptive statistics methods. The standard examination results were presented as the percentage of patients with IBS confirmed by the standard examination among all patients meeting the Rome IV criteria, with a two-sided 95% confidence interval.

RESULTS

The study included 1004 patients with a diagnosis of IBS according to the Rome IV criteria, with 790 (78.7%) patients included in the final analysis. The mean age of patients was 34.0±7.5 years; they were predominantly female (70.4%), Caucasian (99.4%), married (55.1%), urban residents (97.5%) with higher education (64.5%) and a permanent position (74.9%). Patients enrolled in the study have low physical activity and lack a healthy diet. The smoking rate was 26.3%. IBS symptoms with predominant constipation (IBS-C) were observed in 28.1% of patients; 28.9% had IBS with predominant diarrhea (IBS-D), 11.9% had mixed-type IBS, and 31.1% had non-classified IBS. The main IBS symptoms were pain (99.7%), abdominal distension (71.1%), and fullness (36.8%). Biliary tract dysfunction (18.9%) and gastritis (17.2%) were the most frequently reported comorbidities. Prior to enrollment, 28% of patients received drug therapy. The most commonly prescribed drug during the study was mebeverine (54.1%). At 6 months of follow-up, there was a significant reduction of abdominal pain, bloating, and distention, and a twofold reduction in the incidence of constipation and diarrhea in the subgroups of patients with IBS-C and IBS-D, respectively. The overall QoL score measured by the IBS-QoL questionnaire increased from 83.0 to 95.2 points (p<0.05) during the study. In the overall assessment of their condition, 69.6% of patients noted no symptoms and 25.3% reported marked improvement, 35% were asymptomatic according to the physician's overall assessment of the patient's condition, and 51.8% showed significant improvement.

CONCLUSION

IBS patients in the Russian Federation were characterized. The diagnosis of IBS, established following the Rome IV criteria, is confirmed by the results of a standard examination in 96.3% of patients. The Rome IV criteria for the IBS diagnosis make it possible to establish a diagnosis with a probability of 94.7%. For 6 months of follow-up, there was a clinical improvement with a decrease in the severity of symptoms and a QoL improvement.

Translational Gap between Guidelines and Clinical Medicine: The Viewpoint of Italian General Practitioners in the Management of IBS

Irritable bowel syndrome (IBS) guidelines are generally developed by experts, with the possibility of a translational gap in clinical medicine. The aim of our study was to assess an Italian group of general practitioners (GPs) for their awareness and use of criteria for the diagnosis and management of IBS. For this purpose, a survey was carried out involving 235 GPs, divided into two groups according to their years of activity: 65 “junior general practitioners” (JGPs) (≤10 years) and 170 “senior general practitioners” (SGPs) (>10 years). JGPs were more familiar with the Rome IV Criteria and Bristol Scale than SGPs. Abdominal pain, bowel movement frequency and bloating were the symptoms most frequently used to make a diagnosis. The most probable causes of IBS were reported to be abnormal gastrointestinal motility and psychological triggers. SGPs reported more frequently than JGPs that challenging management and patient’s request were motivations for a gastroenterological consultation. The practice of clinical medicine is still far from the guidelines provided by the specialists. Abdominal pain related to defecation and changes in bowel frequency are considered to be the more important symptoms for IBS diagnosis, but most GPs, both JGPs and SGPs, like to consider abdominal bloating as another useful symptom. Involving both gastroenterologists and GPs in developing shared guidelines would be highly desirable in order to improve IBS management strategies in everyday clinical practice.

Clusters of community-dwelling individuals empirically derived from stool diaries correspond with clinically meaningful outcomes

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are diagnosed according to expert consensus criteria based on recall of symptoms over periods of 3 months or longer. Whether the expert opinion concords with underlying disease process and whether individual recall is accurate are both in doubt. This study aimed to identify naturally occurring clusters of individuals with respect to symptom pattern, evaluate their significance, compare cluster profiles with expert opinion and evaluate their temporal stability.

METHODS

As part of a random population study of FGID-related symptoms, we first explored the use of prospective stool and symptom diaries combined with empirical grouping of individuals into clusters using nonhierarchical cluster analysis.

RESULTS

The analysis identified two clusters of individuals, one of which was characterized by elevated scores on all domains of symptoms (26% of the sample) and one that was low to average on all domains (74% of the sample). Cluster membership was found to be stable over a long interval. Clusters were found to differ on most domains of quality-of-life (d = 0.46-0.74), self-rated health (d = -0.42) and depression (d = -0.42) but not anxiety. Prevalence of clinically diagnosed irritable bowel syndrome (IBS) was higher in the more impacted cluster (33%) compared with the healthy cluster (13%; P < 0.0001).

CONCLUSION

A naturalistic classification of individuals challenges consensus criteria in showing that some IBS individuals have a symptom experience not unlike health. The proposed approach has demonstrated temporal stability over time, unlike consensus criteria. A naturalistic disease classification system may have practical advantages over consensus criteria when supported by a decision-analytic system.

Are physicians ready to comply with the guidelines for diagnosis and management of Helicobacter pylori-associated diseases: the survey results 2020–2021

Objective: To assess compliance of physicians with diagnostic and management guidelines for H. pylori-associated diseases with a question-naire-based survey.

Materials and methods: We conducted an anonymous voluntary online survey of 775 physicians of the following specialties: internal medicine 459 (59.2%), gastroenterology 279 (36%), and endoscopy 34 (4.4%). The respondents expressed their level of agreement with the questionnaire items as follows: 0 – I do not know, 1 – disagree, 2 – partially agree, and 3 – fully agree.

Results: 613 (79.4%) of the physicians fully agreed to diagnose and treat H. pylori in patients with chronic atrophic gastritis, 602 (78.0%) in the 1 st degree relatives of gastric cancer patients, 525 (68.0%) in patients with chronic superficial gastritis, 423 (54.8%) in peptic ulcer at remission, and 336 (43.4%) in those with dyspepsia syndrome. The physicians were equally compliant with eradication therapy in the patients, for whom long term use of proton pump inhibitors (PPI) or non-steroid anti-inflammatory drugs (NSAID) is being planned (386 (50.0%) and 397 (51.4%), respectively). Internists were less compliant with diagnosis and management of H. pylori in patients taking both PPI (χ2 = 66.525, p = 0.004) and NSAID (χ2 = 103.354, p = 0.003). Among the primary diagnostic tools for H. pylori the physicians preferred 13/14С-urease breath test (545 physicians, or 70.6%) and gastric bioptate morphology (574, or 74.4%), and among the control diagnostic methods they chose fаeces analyses (enzyme-linked immunosorbent assay and polymerase chain reaction). The respondents considered bismuth-enhanced standard triple therapy with clarithromycin to be the most effective regimen for the 1 st line eradication therapy (606, 78.5%). To increase the efficacy of eradication therapy, the physicians were more prone to administer esomeprazole or rabeprazole (70.6%), bismuth-based agents (79.4%), than to use rebamipid (35%), probiotics (44.9%) and/or to double PPI doses (44.2%). The respondents expressed their concerns with low patient compliance to treatment (59.4%) and limited diagnostic capabilities (49.4%).

Conclusion: Physician's compliance with the guidelines on diagnosis and management of H. pylori-associated diseases is adequate and might depend on both their awareness and availability of the proposed diagnostic and therapeutic methods.

Anemia as a Problem: GP Approach

BACKGROUND

Anemia is a presentation of an underlying disease or deficiency. As stated by the WHO, anemia is defined as hemoglobin (Hb) levels <12.0 g/dL in women and <13.0 g/dL in men. This review of clinical practice aimed to determine the diagnostic approach to anemia in primary care patients.

SUMMARY

Nutritional deficiencies, medications, chronic inflammatory conditions, malignancy, renal dysfunction, and bone marrow and inherent disorders contribute to anemia development. Anemia is classified and diagnosed by the values of hematological parameters, underlying pathological mechanism, and patient history. The diagnostic approach of anemia in primary care settings is focused on history, physical examination, laboratory findings including complete blood cell count, reticulocyte count, and peripheral smear examination, fecal occult blood test, and ultrasound findings.

KEY MESSAGES

Anemia is the most common hematological disorder that represents a major health burden worldwide. Hb levels alter with gender, ethnicity, and physiological status. Anemia is often multifactorial. The evaluation of a patient with anemia in primary care includes clinical history, physical examination, and laboratory findings with fecal occult blood test and abdominal ultrasound. The wide variations in general practice in European countries are based on different health care systems but also knowledge of GPs that reflect educational and research policy.

Jaundice as a Diagnostic and Therapeutic Problem: A General Practitioner's Approach

BACKGROUND

Jaundice is a common clinical finding in clinical practice of hepatologists and general practitioners. It occurs when serum bilirubin levels exceed 3 mg/dL.

SUMMARY

In this review, we summarize the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and laboratory and imaging techniques. Clinical presentation of jaundice manifests through yellow skin and sclera coloration. Evaluation of every patient includes detailed medical history and examination. In the laboratory, evaluation of enzymes of hepatic inflammation as well as cholestatic enzymes with serum bilirubin must be included. Additional laboratory analysis and imaging modalities are needed in order to differentiate jaundice etiology. Moreover, imaging is available and needed in further evaluation, and treatment is dependent on the underlying cause.

KEY MESSAGES

In this review, we will outline the pathophysiological mechanism of jaundice, clinical approach to the patient with jaundice, and diagnostic and treatment approach to these patients.

Chronic Constipation in Adults: The Primary Care Approach

BACKGROUND

Primary care is normally the initial point of presentation and management of patients with chronic constipation (CC). CC has a prevalence of 3-27%, predominantly amongst females and in the older population, and is associated with a reduced quality of life. Effective management can be a challenge without a structured approach.

SUMMARY

Whilst conventional teaching defines constipation as the number of stools per week, patients complain mainly of other symptoms such as straining and stool consistency rather than frequency. Symptoms need to be correlated with the likely causes, and ruling out secondary causes and treatment should be symptom driven, distinguishing between functional constipation and irritable bowel syndrome with CC. Treatment can be stepwise or involve combinations of therapies. There is a poor evidence base for most common managements, including lifestyle measures, although stimulant laxatives can be effective. Key Messages: Failure of routine treatment and an early consideration of alternative causes should lead to collaboration with a specialist, especially as many problems, such as pelvic floor disorders, gynaecological problems, and dyssynergic defecation, require secondary care investigations and remedies. In light of our ageing population, CC should be considered thoughtfully and the diagnosis and management tailored to the individual, to maintain good quality of life.

Undiagnosed microscopic colitis: a hidden cause of chronic diarrhoea and a frequently missed treatment opportunity

Microscopic colitis (MC) is a treatable cause of chronic, non-bloody, watery diarrhoea, but physicians (particularly in primary care) are less familiar with MC than with other causes of chronic diarrhoea. The colon in patients with MC is usually macroscopically normal. MC can only be diagnosed by histological examination of colonic biopsies (subepithelial collagen band >10 µm (collagenous colitis) or >20 intraepithelial lymphocytes per 100 epithelial cells (lymphocytic colitis), both with lamina propria inflammation). The UK National Health Service exerts downward pressure to minimise colonoscopy referrals. Furthermore, biopsies are often not taken according to guidelines. These factors work against MC diagnosis. In this review, we note the high incidence of MC (comparable to ulcerative colitis and Crohn's disease) and its symptomatic overlap with irritable bowel syndrome. We also highlight problems with the recommendation by National Health Service/National Institute for Health and Care Excellence guidelines for inflammatory bowel diseases that colonoscopy referrals should be based on a faecal calprotectin level of ≥100 µg/g. Faecal calprotectin is <100 µg/g in over half of individuals with active MC, building into the system a propensity to misdiagnose MC as irritable bowel syndrome. This raises important questions-how many patients with MC have already been misdiagnosed, and how do we address this silent burden? Clarity is needed around pathways for MC management; MC is poorly acknowledged by the UK healthcare system and it is unlikely that best practices are being followed adequately. There is an opportunity to identify and treat patients with MC more effectively.

Impact of introducing a faecal immunochemical test (FIT) for haemoglobin into primary care on the outcome of patients with new bowel symptoms: a prospective cohort study

Objective

To determine whether a faecal immunochemical test (FIT) for faecal haemoglobin concentration (f-Hb) can be safely implemented in primary care as a rule-out test for significant bowel disease (SBD) (colorectal cancer (CRC), higher risk adenoma (HRA) and inflammatory bowel disease (IBD)) when used as an adjunct to the clinical assessment of new bowel symptoms.

Design

Single-centre prospective cohort study of all patients who attended primary care and submitted a FIT in the first calendar year of the service beginning December 2015. f-Hb was estimated using HM-JACKarc (Kyowa Medex) with a clinical cut-off of ≥10 µg Hb/g faeces. Incident cases of CRC were verified via anonymised record linkage to the Scottish Cancer Registry.

Results

5422 patients submitted 5660 FIT specimens, of which 5372 were analysed (positivity: 21.9%). 2848 patients were referred immediately to secondary care and three with f-Hb <10 µg/g presented acutely within days with obstructing CRC. 1447 completed colonoscopy in whom overall prevalence of SBD was 20.5% (95 CRC (6.6%), 133 HRA (9.2%) and 68 IBD (4.7%)); 6.6% in patients with f-Hb <10 µg/g vs 32.3% in patients with f-Hb ≥10 µg/g. One CRC was detected at CT colonoscopy. 2521 patients were not immediately referred (95.3% had f-Hb <10 µg/g) of which four (0.2%) later developed CRC. Record linkage identified no additional CRC cases within a follow-up period of 23–35 months.

Conclusion

In primary care, measurement of f-Hb, in conjunction with clinical assessment, can safely and objectively determine a patient’s risk of SBD.

Approach to gastroenterological diseases in primary care

Gastroenterological diseases are a source of morbidity, mortality and costs, and have a high frequency in general practice; for this reason, we have evaluated the current literature regarding the knowledge and management of these disorders by general practitioners, finding little knowledge and adherence to guidelines, highlighting the need for continuous updating in this regard, and greater collaboration between specialists and general practitioners. (www.actabiomedica.it)

Reimagining the diagnostic pathway for gastrointestinal cancer

A crisis is looming for the diagnosis of gastrointestinal cancers, one grounded only partly in the steady increase in their overall incidence. Public demand for diagnostic tests to be undertaken early and at lower levels of risk is reflected in early diagnosis being a widely held policy objective for reasons of both clinical outcome and patient experience. In the UK, urgent referrals for suspected lower gastrointestinal cancer have increased by 78% in the past 6 years, with parallel increases in endoscopy and imaging activity. Such growth in demand is unsustainable with current models of care. If gastrointestinal cancer diagnosis is to be affordable, the roles of professionals and their interactions with each other will need to be reframed while retaining public confidence in the process. In this Perspective, we consider how the relationship between medical specialists and generalists could be redefined to make better use of the skills of each while delivering optimal clinical outcomes and a good patient experience.

Use of Rome criteria for the diagnosis of irritable bowel syndrome in primary care: a survey among European countries

BACKGROUND AND OBJECTIVES

The majority of patients with irritable bowel syndrome (IBS) are diagnosed and treated in primary care. The aim of this study was to investigate the implementation of the Rome criteria in daily primary care clinical practice and adherence of general practitioners (GPs) to recommended diagnostic approaches for IBS.

PATIENTS AND METHODS

A survey consisting of 18 questions was distributed across 11 European countries and was used to assess GPs' diagnostic approach of IBS, the use of Rome criteria in daily practice and GPs' perspective on the aetiology of the disorder.

RESULTS

Overall, 185 GPs completed the survey. In daily clinical practice, 32% of GPs reported that they usually make a positive diagnosis on the basis of symptoms only, whereas 36% of GPs reported regular use of the Rome criteria to diagnose IBS. Furthermore, 62% of the responders reported that they applied additional diagnostics, such as blood tests, 31% found it necessary to perform endoscopy to make a positive diagnosis of IBS and 29% referred patients with IBS to a specialist. Psychological factors were the most frequently selected potential aetiological factor of IBS (88% of GPs). Overall, 52% of GPs reported systematically including questions on psychological symptoms in the assessment of history of IBS.

CONCLUSION

Only about one-third of GPs regularly used the Rome criteria to diagnose IBS. In daily primary care practice, IBS largely remains a diagnosis of exclusion. This has implications in terms of GPs' specialty training and questions the applicability of IBS guidelines in daily care, which advocate an early, positive, symptom-based diagnosis.

Comparison of the Rome IV and Rome III criteria for IBS diagnosis: A cross-sectional survey

BACKGROUND AND AIMS

The aims of this study were to investigate the proportion of clinical irritable bowel syndrome (IBS) at a tertiary hospital in China, to compare the Rome III and Rome IV criteria with regard to IBS diagnosis, to describe the agreement between the Rome III and Rome IV criteria, and to identify differences between Rome IV-positive and -negative IBS patients.

METHODS

A cross-sectional survey was performed among outpatients in the gastrointestinal (GI) department of a tertiary hospital. The patients were categorized as having IBS using Rome III and Rome IV criteria.

RESULTS

In total, 1,376 (91.7%) patients completed a GI symptom questionnaire. Among them, 352 were suspected of having IBS and 175 were diagnosed with IBS using the Rome III or Rome IV criteria. In particular, 170 (12.4%) patients were diagnosed with IBS using the Rome III criteria, and 84 (6.1%) patients were diagnosed using the Rome IV criteria. Rome IV IBS patients experienced more pain symptoms (P<0.01) and showed higher IBS severity scores. In contrast, no significant differences were noted for demographic characteristics, stool frequency, IBS subtype, disease course, operation history or GI infection history between Rome IV IBS patients and IBS patients not diagnosed with the Rome IV criteria.

CONCLUSIONS

Rome IV-positive IBS patients represented approximately half of Rome III-positive IBS patients at a tertiary hospital in China. More specifically, Rome IV-positive IBS was mainly a subgroup of Rome III-positive IBS with more serious symptoms.

Explaining variation in cancer survival between 11 jurisdictions in the International Cancer Benchmarking Partnership: a primary care vignette survey

OBJECTIVES

The International Cancer Benchmarking Partnership (ICBP) is a collaboration between 6 countries and 12 jurisdictions with similar primary care-led health services. This study investigates primary care physician (PCP) behaviour and systems that may contribute to the timeliness of investigating for cancer and subsequently, international survival differences.

DESIGN

A validated survey administered to PCPs via the internet set out in two parts: direct questions on primary care structure and practice relating to cancer diagnosis, and clinical vignettes, assessing management of scenarios relating to the diagnosis of lung, colorectal or ovarian cancer.

PARTICIPANTS

2795 PCPs in 11 jurisdictions: New South Wales and Victoria (Australia), British Columbia, Manitoba, Ontario (Canada), England, Northern Ireland, Wales (UK), Denmark, Norway and Sweden.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis compared the cumulative proportion of PCPs in each jurisdiction opting to investigate or refer at each phase for each vignette with 1-year survival, and conditional 5-year survival rates for the relevant cancer and jurisdiction. Logistic regression was used to explore whether PCP characteristics or system differences in each jurisdiction affected the readiness to investigate.

RESULTS

4 of 5 vignettes showed a statistically significant correlation (p<0.05 or better) between readiness to investigate or refer to secondary care at the first phase of each vignette and cancer survival rates for that jurisdiction. No consistent associations were found between readiness to investigate and selected PCP demographics, practice or health system variables.

CONCLUSIONS

We demonstrate a correlation between the readiness of PCPs to investigate symptoms indicative of cancer and cancer survival rates, one of the first possible explanations for the variation in cancer survival between ICBP countries. No specific health system features consistently explained these findings. Some jurisdictions may consider lowering thresholds for PCPs to investigate for cancer-either directly, or by specialist referral, to improve outcomes.

Management of Gastrointestinal Disorders in Central and Eastern Europe: Self-Reported Practice of Primary Care Physicians

Background

Gastrointestinal disorders account for 7–10% of all consultations in primary care. General practitioners’ management of digestive disorders in Central and Eastern European countries is largely unknown.

Aims

To identify and compare variations in the self-perceived responsibilities of general practitioners in the management of digestive disorders in Central and Eastern Europe.

Methods

A cross-sectional survey of a randomized sample of primary care physicians from 9 countries was conducted. An anonymous questionnaire was sent via post to primary care doctors.

Results

We received 867 responses; the response rate was 28.9%. Over 70% of respondents reported familiarity with available guidelines for gastrointestinal diseases. For uninvestigated dyspepsia in patients under 45 years, the “test and treat” strategy was twice as popular as “test and scope”. The majority (59.8%) of family physicians would refer patients with rectal bleeding without alarm symptoms to a specialist (from 7.6% of doctors in Slovenia to 85.1% of doctors in Bulgaria; p<0.001). 93.4% of respondents declared their involvement in colorectal cancer screening. In the majority of countries, responding doctors most often reported that they order fecal occult blood tests. The exceptions were Estonia and Hungary, where the majority of family physicians referred patients to a specialist (p<0.001).

Conclusions

Physicians from Central and Eastern European countries understood the need for the use of guidelines for the care of patients with gastrointestinal problems, but there is broad variation between countries in their management. Numerous efforts should be undertaken to establish and implement international standards for digestive disorders’ management in general practice.

Conducting multinational, cross-cultural research in the functional gastrointestinal disorders: issues and recommendations. A Rome Foundation working team report

BACKGROUND

Cross-cultural, multinational research can advance the field of functional gastrointestinal disorders (FGIDs). Cross-cultural comparative research can make a significant contribution in areas such as epidemiology, genetics, psychosocial modulators, symptom reporting and interpretation, extra-intestinal co-morbidity, diagnosis and treatment, determinants of disease severity, health care utilisation, and health-related quality of life, all issues that can be affected by geographical region, culture, ethnicity and race.

AIMS

To identify methodological challenges for cross-cultural, multinational research, and suggest possible solutions.

METHODS

This report, which summarises the full report of a working team established by the Rome Foundation that is available on the Internet, reflects an effort by an international committee of FGID clinicians and researchers. It is based on comprehensive literature reviews and expert opinion.

RESULTS

Cross-cultural, multinational research is important and feasible, but has barriers to successful implementation. This report contains recommendations for future research relating to study design, subject recruitment, availability of appropriate study instruments, translation and validation of study instruments, documenting confounders, statistical analyses and reporting of results.

CONCLUSIONS

Advances in study design and methodology, as well as cross-cultural research competence, have not matched technological advancements. The development of multinational research networks and cross-cultural research collaboration is still in its early stages. This report is intended to be aspirational rather than prescriptive, so we present recommendations, not guidelines. We aim to raise awareness of these issues and to pose higher standards, but not to discourage investigators from doing what is feasible in any particular setting.

Systematic review: the perceptions, diagnosis and management of irritable bowel syndrome in primary care--a Rome Foundation working team report

OBJECTIVE

To review studies on the perceptions, diagnosis and management of irritable bowel syndrome (IBS) in primary care.

METHODS

Systematic searches of PubMed and Embase.

RESULTS

Of 746 initial search hits, 29 studies were included. Relatively few primary care physicians were aware of (2-36%; nine studies) or used (0-21%; six studies) formal diagnostic criteria for IBS. Nevertheless, most could recognise the key IBS symptoms of abdominal pain, bloating and disturbed defaecation. A minority of primary care physicians [7-32%; one study (six European countries)] preferred to refer patients to a specialist before making an IBS diagnosis, and few patients [4-23%; three studies (two European, one US)] were referred to a gastroenterologist by their primary care physician. Most PCPs were unsure about IBS causes and treatment effectiveness, leading to varied therapeutic approaches and broad but frequent use of diagnostic tests. Diagnostic tests, including colon investigations, were more common in older patients (>45 years) than in younger patients [<45 years; five studies (four European, one US)].

CONCLUSIONS

There has been much emphasis about the desirability of an initial positive diagnosis of IBS. While it appears most primary care physicians do make a tentative IBS diagnosis from the start, they still tend to use additional testing to confirm it. Although an early, positive diagnosis has advantages in avoiding unnecessary investigations and costs, until formal diagnostic criteria are conclusively shown to sufficiently exclude organic disease, bowel investigations, such as colonoscopy, will continue to be important to primary care physicians.

Management of chronic constipation in general practice

BACKGROUND

Chronic constipation is often diagnosed and treated by general practitioners (GPs). The aim of the study was to evaluate the management of constipation by a cohort of Italian GPs.

METHODS

Over the course of 1 month, 41 GPs recorded tests and therapies suggested to patients complaining of chronic constipation. They were classified according to the Rome III criteria as constipated irritable bowel syndrome (C-IBS), functional constipation (FC), or "self-perceived constipation" (SPC) (not consistent with the Rome criteria).

RESULTS

The most frequently prescribed tests for the 229 patients (147 FC, 50 C-IBS, 32 SPC) were routine blood tests (59.3 %), abdominal ultrasounds (37.2 %), thyroid function (36.7 %), fecal occult blood tests (36.7 %), and tumor markers (35 %). Patient sex and age, GP age, and whether the diagnosis was new influenced the GP's request, but FC, C-IBS, or SPC status did not. Dietary suggestions (81.9 %), fiber supplements (59.7 %), reassurance (50.9 %), and laxatives (30.5 %) were the most frequently prescribed treatments. Antispasmodics were more frequently suggested for C-IBS patients; dietary suggestions, fiber, and enemas were more frequently prescribed in SPC patients. Patient and GP age and whether the diagnosis was new influenced the GP's choice of treatment.

CONCLUSIONS

The Rome III criteria do not influence diagnostic strategies and only slightly influence therapeutic strategies of GPs. Other factors (age, gender, new or old diagnosis) have more influence on GPs choice of investigations and treatment.

The role of primary care physicians in early diagnosis and treatment of chronic gastrointestinal diseases

Chronic gastrointestinal disorders are a source of substantial morbidity, mortality, and cost. They are common in general practice, and the primary care physician (PCP) has a central role in the early detection and management of these problems. The need to make cost-effective diagnostic and treatment decisions, avoid unnecessary investigation and referral, provide long-term effective control of symptoms, and minimize the risk of complications constitute the main challenges that PCPs face. The literature review shows that, although best practice standards are available, a considerable number of PCPs do not routinely follow them. Low rates of colorectal cancer screening, suboptimal testing and treatment of Helicobacter pylori infection, inappropriate use of proton pump inhibitors, and the fact that most PCPs are still approaching the irritable bowel disease as a diagnosis of exclusion represent the main gaps between evidence-based guidelines and clinical practice. This manuscript points out that updating of knowledge and skills of PCPs via continuing medical education is the only way for better adherence with standards and improving quality of care for patients with gastrointestinal diseases.

A positive diagnostic strategy is noninferior to a strategy of exclusion for patients with irritable bowel syndrome

BACKGROUND & AIMS

Guidelines recommend a positive strategy based on symptom criteria to diagnose patients with irritable bowel syndrome (IBS). We conducted a randomized noninferiority trial to determine whether a positive diagnostic strategy is noninferior to a strategy of exclusion, with regard to patients' health-related quality of life (HRQOL).

METHODS

We studied 302 patients (18-50 years old) from primary care who were suspected of having IBS and referred by general practitioners. Patients who fulfilled the Rome III criteria for IBS with no alarm signals were randomly assigned to groups assessed by a strategy of exclusion (analyses of blood, stool samples for intestinal parasites, and sigmoidoscopies with biopsies) or a positive strategy (analyses of blood cell count and C-reactive protein). Patients were followed for 1 year. The primary end point was difference in change of HRQOL from baseline to 1 year between groups (on the basis of the Short Form 36 health survey, physical component summary, and noninferiority margin of 3 points). Secondary outcomes were change in gastrointestinal symptoms, satisfaction with management, and use of resources. Findings of diagnostic misclassification were registered.

RESULTS

A positive strategy was noninferior to a strategy of exclusion (difference, 0.64; 95% confidence interval, -2.74 to 1.45). The positive diagnostic strategy had lower direct costs. Each approach had similar effects on symptoms, satisfaction, and subsequent use of health resources. No cases of inflammatory bowel disease, colorectal cancer, or celiac disease were found.

CONCLUSIONS

In diagnosing IBS in primary care, use of a positive diagnostic strategy is noninferior to using a strategy of exclusion with regard to the patients' HRQOL. Our findings support the current guideline recommendations.

Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care

OBJECTIVES

The Rome III criteria for irritable bowel syndrome (IBS) are recommended by guidelines to help identify the syndrome. The majority of IBS patients are managed in primary care, where a pragmatic approach to diagnosis is usually adopted, using clinical judgment and knowledge about the patient. Many general practitioners (GPs) have no or limited knowledge of the diagnostic criteria, few use them, and many consider IBS a diagnosis of exclusion. The aim of this study is to explore the sensitivity of the Rome III criteria in relation to a GP-based clinical diagnosis of IBS, to identify differences between Rome III-positive and -negative patients, and to describe the agreement between the various symptom-based criteria.

METHODS

Patients aged 18-50 years, presenting in primary care with gastrointestinal complaints and identified as IBS patients by their GP, were referred for enrollment. The Manning and Rome I-III criteria were evaluated through interviews and patients completed the questionnaires The Gastrointestinal Symptom Rating Scale (GSRS)/The Gastrointestinal Symptom Rating Scale modified for use in patients with IBS (GSRS-IBS), Short Form 36, Irritable Bowel Syndrome Quality of Life measurement, Work Productivity and Activity Impairment questionnaire-irritable bowel version, and a questionnaire on use of health-care resources.

RESULTS

A total of 604 patients were referred and 499 were included (mean age 32.8 (s.d. 9.5) years, 75% were female). The Rome III criteria were fulfilled by 376 patients (sensitivity 0.75, 95% CI 71-79%). Rome III-positive patients more frequently reported disturbed defecation, had a higher symptom burden, and lower disease-specific health-related quality of life compared with Rome III-negative patients. The various symptom-based criteria identified slightly different subpopulations with the highest agreement between the Rome II and III criteria.

CONCLUSIONS

The Rome III criteria identified three in four patients labeled with IBS in primary care. The relevance of the Rome III for IBS in primary care is supported.

The epidemiology of irritable bowel syndrome in Denmark. A population-based survey in adults ≤50 years of age

OBJECTIVE

Our aims were to investigate the prevalence and subtype distribution of irritable bowel syndrome (IBS) according to the Rome III criteria in Denmark, to describe the difference in symptom reporting between those with gastrointestinal (GI) symptoms not fulfilling Rome III for IBS compared to those classified as IBS, and furthermore to describe the proportion of consulters and formally diagnosed subjects.

MATERIAL AND METHODS

A web-based survey was carried out in January 2010. Questionnaires were emailed to a web panel (n = 19,567) representative of the general Danish population aged 18-50 years on gender, age, and geography. IBS and subtypes were estimated by the Rome III criteria.

RESULTS

Of 6112 responders, 979 (16%) fulfilled the Rome III criteria for IBS and had no organic diagnosis likely to explain their symptoms. Subtypes were: mixed IBS 36%, IBS with diarrhea 33%, IBS with constipation 18%, and unsubtyped IBS 11%. Those with GI symptoms, not fulfilling Rome III for IBS, had symptoms very similar to those classified as IBS, but symptoms were less frequent and of shorter duration. Of IBS subjects, 180/978 (18.4%) had consulted a doctor for GI symptoms within the past 3 months, but only 7.9% were diagnosed with IBS.

CONCLUSION

Symptoms compatible with IBS according to Rome III are highly prevalent in Denmark. A high proportion of sufferers are undiagnosed.

Gastroesophageal Reflux Disease Questionnaire (GerdQ) in real-world practice: a national multicenter survey on 8065 patients

BACKGROUND AND AIM

Recently, Gastroesophageal Reflux Disease Questionnaire (GerdQ) has been developed for diagnosis of GERD. However, no study investigated its value in real-world practice. This study aimed to investigate whether GerdQ can be used for diagnosis of GERD in China.

METHODS

A national multicenter survey was undertaken; all patients who underwent first diagnostic upper endoscopy for upper gastrointestinal (GI) symptoms were included. Data including the gender, age, symptoms, and endoscopic findings were prospectively recorded. The GerdQ score was measured before endoscopic procedure.

RESULTS

Totally, 8065 patients were included. One thousand four hundred and thirty-five patients (17.8%) had reflux esophagitis. Among them, 620 (43.2%) patients' GerdQ score was ≥ 8. For 2025 patients with GerdQ ≥ 8, 620 (30.6%) were found to have reflux esophagitis, but the remaining 69.4% (1405/2025) were normal. Proportions of patients with reflux esophagitis increased in cut-off range from 3-18 for GerdQ. However, 22.2% of the patients with a GerdQ score ≤ 2 also had reflux esophagitis. Twenty-eight (0.3%) patients were diagnosed to have upper GI malignancies, and 10 out of these 28 (35.7%) patients' GerdQ score was ≥ 8.

CONCLUSIONS

The study suggests the proportions of Chinese patients with reflux esophagitis rise up with the increase of GerdQ score, and GerdQ may be used for diagnosis of GERD. However, low GerdQ score cannot exclude the possibility of reflux esophagitis. A minority of Chinese patients has high GerdQ score but is diagnosed with malignancies, even in the absence of alarm features.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

Irritable bowel syndrome and food allergy

Irritable bowel syndrome (IBS) is a kind of functional gastrointestinal disease characterized by abdominal pain or discomfort associated with changes in bowel habits. The alternating symptoms of IBS seriously affect the patients' quality of life. Some studies have found that food could cause or aggravate the symptoms of IBS possibly by inducing food allergy and food intolerance. However, the specific mechanisms have not been established yet. Currently there are "bacterial 'toxin' hypothesis", "immune or inflammatory response hypothesis" and "physical or chemical irritation hypothesis" explaining the role of food in the pathogenesis of IBS. It has been known that food factors play a very important role in the pathogenesis of IBS. This article reviews food allergy and the possible mechanisms, diagnosis and treatment of IBS caused by food.

The management of patients with new onset of upper gastro-intestinal symptoms in primary care

BACKGROUND

Data dealing with dyspepsia management in general practice are lacking, and most of the studies investigated a subset of patients with suspected peptic ulcer disease either with or without previous complaints.

AIMS

To evaluate the one-year management of patients presenting new onset upper abdominal symptoms without alarming features.

METHODS

275 patients were enrolled by 63 Italian general practitioners.

RESULTS

Referral to upper gastro-intestinal tract endoscopy resulted significantly higher in patients with predominant epigastric pain compared to subjects with non-painful symptoms or non-dominant symptoms. Amongst drug therapies, only prokinetics and antacids and anti-secretory therapies were prescribed differently amongst clinical subgroups. The rate and type of management and referrals resulted were not influenced by the age of patients or the use of anti-inflammatory drugs. The most frequent diagnosis at one-year follow-up was reflux oesophagitis. The absence of organic disease was less frequent in patients with dominant epigastric pain than non-painful or non-dominant symptoms.

CONCLUSION

The management of these patients in primary care in Italy is mainly determined by clinical presentation, independent of age. Any judgement about appropriateness of the treatment should consider not only conventional features such as age, but the more complex individual frameworks as well.

Asian consensus on irritable bowel syndrome

BACKGROUND AND AIMS

Many of the ideas on irritable bowel syndrome (IBS) are derived from studies conducted in Western societies. Their relevance to Asian societies has not been critically examined. Our objectives were to bring to attention important data from Asian studies, articulate the experience and views of our Asian experts, and provide a relevant guide on this poorly understood condition for doctors and scientists working in Asia.

METHODS

A multinational group of physicians from Asia with special interest in IBS raised statements on IBS pertaining to symptoms, diagnosis, epidemiology, infection, pathophysiology, motility, management, and diet. A modified Delphi approach was employed to present and grade the quality of evidence, and determine the level of agreement.

RESULTS

We observed that bloating and symptoms associated with meals were prominent complaints among our IBS patients. In the majority of our countries, we did not observe a female predominance. In some Asian populations, the intestinal transit times in healthy and IBS patients appear to be faster than those reported in the West. High consultation rates were observed, particularly in the more affluent countries. There was only weak evidence to support the perception that psychological distress determines health-care seeking. Dietary factors, in particular, chili consumption and the high prevalence of lactose malabsorption, were perceived to be aggravating factors, but the evidence was weak.

CONCLUSIONS

This detailed compilation of studies from different parts of Asia, draws attention to Asian patients' experiences of IBS.

Rural primary care in Greece: working under limited resources

OBJECTIVE

Establishing sufficient primary health-care services in rural areas is of high interest in developing health systems. The objective of the present study was to describe the state of rural health services, in terms of personnel and equipment, in rural primary care settings in Greece.

DESIGN

A questionnaire was sent to all Greek rural settings (RS) (practices) twice during 2007. The questionnaire included questions about the number of doctors in the practice, their specialty, presence of a nurse, population served and average distance from the regional Health Center and hospital. It also included questions about the average number of consultations per day, home visits, maintenance of medical records and medical equipment.

SETTING

Rural primary care settings in Greece.

PARTICIPANTS

Doctors serving primary care needs during the second half of 2007.

INTERVENTION

s) None.

MAIN OUTCOME MEASURE

s) Data concerning staffing, function and available equipment of the RS have been collected.

RESULTS

Five hundred eighty-two (40.9%) of the rural practitioners replied. Twenty-nine percent of the participants were general practitioners (GPs). Doctors reported average population of responsibility of 2263 citizens and a regular average of 26 consultations per day. A nurse was present in 174 RS (29.5%). Medical records of any form were kept in only 36% of the RS. GPs were more prone to maintain patients files compared with non-specialized doctors. Essential equipment proved to be limited in the majority of the RS.

CONCLUSIONS

Rural practices in Greece report shortages of medical staff (GPs), nursing staff and equipment.

Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care

BACKGROUND

Accurate diagnosis and effective management of gastro-oesophageal reflux disease (GERD) can be challenging for clinicians and other health care professionals.

AIM

To develop a patient-centred, self-assessment questionnaire to assist health care professionals in the diagnosis and effective management of patients with GERD.

METHODS

Questions from patient-reported GERD instruments, previously documented in terms of content validity and psychometric properties (RDQ, GSRS and GIS) and data on the diagnosis of GERD in primary and secondary care were used in the formal development of a diagnostic and management tool, the GerdQ, involving psychometric validation and piloting in patient focus groups.

RESULTS

Analyses of data from over 300 primary care patients, moderated by patient input from qualitative interviews, were used to select specific items from the existing instruments to create a new six-item diagnostic and management tool (GerdQ). ROC analysis indicated a sensitivity for GerdQ of 65% and a specificity of 71% for the diagnosis of GERD, similar to that achieved by gastroenterologists.

CONCLUSION

The GerdQ is a potentially useful tool for family practitioners and other health care professionals in diagnosing and managing GERD without initial specialist referral or endoscopy.

Management of gastro-oesophageal reflux disease in primary care: a European observational study

OBJECTIVE

To describe the management of gastro-oesophageal reflux disease (GERD) in primary care, as part of the RANGE (Retrospective ANalysis of GERD) study.

METHODS

Over 4 months, at 134 primary care practices in six European countries, 12 815 patients consulted for GERD-related reasons. A random selection of these patients was invited to enter the study. Data were then collected retrospectively (from the initial consultation) and prospectively (from a follow-up visit). This included information on GERD diagnosis, symptoms and complications, medication use and healthcare resource utilisation.

RESULTS

Of 12 815 patients who underwent consultation for GERD-related reasons, 2678 were randomly selected and accepted the invitation to participate in the study. Across countries, 28-47% of patients reported a significant GERD symptom load at initial consultation. Thereafter, 30-100% of patients were prescribed a proton pump inhibitor (PPI), but a significant GERD symptom load was still experienced by 15-30% (all patients combined) at follow-up (median 5.0-7.5 months after initial consultation). In the majority of patients (65-88%), no diagnostic procedures were performed between initial consultation and follow-up. During the follow-up period, the most common form of healthcare utilisation comprised additional GERD-related consultations with a physician.

CONCLUSIONS

The findings of this pan-European study indicate that current management of primary care patients with GERD is far from optimal, and accounts for a marked burden on patients and healthcare systems alike. A more structured approach to GERD management, by tailoring treatment according to the impact of the disease, may reduce this burden.