Survey of the AGA membership relating to patients with functional gastrointestinal disorders

[Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice]

Frequent Gastro-Intestinal Disorders: Management of Functional Dyspepsia and Irritable Bowel Syndrome in Clinical Practice Abstract: Functional dyspepsia (FD) and irritable bowel syndrome (IBS), two common gastrointestinal entities with overlapping symptoms, should be diagnosed according to Rome IV criteria. This includes one or more of the following symptoms: in FD, postprandial fullness, early satiation, epigastric pain or burning; in IBS, recurrent abdominal pain associated with defecation, change in frequency of stool or form of stool. To exclude structural diseases, attention should be paid to alarm symptoms. As far as treatment is concerned, a stepwise scheme proves to be effective for both diseases. Step 1: doctor-patient discussion with explanation of diagnosis and prognosis as well as clarification of therapy goals; lifestyle adaptations; use of phytotherapeutics; step 2: symptom-oriented medication: for FD, PPIs or prokinetics; for IBS, antispasmodics, secretagogues, laxatives, bile acid sequestrants, antidiarrheals, antibiotics, probiotics; step 3: visceral analgesics (antidepressants).

Association of serotonin transporter promoter polymorphism (5-HTTLPR) with orocecal transit time in irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a multifactorial disorder with altered intestinal motility, secretion, and sensation. Serotonin (5-HT) stimulates gut motility and alters serotonin signaling that may lead to both intestinal and extraintestinal symptoms in IBS.

AIM

The aim of this study was to examine the association of serotonin transporter gene promoter polymorphism (5-HTTLPR) in IBS with orocecal transit time (OCTT) measured by lactulose hydrogen breath test.

METHOD

This prospective case-control study included 151 IBS patients (mean±SD 37.4±11.6 years, median 36, range 19-68). Ninety-two patients were diarrhea-predominant IBS (D-IBS), 44 constipation-predominant IBS (C-IBS), 15 alternating diarrhea and constipation IBS (M-IBS), and 100 healthy controls (mean±SD 37.2±11.4 years, median 36, range 20-64 years). 5-HTTLPR gene polymorphism was studied by polymerase chain reaction-based method. 5-HT levels were measured by enzyme-linked immunosorbent assay (ELISA). Orocecal transit time (OCTT) was measured by a non-invasive lactulose hydrogen breath test. OCTT was also compared with respect to 5-HTTLPR genotypes in different IBS phenotypes.

RESULTS

Serum serotonin levels were significantly higher in overall IBS patients (152±77 ng/mL, p<0.001), D-IBS (184±76 ng/mL, p<0.001), compared to healthy controls (129±56 ng/mL). There was no difference in 5-HT levels between C-IBS (124±53 ng/mL) and controls. In the case of M-IBS, 5-HT levels were (88±49 ng/mL p<0.05) significantly lower than that of controls. OCTT was significantly shorter in D-IBS patients (95±36 min) as compared to controls (112±41 min). In contrast, C-IBS showed significantly prolonged OCTT (136±54 min). There was a significant difference in OCTT between D-IBS and C-IBS patients (p<0.001). There was no significant association found between OCTT and 5-HTTLPR.

CONCLUSIONS

Serum serotonin concentrations were increased in D-IBS compared to controls and C-IBS. OCTT was shorter in D-IBS and delayed in C-IBS patients. There was no association of 5-HTLPR polymorphism with OCTT.

Long-Term Outcome of Multidisciplinary Versus Standard Gastroenterologist Care for Functional Gastrointestinal Disorders: A Randomized Trial

BACKGROUND & AIMS

Functional gastrointestinal disorders are common and costly to the healthcare system. In the Multidisciplinary Treatment of Functional Gastrointestinal Disorders study, we demonstrated that multidisciplinary care resulted in superior clinical and cost outcomes, when compared with standard gastroenterologist-only care at end of treatment. In this study we evaluate the longer-term outcomes.

METHODS

In a single-center, pragmatic trial patients with Rome IV criteria-defined functional gastrointestinal disorders were randomized 1:2 to a gastroenterologist-only standard care vs a multidisciplinary clinic comprising gastroenterologists, dietitians, gut hypnotherapists, psychiatrists, and biofeedback physiotherapists. Outcomes in this study were assessed 12 months after the end of treatment. Global symptom improvement was assessed by using a 5-point Likert scale. Symptoms, specific disorder status, psychological state, quality of life, and cost were additional outcomes. A modified intention-to-treat analysis was performed.

RESULTS

Of 188 randomized patients, 143 (46 standard care, 97 multidisciplinary) formed the longer-term modified intention-to-treat analysis. Sixty-two percent of multidisciplinary clinic patients saw allied clinicians. Sixty-five percent (30/46) standard care versus 76% (74/97) multidisciplinary clinic patients achieved global symptom improvement 12 months after end of treatment (P = .17), whereas 20% (9/46) versus 37% (36/97) rated their symptoms as "5/5 much better" (P = .04). A ≥50-point reduction in Irritable Bowel Syndrome Severity Scoring System occurred in 38% versus 66% (P = .02), respectively, for irritable bowel syndrome patients. Anxiety and depression were greater in the standard care than multidisciplinary clinic (12 vs 10, P = .19), and quality of life was lower in standard care than the multidisciplinary clinic (0.75 vs 0.77, P =·.03). An incremental cost-effectivness ratio found that for every additional 3555AUD spent in the multidisciplinary clinic, a further quality-adjusted life year was gained.

CONCLUSIONS

Twelve months after the completion of treatment, integrated multidisciplinary clinical care achieved a greater proportion of patients with improvement of symptoms, psychological state, quality of life, and cost, compared with gastroenterologist-only care.

CLINICAL TRIALS

gov: number NCT03078634.

A systematic review and meta-analysis on the prevalence of non-malignant, organic gastrointestinal disorders misdiagnosed as irritable bowel syndrome

Treatable gastrointestinal disorders in patients with symptoms typical for irritable bowel syndrome (IBS) may be overlooked. The prevalence of five gastrointestinal conditions-bile acid diarrhoea (BAD), carbohydrate malabsorption (CM), microscopic colitis (MC), pancreatic exocrine insufficiency (PEI) and small intestinal bacterial overgrowth (SIBO) was systematically assessed from studies including consecutive patients meeting diagnostic criteria for IBS. 4 databases were searched from 1978 to 2020. Studies were included if they evaluated the prevalence of these conditions in secondary healthcare setting. Estimated pooled rates were calculated and statistical heterogeneity between studies was evaluated using Q and I2 statistics. Seven studies (n = 597) estimated the pooled prevalence for BAD as 41% (95% CI 29-54). 17 studies (n = 5068) estimated that of MC as 3% (95% CI 2-4%). Two studies (n = 478) suggested a rate of 4.6% (range: 1.8-6.1%) for PEI. Using breath testing, 26 studies (n = 6700) and 13 studies (n = 3415) estimated the prevalence of lactose and fructose malabsorption as 54% (95% CI 44-64%) and 43% (95% CI 23-62%); 36 studies (n = 4630) and 22 studies (n = 2149) estimated that of SIBO as 49% (95% CI 40-57%) with lactulose and 19% (95% CI 13-27%) with glucose. Rates of all conditions were significantly higher than in healthy controls. A significant proportion of patients presenting to secondary care with IBS have an organic condition which may account for their symptoms. Failure to exclude such conditions will deny patients effective treatment.

Stimulation of hypothalamic oxytocin neurons suppresses colorectal cancer progression in mice

Emerging evidence suggests that the nervous system is involved in tumor development in the periphery, however, the role of the central nervous system remains largely unknown. Here, by combining genetic, chemogenetic, pharmacological, and electrophysiological approaches, we show that hypothalamic oxytocin (Oxt)-producing neurons modulate colitis-associated cancer (CAC) progression in mice. Depletion or activation of Oxt neurons could augment or suppress CAC progression. Importantly, brain treatment with celastrol, a pentacyclic triterpenoid, excites Oxt neurons and inhibits CAC progression, and this anti-tumor effect was significantly attenuated in Oxt neuron-lesioned mice. Furthermore, brain treatment with celastrol suppresses sympathetic neuronal activity in the celiac-superior mesenteric ganglion (CG-SMG), and activation of β2 adrenergic receptor abolishes the anti-tumor effect of Oxt neuron activation or centrally administered celastrol. Taken together, these findings demonstrate that hypothalamic Oxt neurons regulate CAC progression by modulating the neuronal activity in the CG-SMG. Stimulation of Oxt neurons using chemicals, for example, celastrol, might be a novel strategy for colorectal cancer treatment.

Abdominal Pain and Depression, Not Bowel Habits, Predict Health Care Utilization in Patients With Functional Bowel Disorders

INTRODUCTION

Patients with disorders of gut-brain interaction (DGBIs) are high users of health care. Past studies exploring predictors of utilization have lacked patient-level clinical data. The aim of the current study is to identify demographic, clinical, and psychological predictors of health care utilization in patients with irritable bowel syndrome (IBS), functional constipation (FC), and functional diarrhea (FDr).

METHODS

Consecutive new patients diagnosed with IBS, FC, and FDr (using Rome IV criteria) completed questionnaires assessing health care utilization as well as clinical and psychological symptoms. Health care utilization was assessed using a 13-item measure inquiring about the previous 6 months. Patient-Reported Outcome Measures Information System (PROMIS) was used to assess severity of abdominal pain, constipation, diarrhea, anxiety, depression, and sleep disturbance.

RESULTS

Of the 507 patients diagnosed with IBS, FC, or FDr, 434 completed the health care utilization questionnaire (mean age of 44 years, 79.5% female, and 73.5% IBS). In the final multivariable models, more severe abdominal pain and higher depression scores were significantly associated with increased utilization of (i) total outpatient visits, (ii) outpatient visits for gastrointestinal (GI) symptoms, and (iii) number of medications for GI symptoms. More severe abdominal pain was also significantly predictive of GI-related emergency department visits. Altered bowel habits were not consistent predictors of health care utilization.

DISCUSSION

Severity of abdominal pain and depressive symptoms, but not bowel habits, is a primary driver of increased care-seeking behavior in patients with IBS, FC, and FDr.

Prevalence of irritable bowel syndrome-like symptoms using Rome IV criteria in patients with inactive inflammatory bowel disease and relation with quality of life

Irritable bowel syndrome (IBS)-like symptoms tend to be common in inflammatory bowel disease (IBD) patients even during the long-standing remission phase, and quality of life (QOL) seem to reduce in IBD patients with such symptoms. Thus, the aim of this study was to define the prevalence of IBS-like symptoms in inactive IBD patients using Rome IV criteria and evaluate the effect of IBS-like symptoms on QOL.Total 137 patients with IBD (56 with ulcerative colitis (UC) and 81 with Crohn disease (CD), who had been in long-standing remission according to the clinical scoring system and 123 control participants were included. These patients completed questionnaires to evaluate IBS-like symptoms according to Rome IV criteria, and the impact of these symptoms on the QOL of inactive IBD patients was compared with and without IBS-like symptoms according to disease-specific inflammatory bowel disease questionnaire (IBDQ).Depending on our research, IBS-like symptoms were found in 32% (18/56) of patients with inactive UC, 35% (29/81) of patients with inactive CD, and 13.8% (17/123) of control participants (P < .001). The QOL seemed to be significantly lower in both inactive UC and CD patients with IBS-like symptoms than in those without such symptoms (P < .001).In conclusion, we defined that the prevalence of IBS-like symptoms in IBD patients in remission is 2 to 3 times higher than that in healthy control participants, and significantly lower IBDQ scores showed QOL was reduced in inactive IBD patients with IBS-like symptoms as compared with patients without IBS-like symptoms.

Possible role of intestinal stem cells in the pathophysiology of irritable bowel syndrome

The pathophysiology of irritable bowel syndrome (IBS) is not completely understood. However, several factors are known to play a role in pathophysiology of IBS such as genetics, diet, gut microbiota, gut endocrine cells, stress and low-grade inflammation. Understanding the pathophysiology of IBS may open the way for new treatment approaches. Low density of intestinal stem cells and low differentiation toward enteroendocrine cells has been reported recently in patients with IBS. These abnormalities are believed to be the cause of the low density of enteroendocrine cells seen in patients with IBS. Enteroendocrine cells regulate gastrointestinal motility, secretion, absorption and visceral sensitivity. Gastrointestinal dysmotility, abnormal absorption/secretion and visceral hypersensitivity are all seen in patients with IBS and haven been attributed to the low density the intestinal enteroendocrine cells in these patients. The present review conducted a literature search in Medline (PubMed) covering the last ten years until November 2019, where articles in English were included. Articles about the intestinal stem cells and their possible role in the pathophysiology of IBS are discussed in the present review. The present review discusses the assumption that intestinal stem cells play a central role in the pathophysiology of IBS and that the other factors known to contribute to the pathophysiology of IBS such as genetics, diet gut microbiota, stress, and low-grade inflammation exert their effects through affecting the intestinal stem cells. It reports further the data that support this assumption on genetics, diet, gut microbiota, stress with depletion of glutamine, and inflammation.

A Brief Review of Nutraceutical Ingredients in Gastrointestinal Disorders: Evidence and Suggestions

The dietary effect on gut health has long been recognized through the empirical practice of soothing gastric discomfort with certain types of food, and recently the correlation between specific diets with lower incidences of several gastrointestinal diseases has been revealed. Ingredients from those considered beneficial foods have been isolated and studied, and some of them have already been put into the supplement market. In this review, we focus on latest studies of these food-derived ingredients for their proposed preventive and therapeutic roles in gastrointestinal disorders, with the attempt of drawing evidence-based suggestions on consuming these products.

Delivery of care for functional gastrointestinal disorders: A systematic review

BACKGROUND

A diverse range of treatments are available for the treatment of functional gastrointestinal disorders (FGIDs). Individual treatments, including drug therapies, behavioral therapy ("biofeedback"), psychological therapies, and dietary therapies, have been well validated in controlled, randomized trials and real-life case series. However, few studies have evaluated models of delivery of care for the whole population of referred patients with an FGID. This review evaluates models of specialist outpatient care for the management of FGIDs.

METHODS

A systematic review was performed of full-text articles published until October 2018 in Pubmed/Medline and Embase. Studies were included if they evaluated a model of outpatient care in a specialist setting for the treatment of adult patients with an FGID and included patient-reported outcomes comprising symptoms, quality of life, or psychological well-being.

RESULTS

Few studies have evaluated the delivery of care for the whole population of referred patients with an FGID, and there was one randomized comparison of different models of care. Two studies that evaluated the outcome of gastroenterologist-only clinics suggested poor long-term results. Two non-comparative case series reported the outcome of multidisciplinary care, including gastroenterologists and psychological therapists, suggesting improved patient quality of life and psychological well-being.

CONCLUSIONS

Despite the high prevalence and cost of treating FGIDs, and the availability of effective treatments, there are few data and limited randomized comparisons reporting the outcome of different types of specialist care. The few data available suggest that multidisciplinary care is superior to gastroenterologist-only care, but this needs to be validated in prospective comparative studies.

Depression and anxiety associated with functional bowel disorders and its impact on quality of life: A cross-sectional study

BACKGROUND

Functional bowel disorder (FBD) is conceptualized as a "biopsychosocial disorder." Psychological factors are important moderators of symptom severity and persistence, treatment seeking and response to treatment. We investigated psychological factors and quality of life (QOL) in patients with FBD.

METHODS

Seventy patients visiting the department of medical gastroenterology diagnosed as FBD were included in the study. Severity of FBD was rated with FBD Severity Index. The Depression, Anxiety, and Stress Scale was applied and patients were divided into two groups, i.e., with moderate stress (Group A) and with severe stress (Group B). QOL in both the groups was assessed by WHOQOL-BREF Scale. Chi-square, t-test was done to compare the groups. Regression analysis was done to find predictors of poor QOL. P < 0.05 was taken as significant.

RESULTS

Patients of Group B had a longer duration of illness and had higher prevalence of depressive disorder (P = 0.03) in comparison to patients in Group A, who had higher prevalence of anxiety disorders (P = 0.06). Severity of FBD was positively correlated with depression (r = 0.8; P = 0.02). Physical and psychological QOL was significantly impaired in Group B patients having depression (P = 0.02; P = 0.03). Regression analysis showed a positive trend for presence of depressive disorder (P = 0.05), anxiety disorder (P = 0.08) and severity of FBD (P = 0.09) as predictors of poor QOL.

CONCLUSION

In our study, the high prevalence of stress, anxiety and depression in patients with FBD indicates the need for routine screening of such symptoms along with a collaborative and holistic treatment approach. Several etiological perspectives explaining the complex gut-brain interaction are also provided.

Defining Optimal Care for Functional Gut Disorders - Multi-Disciplinary Versus Standard Care: A Randomized Controlled Trial Protocol

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are the commonest reason for gastroenterological consultation, with patients usually seen by a specialist working in isolation. There is a wealth of evidence testifying to the benefit provided by dieticians, behavioral therapists, hypnotherapists and psychotherapists in treating these conditions, yet they rarely form a part of the therapeutic team, and these treatment modalities are rarely offered as part of the therapeutic management. There has been little examination of different models of care for FGIDs. We hypothesize that multi-disciplinary integrated care is superior to standard specialist-based care in the treatment of functional gut disorders.

METHODS

The "MANTRA" (Multidisciplinary Treatment for Functional Gut Disorders) study compares comprehensive multi-disciplinary outpatient care with standard hospital outpatient care. Consecutive new referrals to the gastroenterology and colorectal outpatient clinics of a single secondary and tertiary care hospital of patients with an FGID, defined by the Rome IV criteria, will be included. Patients will be prospectively randomized 2:1 to multi-disciplinary (gastroenterologist, gut-hypnotherapist, psychiatrist, behavioral therapist ('biofeedback') and dietician) or standard care (gastroenterologist or colorectal surgeon). Patients are assessed up to 12 months after completing treatment. The primary outcome is an improvement on a global assessment scale at the end of treatment. Symptoms, quality of life, psychological well-being, and healthcare costs are secondary outcome measures.

DISCUSSION

There have been few studies examining how best to deliver care for functional gut disorders. The MANTRA study will define the clinical and cost benefits of two different models of care for these highly prevalent disorders.

TRIAL REGISTRATION NUMBER

Clinicaltrials.govNCT03078634 Registered on Clinicaltrials.gov, completed recruitment, registered on March 13th 2017. Ethics and Dissemination: Ethical approval has been received by the St Vincent's Hospital Melbourne human research ethics committee (HREC-A 138/16). The results will be disseminated in peer-reviewed journals and presented at international conferences. Protocol version 1.2.

Diet in Irritable Bowel Syndrome (IBS): Interaction with Gut Microbiota and Gut Hormones

Diet plays an important role not only in the pathophysiology of irritable bowel syndrome (IBS), but also as a tool that improves symptoms and quality of life. The effects of diet seem to be a result of an interaction with the gut bacteria and the gut endocrine cells. The density of gut endocrine cells is low in IBS patients, and it is believed that this abnormality is the direct cause of the symptoms seen in IBS patients. The low density of gut endocrine cells is probably caused by a low number of stem cells and low differentiation progeny toward endocrine cells. A low fermentable oligo-, di-, monosaccharide, and polyol (FODMAP) diet and fecal microbiota transplantation (FMT) restore the gut endocrine cells to the level of healthy subjects. It has been suggested that our diet acts as a prebiotic that favors the growth of a certain types of bacteria. Diet also acts as a substrate for gut bacteria fermentation, which results in several by-products. These by-products might act on the stem cells in such a way that the gut stem cells decrease, and consequently, endocrine cell numbers decrease. Changing to a low-FODMAP diet or changing the gut bacteria through FMT improves IBS symptoms and restores the density of endocrine cells.

Gut Microbiota in Patients With Irritable Bowel Syndrome-A Systematic Review

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is common but difficult to treat. Altering the gut microbiota has been proposed as a strategy for treatment of IBS, but the association between the gut microbiome and IBS symptoms has not been well established. We performed a systematic review to explore evidence for this association.

METHODS

We searched databases, including MEDLINE, EMBASE, Cochrane CDSR, and CENTRAL, through April 2, 2018 for case-control studies comparing the fecal or colon microbiomes of adult or pediatric patients with IBS with microbiomes of healthy individuals (controls). The primary outcome was differences in specific gut microbes between patients with IBS and controls.

RESULTS

The search identified 2631 citations; 24 studies from 22 articles were included. Most studies evaluated adults presenting with various IBS subtypes. Family Enterobacteriaceae (phylum Proteobacteria), family Lactobacillaceae, and genus Bacteroides were increased in patients with IBS compared with controls, whereas uncultured Clostridiales I, genus Faecalibacterium (including Faecalibacterium prausnitzii), and genus Bifidobacterium were decreased in patients with IBS. The diversity of the microbiota was either decreased or not different in IBS patients compared with controls. More than 40% of included studies did not state whether cases and controls were comparable (did not describe sex and/or age characteristics).

CONCLUSIONS

In a systematic review, we identified specific bacteria associated with microbiomes of patients with IBS vs controls. Studies are needed to determine whether these microbes are a product or cause of IBS.

Identification of Individuals with Functional Dyspepsia With a Simple, Minimally Invasive Test: A Single Center Cohort Study of the Oral Capsaicin Test

OBJECTIVES

The diagnosis of functional dyspepsia (FD) is challenging due to the lack of reliable biological markers to support the diagnosis. We assessed the relevance of a previously validated simple test for chemical hypersensitivity in the setting of a gastrointestinal outpatient department.

METHODS

A total of 224 outpatients who were referred for evaluation of gastrointestinal symptoms in the absence of alarm symptoms swallowed a capsule containing 0.75 mg capsaicin. Severity of symptoms before and after capsule ingestion was assessed by a graded questionnaire and the difference in aggregate symptom scores (delta) was calculated.

RESULTS

Sensitivity of the test was between 0.51-0.59, specificity was 0.84-0.89 and positive predictive value for the diagnosis of FD 70-71%. FD patients had significantly higher median delta symptom scores (10.0; 25% quartile: 3.0; 75% quartile: 16.0) as compared to inflammatory bowel disease (2.5; 1.0/8.5)(P=0.003), peptic ulcer disease (0.0; -1.5/4.5) (P<0.001), irritable bowel syndrome (3.0;0.5/8.5)(P=0.001), and patients classified with "other disease" (2.5;0.0/5.0)(P<0.001). Patients with gastroesophageal reflux disease had significantly lower symptom scores if FD was not concomitantly diagnosed (2.0; 0.0/6.0) than if FD was present (10.0; 4.0/15.0).

CONCLUSIONS

Hypersensitivity for capsaicin discriminates functional dyspepsia from patients with other GI disorders. The capsaicin test is a simple and non invasive method to detect a large subgroup of functional dyspepsia with chemical hypersensitivity. These findings might open new diagnostic options in functional dyspepsia and possibly new therapeutic options by targeting the specific capsaicin receptor TRPV1.

Performance of an algorithm-based approach to the diagnosis and management of functional gastrointestinal disorders: A pilot trial

BACKGROUND

Recent advances in the development of diagnostic criteria and effective management options for functional gastrointestinal disorders (FGIDs) have not yet been integrated into clinical practice. There is a clear need for the development and validation of a simple clinical pathway for the diagnosis and management of FGIDs which can be used in primary care.

METHODS

In this controlled pilot study, we designed and evaluated a non-specialist-dependent, algorithm-based approach for the diagnosis and management of FGIDs (ADAM-FGID). Patients referred to 1 tertiary referral center with clinically suspected functional gastrointestinal disorders were allocated to waitlist control or algorithm group. The algorithm group was screened for organic disease, and those without clinical alarms received a written FGID diagnosis and management options. All participants were followed up for 1 year.

KEY RESULTS

The ADAM-FGID was found to be feasible and acceptable to both patients and primary healthcare providers. The diagnostic component identified that 39% of referrals required more urgent gastroenterological review than original triage category, with organic disease subsequently diagnosed in 31% of these. The majority of patients (82%) diagnosed with a FGID did not receive a relevant alternative diagnosis during follow-up. Patient buy-in to the model was good, with all reading the diagnostic/management letter, 80% entering management, and 61% reporting symptom improvement at 6 weeks. Moreover, 68% of patients and all referring doctors found the approach to be at least moderately acceptable. Patients reported being reassured by the approach and found the management options useful. Primary healthcare providers acknowledged the potential of this approach to reduce waiting times for endoscopic procedures and to provide reassurance to both patients and themselves.

CONCLUSIONS & INFERENCES

This pilot study provides preliminary evidence to support a clinical pathway for the diagnosis and management of FGIDs which does not depend upon specialist review. Further rigorous testing within primary care is needed to conclusively establish safety and efficacy. However, this approach is safer than current management and has potential to build capacity by reducing specialist burden and expediting effective care.

Referrals to a tertiary hospital: A window into clinical management issues in functional gastrointestinal disorders

BACKGROUND AND AIM

To investigate the quality of and reasons for referrals of patients with likely functional gastrointestinal disorders (FGID) and explore patients' experience of clinical management.

METHODS

A cross sectional, mixed-methods study was undertaken. Referrals (July 2013-2015) to one gastroenterology outpatient department triaged as "likely FGID", the referred patients and their referring primary healthcare providers were examined.

RESULTS

A total of 69% of patients reported not yet receiving an initial diagnosis, 52% reported persistent/distressing symptoms or reduced quality of life, 24% feared missed or worsening pathology, and 35% were seeking repeat specialist consultation. Most patients were dissatisfied (40%) or only partially satisfied (36%) with current management. Dissatisfaction was significantly related to the lack of provision of a diagnosis and effective treatment options (P < 0.001). Referral quality was poor and with the reason for referral clearly communicated in only 25%. Common referral reasons included repeat presentations (n = 32), diagnostic uncertainty (n = 19), to ensure nothing is missed (n = 19), patient request (n = 17), no response to treatment (n = 16), and to allay patient fears (n = 14). A total of 28/60 primary healthcare providers were confident that their patient had a FGID, yet sought confirmation (n = 16), second opinion (n = 8), or advice (n = 4).

CONCLUSION

Current management of FGID in usual care is suboptimal, as evidenced by the tertiary referral load, patient dissatisfaction, and the lack of provision of diagnoses and effective treatment options. Some clinicians lack confidence in effectively identifying and managing these conditions. Resources and supports to equip and assist clinicians to identify and manage FGID successfully may enhance patient care.

Effect of diet and individual dietary guidance on gastrointestinal endocrine cells in patients with irritable bowel syndrome (Review)

Irritable bowel syndrome (IBS) is a common chronic gastrointestinal (GI) disorder that is characterized by a combination of abdominal pain or discomfort, bloating and alterations in bowel movements. This review presents recent developments concerning the roles of diet and GI endocrine cells in the pathophysiology of IBS and of individual dietary guidance in the management of IBS. Patients with IBS typically report that food aggravates their IBS symptoms. The interactions between specific types of foodstuffs rich in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAPs) and GI endocrine cells induce changes in cell densities. Providing individual dietary guidance about a low FODMAP intake, high soluble-fiber intake, and changing the proportions of protein, fat and carbohydrates helps to reduce the symptoms experienced by patients with IBS and to improve their quality of life. These improvements are due to restoring the densities of the GI endocrine cells back to normal. The reported observations emphasize the role of GI endocrine cells in the pathophysiology of IBS and support the provision of dietary guidance as a first-line treatment for managing IBS.

Costs associated with functional gastrointestinal disorders and related signs and symptoms in infants: a systematic review protocol

INTRODUCTION

Functional gastrointestinal disorders (FGIDs) and FGID-related signs and symptoms have a fundamental impact on the psychosocial, physical and mental well-being of infants and their parents alike. Recent reviews and studies have indicated that FGIDs and related signs and symptoms may also have a substantial impact on the budgets of third-party payers and/or parents. The objective of this systematic review is to investigate these costs.

METHODS AND ANALYSIS

The population of interest is healthy term infants (under 12 months of age) with colic, regurgitation and/or functional constipation. Outcomes of interest will include the frequency and volume of reported treatments, the cost to third-party payers and/or parents for prescribed or over the counter treatments, visits to health professionals and changes in infant formula purchases, and the loss of income through time taken off work and out of pocket costs. Relevant studies will be identified by searching databases from 2005 onwards (including MEDLINE, EMBASE, PsycINFO, NEXIS, DARE, Health Technology Assessment database, National Health Service Economic Evaluation Database and others), conferences from the previous 3 years and scanning reference lists of eligible studies. Study selection, data extraction and quality assessment will be conducted by two independent reviewers and disagreements resolved in discussion with a third reviewer. Quality assessment will involve study design-specific checklists. Relevant studies will be summarised narratively and presented in tables. An overview of treatments and costs will be provided, with any geographical or other differences highlighted. An assessment of how the totals for cost differ across countries and elements that contribute to the differences will be generated.

ETHICS AND DISSEMINATION

This is a systematic review of published studies that will be submitted for publication to a peer-reviewed journal. Ethical committee approval is not required.

TRIAL REGISTRATION NUMBER

CRD42016033119.

New and emerging therapies for the treatment of irritable bowel syndrome: an update for gastroenterologists

Irritable bowel syndrome is a functional bowel disorder with gastrointestinal symptoms (e.g. abdominal pain, straining, urgency, incomplete evacuation, nausea, and bloating) that occur alongside bowel function alterations (i.e. constipation, diarrhea, or both). Patients with irritable bowel syndrome may also experience comorbid anxiety and depression. Irritable bowel syndrome is common, with a prevalence estimated between 3% and 28%, affecting patient health and quality of life. Patients with moderate or severe irritable bowel syndrome generally seek medical care, whereas those with milder symptoms may choose self-management. Most patients with irritable bowel syndrome receive outpatient care, but irritable bowel syndrome-related hospitalizations do occur. The pathophysiology of irritable bowel syndrome is multifactorial (i.e. genetics, immune components, changes in the gut microbiota, disturbances in physiologic stress response systems, and psychosocial factors). Management of irritable bowel syndrome can include lifestyle changes, dietary interventions, counseling, psychologic medication, and agents that affect gastrointestinal motility. A number of therapies have emerged in recent years with clinical trial data demonstrating efficacy and safety for patients with irritable bowel syndrome, including agents that target gastrointestinal motility (i.e. linaclotide), gastrointestinal opioid receptors (i.e. asimadoline, eluxadoline), and gut microbiota (i.e. rifaximin). Linaclotide has been shown to significantly improve stool frequency and abdominal pain compared with placebo in constipation-predominant irritable bowel syndrome (number needed to treat, 5.1). Asimadoline shows efficacy in patients with moderate-to-severe irritable bowel syndrome-related pain. Rifaximin provided adequate relief of global irritable bowel syndrome symptoms versus placebo for a significantly greater percentage of patients with diarrhea-predominant irritable bowel syndrome (p < 0.001). Management that encompasses all aspects of irritable bowel syndrome (gastrointestinal symptoms) and comorbid psychologic symptoms (e.g. anxiety or depression) is important for improving overall patient health and well-being.

Effects of Birth Cohorts on the Irritable Bowel Syndrome Support Early-Life Risk Factors

BACKGROUND

Irritable bowel syndrome (IBS) is common with prevalence reported between 10 and 20 %. IBS clusters in families but it is unknown whether this is explained by a common environment, genes, or both. If early-life factors are important, IBS might be expected to demonstrate a birth cohort phenomenon.

AIM

To investigate whether there is a birth cohort phenomenon for subjects with IBS.

METHODS

Validated questionnaires were sent to a random sample of Olmsted County, Minnesota, residents who recorded gastrointestinal symptoms; IBS diagnosis was based on the modified Rome criteria. Birth cohorts were chosen a priori based on historical national trends in birth weights using 10-year increments. Logistic regression was used to develop odds ratios to assess the association of IBS with calendar period, birth cohort, age, gender, and somatic symptom score.

RESULTS

A total of 4,893 surveys were completed with an overall survey response rate of 58 %. The survey responders were between 25 and 94 years of age and 53 % were female. The overall prevalence of IBS was 16.2 % (95 % CI 15.3-17.4). The univariate association of IBS with birth cohort was significant (p < 0.001) as was the association adjusted for age and gender. The prevalence of IBS was highest for the birth cohort 1963-1972 with an odds ratio of 2.6 (95 % CI 0.97-7.0, p = 0.058).

CONCLUSIONS

Population-based data support a possible birth cohort phenomenon in IBS. If correct, early-life risk factors likely play a key role in the development of IBS.

Determination of rifaximin treatment period according to lactulose breath test values in nonconstipated irritable bowel syndrome subjects

Small intestinal bacterial overgrowth (SIBO) can partly explain irritable bowel syndrome (IBS), and rifaximin has been observed to improve abdominal symptoms in nonconstipated IBS patients. However, there are few reports on the association of the rifaximin treatment periods with the results of a lactulose breath test (LBT). Therefore, we performed a retrospective review of patient charts to investigate the relation between the rifaximin treatment periods with LBT results in nonconstipated IBS patients. We also evaluated the time to achieve a symptomatic improvement in the IBS patients as compared to the changes in the LBT. We reviewed the charts for patients who showed IBS symptoms with documented positive results for LBT during their initial visit and who had a follow-up LBT after treatment with rifaximin. The LBT values were compared to the subjects' symptom scores. A total of 102 subjects had a follow-up LBT to assess LBT normalization. The subjects were divided into groups according to treatment periods of 4 weeks (n = 36), 8 weeks (n = 43), and 12 weeks (n = 23). The groups with a longer treatment exhibited an increase in the hydrogen gas value at 90 min and its sum during 90 min at the initial LBT. There were significant differences in hydrogen gas value at 90 min and in its sum during 90 min at the initial LBT between the groups treated for 4 and 12 weeks. The most significant treatment response was observed during the first 4 weeks for all treatment groups. Symptomatic improvement occurred earlier than LBT normalization in the treatment period over 4 weeks. The results indicate that different rifaximin treatment periods are needed in accordance with LBT levels to effectively eradicate SIBO.

Psychometric development of the Gastrointestinal Symptom Rating Questionnaire (GSRQ) demonstrated good validity

OBJECTIVES

To develop and validate a gastrointestinal (GI) symptom rating questionnaire for patients with luminal GI symptoms including where no diagnosis has been made.

STUDY DESIGN AND SETTING

We developed and validated the Gastrointestinal Symptom Rating Questionnaire (GSRQ) in three stages: (1) item generation to identify the relevant items for scale inclusion; (2) development and piloting on patients with a known GI disorder; and (3) testing in a sample of trial patients. We examined the underlying dimensions of the scale, internal consistency, validity, reproducibility, and responsiveness.

RESULTS

We identified four interpretable factors on the GSRQ. The GSRQ had good internal consistency (corrected item-subscale correlations between 0.4 and 0.8) and Cronbach's alpha greater than 0.7 for each subscale. Construct validity was demonstrated by modest but significant correlations with the Short Form 36 and the EQ5D index value. We demonstrated good reproducibility with intraclass correlations for test-retest scores between 0.71 and 0.77, and significant responsiveness ratios for all subscales in patients who had improved, and in two of the subscales in patients who had deteriorated.

CONCLUSION

The GSRQ could be a useful tool to monitor quality of life in various luminal GI conditions and where a formal diagnosis has not been made.

So-eum type as an independent risk factor for irritable bowel syndrome: a population-based study in Korea

OBJECTIVES

It has been hypothesized that Sasang constitutional types (SCTs) have a specific hypoactive organ, which can account for vulnerability to related diseases or symptoms. This study examined the relationship between SCTs and irritable bowel syndrome (IBS).

DESIGN

Cross-sectional study in a population-based cohort study in Korea.

PARTICIPANTS

1362 individuals (705 men and 657 women) who participated in the Korean Genome and Epidemiology Study.

OUTCOME MEASURES

The participants were classified into SCTs by the integrated diagnostic model and asked about symptoms related to IBS using the Rome II criteria.

RESULTS

The prevalence of IBS differed significantly among the SCTs, with 33 (18.3%) of the So-eum (SE) type, 74 (9.9%) of the Tae-eum (TE) type, and 57 (13.2%) of the So-yang (SY) type having IBS. Even after adjustment for possible confounders, the SE type for both sexes continued to show 1.82-fold (95% confidence interval [CI], 1.05-3.16) excess odds of having IBS. Men with SE type had a 2.97 times (95% CI, 1.34-6.58) and a 2.50 times (95% CI, 1.15-5.47) significantly higher odds of having IBS than the TE and SY types, respectively. In analysis for the joint effect of SCT and psychological stress, the multivariate odds ratio of IBS was 3.21 (95% CI, 1.33-7.75) for the SE type and Psychological Well-Being Index-Short Form (PWI-SF) score (<27), and 5.83 (95% CI, 1.80-18.88) for the SE type and PWI-SF (≥27) compared with the TE type and PWI-SF score (<27).

CONCLUSIONS

The SE type of SCT is an independent risk factor for IBS. The findings support the hypothesis that persons with SE type are vulnerable to gastrointestinal diseases.

[The prevalence of irritable bowel symptoms in a population of shopping mall visitors in Santiago de Chile]

BACKGROUND

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain or discomfort that is associated with altered bowel habit. Both its prevalence and clinical characteristics vary throughout Latin America. A percentage of patients does not seek medical attention, therefore a reliable prevalence figure can only be established by interviewing non-selected populations.

AIMS

To study the prevalence and clinical characteristics of IBS symptoms in non-selected subjects in Santiago, Chile.

METHODS

A total of 437 shopping mall visitors above the age of 15 years (246 women) participated in the study by answering the Rome II validated questionnaire for IBS. The demographic and socioeconomic backgrounds, comorbidities, and a family history of IBS were registered.

RESULTS

A total of 64.1% subjects reported having gastrointestinal symptoms and 28.6% had symptoms suggestive of IBS. When the subjects with IBS symptoms were compared with the asymptomatic individuals, a predominance of women (65.6 vs. 42.9, P<.001) and a greater cholecystectomy frequency (33.6 vs. 12.9% P<.05) were observed in the former. The age of symptom onset was 30.4 years. An equal percentage of subjects (42.4%) presented with diarrhea and constipation and 15.2% presented with alternating IBS. Participants with a higher educational level reported a lower percentage of IBS (P<.05). A family history of the disease was present in 40% of the subjects with IBS, compared with 14.9% in the asymptomatic individuals (P<.05). Only 39.2% of the subjects had seen a physician for their symptoms and the treatment and tests ordered were inappropriate.

CONCLUSION

The prevalence of IBS symptoms in the population studied is one of the highest described. Therefore, health teams should have the necessary knowledge and skill required for its management.

In-patient discharge rates for the irritable bowel syndrome - an analysis of national trends in the United States from 1997 to 2010

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most common out-patient diagnoses in primary care and gastroenterology. There are limited data on the rate and costs associated with in-patient discharges for IBS.

AIM

To estimate the incidence and costs of hospital discharges for IBS in the United States.

METHODS

We analysed the National Inpatient Sample database for all subjects in which IBS (ICD-9 code: 564.1) was the principal discharge diagnosis from 1997 to 2010. The National Inpatient Sample contains data from approximately 8 million hospital stays each year. Our findings reflected patient and hospital characteristics like geographical region and bed size.

RESULTS

In 1997, there were 11 433 patients with a principal discharge diagnosis of IBS as compared to 12 842 in 2010 (P > 0.9, GoF test). The mean length of stay for IBS also remained the same between 1997 and 2010 at 3.7 ± 0.1 days. However, during this period, the mean hospital charges per hospitalization increased by 207.8% from $6873 ± 198 in 1997 to $21 153 ± 598 in 2010 (P < 0.01). The aggregate charges (i.e., 'national bill') for IBS increased by 245.5% from $78 524 129 ± 3 781 316 in 1997 to $271 311 405 ± 14 023 289 in 2010 (P < 0.01).

CONCLUSIONS

The number of in-patient discharges and length of stay for IBS have remained relatively stable between 1997 and 2010, whereas the cost associated with these discharges has increased significantly. In-patient costs associated with IBS contribute significantly to the total healthcare bill. Further research on the cost-effectiveness of diagnostic procedures and therapies in IBS is required.

Mind/Body psychological treatments for irritable bowel syndrome

Currently, the goal of treatment for those with irritable bowel syndrome (IBS) is to improve the quality of life through a reduction in symptoms. While the majority of treatment approaches involve the use of traditional medicine, more and more patients seek out a non-drug approach to managing their symptoms. Current forms of non-drug psychologic or mind/body treatment for IBS include hypnotherapy, cognitive behavioral therapy and brief psychodynamic psychotherapy, all of which have been proven efficacious in clinical trials. We propose that incorporating the constructs of mindfulness and acceptance into a mind/body psychologic treatment of IBS may be of added benefit due to the focus on changing awareness and acceptance of one's own state which is a strong component of traditional and Eastern healing philosophies.

Effect of age and correlation between esophageal visceral chemosensitivity and mechanosensitivity in healthy Japanese subjects

BACKGROUND

The aim of this study was to examine the impact of age on esophageal sensation, and to determine whether esophageal mechanosensitivity and chemosensitivity are correlated in healthy Japanese subjects.

METHODS

To evaluate chemosensitivity, a catheter was inserted and placed 10 cm above the upper border of the lower esophageal sphincter (LES), which was determined with an esophageal manometric catheter. After saline had been infused into the esophagus at a rate of 10 mL/min for 2 min, 0.1 N hydrochloric acid, instead of saline-without the subjects' knowledge-was infused for 10 min at the same rate. The acid perfusion sensitivity score (APSS) was assessed. To evaluate mechanosensitivity, a barostat test was performed, with a balloon being placed 10 cm above the upper border of the LES. The initial perception threshold (IPT), pain threshold (PT), and maximal pain were quantified.

RESULTS

The APSS was significantly inversely correlated with age. IPT, PT, and mean maximal pain were significantly correlated with age. Body mass index, drinking, and smoking habits were not correlated with the esophageal perception threshold. The correlation of chemosensitivity and mechanosensitivity was also assessed, and the APSS was inversely correlated with IPT, PT, and maximal pain.

CONCLUSIONS

The thresholds of esophageal visceral chemosensitivity and mechanosensitivity in same individuals were significantly correlated and both of these thresholds were inversely correlated with age.

Autonomic nervous system activity in constipation-predominant irritable bowel syndrome patients

Background

The main mechanism underlying irritable bowel syndrome is currently believed to be a dysfunction of the brain-gut axis. Autonomic nervous system dysfunction can contribute to development of irritable bowel syndrome symptoms by disturbing visceral sensations.

Material/Methods

Thirty patients with a diagnosis of constipation-predominant irritable bowel syndrome and 30 healthy volunteers were included in the study. Resting and functional autonomic nervous system tests and percutaneous electrogastrography were performed. Plasma adrenalin, noradrenalin, insulin, ghrelin and cholecystokinin activity was analyzed.

Results

Increased sympathetic activation with disturbed parasympathetic function was demonstrated. Patients had substantially higher plasma catecholamine concentration, which confirms sympathetic overbalance. Hyperinsulinemia may explain sympathetic predominance followed by gastric and intestinal motility deceleration. Abnormal, reduced ghrelin and cholecystokinin titre may disturb brain-gut axis functioning and may be responsible for gastric motility deceleration. In electrogastrography, distinctly lower values of fasting normogastria percentage and dominant power were observed. Patients had substantially lower slow wave coupling percentage both in fasting and postprandial periods, which negatively correlated with plasma catecholamines level. Gastric myoelectrical activity disturbances may result from lack of sympatho-parasympathetic equilibrium.

Conclusions

Central sympathetic influence within the brain-gut axis is most probably responsible for myoelectrical activity disturbances in irritable bowel syndrome patients.

Experimental endotoxemia as a model to study neuroimmune mechanisms in human visceral pain

The administration of bacterial endotoxin (i.e., lipopolysaccharide, LPS) constitutes a well-established experimental approach to study the effects of an acute and transient immune activation on physiological, behavioral, and emotional aspects of sickness behavior in animals and healthy humans. However, little is known about possible effects of experimental endotoxemia on pain in humans. This knowledge gap is particularly striking in the context of visceral pain in functional as well as chronic-inflammatory gastrointestinal disorders. Although inflammatory processes have been implicated in the pathophysiology of visceral pain, it remains incompletely understood how inflammatory mediators interact with bottom-up (i.e., increased afferent input) and top-down (i.e., altered central pain processing) mechanisms of visceral hyperalgesia. Considering the recent findings of visceral hyperalgesia after LPS application in humans, in this review, we propose that experimental endotoxemia with its complex peripheral and central effects constitutes an experimental model to study neuroimmune communication in human pain research. We summarize and attempt to integrate relevant animal and human studies concerning neuroimmune communication in visceral and somatic pain, discuss putative mechanisms, and conclude with future research directions.

Irritable bowel syndrome: Diagnosis and pathogenesis

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder that considerably reduces the quality of life. It further represents an economic burden on society due to the high consumption of healthcare resources and the non-productivity of IBS patients. The diagnosis of IBS is based on symptom assessment and the Rome III criteria. A combination of the Rome III criteria, a physical examination, blood tests, gastroscopy and colonoscopy with biopsies is believed to be necessary for diagnosis. Duodenal chromogranin A cell density is a promising biomarker for the diagnosis of IBS. The pathogenesis of IBS seems to be multifactorial, with the following factors playing a central role in the pathogenesis of IBS: heritability and genetics, dietary/intestinal microbiota, low-grade inflammation, and disturbances in the neuroendocrine system (NES) of the gut. One hypothesis proposes that the cause of IBS is an altered NES, which would cause abnormal GI motility, secretions and sensation. All of these abnormalities are characteristic of IBS. Alterations in the NES could be the result of one or more of the following: genetic factors, dietary intake, intestinal flora, or low-grade inflammation. Post-infectious IBS (PI-IBS) and inflammatory bowel disease-associated IBS (IBD-IBS) represent a considerable subset of IBS cases. Patients with PI- and IBD-IBS exhibit low-grade mucosal inflammation, as well as abnormalities in the NES of the gut.

Dietary triggers in irritable bowel syndrome

Irritable bowel syndrome (IBS) is a frequently occurring, benign functional gastrointestinal disorder with a complex poorly understood pathology which appears to be multifactorial in nature. There is no association with structural or biochemical abnormalities in the gastrointestinal tract. Functional variations in myoelectrical activity, visceral hypersensitivity and illness behaviours have all been observed in patients experimentally. In conjunction with environmental, psychological and alimentary factors, these mechanisms have been proposed as the major determinants of symptom genesis. Certainly, dietary factors are frequently perceived by sufferers as powerful symptom triggers, with many reporting multiple food intolerance. Physicians, however, remain divided upon the relevance of food to the disorder, with many eschewing a nutritional connection. This is unsurprising as, despite much experimental work to determine the clinical relevance of food intolerance and allergy to the aetiology of the disorder, the vast range of foodstuffs available for testing, inherent procedural problems with test foods, methodological insufficiencies and the continually evolving knowledge of the disorder, particularly the subgrouping of sufferers, have restricted the scientific validity of current findings. At the present time, it is difficult to make informed judgement upon the importance of food in IBS, and rigorously designed, large scale trials devised in the light of recent knowledge are required before conclusions can be drawn.

IBS patients' willingness to take risks with medications

OBJECTIVES

We explored irritable bowel syndrome (IBS) patients' impulsivity and risk-taking behavior and their willingness to take medication risks.

METHODS

A validated questionnaire assessed the illness experience of IBS patients. A standard gamble evaluated respondents' willingness to take medication risks.

RESULTS

IBS patients with severe symptoms were more willing to take significant medication risks than those with mild or moderate symptoms. Impulsivity scores were not associated with an increased likelihood of taking medication risks. Age, gender, and years of IBS symptoms were not associated with medication risk-taking behavior. IBS patients reported they would accept a median 1% risk of sudden death for a 99% chance of cure for their symptoms using a hypothetical medication.

CONCLUSIONS

IBS patients are willing to take significant medication risks to cure their symptoms. To counsel patients effectively, physicians must determine and understand IBS patients' risk aversion.

Stress and animal models of inflammatory bowel disease--an update on the role of the hypothalamo-pituitary-adrenal axis

Chronic psychosocial stress has been repeatedly shown in humans to be a risk factor for the development of several affective and somatic disorders, including inflammatory bowel diseases (IBD). There is also a large body of evidence from rodent studies indicating a link between stress and gastrointestinal dysfunction, resembling IBD in humans. Despite this knowledge, the detailed underlying neuroendocrine mechanisms are not sufficiently understood. This is due, in part, to a lack of appropriate animal models, as most commonly used rodent stress paradigms do not adequately resemble the human situation and/or do not cause the development of spontaneous colitis. Therefore, our knowledge regarding the link between stress and IBD is largely based on rodent models with low face and predictive validity, investigating the effects of unnatural stressors on chemically induced colitis. These studies have consistently reported that hypothalamo-pituitary-adrenal (HPA) axis activation during stressor exposure has an ameliorating effect on the severity of a chemically induced colitis. However, to show the biological importance of this finding, it needs to be replicated in animal models employing more clinically relevant stressors, themselves triggering the development of spontaneous colitis. Important in view of this, recent studies employing chronic/repeated psychosocial stressors were able to demonstrate that such stressors indeed cause the development of spontaneous colitis and, thus, represent promising tools to uncover the mechanisms underlying stress-induced development of IBD. Interestingly, in these models the development of spontaneous colitis was paralleled by decreased anti-inflammatory glucocorticoid (GC) signaling, whereas adrenalectomy (ADX) prior to stressor exposure prevented its development. These findings suggest a more complex role of the HPA axis in the development of spontaneous colitis. In the present review I summarize the available human and rodent data in order to provide a comprehensive understanding of the biphasic role of the HPA axis and/or the GC signaling during stressor exposure in terms of spontaneous colitis development.

INSPIRE study: does stress management improve the course of inflammatory bowel disease and disease-specific quality of life in distressed patients with ulcerative colitis or Crohn's disease? A randomized controlled trial

BACKGROUND

The use of stress management psychotherapy is hypothesized to produce greater improvement in disease course and disease-specific quality of life (IBDQ) compared to usual medical care alone in patients with ulcerative colitis (UC) or Crohn's disease (CD) showing high levels of stress (based on the Perceived Stress Questionnaire [PSQ]).

METHODS

Fifty-eight patients with UC and 56 patients with CD who had experienced continuous disease activity or had relapsed over the previous 18 months, with an activity index for UC or CD ≥ 4, a PSQ ≥ 60, and without serious psychiatric disorders or other serious medical conditions were randomized to receive either treatment as usual (TAU) or TAU plus stress management psychotherapy. Psychotherapy consisted of three group sessions (psychoeducation, problem-solving, relaxation) and 6-9 individual sessions based on cognitive behavior therapy-related methods with 1-3 booster sessions at 6 and 12 months follow-up. Gastroenterologists blinded to intervention group assessed disease activity and course at baseline and at 3, 6, 12, and 18 months. Patients completed the IBDQ at baseline, 6, 12, and 18 months.

RESULTS

The intervention did not improve disease or reduce relapse; however, it increased the IBDQ score (P = 0.009, mean differences 16.3 [SD 6.1]). On analysis of UC and CD separately, improvement of IBDQ was only found in the UC group.

CONCLUSIONS

Stress management psychotherapy does not appear to improve disease course or reduce relapse in patients with IBD. It might improve quality of life, particularly in patients with UC.

The role of diagnostic testing in irritable bowel syndrome

This article discusses the diagnostic criteria and processes applicable to irritable bowel syndrome (IBS). The authors describe the various diagnostic criteria with a focus on the Rome criteria for IBS and the judicious application of historical information such as alarm features and the yield of various diagnostic modalities such as blood, stool, breath, and endoscopic tests.

Differences in the health-related quality of life, affective status, and personality between irritable bowel syndrome and inflammatory bowel disease patients

OBJECTIVES

To investigate differences in the health-related quality of life (HRQoL), number of stressful life events, affective status, and some personality characteristics between patients with inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) as well as their possible role in disease activity.

METHODS

Fifty-six IBS outpatients, age range 25-75 years (mean = 48.64; SD = 13.04) and 43 outpatients with IBD, age range 19-74 years (mean = 42.90; SD = 15.44), participated in this study. Patients filled out the following questionnaires: Short-Form 36 Health Survey, Beck Depression Inventory, Spielberger's Trait-Anxiety Inventory, Big Five Inventory, and Stressful Life Events Questionnaire.

RESULTS

There were significant differences in the physical component (F = 10.80, P<0.001) of the general HRQoL as well as in anxiety (F = 7.23, P<0.01) and neuroticism (F = 8.90, P<0.01) between patients with IBS and IBD. IBS patients showed a significantly higher level of anxiety and neuroticism and better physical aspects of general HRQoL compared with IBD patients. The results of standard regression analyses indicated that a significant predictor (beta = -0.44, P<0.01) for the perceived disease activity in IBS was neuroticism as a personality trait.

CONCLUSION

The results of this study show that the patients with IBS are more prone to the effect of psychosocial variables on gastrointestinal symptoms compared with patients with organic gastrointestinal diseases such as IBD. IBS patients experienced a higher level of anxiety and expressed a higher level of neuroticism as a personality trait compared with IBD patients.

Treatment of psychological co-morbidities in common gastrointestinal and hepatologic disorders

Anxiety and depressive disorders frequently coexist with gastrointestinal and hepatologic conditions. Despite their high prevalence, approach to treating these co-morbidities is not always straightforward. This paper aims to review the current literature into etiology of psychological co-morbidities and their treatment in three conditions commonly encountered at gastroenterology outpatient clinics, namely inflammatory bowel disease (IBD), irritable bowel syndrome (IBS) and chronic hepatitis C (HepC). The paper demonstrates that although psychotherapy (and cognitive-behavioural therapy in particular) has been established as an effective treatment in IBS, more studies are needed in HepC and IBD. Antidepressants have been recognized as an effective treatment for psychological and somatic symptoms in IBS and for depression in HepC, but good quality studies in IBD are lacking despite the promising preliminary findings from animal models and case studies. Further studies in this area are needed.

Impact of functional gastrointestinal disorders on survival in the community

OBJECTIVES

Functional gastrointestinal disorders (FGIDs) comprise a constellation of symptoms that have no identifiable structural or biochemical abnormality. In view of the lack of data from large-scale population-based studies evaluating the effects of these disorders on survival, we aimed to examine whether FGIDs are associated with impaired survival.

METHODS

Between 1988 and 1993, valid self-report questionnaires that recorded gastrointestinal symptoms required for the diagnosis of irritable bowel syndrome (IBS), chronic constipation, chronic diarrhea, dyspepsia, and abdominal pain were mailed to randomly selected cohorts of Olmsted County, Minnesota residents. Minnesota administrative death records were used to identify which of the survey respondents had died over the follow-up period (through April 2008). The association between survival and each FGID was assessed using proportional hazards regression models with univariate and adjusted hazard ratios (HRs, 95% confidence intervals (CIs)), adjusting for age at time of survey, gender, smoking, alcohol, marital status, and Charlson Comorbidity Index (CCI).

RESULTS

Of the 5,262 randomly selected eligible subjects who received a questionnaire, a total of 4,176 responded to the surveys (overall response rate 79%). From these respondents, 243 subjects were excluded because of lack of research authorization (or were registered solely at a different medical institution in Olmsted County, MN), resulting in 3,933 eligible subjects for analysis (eligible response rate 75%); 10% reported symptoms of IBS; 16% chronic constipation; 18% chronic diarrhea; 2% dyspepsia; and 15% abdominal pain. At baseline, the mean (s.d.) age was 54 (18) years, and 52% were female. No association with overall survival was detected for IBS (HR=1.06 (95% CI: 0.86-1.32)), chronic diarrhea (HR=1.03 (95% CI: 0.90-1.19)), abdominal pain (HR=1.09 (95% CI: 0.92-1.30)), or dyspepsia (HR=1.08 (95% CI: 0.58-2.02)). Reporting symptoms of chronic constipation was associated with poorer survival (HR=1.23 (95% CI: 1.07-1.42)). This association remained significant after adjusting for the CCI (HR=1.19 (95% CI: 1.03-1.37)).

CONCLUSIONS

In this large population-based cohort study with over 30,000 person-years of follow-up, no significant association was observed between survival and IBS, chronic diarrhea, dyspepsia, or abdominal pain. Furthermore, no association was found between increasing burden of FGIDs and survival. However, in contrast to these other FGIDs, subjects with symptoms of chronic constipation were found to be at increased risk of poorer survival. Further investigation is required to determine the cause of this observed association.

Prevalence of functional dyspepsia in an outpatient clinic with primary care physicians in Japan

BACKGROUND

Since little is known about the prevalence of patients with functional gastrointestinal disorders (FGID), this study was performed to clarify the prevalence of FGID, especially functional dyspepsia (FD), in new patients of an outpatient clinic with primary care physicians in Japan.

METHODS

We analyzed consecutive outpatients (n = 5183) who first visited the Department of General Medicine, Asahikawa Medical College Hospital, between April 2004 and March 2009.

RESULTS

Out of 5813 patients, 818 (14.1%) visited because of abdominal symptoms. Final diagnoses of the 818 patients were FGID (n = 320, 39.1%), organic gastrointestinal diseases (n = 237, 28.9%), organic non-GI disease (n = 135, 16.5%), and others (n = 126, 15.4%). The 320 patients with FGID had FD (n = 170), irritable bowel syndrome (IBS) (n = 68), and other FGIDs (n = 88). The rate of FGID or FD in all patients was 5.5% or 2.9%, respectively. Among outpatients (n = 381) who complained of upper abdominal symptoms, approximately 45% had FD. There was no gender difference in the frequency of FGID, FD, or IBS in all ages of patients. A lower incidence of FD was shown in female patients over 70 years old and a higher incidence of IBS in male patients under 29 years old.

DISCUSSION

These results suggest that the prevalence of FGID, especially FD, is very high in an outpatient clinic with primary care physicians in Japan.

Which patients improve: characteristics increasing sensitivity to a supportive patient-practitioner relationship

Supportive social relationships, including a positive patient-practitioner relationship, have been associated with positive health outcomes. Using the data from a randomized controlled trial (RCT) undertaken in the Boston area of the United States, this study sought to identify baseline factors predictive of patients' response to an experimentally applied supportive patient-practitioner relationship. To sort through the hundreds of potential attributes affecting the patient-practitioner relationship, we applied a false discovery rate method borrowed from the field of genomics and bioinformatics. To our knowledge such a method has not previously been applied to generate hypotheses from clinical trial data. In a previous RCT, our team investigated the effect of the patient-practitioner relationship on symptom improvement in patients with irritable Bowel syndrome (IBS). Data were collected on a sample of 289 individuals with IBS using a three-week, single blind, three arm, randomized controlled design. We found that a supportive patient-practitioner relationship significantly improved symptomatology and quality of life. A complex, multi-level measurement package was used to prospectively measure change and identify factors associated with improvement. Using a local false discovery rate procedure, we examined the association of 452 baseline subject variables with sensitivity to treatment. Out of 452 variables, only two baseline factors, reclusiveness, and previous trial experience increased sensitivity to the supportive patient-practitioner relationship. A third variable, additional opportunity during the study for subjects to discuss their illness through experiential interview, was associated with improved outcomes among subjects who did not receive the supportive patient-practitioner relationship. The few variables associated with differential benefit suggest that a patient-centered supportive patient-practitioner relationship may be beneficial for most patients. This may be especially important for reclusive individuals. Within the context of our study, additional study attention in the form of repeated experiential interviews compensated for a lack of positive patient-practitioner support. A supportive patient-practitioner relationship may also help overcome low provider expectations for subjects with previous trial experience. These results converge with the results of the parent trial, implicating the importance of the social world in healing.

Association of alpha 2A adrenergic receptor gene (ADRAlpha2A) polymorphism with irritable bowel syndrome, microscopic and ulcerative colitis

BACKGROUND

Alpha 2 adrenergic receptors (alpha2 ARs) play a central role in the regulation of systemic sympathetic activity. Prejunctional alpha 2A adrenoceptor regulates through negative feedback at presynaptic nerve ending. A-1291 C>G polymorphism located in alpha2-adrenergic receptor gene (ADRAlpha2A) has been identified. We investigated the possible association between 1291 C>G polymorphism in the promoter region of ADRAlpha2A in clinical subtypes of IBS, ulcerative and microscopic colitis patients.

METHODS

This prospective case control study included 92 patients with diarrhea predominant IBS (D-IBS), 44 with constipation predominant IBS (C-IBS), 15 with alternating diarrhea and constipation IBS (M-IBS), 75 ulcerative colitis (UC), 41 microscopic colitis (MC) and 100 healthy controls. The subjects were genotyped by using PCR amplification of the promoter region of ADRAlpha2A gene followed by digestion with the restriction enzyme MspI. The study was approved by the institute ethical committee.

RESULTS

A strong genotypic association was observed between alpha2A-1291 C>G polymorphism and D-IBS (chi2=6.38, df=2, p<0.05). There was no significant difference in alpha2A-1291 C>G genotype and allele frequency between C-IBS, M-IBS, UC, MC cases and control subjects.

CONCLUSIONS

A significant association was observed between alpha2A-1291C>G polymorphism and D-IBS. Thus, alpha2 AR gene may be a potential candidate involved in the pathophysiology of D-IBS.

Gastroesophageal reflux disease (GERD) and irritable bowel syndrome (IBS)--is it one disease or an overlap of two disorders?

Up to 79% of IBS patients report gastroesophageal reflux disease (GERD) symptoms, and up to 71% of GERD patients report irritable bowel syndrome (IBS) symptoms. There are two principal hypotheses for the common presence of IBS symptoms in GERD patients. The first theory suggests that GERD and IBS overlap in a significant number of patients. The second theory suggests that IBS-like symptoms are part of the spectrum of GERD manifestation. The first theory is supported by genetic studies and similarities in gastrointestinal sensory-motor abnormalities potentially due to general gastrointestinal disorder of smooth muscle or sensory afferents. The other theory is primarily supported by studies demonstrating improvement of IBS-like symptoms in GERD patients receiving anti-reflux treatment. The close relationship between GERD and IBS could be explained by either GERD affecting different levels of the GI tract or a high overlap rate between GERD and IBS due to similar underlying GI dysfunction.