Psychosocial aspects of functional gastrointestinal disorders

Anatomical Evidence for the Neural Connection from the Emotional Brain to Autonomic Innervation in the Anterior Chamber Structures of the Eye

OBJECTIVE

Previous studies have shown that the autonomic nervous system (ANS), which can be affected by emotions, is important in the occurrence or progression of glaucoma. The autonomic innervation distributed in the anterior chamber (AC) structures might play an efferent role in the neural regulation of intraocular pressure (IOP). This study aimed to investigate the anatomic neural connection from the emotional brain to autonomic innervation in the AC.

METHODS

A retrograde trans-multisynaptic pseudorabies virus encoded with an enhanced green fluorescent protein (PRV531) and non-trans-synaptic tracer FAST Dil were injected into the right eye of mice, respectively. Fluorescent localization in the emotional brain and preganglionic nuclei was studied. Five and a half days after PRV531 injection into the right AC, fluorescent signals were observed in several emotional brain regions, including the amygdala, agranular insular cortex, lateral septal nuclei, periaqueductal gray, and hypothalamus. Autonomic preganglionic nuclei, including Edinger-Westphal nucleus, superior salivatory nucleus, and intermediolateral nucleus, were labeled using PRV531.

RESULTS

The sensory trigeminal nuclei were not labeled using PRV531. The fluorescence signals in the nuclei mentioned above showed bilateral distribution, primarily on the ipsilateral side. Seven days after injecting FAST Dil into the AC, we observed no FAST Dil-labeled neurons in the central nervous system.

CONCLUSION

Our results indicate a neural connection from the emotional brain to autonomic innervation in the AC, which provides anatomical support for the emotional influence of IOP via the ANS.

A Study of Psychological Factors Associated with Functional Gastrointestinal Disorders and Use of Health Care

Objective

The purpose of this study was to analyze the symptoms of depression, anxiety, and childhood trauma in functional gastrointestinal disorder (FGID) patients who visited the brain-gut axis clinic.

Methods

The study participants included 99 individuals who were diagnosed with FGID by gastroenterologists, 88 individuals who had no FGID but showed symptoms of FGID based on the Rome criteria, and 79 individuals who did not show any symptoms or were diagnosed with FGID. Symptoms of depression, anxiety, and childhood trauma were evaluated by the Korean version of Beck-depression inventory-II (K-BDI-II), Korean version of Beck anxiety inventory (K-BAI), and Korean version of childhood trauma questionnaire (K-CTQ), respectively.

Results

The BDI score, BAI score, and CTQ score were significantly different between the groups. The group also had higher odds for developing anxiety as compared to the control group (odds ratio [OR] = 10.215, 95% confidence intervals [CI] 2.49−41.76). Additionally, the FGID group had higher odds for developing symptoms of depression (OR = 5.554, 95% CI 2.06−14.97) and experiencing physical violence (OR = 3.128, 95% CI 1.53−6.38) than the non-FGID group.

Conclusion

This study showed that FGID patients were more likely to have symptoms of depression, severe anxiety, and childhood trauma, which were the risk factors of FGID.

Factors associated with uninvestigated dyspepsia in students at 4 Latin American schools of medicine: A multicenter study

INTRODUCTION AND AIMS

Dyspepsia is a multifactorial disease that can involve alcohol, tobacco, or nonsteroidal anti-inflammatory drug use, as well as lifestyle, diet, socioeconomic elements, or psychologic factors. The aim of the present article was to establish the frequency of uninvestigated dyspepsia and determine its associated factors in students at 4 Latin American schools of medicine.

MATERIALS AND METHODS

A cross-sectional, analytic study was conducted, in which a survey made up of closed-ended questions was applied at just one point in time. The association between the variables was then analyzed. A new questionnaire for the diagnosis of dyspepsia was one of the tests utilized to diagnose uninvestigated dyspepsia. Generalized linear models were used for the bivariate and multivariate analyses, employing the Poisson model with the log link function, obtaining crude prevalence ratios, adjusted prevalence ratios, and their 95% confidence intervals.

RESULTS

Of the 1,241 individuals surveyed, 54% (841) were females and the median age was 21 years (range: 19-23 years). Prevalence of uninvestigated dyspepsia was 46%. The factors that had a direct association with dyspepsia were: depression, difficulty sleeping, and coffee consumption. On the contrary, eating regularly in a boarding house and the male sex had an inverse association.

CONCLUSIONS

Uninvestigated dyspepsia frequency was high in students at 4 Latin American schools. Depression, difficulty sleeping, and steady coffee drinking were factors directly associated with dyspepsia, whereas male sex and eating out at regular hours were factors with a reverse association. Therefore, we recommend that universities implement early detection programs for this highly preventable pathology.

Self-reported Sleep Impairment in Functional Dyspepsia and Irritable Bowel Syndrome

BACKGROUND/AIMS

Sleep impairment is a common complaint among patients with irritable bowel syndrome (IBS) and functional dyspepsia (FD). This study aimed to evaluate the prevalence of sleep impairment in FD or IBS patients, and to determine whether IBS-FD overlap induced more sleep disturbance than FD or IBS alone.

METHODS

A population-based cohort in South Korea including 2251 subjects was asked about gastrointestinal symptoms including IBS and dyspepsia-related symptoms. In addition, sleep disturbance was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale questionnaires. One-way ANOVA and logistic regression were used to assess differences among the 4 groups (healthy subjects, IBS alone, FD alone, and IBS-FD overlap).

RESULTS

Of 2251 subjects who were surveyed by questionnaire, 2031 responded (92.5% response rate) and were analyzed. The prevalence of IBS, FD, and IBS-FD overlap was 8.0% (95% confidence interval [CI], 6.8-9.2%), 4.8% (95% CI, 3.9-5.8%), and 1.8% (95% CI, 1.2-2.4%), respectively. FD alone, but not IBS alone, was significantly associated with a poorer sleep quality index (OR, 2.68; 95% CI, 1.43-5.01) and more daytime sleepiness (OR, 2.21; 95% CI, 1.14-4.30), compared to healthy subjects. IBS-FD overlap had the greatest likelihood of a poorer sleep quality index (OR, 3.88; 95% CI, 1.83-8.19), daytime sleepiness (OR, 2.47; 95% CI, 1.01-5.67), and insomnia (OR, 2.84; 95% CI, 1.39-5.82), compared to healthy subjects.

CONCLUSION

A correlation between functional gastrointestinal disorders and sleep disturbance was demonstrated, which was significantly pronounced in the context of IBS-FD overlap.

Self-reported Sleep Impairment in Functional Dyspepsia and Irritable Bowel Syndrome

Background/Aims

Sleep impairment is a common complaint among patients with irritable bowel syndrome (IBS) and functional dyspepsia (FD). This study aimed to evaluate the prevalence of sleep impairment in FD or IBS patients, and to determine whether IBS-FD overlap induced more sleep disturbance than FD or IBS alone.

Methods

A population-based cohort in South Korea including 2251 subjects was asked about gastrointestinal symptoms including IBS and dyspepsia-related symptoms. In addition, sleep disturbance was measured using the Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale questionnaires. One-way ANOVA and logistic regression were used to assess differences among the 4 groups (healthy subjects, IBS alone, FD alone, and IBS-FD overlap).

Results

Of 2251 subjects who were surveyed by questionnaire, 2031 responded (92.5% response rate) and were analyzed. The prevalence of IBS, FD, and IBS-FD overlap was 8.0% (95% confidence interval [CI], 6.8–9.2%), 4.8% (95% CI, 3.9–5.8%), and 1.8% (95% CI, 1.2–2.4%), respectively. FD alone, but not IBS alone, was significantly associated with a poorer sleep quality index (OR, 2.68; 95% CI, 1.43–5.01) and more daytime sleepiness (OR, 2.21; 95% CI, 1.14–4.30), compared to healthy subjects. IBS-FD overlap had the greatest likelihood of a poorer sleep quality index (OR, 3.88; 95% CI, 1.83–8.19), daytime sleepiness (OR, 2.47; 95% CI, 1.01–5.67), and insomnia (OR, 2.84; 95% CI, 1.39–5.82), compared to healthy subjects.

Conclusion

A correlation between functional gastrointestinal disorders and sleep disturbance was demonstrated, which was significantly pronounced in the context of IBS-FD overlap.

ASSESSING THE SLEEP QUALITY AND DEPRESSION-ANXIETY-STRESS IN IRRITABLE BOWEL SYNDROME PATIENTS

ABSTRACT BACKGROUND Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders with chronic abdominal pain and altered bowel habit without any organic reason. Sleep disorders may be associated to IBS. OBJECTIVE We aimed to assess sleep disturbances and depression-anxiety-stress in IBS patients. METHODS In this analytical cross sectional study from November 2013 to May 2014, A total of 123 IBS patients were recruited by simple random sampling. IBS was diagnosed using ROME-III criteria. Demographic and basic data were driven from all patients then Pittsburg Sleep Quality Index questionnaire was utilized to estimate sleep quality and DASS (depression anxiety stress scale) questionnaire was filled out for depression, anxiety and stress. RESULTS The mean age of patients was 29±9, where 48 cases (39%) were male. Twelve cases (10%) had a background disease. Types of IBS in patients were included 38% diarrhea, 42% constipation and 20% mixed. From all IBS patients 87 (71%) cases had depression, 97 (79%) patients stress, 94 (76%) patients had anxiety. Seventy-six (62%) cases of IBS patients had poor sleep quality. Simultaneously employing predictors demonstrate that gender, background disease, and type of IBS did not statistically significant. On the other hand, depression (P=0.034, OR=2.35), anxiety (P=0.011, OR=3.022), and stress (P=0.029, OR=2.77) were significantly effect on sleep quality in poor sleepers. CONCLUSION Many of IBS patients is suffering from poor sleep quality. It seems that sleep disorder should be considered and treated in this patients.

Anxiety, depression and distress among irritable bowel syndrome and their subtypes: An epidemiological population based study

Background:

Psychiatric disorders are common in irritable bowel syndrome (IBS). We conducted this study to investigate the relationship of IBS and their subtypes with some of psychological factors.

Materials and Methods:

A cross-sectional study was performed among 4763 staff of Isfahan University of Medical Sciences in 2011. Modified ROME III questionnaire and Talley Bowel Disease Questionnaire were used to evaluate IBS symptoms. Hospital Anxiety and Depression Scale and 12-item General Health Questionnaire were utilized to assess anxiety, depression and psychological distress. Logistic regression analysis was used to determine the association of psychological states and IBS in the total subject and both genders.

Results:

About, 4763 participants with mean age 36/58 ± 8/09 were included the 2106 males and 2657 females. Three thousand and seven hundred and seventy-six (81.2%) and 2650 (57.2%) participants were married and graduated respectively. Subtype analysis of IBS and its relationship with anxiety, depression and distress comparing the two genders can be observed that: IBS and clinically-significant IBS have higher anxiety, depression symptoms, and distress than the subject without IBS (P < 0.001). Women with IBS, have higher scores than men (P < 0.001). Compared to other subtypes, mixed IBS subtype has a higher anxiety, depression, and distress score.

Conclusion:

A high prevalence of anxiety, depression symptoms and distress in our subjects emphasize the importance of the psychological evaluation of the patients with IBS, in order to better management of the patients and may also help to reduce the burden of health care costs.

Dyspeptic symptoms in patients with type 1 diabetes: endoscopic findings, Helicobacter pylori infection, and associations with metabolic control, mood disorders and nutritional factors

OBJECTIVES

To evaluate, in a group of patients with long-standing type 1 diabetes (DM1), an association of dyspepsia symptoms with: changes in the gastroduodenal mucosa, infection by Helicobacter pylori, glycemic control, and psychological and nutritional factors.

SUBJECTS AND METHODS

A total of 32 patient with DM1 were studied (age: 38 ± 9 years; females: 25; diabetes duration: 22 ± 5 years). All patients answered a standardized questionnaire for the evaluation of gastrointestinal symptoms and underwent upper gastrointestinal endoscopy, with gastric biopsies for the evaluation of Helicobacter pylori infection. The presence of anxiety and depression was evaluated by the HAD scale. Nutritional parameters were BMI, arm and waist circumference, skinfold measurement, and body fat percentage.

RESULTS

Upper endoscopy detected lesions in the gastric mucosa in 34.4% of the patients, with similar frequency in those with (n = 21) and without dyspepsia (n = 11). The patients with dyspepsia complaints showed greater frequency of depression (60% vs. 0%; p = 0.001), higher values for HbA1c (9.6 ± 1.7 vs. 8.2 ± 1.3%; p = 0.01) and lower values for BMI (24.3 ± 4.1 vs. 27.2 ± 2.6 kg/m2; p = 0.02), body fat percentage (26.6 ± 6.2 vs. 30.8 ± 7.7%; p = 0.04), and waist circumference (78.7 ± 8 vs. 85.8 ± 8.1 cm; p = 0.02). No association was found between the symptoms and the presence of Helicobacter pylori.

CONCLUSIONS

Dyspepsia symptoms in patients with long-standing DM1 were associated with glycemic control and depression, and they seem to negatively influence the nutritional status of these patients.

Brain-based Correlations Between Psychological Factors and Functional Dyspepsia

Background/Aims

Increasing evidence shows involvement of psychological disorders in functional dyspepsia (FD), but how psychological factors exert their influences upon FD remains largely unclear. The purpose of the present study was to explore the brain-based correlations of psychological factors and FD.

Methods

Based on Fluorine-18-deoxyglucose positron emission tomography-computed tomography, the altered cerebral glycometabolism was investigated in 40 FD patients compared with 20 healthy controls during resting state using statistical parametric mapping software.

Results

FD patients exhibited increased glucose metabolism in multiple regions relative to controls (P < 0.001, family-wise error corrected). After controlling for the dyspeptic symptoms, increased aberrations persisted within the insula, anterior cingulate cortex (ACC), middle cingulate cortex (MCC) and middle frontal cortex (midFC), which was related to anxiety and depression score. Interestingly, FD patients without anxiety/depression symptoms also showed increased glycometabolism within the insula, ACC, MCC and midFC. Moreover, FD patients with anxiety/depression symptoms exhibited more significant hypermetabolism within the above 4 sites compared with patients without anxiety/depression symptoms.

Conclusions

Our results suggested that the altered cerebral glycometabolism may be in a vicious cycle of psychological vulnerabilities and increased gastrointestinal symptoms.

Psychological features in patients with and without irritable bowel syndrome: A case-control study using Symptom Checklist-90-Revised

CONTEXT

Recent studies have demonstrated that a high proportion of irritable bowel syndrome (IBS) patients shows an association with psychological factors. A few studies were conducted on the investigation of psychological features of IBS patients in Iran.

AIMS

We aimed to evaluate the relationship of psychological distress with IBS in outpatient subjects.

SETTINGS AND DESIGN

A total of 153 consecutive outpatients met Rome III criteria, and 163 controls were interred to study and invited to complete the Symptom Checklist-90-Revised (SCL-90-R) instrument in order to assessment of psychological distress.

STATISTICAL ANALYSIS

Univariate (t-test and Chi-square) and multivariate (logistic regression) methods were used for data analysis.

RESULTS

A significant association of IBS with all nine subscale and three global indices including global severity index (GSI), positive symptom distress index (PSDI), and positive symptom total (PST) of the SCL-90-R were detected. Patients with IBS reported significantly higher levels of poor appetite, trouble falling asleep, thoughts of death or dying, early morning awakening, disturbed sleep, and feelings of guilt compared to the controls. Multivariate analysis indicated that interpersonal sensitivity, somatization, paranoid ideation, depression and phobic anxiety subscales, and PST, PSDI, and GSI global indices were significantly associated with IBS (age, gender, educational level, marital status, employment status, smoking, alcohol use, and body mass index).

CONCLUSIONS

Psychological features are strongly associated with IBS; notably, interpersonal sensitivity, somatization, paranoid ideation, depression, phobic anxiety, and all global indices including PST, PSDI, and GSI is significantly associated with. Hence, the appropriate psychological assessment in these patients is critically important.

Correlation between social factors and anxiety-depression in function dyspepsia: do relationships exist?

INTRODUCTION

Function dyspepsia (FD) may cause patients to suffer from anxiety and depression, and psychosocial disorders would have a significant effect on FD symptoms.

AIM

To examine the prevalence of anxiety and depression among function dyspepsia (FD) patients and to identify social factors of anxiety-depression among FD patients.

MATERIAL AND METHODS

Patients with FD, who fulfilled the Rome III criteria, were enrolled. All patients were administered a validated Chinese version of the self-rating scale (SDS) and self-rating anxiety scale (SAS), and investigated regarding the patients' social factors.

RESULTS

A total of 907 patients were enrolled, including 516 (56.89%) FD patients within anxiety-depression status; SDS mean scores were 51.57 ±8.22; SAS mean scores were 51.04 ±7.53; 52.28% were male and 64.25% were female (χ(2) = 262.54, p < 0.01); 56.16% were aged 18-29 years, 54.15% were aged 30-39 years, 54.77% were aged 40-49 years, 62.02% were aged 50-59 years, 69.23% were aged above 60 years (χ(2) = 18.14, p < 0.01); 67.44% were the retirees; 63.31% were manual workers; 55.10% were soldiers; 43.57% were mental workers; 38.89% were students (χ(2) = 716.53, p < 0.01); 64.20% had junior high school degree or below; 57.36% had high school degrees; 42.03% had college degrees; 44.44% had master's or above degrees (χ(2) = 27.21, p < 0.05); 38.10% were in good health condition; 61.90% were in poor health condition (χ(2) = 7.94, p < 0.01); 20.31% had correlative family history; and 79.69% had no correlative family history (χ(2) = 2.23, p > 0.05).

CONCLUSIONS

The FD patients have higher rates of anxiety and depression. Gender, age, occupation, education level, and health condition have a significant effect on anxiety and depression status. Female gender, advanced age, high-stress occupation, lower education level, and poor health condition all are risk factors. Family history has no relationship with anxiety and depression among FD patients.

Are self-administered or minimal therapist contact psychotherapies an effective treatment for irritable bowel syndrome (IBS): a systematic review

OBJECTIVE

Irritable bowel syndrome is a highly prevalent gastrointestinal condition that is known to be associated with maladaptive psychological coping and is extremely costly to the health-care system. Psychotherapy has been found to improve both physical and psychological symptoms in IBS. However, it is unknown whether 'no therapist' or 'minimal therapist' contact self-help psychotherapy programs are effective treatments for IBS. Thus, this paper aims to determine whether 'no therapist' or 'minimal therapist' contact self-help psychotherapy programs are effective treatments for IBS.

METHODS

A search of PubMed, SCOPUS, Cochrane Library, and Ebscohost research databases was conducted without language or date restriction in July 2012.

RESULTS

Nine relevant publications were included in the final review, all of which were randomized controlled trials (RCTs) and included an intervention that was primarily self-administered. It was found that 'no therapist' contact self-help programs are likely to have poor results due to lack of engagement in the program, whilst 'minimal therapist' contact programs appear to produce positive results in terms of symptom relief. Trends towards 'minimal therapist' contact self-help programs having a positive impact on quality of life (QOL) and psychological outcomes were evident.

CONCLUSION

'Minimal therapist' contact psychotherapy programs have the potential to reduce healthcare seeking behaviour and potentially reduce healthcare costs. However, further studies need to be conducted to confirm this effect as there is poor standardisation in the measurements of the available studies.

Increased severity of dyspeptic symptoms related to mental stress is associated with sympathetic hyperactivity and enhanced endocrine response in patients with postprandial distress syndrome

BACKGROUND

Mental stress (MS) may alter gastric sensory-motor function. The aim of the study was to assess postprandial autonomic nervous system activity and stress hormones in response to acute mental stress in dyspeptic patients.

METHODS

A total of 25 patients with postprandial distress syndrome (PDS; 11 mol L(-1), age 35.9 ± 9.3 years) and 12 healthy controls (5 mol L(-1), age 25.8 ± 4.6 years) underwent electrogastrography and (13) C-octanoate gastric emptying study using a 480 kcal solid meal. Heart rate variability (LF/HF ratio) and corticotrophin-releasing factor, adrenocorticotropic hormone (ACTH), and cortisol serum levels were also evaluated. Dyspeptic symptoms were scored by analogue visual scale and expressed as symptoms total score (TS). The protocol was repeated twice in each subject, with and without a mental stress test before the meal.

KEY RESULTS

Mental stress significantly increased postprandial symptoms severity in patients (TS: stress 111 ± 18 vs basal 50 ± 10; P < 0.05). Low-/high-frequency component ratio was significantly higher in patients after MS at 120 min (stress 5.46 ± 0.41 vs basal 3.41 ± 0.64; P < 0.01) and 180 min (stress 5.29 ± 0.2 vs basal 3.58 ± 0.19; P < 0.05). During stress session, in patients we found a significantly higher ACTH level than baseline at 30, 60, 90, 150, 210, 240, and 270 min and a significantly higher cortisol level at 30, 60, 90, 120, 210, and 270 min. Gastric emptying rate and electrical activity were not influenced by MS.

CONCLUSIONS & INFERENCES

In PDS patients, administration of MS before meal increases symptoms severity by inducing sympathetic hyperactivity and increased stress hormones levels. As the gastric emptying looks not altered, we conclude that these neurohormonal responses mainly affect sensitive function.

Anxiety, personality traits and quality of life in functional dyspepsia-suffering patients

BACKGROUND

Psychosocial stressors either acute or more sustained frequently precede the onset and exacerbation of the symptoms of the functional dyspepsia (FD). Depressive mood and quality of life have been already reported for interference in functional dyspepsia suffering patients.

METHODS

The examination were performed on 60 FD patients (30 females and 30 males), aged 20-79 years, 60 peptic ulcer subjects and 60 healthy volunteers in which we have investigate levels of anxiety and depression, personality traits and quality of life.

RESULT

According to the Hamilton Depression and Anxiety Rating Scales, the population with FD had the average score which classified them into the group of patients with the moderate depression (20.57 ± 4.45). Personality traits estimation based on data obtained by the Eysenck personality questionnaire revealed higher neuroticism scores in the group with functional dyspepsia. Both parameters, level of the neuroticism and anxiety level, expressed highly significant level of mutual concordance. Patients with functional dyspepsia reported a greater adverse impact of symptoms of emotional distress and food and drink problems.

CONCLUSION

Results are indicating that the depression and anxiety level is the highest in patients with functional dyspepsia and that anxiety level corroborates with the neuroticism level from the Eysenck scale. Psychological disturbances are influencing the quality of life mostly in patients with dyspepsia in the form of emotional distress and the problem with the food and beverage intake.

Treatment of the severe refractory irritable bowel patient

Determining which patients with irritable bowel syndrome (IBS) are "refractory" is highly subjective. The duration, severity, and type of symptoms and a host of other epidemiologic and psychosocial factors play a role in this determination. Long duration of symptoms alone does not portray the severe IBS patient. Several studies have shown that patients concerned with pain rather than altered bowel habits (diarrhea and constipation) are more likely to be disabled by their disease. Pragmatically, refractory patients can be defined as those who fail to improve on multiple drug regimens and who have high health care utilization despite aggressive therapy. In some cases, psychosocial and psychiatric comorbidity can also contribute to an inability to improve despite reasonable medical management. Finally, IBS patients who are unhappy about their care and who have the unrealistic expectation of "cure" may become refractory. The key to dealing with so-called "refractory" IBS patients is to understand that their behaviors often relate to underlying needs that the patients may have difficulty communicating to the physician. Unfortunately, these patients are often labeled as "difficult," "unpleasant," or "crazy," and are often dismissed by their treating physicians. This leads to a continued cycle of pain, frustration, and health care over-utilization, with patients seeking the elusive "cure." Failure to understand these correlates leads to continued frustration and treatment failure, which unfortunately often characterizes the care of these patients.

Changes of ultrastructure and downregulation of heat shock protein 70 and fibroblast growth factor 2 in gastric mucosa of rats with depressive-like behaviour

OBJECTIVE

To understand the underlying mechanism of gastric symptoms in patients with depressive disorder.

METHODS

This study tested in the rat depression model evoked with chronic mild stress whether the microstructure gastric mucosa is injured using scanning electronic microscopy and transmission electronic microscopy (TEM). In addition, the expression of heat shock protein 70 (HSP70) and fibroblast growth factor 2 (FGF2) proteins in the gastric mucosa were measured by Western blotting.

RESULTS

We found that the gastric epithelial cells were ruptured and the gastric pits were widened in rats with depression. The amount of mucous granules was also reduced in the surface mucous cells. Moreover, parietal cells became active, and the secretory canaliculi were magnified. Expression of HSP70 and FGF2 was reduced in the gastric mucosa.

CONCLUSIONS

These findings suggested that gastric symptoms in rats with depressive-like behaviour were caused by the injury of the gastric mucosa, AQ1 and HSP70 and FGF2 may be key molecules in the pathogenesis.

Evaluation of psychological aspects among subtypes of irritable bowel syndrome

CONTEXT

While some studies have found disparities between subtypes of irritable bowel syndrome (IBS), others did not found such differences.

AIM

This study aimed to investigate whether there are differences in psychological features between the subtypes of IBS.

SETTINGS AND DESIGN

A cross-sectional study was performed on all consecutive outpatients IBS diagnosed (from Oct. 2010 to Oct. 2011) in Taleghani Hospital gastroenterology clinic, Tehran, Iran.

MATERIALS AND METHODS

A total of 153 consecutively diagnosed IBS patients (using Rome III criteria); including 80 constipation-predominant (IBS-C), 22 diarrhea-predominant (IBS-D), and 51 mixed IBS (IBS-M) were asked to complete the Symptom Checklist 90 Revised (SCL-90-R).

STATISTICAL ANALYSIS

Pearson's chi-square test was used to compare nominal variables. One-way ANOVA was used to compare continuous variables.

RESULTS

Although IBS-C patients were more suffered from psychiatric disorders, there were no statistical differences between mean score of IBS-C, IBS-D, and IBS-M patients regarding to all of SCL-90-R subscales and three global indices including Global Severity Index (GSI), Positive Symptom Distress Index (PSDI) and Positive Symptom Total (PST) (P<0.05).

CONCLUSION

Our finding showed that there are no different symptomatic profiles between IBS subtypes.

Anxiety-depressive disorders among irritable bowel syndrome patients in Guilan, Iran

Background

Psychiatric disorders are common in irritable bowel syndrome (IBS) patients. The prevalence of psychiatric disorders in IBS patients varies in different cultures. We conducted this study to determine the prevalence of psychiatric disorders

Methods

In a cross-sectional study, 256 IBS patients were selected (using the criteria of Rome III) and evaluated for psychiatric disorders. In the first phase, subjects were screened using the General Health Questionnaire 28 (GHQ28). In the second phase, those who had scores ≥ 23 were assessed through semi-structured psychiatric interviews.

Results

Thirty out of 256 subjects had no significant psychiatric symptoms after performing GHQ28. In further psychiatric evaluation of the remaining subjects (226) who suffered from some degree of a psychiatric problem, 36 were diagnosed without Anxiety/Depressive disorder. Thus 66 subjects (25.8%) were known as a group without any significant psychiatric problem. A total of 190 subjects (74.2%) with anxiety-depressive problems were diagnosed; 89 were suffering from pure anxiety disorders, 41 were suffering from depressive disorders and 60 had co-morbid anxiety-depressive disorders. When comparing anxiety-depressive patients (n = 190) with normal subjects (n = 66), gender (P = 0.016), occupation (P = 0.002) and intensity of IBS (P < 0.001) showed statistically significant differences.

Conclusion

The high prevalence of anxiety-depressive disorders in this study indicates the necessity of psychiatric assessment, early diagnosis and treatment of the patients with IBS. It may improve management of the patients suffering from IBS.

Cortical-limbic regions modulate depression and anxiety factors in functional dyspepsia: a PET-CT study

OBJECTIVE

To observe some specific brain areas or cerebral functional network participating in the modulation of depression and anxiety factors in functional dyspepsia (FD) patients by detecting cerebral glucose metabolism (CGM) in fluorine-18 fluorodeoxyglucose ((18)F-FDG) positron emission tomography-computed tomography (PET-CT) scans.

METHODS

Eight FD patients with depression and anxiety (DA-FD group) and eight FD patients without depression and anxiety (non-DA-FD group) were recruited and evaluated by the Nepean Dyspepsia Index (NDI) and Dyspepsia Symptom Scores (DSS). Cerebral (18)F-FDG PET-CT scans were performed on the DA-FD group and non-DA-FD group, respectively. The differences in CGM between the two groups were analyzed with SPM2.

RESULTS

Extensive changes in the CGM signals were observed in the cerebral cortex and limbic system of FD patients with depression and anxiety. Compared to non-DA-FD patients, DA-FD patients showed a higher glucose metabolism in the right postcentral gyrus (BA 1 and 5), inferior frontal gyrus (BA 45), superior temporal gyrus (BA 22), middle temporal gyrus (BA 22), inferior parietal lobule (BA 40), lingual gyrus (BA 18) and the left middle occipital gyrus (BA 37), as well as the limbic system including the left thalamus, lateral globus pallidus, parahippocampal gyrus (BA 35), right insular cortex (BA 13) and parahippocampal gyrus (BA 18); a lower glucose metabolism was presented in the left middle cingulated gyrus (BA 24), the right superior frontal gyrus (BA 6), the medial frontal gyrus (BA 6) and middle temporal gyrus (BA 21).

CONCLUSION

An extensive cortical-limbic brain network might modulate the procession of FD patients with depression and anxiety factors.

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

BACKGROUND

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

METHODS

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

KEY RESULTS

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

CONCLUSIONS & INFERENCES

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

Dysfunctional cognitions, anxiety and depression in irritable bowel syndrome

GOALS AND BACKGROUND

Patients with irritable bowel syndrome (IBS) have significantly impaired quality of life (QoL). We investigated the presence of dysfunctional cognitions, anxiety, and depression symptoms and their impact on daily symptoms and QoL in a large IBS cohort.

STUDY

A total of 268 IBS patients (Rome II criteria, age 18 to 65 y) were included. Patients completed a 2-week daily symptom diary. The Short Form-36 was used to score QoL. The 31-items Cognitive Scale for Functional Bowel Disorders (CSFBD) and the Hospital Anxiety and Depression Scale (HADS) were used to analyze the psychological factors.

RESULTS

Possible anxiety and depression disorders were present in 30% and 22% of IBS patients, respectively. Patients with anxiety and depression had significantly higher mean symptom scores, impaired QoL, and higher CSFBD scores (P<0.01). Physical and mental QoL were both affected by depression (HADS-D) and dysfunctional cognitions (P<0.01). Only physical QoL, not mental QoL, was affected by referral type (hospital setting vs. community based; P<0.01). Only mental QoL was affected by anxiety (HADS-A) (P<0.01). Dysfunctional cognitions independently of anxiety and depression influenced QoL and IBS symptoms.

CONCLUSIONS

In this IBS cohort, dysfunctional cognitions independently influence physical and mental QoL and symptom severity. Presence of possible anxiety and depression disorders resulted in higher symptoms, lower QoL, and higher CSFBD scores. The results point toward an important role of psychological factors, especially dysfunctional cognitions on QoL and symptom scores in IBS patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Influence of abuse history on gastric sensorimotor function in functional dyspepsia

Patients with functional gastrointestinal disorders have elevated rates of sexual or physical abuse, which may be associated with altered rectal sensorimotor function in irritable bowel syndrome. The aim was to study the association between abuse history and gastric sensorimotor function in functional dyspepsia (FD). We studied gastric sensorimotor function with barostat (sensitivity, compliance and accommodation) and gastric emptying test in 233 consecutive FD patients from a tertiary care centre (162 women, mean age 41.6 +/- 0.9). Patients filled out self-report questionnaires on history of sexual and physical abuse during childhood or adulthood. Eighty-four patients (out of 198, 42.4%) reported an overall history of abuse [sexual and physical in respectively 30.0% (60/200) and 20.3% (42/207)]. FD patients reporting general as well as severe childhood sexual abuse have significantly lower discomfort thresholds during gastric distension [respectively 10.5 +/- 0.4 vs 7.5 +/- 1.0 mmHg above minimal distending pressure (MDP), P = 0.014 and 10.5 +/- 0.4 vs 6.6 +/- 1.2 mmHg above MDP, P = 0.007]. The corresponding intra-balloon volume was also significantly lower (respectively 579 +/- 21 vs 422 +/- 59 mL, P = 0.013 and 579 +/- 19 vs 423 +/- 79 mL, P = 0.033). Gastric accommodation was significantly more pronounced in patients reporting rape during adulthood (91 +/- 12 vs 130 +/- 40 mL, P = 0.016). Abuse history was not associated with differences in gastric emptying. A history of abuse is associated with alterations in gastric sensorimotor function in FD. Particularly sexual abuse, rather than physical abuse, may influence gastric sensitivity and motor function.

Recurrent symptoms after fundoplication with a negative pH study--recurrent reflux or functional heartburn?

INTRODUCTION

A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Over two thirds of these patients will have a negative 24-h pH study. The aim of our study is to determine whether these patients have an associated functional disorder or abnormal cytokine activity and to examine the reproducibility of pH testing.

METHODS

A prospective analysis was carried out on a cohort of patients who had undergone a fundoplication and postoperative pH testing for recurrent heartburn: group A--patients with recurrent heartburn and a negative 24-h pH study and group B (control group)--patients with recurrent heartburn and a positive pH study. Questionnaires, a blood sample, and repeat pH testing were completed.

RESULTS

Sixty-nine patients were identified. Group A's depression score (8.6 +/- 4.1) was significantly higher than group B's (5.9 +/- 4.2; P = 0.03). Cytokine levels were similar in both groups. Forty-seven of 49 (96%) patients who underwent repeat pH testing had a negative study. Symptom-reflux correlation was highly significant (P < 0.001).

CONCLUSION

Some patients with recurrent heartburn and a negative pH study have associated functional or psychiatric comorbidities such as depression. Reproducibility of 24-h pH testing in these patients is excellent.

Influence of experimentally induced anxiety on rectal sensorimotor function in healthy humans

Psychological processes, especially anxiety, may have an influence on visceral perception and gastrointestinal (GI) motor function, thereby eliciting or aggravating GI symptoms. Anxiety has been shown to affect gastric sensorimotor function but it is conceivable that anxiety affects not only the stomach but also other parts of the GI tract, such as the rectum. The aim of this study was to investigate whether experimentally induced anxiety would alter rectal sensorimotor function in health. Eighteen healthy subjects (mean age 26.97 +/- 1.75 years) underwent a rectal barostat study. To assess sensitivity to rectal distension and rectal compliance, stepwise isobaric distension was performed during anxious and neutral emotional state. Two methods of emotion induction were used simultaneously: audiotape assisted recall of a neutral or anxious autobiographical experience and viewing of a set of validated neutral or fearful facial expressions. Anxiety levels were assessed by means of the Spielberger State-Trait Anxiety Inventory (STAI) and anxiety scores on a Likert scale. Anxiety scores (AUC: 2.11 +/- 1.45 vs 42.78 +/- 6.17 mm mmHg, P < 0.0001) and STAI scores (36.06 +/- 2.09 vs 45.56 +/- 2.52, P = 0.005) confirmed the efficacy of anxiety induction. Rectal compliance was not different during anxious compared with neutral emotional state (11.62 +/- 0.93 vs 10.61 +/- 0.96 mL mmHg(-1), P = NS). Pressure and volume thresholds inducing discomfort during rectal distension were not significantly different during anxious and neutral emotional state (29.33 +/- 1.41 vs 29.78 +/- 1.49 mmHg, P = NS and 249.26 +/- 16.22 vs 231.38 +/- 21.19 mL, P = NS respectively). Contrary to its influence on gastric sensorimotor function, experimentally induced anxiety does not affect rectal sensitivity or rectal compliance in healthy subjects.

Functional brain imaging of gastrointestinal sensation in health and disease

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

Relationship between anxiety and gastric sensorimotor function in functional dyspepsia

OBJECTIVE

To investigate the relationship between anxiety and gastric sensorimotor function in patients with (hypersensitive) functional dyspepsia (FD). Comorbidity between FD and anxiety disorders is high. In FD, epigastric pain is associated with gastric hypersensitivity and neuroticism, a personality trait related to anxiety. Experimentally induced anxiety in healthy volunteers is associated with changes in sensorimotor function of the proximal stomach.

METHODS

A total of 139 patients with FD (n = 102 women) underwent a barostat investigation to determine gastric compliance, meal accommodation, and thresholds for discomfort and pain. Anxiety was measured by the State-Trait Anxiety Inventory (STAI) scale (anxiety as a stable personality trait) and the STAI-State scale (momentary anxiety). The anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) was filled out to detect comorbid anxiety disorders.

RESULTS

Hyper- and normosensitive patients had similar anxiety scores, but gastric compliance was significantly lower in hypersensitive patients (11.4 versus 32.8 ml/mm Hg; p < .001). In the whole patient group, no significant correlations between STAI scores and gastric sensorimotor function were found. In hypersensitive patients (n = 53, 43 women), state anxiety was negatively correlated with discomfort threshold (rho = -.49; p = .001), pain threshold (rho = -.48; p = .02), and gastric compliance (rho = -.46; p = .002). These results were confirmed by multiple linear and logistic regression analyses.

CONCLUSION

In hypersensitive patients with FD, state anxiety is significantly and negatively correlated with discomfort threshold, pain threshold, and compliance. These results strengthen the hypothesis that anxiety is important in FD, especially in hypersensitive patients.

Peripheral and central mechanisms of visceral sensitization in man

Visceral hypersensitivity (perception of gastrointestinal sensory events at a lower-than-normal threshold) is considered to be an important pathophysiological mechanism in the development of functional gastrointestinal disorders (FGIDs), such as irritable bowel syndrome, non-cardiac chest pain and functional dyspepsia. These disorders are associated with significant health care and socioeconomic costs due to factors such as repeated visits to consultants, hospitalizations and work absenteeism. Despite the presence of extensive evidence linking visceral hypersensitivity and FGIDs, the mechanism(s) underlying visceral hypersensitivity has not been fully elucidated. Suggested hypotheses include sensitization of afferent neurones, both at the level of the enteric and the (afferent) autonomic nervous system (peripheral sensitization), sensitization of spinal cord dorsal horn neurones (central sensitization) and psychosocial factors/psychiatric comorbidity influencing the processing of afferent signals at the level of the brain. Importantly, these hypotheses may be complementary rather than mutually exclusive. However, the degree to which each of these mechanisms contributes to the overall perception of visceral pain, and therefore the generation of symptoms, still remains unclear. This article discusses the mechanisms that may underlie visceral hypersensitivity, with reference to FGIDs. Understanding these mechanisms is essential in order to improve the diagnosis and treatment of patients with these disorders.

Influence of alcohol consumption on IBS and dyspepsia

The role of alcohol use in irritable bowel syndrome (IBS) and dyspepsia is not well understood. We hypothesised that people with psychological distress who drink no alcohol, or excess alcohol, are at increased risk of having IBS or dyspepsia. Valid gastrointestinal (GI) symptom surveys were mailed to randomly selected cohorts of community residents. Associations between IBS, dyspepsia and abdominal pain and alcohol use were assessed using logistic regression adjusted for a Somatic Symptom Checklist score (SSC). A total of 4390 (80%) responded; of these, 10.5% reported IBS, 2% dyspepsia and 22% abdominal pain. Alcohol consumption >7 drinks week(-1) was associated with a greater odds for dyspepsia (OR 2.3; 95% CI:1.1-5.0) and frequent abdominal pain (OR 1.5; 95% CI: 1.1-2.0) but not IBS. However, significant interactions among gender, alcohol use and SSC scores were detected (P < 0.005). In females with a low SSC score, consuming alcohol > or =7 drinks week(-1) increased the odds of IBS compared to drinking alcohol moderately. Alcohol consumption was associated with dyspepsia and abdominal pain. A relationship with IBS was identified when interactions with somatization and gender were appropriately considered. Whether these associations are due to the effects of alcohol on the gut, or a common central mechanism remains to be determined.

A prospective 1-year follow-up study in patients with functional or organic dyspepsia: changes in gastrointestinal symptoms, mental distress and fear of serious illness

BACKGROUND

Psychosocial factors are common among patients with functional gastrointestinal disorders (FGIDs). Whether they affect the course of the disease remains unresolved.

AIM

To evaluate whether reassuring investigations of primary care patients with functional dyspepsia (FD) and organic dyspepsia (OD) influence gastrointestinal (GI) symptoms and psychological factors, and to assess whether these changes are correlated.

METHODS

Four hundred consecutive patients with dyspepsia were referred for thorough examinations. Patients completed questionnaires screening symptoms at baseline and on 1-year follow-up.

RESULTS

At baseline, there was no difference in GI symptoms, prevalence of mental distress or fear of serious illness between patients with FD or OD. On follow-up, the patients with FD had more GI symptoms, but there was no difference in mental distress or fear of serious illness. Relevant GI symptom reduction related to alleviation of mental distress (53.4% vs. 20.5%, P < 0.001) and fear of serious illness (56.5% vs. 23.7%, P = 0.002), but reached statistical significance only in patients with OD.

CONCLUSIONS

Gastrointestinal symptoms in FD patients are long lasting compared with those with organic diseases. Reassuring investigations could lower mental distress and fear of serious illness in these patients. Psychological factor change correlates with the change in GI symptom severity and is not specific to FGIDs.

Nonsurgical factors affecting symptomatic outcomes of antireflux surgery

A small number of patients will have persistent or new symptoms after antireflux surgery for gastroesophageal reflux disease (GERD). Most of these symptoms are due to recurrent reflux or some complication or side-effect of the operation. However, a few of these patients will be symptomatic without objective findings to explain these symptoms. The purpose of this review is to highlight potential non-surgical factors that may proceed to a poor symptomatic outcome after antireflux surgery. These factors include underlying esophageal pathophysiology, issues related to chronic pain and pain perception, personality and psychoemotional disorders, functional esophageal and/or bowel disorders, and the nocebo phenomenon. Awareness of these other causes can lead to more appropriate treatments.

Chronic nausea and vomiting: new insights and approach to treatment

Chronic vomiting of unclear etiology has been given a number of names over time. For many years, it was known as "psychogenic" vomiting because a psychiatric etiology was considered the most likely cause. More recently, the concepts of cyclic vomiting syndrome (CVS) and functional vomiting (FV) have been proposed to better explain this perplexing phenomenon. CVS is a dramatic clinical syndrome characterized by intense episodes of vomiting lasting over a period of days but alternating with periods of intense quiescence. FV, as defined by the Rome II diagnostic criteria, is vomiting of at least 3 months, which need not be consecutive, in the preceding year with at least three separate vomiting episodes in a week. It is found in the absence of obvious metabolic, structural, or psychiatric disorders which could explain the vomiting (Table 1). It will be the purpose of this article to review the history of chronic vomiting from a nomenclature perspective. Methodologic limitations of early studies will be described as well as more contemporary reviews that used updated methodologic approaches to describe this perplexing problem.

Cyclic Vomiting Syndrome in 41 adults: the illness, the patients, and problems of management

BACKGROUND

Cyclic Vomiting Syndrome (CVS) is a disorder characterized by recurrent, stereotypic episodes of incapacitating nausea, vomiting and other symptoms, separated by intervals of comparative wellness. This report describes the clinical features, co-morbidities and problems encountered in management of 41 adult patients who met the diagnostic criteria for CVS.

METHODS

This is a retrospective study of adults with CVS seen between 1994 and 2003. Follow-up data were obtained by mailed questionnaires.

RESULTS

Age of onset ranged from 2 to 49 years. The duration of CVS at the time of consultation ranged from less than 1 year to 49 years. CVS episodes were stereotypic in respect of their hours of onset, symptomatology and length. Ninety-three percent of patients had recognizable prodromes. Half of the patients experienced a constellation of symptoms consisting of CVS episodes, migraine diathesis, inter-episodic dyspeptic nausea and a history of panic attacks. Deterioration in the course of CVS is indicated by coalescence of episodes in time. The prognosis of CVS is favorable in the majority of patients.

CONCLUSION

CVS is a disabling disorder affecting adults as well as children. Because its occurrence in adults is little known, patients experience delayed or mis-diagnosis and ineffectual, sometimes inappropriately invasive management.

Influence of experimentally induced anxiety on gastric sensorimotor function in humans

BACKGROUND & AIMS

Unexplained dyspeptic symptoms are associated with changes in gastric sensorimotor function and several psychopathologic dimensions, including anxiety. It is unclear whether this reflects common predisposition or a causal relationship. The aim of this study was to investigate whether experimentally induced anxiety would alter gastric sensorimotor function in health.

METHODS

Fourteen subjects underwent a gastric barostat study to assess gastric sensitivity and accommodation. Eighteen subjects underwent a 10-minute satiety drinking test (30 mL/min) with registration of epigastric symptoms on a visual analogue scale (VAS) at 2-minute intervals. Emotional context was modulated for 10 minutes at the start of each experiment by combined projection of validated facial expressions and an audiotape recalling a neutral or an anxious autobiographical experience. Anxiety levels were assessed using a VAS and the Spielberger State-Trait Anxiety Inventory (STAI).

RESULTS

VAS and STAI scores confirmed efficacy of anxiety induction. During the anxiety condition, gastric compliance was significantly decreased (57 +/- 5 vs 40 +/- 5 mL/mm Hg; P < .01). Intraballoon pressures inducing discomfort during gastric distention were not altered, but the corresponding volume (630 +/- 47 vs 489 +/- 39 mL; P < .005) was significantly lower. Meal-induced relaxation was inhibited during the anxiety condition and this persisted for the 60-minute measurement (157 +/- 29 vs 100 +/- 24 mL; P < .05). During the satiety drinking test, the anxiety condition was associated with significantly higher scores for satiety, fullness, and bloating.

CONCLUSIONS

Experimentally induced anxiety alters gastric sensorimotor function, suggesting that psychological factors may play a causal role in the pathogenesis of some dyspeptic symptoms and mechanisms.

Functional dyspepsia pathogenesis and therapeutic options--implications for management

Functional dyspepsia is far more common than dyspepsia due to organic disease, both in the community and general practice. Proposed aetiopathogenic factors include gastric acid, Helicobacter pylori infection, delayed emptying, hypersensitivity or impaired accommodation of the stomach, dysfunction of the duodenum or brain-gut axis, psychosocial morbidity and post-infective mucosal damage. More effective therapy will depend on the development of drugs targeted at these putative pathophysiological mechanisms. On current evidence tricyclic antidepressants appear to be more effective than either acid suppressants or H. pylori eradication.

Stress and the gastrointestinal tract

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the brain-gut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray. It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamus-pituitary-adrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response. Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus. Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4(+) lymphocytes. The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

Management of Functional Abdominal Pain

The diagnosis of functional abdominal pain should be made based on the Rome II symptom criteria with only limited testing to exclude other disease. During physical examination the clinician may look for evidence of pain behavior which would be supportive of the diagnosis. Reassurance and proper education regarding the clinical entity of functional abdominal pain is critical for successful treatment and good patient satisfaction. Education should include validation that symptoms are real, and that other individuals experience similar symptoms. No further treatment may be required for those with mild symptoms. For patients with more severe symptoms, a long-term management plan of either pharmacological or psychological treatments is warranted. This will require a commitment by both the patient and the physician to engage in a partnership with active involvement and responsibility by both individuals. The goal of treatment--to decrease pain and increase function over time, not to cure the disorder-- should be explained. Strong consideration should be made for the use of an antidepressant to treat analgesic effects. Tricyclic antidepressants are the mainstay of therapy for functional pain disorders. The analgesic effect is generally quicker in onset and occurs at a lower dose than their effect on mood. To maximize patient compliance, patients should be told the rationale behind their use, warned of the potential side effects, and reassured that many of the side effects will disappear with time. Choice of an antidepressant should be based on the presence of concomitant symptoms (eg, depression), cost, and physician familiarity with specific agents. All patients with functional abdominal pain should be screened for underlying psychiatric disturbance as an untreated mood disorder will adversely affect response to treatment. If a concurrent mood disorder is found, it should be treated by either using a higher dose of the tricyclic antidepressant or by adding another antidepressant agent. Psychological interventions such as cognitive behavioral therapy may be important as adjuvant therapy or as an alternative to treatment with antidepressants for those patients who find antidepressants ineffective or are intolerant to them. Narcotics and benzodiazepines should not be used to treat chronic abdominal pain due to the high risk of physical and psychological dependence.

Central nervous system involvement in functional gastrointestinal disorders

Although functional gastrointestinal disorders (FGID) are common, their pathophysiology remains incompletely understood. It is generally accepted that dysfunction of the bidirectional pathways between the gastrointestinal tract and the central nervous system (the 'brain-gut axis') at any level can cause FGID symptoms. In this review article, we focus on the role of the central nervous system in the brain-gut axis. First, we describe the functional anatomy of the brain-gut axis. Second, we focus on the results from brain-imaging studies both in healthy volunteers and in FGID patients. These new investigational techniques made identification of brain regions critically involved in processing of visceral afferent information possible. Differences in central nervous system response to visceral stimuli between controls and FGID patients will be highlighted. Third, we will address the issue of high comorbidity with psychiatric disorders. Some hypotheses about common pathophysiological substrates will be discussed.

Empirically derived symptom sub-groups correspond poorly with diagnostic criteria for functional dyspepsia and irritable bowel syndrome. A factor and cluster analysis of a patient sample

AIM

To determine how clusters (groups) of patients with respect to symptoms compare with a clinical diagnosis in patients with irritable bowel syndrome and non-ulcer dyspepsia.

METHODS

All patients who attended a gastroenterology practice at Nepean Hospital were included in the study. All patients received the previously validated Bowel Disease Questionnaire, and were independently assessed by the gastroenterologist. Factor analysis and a k-means cluster analysis were completed.

RESULTS

The study population comprised 897 patients [320 males (36%) and 577 females (64%)]. Factor analysis identified nine symptom factors: (1) diarrhoea; (2) constipation; (3) dysmotility; (4) dyspepsia/reflux; (5) nausea/vomiting; (6) bowel; (7) meal-related pain; (8) weight loss; and (9) abdominal pain. A k-means cluster analysis identified seven distinct subject groups, which included an undifferentiated group: (1) diarrhoea; (2) meal-related pain; (3) abdominal pain; (4) faecal indicators; (5) nausea/vomiting/weight loss; and (6) constipation. The majority of irritable bowel syndrome patients fitted into two cluster groups [diarrhoea (25%) and constipation (20%)], whereas those with non-ulcer dyspepsia predominantly fitted into the undifferentiated cluster (34%) and the nausea/vomiting cluster (18%).

CONCLUSION

This study supports the concept of symptom subgroups, including the subdivision of patients into diarrhoea- and constipation-predominant irritable bowel syndrome.