Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population

Cholecystectomy is associated with a higher risk of irritable bowel syndrome in the UK Biobank: a prospective cohort study

Background: Recent studies have shown that bile acids are essential in irritable bowel syndrome (IBS) pathology, and cholecystectomy has direct effects on bile acid metabolism. However, whether cholecystectomy increases the risk of IBS remains unclear. We aimed to investigate the association between cholecystectomy and IBS risk in the UK Biobank (UKB). Methods: This study is a prospective analysis of 413,472 participants who were free of IBS, inflammatory bowel disease, cancer, or common benign digestive tract diseases. We identified incidents of IBS through self-reporting or links to primary healthcare and hospitalization data. We evaluated hazard ratios (HRs) adjusted for sociodemographic characteristics, health behaviours, comorbidities, and medications. Results: During a median follow-up period of 12.7 years, we observed 15,503 new cases of IBS. Participants with a history of cholecystectomy had a 46% higher risk of IBS than those without (HR = 1.46, 95% CI: 1.32-1.60), and further subtype analysis showed that the risk of IBS with diarrhoea was significantly higher than the risk of IBS without diarrhoea (HR = 1.71, 95% CI: 1.30-2.25 vs. HR = 1.42, 95% CI: 1.28-1.58). The overall covariate-adjusted HRs for IBS were similar between the group with both cholecystectomy and gallstones (HR = 1.45, 95% CI: 1.32-1.58) and the group with cholecystectomy without gallstones (HR = 1.50, 95% CI: 1.36-1.67) when the group without both cholecystectomy and gallstones was used as a reference. The overall covariate-adjusted HR was not significantly different in the group without cholecystectomy with gallstones (HR = 1.18, 95% CI: 0.95-1.47). The positive association of cholecystectomy with IBS risk did not change when stratifying the data based on age, sex, BMI, smoking, alcohol consumption, healthy diet, quality sleep, physical activity, type 2 diabetes, hypertension, hyperlipidaemia, mental illness, NSAID intake, or acid inhibitor intake. Sensitivity analyses, including propensity score matching analysis and lagging the exposure for two or four years, indicated that the effects were robust. Conclusion: Cholecystectomy was associated with a higher risk of IBS, especially IBS with diarrhoea. Additional prospective randomized controlled and experimental studies are warranted to further validate the association and to explore the relevant biological mechanisms.

Diagnostic Implications of Irritable Bowel Syndrome Is an Independent Risk Factor for Undergoing Surgical Interventions in Patients with Inflammatory Bowel Disease

BACKGROUND

Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) can present with overlapping symptoms, making diagnosis and management challenging. Patients with IBD in remission may continue to experience IBS symptoms. Patients with IBS were found to have a disproportionately higher prevalence of abdominal and pelvic surgeries than the general population.

AIMS

The aim of this study was to determine whether IBS is a risk factor for undergoing surgical interventions in patients with IBD and explore the diagnostic implications of these findings.

METHODS

A population-based cohort analysis was performed using TriNetX. Patients with Crohn's disease + IBS (CD + IBS) and ulcerative colitis + IBS (UC + IBS) were identified. The control groups consisted of patients with CD or UC alone without IBS. The main outcome was to compare the risks of undergoing surgical interventions between the cohorts. The secondary outcomes were to compare the risks of developing gastrointestinal symptoms and IBD-related complications between the cohorts.

RESULTS

Patients with IBD who subsequently developed IBS were more likely to experience gastrointestinal symptoms than those without IBS (p < 0.0001). Patients with concomitant IBD and IBS were more likely to develop IBD-related complications, including perforation of the intestine, gastrointestinal bleeding, colon cancer, and abdominal abscess (p < 0.05). Patients with concomitant IBD and IBS were more likely to undergo surgical interventions than patients without IBS, including colectomy, appendectomy, cholecystectomy, exploratory laparotomy, and hysterectomy (p < 0.05).

CONCLUSIONS

IBS appears to be an independent risk factor for patients with IBD to develop IBD-related complications and undergo surgical interventions. Patients with concomitant IBD and IBS could represent a unique subgroup of IBD patients with more severe symptoms, highlighting the importance of accurate diagnosis and management in this population.

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

BACKGROUND

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

AIM

To characterize the Russian population of IBS patients.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Factors related to irritable bowel syndrome and differences among subtypes: A cross-sectional study in the UK Biobank

Background: Irritable bowel syndrome (IBS) reduces patients' quality of life and causes great burdens due to its unclear pathogenesis and criteria for diagnosis. This study aimed to explore the differences in prevalence and the influencing factors for IBS and its subtypes. Methods: The UK Biobank surveyed 174,771 adult participants who completed the Digestive Health Questionnaire (DHQ) through emails and websites. DHQ included the Rome III criteria, IBS symptom severity score, and Patient Health Questionnaire 12 Somatic Symptom score. The UK Biobank also asked regarding previous IBS diagnosis, diagnosis for post-infectious IBS (PI-IBS), and environmental exposures and associated conditions (including anxiety or depression, based on treatment sought or offered). Pearson's Chi-squared test or Wilcoxon's rank-sum test was used for potential associations. Binary logic regression based on sex stratification was used to examine associations between selected factors and IBS and its subtypes. Results: This study included 31,918 participants who met the Rome III criteria for IBS. The pooled prevalence of IBS in the UK Biobank was 18.3%, with mixed IBS as the predominant subtype (59.0%), followed by diarrhea-predominant IBS (25.1%), constipation-predominant IBS (14.7%), and untyped IBS (1.1%). IBS was significantly associated with somatization (male: OR = 5.326, 95% CI = 4.863-5.832; female: OR = 4.738, 95% CI = 4.498-4.992) and coeliac disease (male: OR = 4.107, 95% CI = 3.132-5.385; female: OR = 3.783, 95% CI = 3.310-4.323). Differences in antibiotics and mental status were presented among subtypes and sex. Furthermore, 1,787 individuals were diagnosed with PI-IBS in the group of patients with IBS. The prevalence of PI-IBS in IBS was 16.6% in the UK Biobank, and it was characterized by diarrhea, fever, bloody diarrhea, and vomiting. Conclusion: Somatization and coeliac disease are primary risk factors for IBS. Distinguishing differential risk factors is critical for the precise diagnosis and treatment of IBS subtypes, particularly sex-specific differences in mental health status. General practitioners should focus on the treatment according to IBS subtypes.

Health care utilization of individuals with Rome IV irritable bowel syndrome in the general population

BACKGROUND

Irritable bowel syndrome (IBS) is highly prevalent worldwide but mechanisms for healthcare seeking behaviours in this patient group are poorly understood.

OBJECTIVE

To describe healthcare utilization and identify factors associated with seeking healthcare amongst IBS subjects in the general population.

METHODS

An internet survey was completed by 6,300 individuals equally distributed between United States, United Kingdom and Canada. The Rome IV diagnostic questionnaire was used to identify subjects with IBS. Data on demographics, medical history, gastrointestinal (GI) and non-GI symptoms, quality of life and health care consumption was collected.

RESULTS

A total of 5,931 subjects were included; 274 (4.6%) IBS subjects and 5657 (95.3%) non-IBS controls. IBS subjects reported more doctor consultations for both GI and other health problems as well as increased use of medication and rate of abdominal surgery (appendectomy excluded). Having healthcare insurance or access to free public healthcare (adjusted odds ratio (AOR) 4.49, 95% confidence interval (CI) 1.31-15.44), followed by high frequency of bloating (AOR 2.65, 95% CI 1.42-4.93) and increasing age (AOR 1.02, 95% CI 1.01-1.05) were found to be independently associated with being an IBS consulter while doctor-diagnosed IBS subjects were more likely to be female and to report abdominal pain as their most bothersome GI symptom than other consulters with IBS.

CONCLUSION

IBS subjects have higher healthcare utilization than non-IBS controls, medication use and abdominal surgery included. Furthermore, consulters with and without an IBS diagnosis differ in sex distribution and symptom profiles. Hence, awareness of the possibility of unnecessary medical and surgical treatment in IBS subjects and a sex-related diagnostic bias by doctors is warranted.

Irritable bowel syndrome in midlife women: a narrative review

Midlife women between the ages of 40 and 65 years have reported multiple challenges due to menopausal, developmental, and situational transitions from younger to older adulthood. During the midlife period, many women seek health care for gastrointestinal symptoms and irritable bowel syndrome (IBS). Multiple factors including stress, poor sleep, diet, and physical inactivity may contribute to IBS or gastrointestinal symptoms in midlife women. As such, a comprehensive assessment and treatment approach is needed for midlife women suffering gastrointestinal symptoms. This article reviews the main aspects of the menopausal transition, sex hormonal changes, abdominal and pelvic surgery, psychosocial distress, behavioral factors, and gut microbiome, as well as their relevance on IBS and gastrointestinal symptoms in midlife women. Also, management strategies for IBS in midlife women are discussed. To date, gastrointestinal symptoms during midlife years remain a critical area of women’s health. Additional research is needed to better understand the contributors to gastrointestinal symptoms in this group. Such efforts may provide a new window to refine or develop treatments of gastrointestinal symptoms for midlife women.

Aberrant Gut-To-Brain Signaling in Irritable Bowel Syndrome - The Role of Bile Acids

Functional bowel disorders such as irritable bowel syndrome (IBS) are common, multifactorial and have a major impact on the quality of life of individuals diagnosed with the condition. Heterogeneity in symptom manifestation, which includes changes in bowel habit and visceral pain sensitivity, are an indication of the complexity of the underlying pathophysiology. It is accepted that dysfunctional gut-brain communication, which incorporates efferent and afferent branches of the peripheral nervous system, circulating endocrine hormones and local paracrine and neurocrine factors, such as host and microbially-derived signaling molecules, underpins symptom manifestation. This review will focus on the potential role of hepatic bile acids in modulating gut-to-brain signaling in IBS patients. Bile acids are amphipathic molecules synthesized in the liver, which facilitate digestion and absorption of dietary lipids. They are also important bioactive signaling molecules however, binding to bile acid receptors which are expressed on many different cell types. Bile acids have potent anti-microbial actions and thereby shape intestinal bacterial profiles. In turn, bacteria with bile salt hydrolase activity initiate the critical first step in transforming primary bile acids into secondary bile acids. Individuals with IBS are reported to have altered microbial profiles and modified bile acid pools. We have assessed the evidence to support a role for bile acids in the pathophysiology underlying the manifestation of IBS symptoms.

Risk of irritable bowel syndrome in patients who underwent appendectomy: A nationwide population-based cohort study

BACKGROUND

Appendectomy is one of the most common surgical procedures; however, the possible long-term consequences have not been fully explored. The appendix has been associated with microflora of the gut and immune functions. However, literature examining the relationship between prior appendectomy and the risk of irritable bowel syndrome (IBS) is lacking. The aim of this study was to evaluate the risk of irritable bowel syndrome for patients who underwent appendectomy by using a nationwide longitudinal population-based cohort.

METHODS

Data from this study was collected from Taiwan's National Health Insurance Research Database (NHIRD), a population-based database. We identified 12,760 patients who underwent appendectomy between January 1, 2000 and December 31, 2012. A total of 9236 patients who had appendectomy (case group) were randomly matched with 9236 patients who had not undergone appendectomy (control group) in a ratio of 1:1 by means of propensity scores. The hazard ratio (HR) of IBS was calculated by multiple Cox regression. Furthermore, sensitivity test and stratified analysis were performed.

FINDINGS

The incidence rate of IBS was 51.30 per 10,000 person-years in patients having appendectomy, more than the 35.28 per 10,000 person-years in patients not having appendectomy. Patients who underwent appendectomy had 1.46-fold risk of IBS compared to patients not having appendectomy (HR, 1.46; 95% CI, 1.24-1.72). Stratified analysis revealed that the higher HR of 1.55 (95% CI, 1.18-2.04) in patients <40 years old, and particularly within the first 5 years follow-up period of undergoing appendectomy. In addition, patients diagnosed with fibromyalgia had a greater risk of suffering IBS after appendectomy (HR, 1.41; 95% CI, 1.04-1.92).

INTERPRETATION

Patients with appendectomy have a higher incidental risk of IBS than the control population. The risk is higher for patients under 40 years old and those who received appendectomy within 5 years. Physicians could take this into consideration for treatment plans of patients who have underwent this surgery. Further research on the pathogenesis of this association is required.

FUNDING

This work was supported by grants from the Ministry of Health and Welfare, Taiwan (MOHW108-TDU-B-212-133004), China Medical University Hospital, Academia Sinica Stroke Biosignature Project (BM10701010021), MOST Clinical Trial Consortium for Stroke (MOST 108-2321-B-039-003-), Tseng-Lien Lin Foundation, Taichung, Taiwan, and Katsuzo and Kiyo Aoshima Memorial Funds, Japan.

Presence of Irritable Bowel Syndrome Symptoms in Quiescent Inflammatory Bowel Disease Is Associated with High Rate of Anxiety and Depression

BACKGROUND

Inflammatory bowel disease (IBD; Crohn's disease, CD and Ulcerative colitis, UC) and irritable bowel syndrome (IBS) have overlapping symptoms. Few prevalence studies of IBS in quiescent IBD have used colonoscopy with histology to confirm inactive disease. The aims were (1) to determine the percentage of IBD patients in deep remission whose persistent IBS-like symptoms (IBD/IBS+) would cause them to be classified as having active disease, based on the calculation of Harvey Bradshaw Index (HBI) or UC disease activity index (UCDAI); (2) to identify demographic and disease characteristics that are associated with IBD/IBS+.

METHODS

This was a prospective study at a single tertiary care IBD center. 96/112 patients with colonoscopy and histology confirmed quiescent disease consented and completed Rome III criteria for IBS Survey, and the hospital anxiety and depression scale (HADS). Other demographic and disease specific data were collected.

RESULTS

36% (28/77) and 37% (7/19) of CD and UC patients, respectively, met diagnostic criteria for IBS. Significantly higher HBI/UCDAI scores (p = 0.005) and low short inflammatory bowel disease questionnaire (SIBDQ) scores (p ≤ 0.0001) were seen in IBD/IBS+ patients. 29% of patients in deep remission were mis-categorized by HBI/UCDAI as having active disease when they fulfilled Rome III criteria for IBS. Psychiatric diagnosis (OR 3.53 95% CI 1.2-10.2) and earlier onset of IBD (OR 1.056 95% CI 1.015-1.096) were associated with IBD/IBS+. Patients fulfilling IBS criteria had higher hospital anxiety and depression scale (HADS).

CONCLUSION

IBD/IBS+ affect scoring of IBD disease activity scales and become less useful in guiding treatment plans.

Healthcare use by 30,000 patients with irritable bowel syndrome (IBS) in France: a 5-year retrospective and one-year prospective national observational study

BACKGROUND

Irritable bowel syndrome (IBS) can be responsible for alteration in quality of life and economic burden. The aim of this study was to evaluate healthcare use related to this disorder in France.

METHODS

The French health data system was used to select adults covered by the general health scheme (87% of population) through their first IBS hospitalization in 2015. We studied the healthcare refunded during the previous 5 years, 1 year before and after hospitalization.

RESULTS

Among 43.7 million adults who used refunded healthcare in 2015, 29,509 patients were identified (0.07, 33% males, 67% females, mean age 52 years, 30% admitted through emergency room). During their hospitalization, 33% had upper endoscopy and 64% colonoscopy. Over the five previous years, 3% had at least one hospitalization with an IBS diagnosis, 58% had abdominal ultrasonography, 27% CT scan, 21% upper endoscopy, 13% colonoscopy and 83% a gastroenterologist visit. The year before, these rates were respectively: 0, 36, 16, 6, 4 and 78%. Some of those rates decreased the year after the hospitalization with respectively: 1, 27, 13, 5, 4 and 19%. The year before, 65% had at least one CRP dosage (13% three or more), 58% a TSH dosage (7%) and 8% a test for coeliac diseases (1%) and the year after: 44% (8%), 43% (5%) and 3% (0.3%). At least one refund of a drug used to treat IBS was found for 85% of patients 5 years before, 65% one year before and 51% one year after.

CONCLUSION

This first study using French health data system for healthcare consumption assessment in IBS points out the repetition of outpatient visits, examinations and in particular radiological examinations, without a strong decrease after hospitalization for IBS and gastroenterologist visit.

Key mechanisms of cognitive behavioural therapy in irritable bowel syndrome: The importance of gastrointestinal related cognitions, behaviours and general anxiety

BACKGROUND

Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterised by abdominal pain and altered bowel movements. Cognitive behavioural therapy (CBT) has been shown to be effective in reducing symptom severity in IBS and enhancing quality of life/functioning. The present study sought to identify how CBT achieves change in these outcomes.

METHOD

Secondary analysis was conducted on 149 patients with irritable bowel syndrome who had been randomised to cognitive behavioural therapy plus an antispasmodic medication or antispasmodic alone. Single and sequential mediation was modelled using structural equation modelling. Gastrointestinal (GI) related avoidance behaviour, safety behaviour, cognitions and general anxiety were included as mediators.

RESULTS

GI safety behaviours, cognitions and general anxiety mediated treatment effect on the outcomes of symptom severity and work and social adjustment. Avoidance behaviour was not a significant mediator for either outcome. Sequential mediation models indicated that unhelpful GI related cognitions reduced before anxiety did, and this sequential path (R➔GI related cognitions➔anxiety➔outcome) was significant for both symptom severity (b = -0.22, CI [-0.40 to -0.90], p = .005) and work and social adjustment (b = -0.26, CI [-0.44 to -0.11], p = .003) where 'R' is randomisation. Reduction in GI safety behaviours also preceded reduction in anxiety. This sequence (R ➔GI safety behaviours➔anxiety➔outcome) was significant for both symptom severity (b = -0.11, CI [-0.24 to -0.01], p = .049) and work and social adjustment (b = -0.12, CI [-0.23 to -0.03], p = .03).

CONCLUSION

Results suggest that it is important for psychological treatments to target IBS specific factors for change.

The Prevalence and Impact of Overlapping Rome IV-Diagnosed Functional Gastrointestinal Disorders on Somatization, Quality of Life, and Healthcare Utilization: A Cross-Sectional General Population Study in Three Countries

OBJECTIVES

The population prevalence of Rome IV-diagnosed functional gastrointestinal disorders (FGIDs) and their cumulative effect on health impairment is unknown.

METHODS

An internet-based cross-sectional health survey was completed by 5,931 of 6,300 general population adults from three English-speaking countries (2100 each from USA, Canada, and UK). Quota-based sampling was used to generate demographically balanced and population representative samples with regards to age, sex, and education level. The survey enquired for demographics, medication, surgical history, somatization, quality of life (QOL), doctor-diagnosed organic GI disease, and criteria for the Rome IV FGIDs. Comparisons were made between those with Rome IV-diagnosed FGIDs against non-GI (healthy) and organic GI disease controls.

RESULTS

The number of subjects having symptoms compatible with a FGID was 2,083 (35%) compared with 3,421 (57.7%) non-GI and 427 (7.2%) organic GI disease controls. The most frequently met diagnostic criteria for FGIDs was bowel disorders (n=1,665, 28.1%), followed by gastroduodenal (n=627, 10.6%), anorectal (n=440, 7.4%), esophageal (n=414, 7%), and gallbladder disorders (n=10, 0.2%). On average, the 2,083 individuals who met FGID criteria qualified for 1.5 FGID diagnoses, and 742 of them (36%) qualified for FGID diagnoses in more than one anatomic region. The presence of FGIDs in multiple regions was associated with increasing somatization, worse mental/physical QOL, more medical therapies, and a higher prevalence of abdominal surgeries; all P<0.001. Notably, individuals with FGIDs in multiple regions had greater somatization and worse QOL than organic GI disease controls.

CONCLUSIONS

Roughly a third of the general adult population fulfils diagnostic criteria for a Rome IV FGID. In a third of this subset multiple GI regions are involved and this overlap is associated with increased health impairment.

Spotlight on eluxadoline for the treatment of patients with irritable bowel syndrome with diarrhea

BACKGROUND

Irritable bowel syndrome with diarrhea (IBS-D) has limited options for treatment currently, including mainly anti-motility medications, antispasmodics, and antidepressants. This review discusses the properties of a new drug, eluxadoline, a gut-targeting mu- and kappa-opioid receptor agonist and a delta-opioid receptor antagonist, and its efficacy and safety in patients with IBS-D.

MATERIALS AND METHODS

A systematic review of the literature was undertaken to identify studies that had investigated eluxadoline as a treatment in IBS-D. A narrative review of other information is provided with respect to pharmacological and chemical properties. Where suitable, meta-analysis was performed with a random-effects model to produce a pooled estimate.

RESULTS

Eluxadoline showed efficacy improving stool consistency (standardized mean difference [SMD]: -0.29 at 12 weeks, p = 0.0004; -0.46 at 26 weeks, p = 0.0001), global symptoms (SMD: -0.15 at 12 weeks, p = 0.006; -0.14 at 26 weeks, p = 0.02), quality of life (SMD: 0.21 at 12 weeks, p < 0.0001; 0.16 at 26 weeks, p = 0.007), pain (SMD: -0.17 at 12 weeks, p = 0.001; -0.16 at 26 weeks, p = 0.01), and adequate relief (odds ratio [OR]: 1.99 at 12 weeks, p < 0.00001; 1.78 at 26 weeks, p < 0.0001). It also improved IBS severity and other abdominal symptoms such as bloating, discomfort, and risk of urgency and fecal incontinence. Its main side effects included constipation (OR: 3.49, p < 0.00001), vomiting (OR: 3.42, p = 0.0002), abdominal pain (OR: 1.78, p = 0.007), and nausea (OR: 1.42, p = 0.07). The overall quality of trials was satisfactory with the meta-analyses providing largely homogeneous outcomes.

CONCLUSION

Eluxadoline's place in clinical practice might prove useful since the pharmacological options of IBS-D are limited and eluxadoline showed a positive effect in treating the symptoms of IBS-D.

The global prevalence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome Foundation working team literature review

OBJECTIVES

The global prevalence of IBS is difficult to ascertain, particularly in light of the heterogeneity of published epidemiological studies. The aim was to conduct a literature review, by experts from around the world, of community-based studies on IBS prevalence.

DESIGN

Searches were conducted using predetermined search terms and eligibility criteria, including papers in all languages. Pooled prevalence rates were calculated by combining separate population survey prevalence estimates to generate an overall combined meta-prevalence estimate. The heterogeneity of studies was assessed.

RESULTS

1451 papers were returned and 83, including 288 103 participants in 41 countries, met inclusion criteria. The mean prevalence among individual countries ranged from 1.1% in France and Iran to 35.5% in Mexico. There was significant variance in pooled regional prevalence rates ranging from 17.5% (95% CI 16.9% to 18.2%) in Latin America, 9.6% (9.5% to 9.8%) in Asia, 7.1% (8.0% to 8.3%) in North America/Europe/Australia/New Zealand, to 5.8% (5.6% to 6.0%) in the Middle East and Africa. There was a significant degree of heterogeneity with the percentage of residual variation due to heterogeneity at 99.9%.

CONCLUSIONS

The main finding is the extent of methodological variance in the studies reviewed and the degree of heterogeneity among them. Based on this, we concluded that publication of a single pooled global prevalence rate, which is easily calculated, would not be appropriate or contributory. Furthermore, we believe that future studies should focus on regional and cross-cultural differences that are more likely to shed light on pathophysiology.

Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease

OBJECTIVE

There are considerable variations in cholecystectomy rates between countries, but it remains unsettled whether high cholecystectomy rates prevent future gallstone complications by reducing the gallstone prevalence. The aims of this study were to investigate the regional differences in cholecystectomy rates and their relation to the incidence of gallstone complications.

MATERIAL AND METHODS

Nation-wide registry-based study of the total number of cholecystectomies in Sweden between 1998 and 2013. Data were obtained from the Swedish Inpatient Registry covering the entire population and subdivided for by the 21 different counties. Indications for the procedure were prospectively collected during the years 2006-2013 in the National Registry for Gallstone Surgery and ERCP. The detailed demography of the total number of patients undergoing cholecystectomy and its relation to the respective indications were analysed by linear regression.

RESULTS

The annual rates of cholecystectomy in the Swedish counties ranged from 100 to 207 per 100,000 inhabitants, with a mean of 157 (95% CI 145-169). The majority of cholecystectomies were done in females based on the indication biliary colic, with a peak incidence in younger ages. Cholecystectomies performed due to gallstone complications, pancreatitis and cholecystitis, were mainly carried out in the older age groups. No significant relationship could be demonstrated between cholecystectomy rates in the different regions and the respective incidences of gallstone complications.

CONCLUSIONS

There are wide regional variations in cholecystectomy rates in Sweden. The present study does not give support that frequent use of cholecystectomy in uncomplicated gallstone disease prevents future gallstone complications.

Frequency of Irritable Bowel Syndrome Among Healthcare Personnel

This study aims to investigate the frequency of irritable bowel syndrome (IBS) among healthcare professionals. A total of 394 healthcare professionals and 207 individuals who were selected as a control group were included in the study. A questionnaire form containing Rome III diagnostic criteria was administered to health workers and the control group. The study groups were evaluated according to age, gender, occupation, profession, presence of chronic disease, drug usage, smoking, awareness of IBS, alarm symptoms, and the type of IBS they have. Irritable bowel syndrome was diagnosed in 44 healthcare workers and 10 control group participants. Of the 44 healthcare professionals with IBS, 6 had alternate, 13 had constipated-dominant, and 25 had diarrhea-dominant IBS. Of the 10 persons in the control group who were diagnosed as having IBS, 5 were diarrhea-dominant and 5 were constipated-dominant type. Irritable bowel syndrome was more frequent in healthcare professionals than in the control group. Healthcare workers are more prone to IBS due to their stressful working environment.

Complications After Laparoscopic Cholecystectomy: A Video Evaluation Study of Whether the Critical View of Safety was Reached

BACKGROUND

Achieving the critical view of safety (CVS) before transection of the cystic artery and duct is important to reduce biliary duct injury in laparoscopic cholecystectomy. To gain more insight into complications after laparoscopic cholecystectomy, we investigated whether the criteria for CVS were met during surgery by analyzing videos of operations performed at our institution.

METHODS

All consecutive patients who underwent a completed laparoscopic cholecystectomy between 2009 and 2011 were included. The videos of the operations of patients with complications were independently reviewed and rated by two investigators with a third consulted in the event of a disagreement. The reviewers answered consecutive questions about whether the CVS criteria were met. Patients who underwent an elective laparoscopic cholecystectomy and had no complications were used as a control group for comparison.

RESULTS

Of the 1108 consecutive patients who had undergone a laparoscopic cholecystectomy during the study period, 8.8 % developed complications (average age 51 years) and 1.7 % had bile duct injuries [six patients (0.6 %) had a major bile duct injury, type B, D, or E injury]. In the 65 surgical videos available for analysis, CVS was reached in 80 % of cases according to the operative notes. However, the reviewers found that CVS was reached in only 10.8 % of the cases. Only in 18.7 % of the cases the operative notes and video agreed about CVS being reached. CVS was not reached in any of the patients who had biliary injuries. In the control group, CVS was reached significantly more often in 72 %.

CONCLUSIONS

In our institutional series of laparoscopic cholecystectomies with postoperative complications, CVS was reached in only a few cases. Evaluating surgical videos of laparoscopic cholecystectomy cases are important and we recommend its use to improve surgical technique and decrease the number of biliary injuries.

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey

AIM

Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria.

METHOD

A cross-sectional survey was conducted in a primary care setting in Sydney, Australia. A self-administered questionnaire was used to collect demographic information and diagnose FBDs (irritable bowel syndrome, constipation, functional bloating and functional diarrhoea) based on Rome III criteria. The severity of FI was determined using the Vaizey incontinence score. Associations with medical/surgical history and healthcare utilization were assessed.

RESULTS

Of 596 subjects approached, 396 (66.4%) agreed to participate. Overall, 33% had FBD and/or FI. Irritable bowel syndrome was present in 11.1% and these participants were more likely to report anxiety/depression (P < 0.01) and to have had a previous colonoscopy (P < 0.001) or cholecystectomy (P = 0.02). Functional constipation was present in 8.1%, and functional bloating and functional diarrhoea were diagnosed in 6.1%, and 1.5%, respectively. FI was present in 12.1% with the majority (52%) reporting moderate/severe incontinence (Vaizey score > 8). Participants with FI were more likely to have irritable bowel syndrome, urinary incontinence and previous anal surgery (P < 0.01).

CONCLUSION

FBDs and FI are prevalent conditions amongst primary healthcare seekers and the needs of those affected appear to be complex given their coexisting symptoms and conditions. Currently, the majority do not reach colorectal services, although increased awareness by primary care providers could lead to sufferers being referred for specialist management.

Review article: the economic impact of the irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic functional disorder of the gastrointestinal system affecting a large number of people worldwide. Whilst it has no attributable mortality, it has substantial impact on patients' quality of life (QoL) and is associated with considerable healthcare resource use.

AIM

To review the economic impact of IBS, firstly on the individual, secondly on healthcare systems internationally and thirdly to society.

METHODS

Appropriate databases were searched for relevant papers using the terms: Irritable Bowel Syndrome; IBS; irritable colon; functional bowel/colonic disease; economics; health care/service costs; health expenditure/resources; health care/service utilisation; productivity.

RESULTS

Irritable bowel syndrome impacts most substantially on patients' work and social life. Reduction in QoL is such that on average patients would sacrifice between 10 and 15 years of their remaining life expectancy for an immediate cure. Between 15% and 43% of patients pay for remedies. No studies quantify loss of earnings related to IBS. Direct care costs are substantial; 48% of patients incur some costs in any year with annual international estimates per patient of: USA $742-$7547, UK £90-£316, France €567-€862, Canada $259, Germany €791, Norway NOK 2098 (€262) and Iran $92. Minimising extensive diagnostic investigations could generate savings and has been shown as not detrimental to patients. Cost to industry internationally through absenteeism and presenteeism related to IBS is estimated between £400 and £900 per patient annually.

CONCLUSIONS

Irritable bowel syndrome is associated with substantial costs to patients, healthcare systems and society. Considerable benefit could be obtained from effective interventions.

Potential for developing purinergic drugs for gastrointestinal diseases

Treatments for inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), functional dyspepsia, or motility disorders are not adequate, and purinergic drugs offer exciting new possibilities. Gastrointestinal symptoms that could be targeted for therapy include visceral pain, inflammatory pain, dysmotility, constipation, and diarrhea. The focus of this review is on the potential for developing purinergic drugs for clinical trials to treat gastrointestinal symptoms. Purinergic receptors are divided into adenosine P1 (A(1), A(2A), A(2B), A(3)), ionotropic ATP-gated P2X ion channel (P2X(1-7)), or metabotropic P2Y(1,2,4,6,11-14) receptors. There is good experimental evidence for targeting A(2A), A(2B), A(3), P2X(7), and P2X(3) receptors or increasing endogenous adenosine levels to treat IBD, inflammatory pain, IBS/visceral pain, inflammatory diarrhea, and motility disorders. Purine genes are also potential biomarkers of disease. Advances in medicinal chemistry have an accelerated pace toward clinical trials: Methotrexate and sulfasalazine, used to treat IBD, act by stimulating CD73-dependent adenosine production. ATP protects against NSAID-induced enteropathy and has pain-relieving properties in humans. A P2X(7)R antagonist AZD9056 is in clinical trials for Crohn's disease. A(3) adenosine receptor drugs target inflammatory diseases (e.g., CF101, CF102). Dipyridamole, a nucleoside uptake inhibitor, is in trials for endotoxemia. Drugs for pain in clinical trials include P2X(3)/P2X(2/3) (AF-219) and P2X(7) (GSK1482160) antagonists and A(1) (GW493838) or A(2A) (BVT.115959) agonists. Iberogast is a phytopharmacon targeting purine mechanisms with efficacy in IBS and functional dyspepsia. Purinergic drugs have excellent safety/efficacy profile for prospective clinical trials in IBD, IBS, functional dyspepsia, and inflammatory diarrhea. Genetic polymorphisms and caffeine consumption may affect susceptibility to treatment. Further studies in animals can clarify mechanisms and test new generation drugs. Finally, there is still a huge gap in our knowledge of human pathophysiology of purinergic signaling.

The epidemiology of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a functional condition of the bowel that is diagnosed using clinical criteria. This paper discusses the nature of the diagnostic process for IBS and how this impacts epidemiological measurements. Depending on the diagnostic criteria employed, IBS affects around 11% of the population globally. Around 30% of people who experience the symptoms of IBS will consult physicians for their IBS symptoms. These people do not have significantly different abdominal symptoms to those who do not consult, but they do have greater levels of anxiety and lower quality of life. Internationally, there is a female predominance in the prevalence of IBS. There is 25% less IBS diagnosed in those over 50 years and there is no association with socioeconomic status. IBS aggregates within families and the genetic and sociological factors potentially underlying this are reviewed. Patients diagnosed with IBS are highly likely to have other functional disease and have more surgery than the general population. There is no evidence that IBS is associated with an increased mortality risk. The epidemiological evidence surrounding these aspects of the natural history is discussed.

The Zelnorm epidemiologic study (ZEST): a cohort study evaluating incidence of abdominal and pelvic surgery related to tegaserod treatment

Background

Pre-marketing clinical studies of tegaserod suggested an increased risk of abdominal surgery, particularly cholecystectomy. We sought to quantify the association between tegaserod use and the occurrence of abdominal or pelvic surgery, including cholecystectomy.

Methods

This cohort study was conducted within an insured population. Tegaserod initiators and similar persons who did not initiate tegaserod were followed for up to six months for the occurrence of abdominal or pelvic surgery. Surgical procedures were identified from health insurance claims validated by review of medical records. The incidence of confirmed outcomes was compared using both as-matched and as-treated analyses.

Results

Among 2,762 tegaserod initiators, there were 94 abdominal or pelvic surgeries (36 gallbladder): among 2,762 comparators there were 134 abdominal or pelvic surgeries (37 gallbladder) (hazard ratio HR] = 0.70, 95% confidence interval [C.I.] = 0.54-0.91 overall, HR = 0.98, 95% C.I. = 0.62-1.55 for gallbladder). Current tegaserod exposure compared to nonexposure was associated with a rate ratio [RR] of 0.68 (95% C.I. = 0.48-0.95) overall, while the RR was 0.99 (95% C.I. = 0.56-1.77) for gallbladder surgery.

Conclusions

In this study, tegaserod use was not found to increase the risk of abdominal or pelvic surgery nor the specific subset of gallbladder surgery.

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.

Preoperative symptoms of irritable bowel syndrome predict poor outcome after laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis. This study examines the effect LC has on quality of life (QOL) and gastrointestinal (GI) symptoms and determines whether patients with symptoms of irritable bowel syndrome (IBS) gain the same benefit as those without.

METHODS

A total of 158 patients who underwent LC for symptomatic gallstones were recruited to this prospective observational study. IBS Manning scores were calculated and QOL was measured using the Gastrointestinal Quality of Life Index (GIQLI) preoperatively, at 6 weeks, 3 months, and 2 years postoperatively. Linear regression analysis was used to identify preoperative symptoms that predict outcome.

RESULTS

One hundred twelve patients had sufficient data sets for inclusion. Patient's GIQLI scores were calculated for the four time points in the study. The mean preoperative score was 88.8 ± 1.3 (61.7% of 144, the highest score possible) and improved 6 weeks after surgery to 105.5 ± 1.3 (p < 0.001). This improvement was maintained at 3 months, but at 2 years analysis showed regression toward the baseline of 7.6 ± 2.3 (p = 0.003) points. There was a negative correlation of -5.2 ± 1.29 (p < 0.001) points between each Manning symptom and QOL scores. The largest effect was seen in patients describing loose bowel movement with the onset of pain. Patients with this symptom had a -17.3 ± 4.6 (p < 0.001) lower global QOL score.

CONCLUSIONS

Patients with symptoms of IBS indicated by the Manning criteria show less improvement in quality of life after laparoscopic cholecystectomy for gallstones.

An epidemiological study of major surgical procedures in an urban population of East delhi

Surgery has become an integral part of global health care, with an estimated 234 million operations performed yearly. The World Bank in 2002 reported that an estimated 164 million disability-adjusted life years, representing 11% of the entire disease burden, were attributable to surgically treatable conditions. To study the prevalence of various surgical operations undergone by individuals in their life time, in an urbanized community of Delhi. Cross-sectional study, conducted from October 2008 to April 2009 in Vivek Vihar-an urban affluent colony in Delhi. A total of 3,043 individuals residing in 622 households were interviewed as part of the study. Total number of households with some member having ever undergone surgery was 306 (49.2%). 12.3% of our study population (375 out of 3,043) had undergone one or the other form of major surgical operation in their life time. Caesarean section was found to be the most common surgical procedure performed. 61.7% surgeries were elective in nature and 81.9% were performed in a private hospital. The lifetime prevalence of surgical procedures was 1.77% among children, 12.6% among adult males and 15.8% among adult females (p < 0.001). It was observed that the expense of surgeries conducted in private hospitals was more compared to government. Our findings suggest that surgery occurs at a substantial rate, at least among the urban affluent, with most of the patients choosing to refer to a private hospital for their surgery.

Diagnosis and management of IBS

IBS is a common gastrointestinal condition characterized by chronic or recurrent abdominal pain associated with altered bowel habits. IBS is considered a functional bowel disorder (that is, not defined by structural or biochemical abnormalities) and is diagnosed using symptom-based criteria. Limited and judicious use of diagnostic testing is recommended, particularly in patients with typical symptoms of IBS without alarm signs and symptoms. Management of IBS is based on a multifactorial approach and includes establishment of an effective patient-provider relationship, education, reassurance, dietary alterations, pharmacotherapy, behavioral and psychological treatment. Patient-centered care is recommended, in which management is focused on the patient's most bothersome and impactful symptoms, their preferences and previous experiences with treatment, and addressing factors associated with the onset and exacerbation of symptoms. Pharmacotherapy is typically targeted against the predominant symptom. This Review discusses the current evidence-based recommendations for the diagnosis and management of IBS. An improved understanding of the recommended diagnostic and therapeutic approaches for IBS will lead to greater patient satisfaction, as well as reduced health-care costs.

The current prevalence of irritable bowel syndrome in Asia

Irritable bowel syndrome (IBS) has been one of the commonly presented gastrointestinal disorders. It is of interest how commonly it presents in the society. Western studies indicated that most population-based IBS prevalences range 10%-15%. It is believed that IBS is prevalent in both East and West countries without a significant prevalence difference. Most recently, the Asia IBS prevalence has a higher trend in the affluent cities compared to South Asia. Since many Asia IBS prevalence studies have been published in the recent decade, we could compare the IBS prevalence data divided by various criteria in looking whether they were also comparable to this of West community. Summarized together, most Asia community IBS prevalences based on various criteria are usually within the range 1%-10% and are apparently lower than these of selected populations. Within the same population, the prevalence orders are first higher based on Manning criteria, then followed by Rome I criteria and finally reported in Rome II criteria. Overall, the median value of Asia IBS prevalences defined by various criteria ranges 6.5%-10.1%. With regard to gender difference, female predominance is usually found but not uniquely existed. For the IBS subtypes, the proportions of diarrhea predominant-IBS distribute widely from 0.8% to 74.0%, while constipation predominant-IBS proportion ranges 12%-77%. In conclusions, current Asia IBS prevalence is at least equal to the Western countries. Female predominant prevalence in Asia is common but not uniquely existed, while the proportions of IBS subtypes are too variable to find a rule.

Asian consensus on irritable bowel syndrome

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epidemiology of gallstones

Gallstones are common with prevalences as high as 60% to 70% in American Indians and 10% to 15% in white adults of developed countries. Ethnic differences abound with a reduced frequency in black Americans and those from East Asia, while being rare in sub-Saharan Africa. Certain risk factors for gallstones are immutable: female gender, increasing age, and ethnicity/family (genetic traits). Others are modifiable: obesity, the metabolic syndrome, rapid weight loss, certain diseases (cirrhosis and Crohn disease), gallbladder stasis (from spinal cord injury or drugs, such as somatostatin), and lifestyle.

Demography of aging and the epidemiology of gastrointestinal disorders in the elderly

Population aging is a global phenomenon. It is estimated that there were 600 million people in the world aged 60 and over in 2000 and that there will be 1.2 billion by 2025. People aged 65 and over comprise 16% of the population of Europe. About half of the world's elderly population live in the developing world. Many of the gastrointestinal disorders seen in specialist practise show age-specific incidence and prevalence rates that increase substantially with increasing age. In this review, hospitalization rates for gastroenterological disorders in England are presented by age to demonstrate gradients with age. Some of the disorders, such as colorectal cancer, appendicitis, diverticular disease and inflammatory bowel disease, became common in developed countries in association with economic development and changes in lifestyle. As the developing world becomes more urbanised and westernised, disorders that are now rare in the developing world will probably become much more common.

Efficient diagnosis of suspected functional bowel disorders

Functional bowel disorders (FBDs) are common disorders that are characterized by various combinations of abdominal pain and/or discomfort, bloating and changes in bowel habits. At present, diagnosing FBDs often incurs considerable health-care costs, partly because unnecessary investigations are performed. Patients are currently diagnosed as having an FBD on the basis of a combination of typical symptoms, normal physical examination and the absence of alarm features indicative of an organic gastrointestinal disease. Basic laboratory investigations, such as a complete blood count, measurement of the erythrocyte sedimentation rate and serological tests for celiac disease, are useful in the initial evaluation. No further investigations are needed for most patients who have typical symptoms and no alarm symptoms. The most important alarm symptoms include signs of gastrointestinal bleeding, symptom onset above 50 years of age, a family history of colorectal cancer, documented weight loss and nocturnal symptoms. The presence of alarm symptoms obviously does not exclude an FBD, but further investigation is needed before confirmation of the diagnosis. For patients with predominant and severe diarrhea, a more thorough diagnostic work-up should normally be considered, including colonoscopy with colonic biopsies and a test for bile-acid malabsorption.

Gallstones, cholecystectomy and irritable bowel syndrome (IBS) MICOL population-based study

BACKGROUND

Subjects with irritable bowel syndrome may undergo an excess of cholecystectomy. It is not known, however, whether the cholecystectomy rate parallels an increased risk of gallstones.

AIM

Aim was to assess the prevalence and the incidence of gallstones and cholecystectomy in subjects with irritable bowel syndrome symptoms.

SUBJECTS AND METHODS

In this population-based study, 29,139 subjects (63.2% of 46,139 randomly selected subjects, age 30-69 years) underwent a physical examination, an interview on gastrointestinal symptoms and an upper abdominal ultrasonography. An identical survey was carried out 7.8+/-1.0 (M+/-S.D.) years later on 8460 gallstone-free subjects at the first survey. Prevalence and incidence of gallstones and cholecystectomy were assessed in subjects with (1) irritable bowel syndrome; (2) abdominal pain and normal bowel; (3) altered bowel and no abdominal pain and (4) asymptomatic controls; univariate and multivariate regression logistic models were used for statistical analysis.

RESULTS

Prevalence odds of gallstones and cholecystectomy were significantly higher in irritable bowel syndrome and abdominal pain and normal bowel than in controls. Irritable bowel syndrome and abdominal pain and normal bowel subjects were more aware of gallstones than controls (p<0.001), and the prevalence of gallstones in irritable bowel syndrome subjects unaware of their gallbladder status was not significantly different from the controls. The incidence of gallstone disease in irritable bowel syndrome, abdominal pain and normal bowel, and altered bowel and no abdominal pain subjects did not differ from the controls. The incidence of cholecystectomy was higher in irritable bowel syndrome and abdominal pain and normal bowel groups than in controls and altered bowel and no abdominal pain group.

CONCLUSIONS

Irritable bowel syndrome subjects have an increased risk of cholecystectomy that is not due to an increased risk of gallstones, but rather to abdominal pain, awareness of having gallstones, and inappropriate surgical indications.

Biliary events and an increased risk of new onset irritable bowel syndrome: a population-based cohort study

BACKGROUND

Prospective data are lacking to determine if irritable bowel syndrome (IBS) is a risk factor for cholecystectomy, or if biliary disease and cholecystectomy predisposes to the development of IBS.

AIM

To test the hypothesis that IBS and biliary tract disease are associated.

METHODS

Validated symptom surveys sent to cohorts of Olmsted County, MN, (1988-1994) with follow-up in 2003. Medical histories were reviewed to determine any 'biliary events' (defined by gallstones or cholecystectomy). Analyses examined were: (i) time to a biliary event post-initial survey and separately and (ii) risk of IBS (Rome II) in those with vs. without a prior biliary event.

RESULTS

A total of 1908 eligible subjects were mailed a follow-up survey. For analysis (i) of the 726 without IBS at initial survey, 44 (6.1%) had biliary events during follow up, in contrast to 5 of 93 (5.4%) with IBS at initial survey (HR 0.8, 95% CI 0.3-2.1). For analysis (ii) of the 59 subjects with a biliary event at initial survey, 10 (17%) reported new IBS on the follow-up survey, while in 682 without a biliary event up to 1.5 years prior to the second survey, 58 (8.5%) reported IBS on follow-up (OR = 2.2, 95% CI 1.1-4.6, P = 0.03).

CONCLUSION

There is an increased risk of new IBS in community subjects who have been diagnosed as having a biliary event.

Development of abdominal pain and IBS following gynecological surgery: a prospective, controlled study

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) develops after bacterial enteritis that causes injury to the bowel mucosa. It's unclear whether abdominal pain or IBS results from gynecological surgery that could injure abdominopelvic nerves. The aim of this prospective, controlled study was to assess the incidence of pain or IBS in women undergoing elective gynecological surgery compared to non-surgical controls and to identify factors associated with their development.

METHODS

One hundred thirty-two women without GI symptoms undergoing elective gynecological surgery for non-painful conditions were compared with 123 non-surgery controls without GI symptoms. Socio-demographic, psychosocial, and surgery-related variables were potential predictor variables of pain at 3 and/or 12 months.

RESULTS

Three surgical patients (2.7%), but no controls, developed IBS at 12 months. Significantly more surgical patients had abdominal pain at 3 or 12 months (15.3% vs 3.6%, P=.003). No socio-demographic or surgery-related variables predicted pain development, but it was predicted by psychosocial factors including anticipation of difficult recovery from surgery (P=.01), perception of severity/constancy of illness (P=.04), and reduced sense of coherence (P=.01).

CONCLUSIONS

Among women undergoing gynecological for non-pain indications the development of IBS was not significantly greater than controls. However, abdominal pain did develop in 17% of women in the surgical group, suggesting that surgery facilitated its development. Notably, only psychosocial variables predicted pain development, implying that pain development associated with central registration and amplification of the afferent signal (via cognitive and emotional input) must be considered along with the peripheral injury itself. These findings contribute to understanding the pathophysiology of functional GI pain.

Irritable bowel syndrome: quality of life and nursing interventions

Irritable bowel syndrome (IBS) is a functional bowel disorder. It is one of the most common gastrointestinal diseases diagnosed in medical practice and can account for up to 50% of referrals to gastroenterology outpatient clinics. IBS remains a poorly understood and mysterious medical condition. Individuals can suffer from abdominal pain and abnormal bowel function for unexplained reasons and the impact of these symptoms can have a detrimental affect on health-related quality of life. In this article the incidence, causes, diagnosis and management of IBS are addressed. Specific attention is given to the nursing role in the management of this chronic condition.

Prevalence of irritable bowel syndrome in Korea: population-based survey using the Rome II criteria

BACKGROUND

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder in the West. But information on the prevalence of IBS in Asia is still lacking, especially in Korea. Therefore, the aims of the present study were to estimate the prevalence of IBS in the general population of Korea and also to investigate characteristics of IBS and health-care-seeking behavior of IBS patients.

METHODS

Telephone interview survey was conducted by Gallup, Korea using a validated questionnaire based on the Rome II criteria. The response rate of the telephone interview survey was 25.2% (n = 1066, 535 male and 531 female responders). A random sample of gender and age (between 18 and 60 years), based on a per capita ratio was obtained.

RESULTS

Among 1066 subjects, the prevalence of IBS was 6.6% (70 subjects; 7.1%, male; 6.0%, female). The difference in IBS prevalence by gender was not significant. The prevalence was higher among those in their 20s (P = 0.036). Among 70 subjects with IBS, 10/20 IBS subjects sought health care due to abdominal pain. Among the risk factors of IBS, marital status had a significant difference; the following risk factors are arranged in descending order: age (odds ratio [OR]: 1.38, 95% confidence interval [CI]: 0.85-2.25), alcohol intake (OR: 1.38, 95%CI: 0.81-2.35), gender (OR: 1.19, 95%CI: 0.73-1.94), demographics (OR: 1.09, 95%CI: 0.53-2.25), income (OR: 0.88, 95%CI: 0.54-1.45), education level (OR: 0.81, 95%CI: 0.46-1.40), smoking (OR: 0.64, 95%CI: 0.37-1.12), and marital status (OR: 0.59, 95%CI: 0.35-0.99).

CONCLUSIONS

The prevalence of IBS in the Korean population is 6.6%, and the male:female ratio is similar. Also, IBS is more frequent in younger subjects. Irritable bowel syndrome subjects visited a physician mostly due to abdominal pain.

Physical and psychological co-morbidity in irritable bowel syndrome: a matched cohort study using the General Practice Research Database

BACKGROUND

Irritable bowel syndrome is a common problem known to have a complex relationship with psychological disorders and other physical symptoms. Little information, however, is available concerning physical and psychological comorbidity in irritable bowel syndrome patients studied over an extended period.

AIM

To evaluate physical and psychological morbidity 2 years before and during 6 years after the time of diagnosis in incident cases of irritable bowel syndrome and control subjects.

METHODS

A matched cohort study was implemented in 123 general practices using the General Practice Research Database. Irritable bowel syndrome cases (n = 1827) and controls (n = 3654) were compared for 2 years before and 6 years after diagnosis.

RESULTS

The age-standardized incidence of irritable bowel syndrome in patients over 15 years of age was 1.9 per 1,000 in men and 5.8 per 1,000 in women. From 2 years before the date of diagnosis, more irritable bowel syndrome cases (13%) than controls (5%) consulted with depression or were prescribed antidepressant drugs. Consultation and prescription rates for anxiety were also higher before diagnosis, and both anxiety and depression remained prevalent up to 6 years after diagnosis. Asthma, symptoms of urinary tract infection, gall-bladder surgery, hysterectomy and diverticular disease were recorded more frequently in irritable bowel syndrome patients, who were also more likely than controls to be referred to hospital.

CONCLUSIONS

People who are diagnosed with irritable bowel syndrome experience more anxiety and depression and a range of physical problems, compared with controls; they are more likely to be referred to hospital.

Effects of tegaserod on bile composition and hepatic secretion in Richardson ground squirrels on an enriched cholesterol diet

Background

Tegaserod is effective in treating IBS patients with constipation, and does not alter gallbladder motility in healthy individuals or in patients with IBS. However, it is not known if tegaserod affects the biliary tract in gallstone disease, so to this end the effects of tegaserod on bile composition and hepatic secretion of Richardson ground squirrels maintained on an enriched cholesterol diet were examined.

Results

Animals were fed either a control (0.03%) or enriched (1%) cholesterol diet for 28 days, and treated s.c. with tegaserod (0.1 mg/kg BID) or vehicle. Bile flow, bile acid, phospholipids and cholesterol secretion were measured with standard methods. Tegaserod treatment or enriched cholesterol diet, alone or combination, did not alter body or liver weights. The enriched cholesterol diet increased cholesterol saturation index (CSI), cholesterol concentrations in gallbladder and hepatic duct bile by ~50% and decreased bile acids in gallbladder bile by 17%. Tegaserod treatment reversed these cholesterol-induced changes. None of the treatments, drug or diet, altered fasting gallbladder volume, bile flow and bile salts or phospholipid secretion in normal diet and cholesterol-fed animals. However, tegaserod treatment prevented the decreases in bile acid pool size and cycling frequency caused by the enriched cholesterol diet, consequent to re-establishing normal bile acid to concentrations in the gall bladder. Tegaserod had no effect on these parameters with normal diet animals.

Conclusion

Tegaserod treatment results in increased enterohepatic cycling and lowers cholesterol saturation in the bile of cholesterol-fed animals. These effects would decrease conditions favorable to cholesterol gallstone formation.

Increased cholecystectomy rate in the laparoscopic era: a study of the potential causative factors

BACKGROUND

It has been suggested that an increased cholecystectomy rate in the laparoscopic era may be due to a reduced threshold for surgery or diagnostic confusion with irritable bowel syndrome (IBS). This study aims to determine the validity of these suggestions.

METHODS

Questionnaires were sent to patients who had undergone cholecystectomy between 1988-1990 (open) and 1998-2000 (laparoscopic). Patients were asked about abdominal pain, fatty food intolerance, jaundice, and indigestion pre- and postoperatively. Questionnaires included Rome II criteria for the diagnosis of IBS and SF-36 quality-of-life data. Histological severity of gallbladder disease was assessed using a standard scoring system.

RESULTS

A total of 124 of 196 patients in the open group and 264 of 400 patients in the laparoscopic group replied. There was no difference between the groups in gender, age at surgery, IBS incidence, or quality-of-life scores. The laparoscopic group reported a lower incidence of preoperative fat intolerance (45.8 vs 58.1%, p < 0.05) and a higher incidence of persistent postoperative abdominal pain (27.3 vs 17.7%, p < 0.05). Mean histopathology severity scores were higher in the open group (4.42 vs 3.95, p < 0.01).

CONCLUSIONS

Increased cholecystectomy rate in the laparoscopic era cannot be attributed to diagnostic confusion with IBS. However, a reduction in the threshold for surgery may have contributed to the increased rate of cholecystectomy.

Physician knowledge of Rome symptom criteria for irritable bowel syndrome is poor among non-gastroenterologists

Rome I criteria are highly specific for irritable bowel syndrome (IBS) when red flag signs and symptoms are absent. Physician knowledge of Rome criteria may reduce diagnostic testing. We assessed: (i) physician knowledge of Rome criteria among internists, gastroenterologists and surgeons; (ii) laboratory and endoscopical testing suggested by physicians for sample IBS patients. Physicians of all training levels in internal medicine, gastroenterology, and surgery completed an anonymous questionnaire at a University Medical Center. Subjects were asked to identify Rome criteria among distracters. Sample IBS patients were presented, and physicians were asked to suggest a diagnostic workup based on the choices provided on the questionnaire. Rome knowledge was highest among gastroenterologists and lowest among surgeons. Physicians suggested endoscopical procedures in 67% of IBS patients with diarrhoea and in 46% with constipation. There was no difference among specialties in amount of laboratory or endoscopical testing suggested. Knowledge and use of the Rome criteria or their positive predictive value (PPV) for IBS did not correlate with reduced diagnostic testing. Education regarding the Rome criteria should be extended to surgical specialists who are likely to evaluate and operate on IBS patients. Endoscopical evaluation of IBS patients may be excessive.

Gallstone disease: Epidemiology of gallbladder stone disease

Gallstone disease is common: >700,000 cholecystectomies and costs of approximately 6.5 billion dollars annually in the U.S. The burden of disease is epidemic in American Indians (60-70%); a corresponding decrease occurs in Hispanics of mixed Indian origin. Ten to fifteen per cent of white adults in developed countries harbour gallstones. Frequency is further reduced in Black Americans, East Asia and sub-Saharan Africa. In developed countries, cholesterol gallstones predominate; 15% are black pigment. East Asians develop brown pigment stones in bile ducts, associated with biliary infection or parasites, or in intrahepatic ducts (hepatolithiasis). Certain risk factors for gallstones are immutable: female gender, increasing age and ethnicity/family (genetic traits). Others are modifiable: obesity, the metabolic syndrome, rapid weight loss, certain diseases (cirrhosis, Crohn's disease) and gallbladder stasis (from spinal cord injury or drugs like somatostatin). The only established dietary risk is a high caloric intake. Protective factors include diets containing fibre, vegetable protein, nuts, calcium, vitamin C, coffee and alcohol, plus physical activity.

The hysterectomized woman

OBJECTIVE

To delineate the health profile of hysterectomized women and to assess whether women who have undergone hysterectomy have a different health profile even before surgery.

MATERIAL AND METHODS

The WHILA project covers all women (n = 10,766) aged 50-60, living in the Lund area and are based on questionnaires and personal interviews tied to laboratory examinations.

RESULTS

6917 women (64.2%) had complete questionnaires and laboratory tests, 800 were hysterectomized (11.6%). Logistic regression analysis revealed that hysterectomized women had more "dizziness" 1.40 (1.19-1.66), "nervous problems" 1.29 (1.07-1.56), "backache" 1.37 (1.16-1.62), "joint problems" 1.29 (1.09-1.52), "eye problem" 1.20 (1.02-1.42) and "headache" 1.17 (1.00-1.37). For both somatic (5.22 versus 4.49 mean value, p < 0.001) and psychological (4.19 versus 3.86 mean value, p = 0.002) symptoms, the number was higher in hysterectomized women. Logistic regression analysis revealed that among hysterectomized women university education was less common odds ratios 0.73 (95% confidence interval 0.58-0.91) as well as working full time 0.76 (0.62-0.93). A higher body weight at the age 25, 1.01 (1.001-1.02) as well as a weight gain of more than 5 kg during the last 5 years 1.27 (1.07-1.50), elevation of serum triglycerides 1.29 (1.16-1.44), high-density (HDL) 1.44 (1.14-1.80) and low-density lipoprotein (LDL) cholesterol 1.11 (1.02-1.21) as well as the bone density 1.08 (1.00-1.17). Hysterectomized women had a lower age at giving first birth (p < 0.001), shorter interval between menstrual periods (p < or = 0.001) and less frequent amenorrhic episodes (p < 0.05). The hysterectomized women used IUD to a lesser extent (p < 0.05) but used hormone therapy (HT) (p < 0.001) and utilized health care services (p < 0.001) more often.

CONCLUSIONS

Long after surgery, several somatic and psychological symptoms were still more common in hysterectomized women. A low frequency of amenorrhic episodes and lower age at giving first birth, concomitant with a higher body weight already at age 25 may imply that women who end up hysterectomized have a specific health profile long before as well as long after surgery.

The incidence of abdominal and pelvic surgery among patients with irritable bowel syndrome

Rates of abdominopelvic surgery, with a particular focus on gallbladder procedures, were measured in patients with irritable bowel syndrome (IBS) (n = 108,936) and compared with those in a general population sample (n = 223,082). The patient sample was selected from persons who were members of a managed care organization during the years 1995-2000. Medical records from a randomly selected subset of IBS patients were reviewed to confirm the diagnosis. Crude and standardized rates and adjusted rate ratios for surgery were calculated. The incidence of abdominopelvic surgery, excluding gallbladder procedures, was 87% higher in patients with IBS than that for the general population. The incidence of gallbladder surgery was threefold higher in IBS patients than the general population. Patients with IBS have an increased risk for abdominopelvic and gallbladder surgery and, thus, an associated risk for experiencing morbidity and mortality associated with these surgical procedures.