Fatigue is not a specific symptom in patients with primary biliary cirrhosis

Quality of life in patients with primary biliary cholangitis: A cross-geographical comparison

Background & aims

Several symptoms impair the quality of life (QoL) of patients with primary biliary cholangitis (PBC). They are reported to vary significantly in different countries. Aim of our study was to explore whether there is a geographical clustering that accounts for symptoms in PBC.

Methods

Data was analysed from four cohorts of PBC patients from the UK, Spain, Japan and Italy using the PBC-27 scale.

Results

Overall, 569 patients from four cohorts were identified, including 515 females (90.5%) with a mean age of 61 years. The analysis provided evidence for strict factorial invariance of the scale, a robust indicator of its validity for cross-cultural research. The mean of the fatigue domain of British patients was significantly greater than that of the Japanese (p ​< ​0.05), Italian (p ​< ​0.05), and Spanish patients (p ​< ​0.001). The mean of the cognitive domain after 54 years of age, was significantly greater in the British patients than in the Japanese (p ​< ​0.05) and Spanish patients (p ​< ​0.01). However, after 69 years of age, there were not significant differences between countries. The mean of the emotion domain after 54 years of age, was greater in the British that in the Spanish (p ​< ​0.01) and Italian patients (p ​< ​0.01).

Conclusions

Differences in the four countries concerning fatigue, cognitive and emotional dysfunction were found. The association of latitude and symptoms might provide new insights into the role of sun exposure, genetics and/or cultural component into disease phenotype in PBC.

Fatigue: a distressing symptom for patients with irritable bowel syndrome

BACKGROUND

Fatigue is a frequent symptom in patients with irritable bowel syndrome (IBS), and is associated with poor quality of life. However, few studies have evaluated its impact on daily life or the perceived distress it can cause. Using a multi-methods approach, this study describes the impact and manifestations of fatigue in patients with IBS and investigates the relationship between fatigue severity and illness-related and health-promoting factors.

METHODS

A total of 160 patients with IBS completed self-reported questionnaires assessing fatigue, gastrointestinal symptoms, psychological distress, and sense of coherence. Fatigue was assessed with the Fatigue Impact Scale, which also includes structured and open-ended questions which were analyzed with a deductive qualitative analysis. Patients were classified as having severe, moderate, or mild fatigue based on frequency, distress and impact on daily life.

KEY RESULTS

The open-ended questions revealed a multidimensional impact on life. Fatigue mainly interfered with the ability to perform physical activities, work, and domestic work, and the ability to interact socially. Decreased stamina was evident, along with strategies to limit the bodily consequences of tiredness. Severe fatigue was accompanied by more severe IBS symptoms, anxiety and depression and lower sense of coherence.

CONCLUSIONS & INFERENCES

Fatigue is a distressing symptom which occurs in a sizeable proportion of patients with IBS. It affects life in a multidimensional way, with poor bodily stamina being the most prominent feature. Fatigue, along with sense of coherence, depression and anxiety, needs to be assessed, confirmed and targeted for interventions.

Fatigue Measures in Noncancer Gastrointestinal Disorders: A Critical Review

Fatigue is commonly reported by patients with noncancer gastrointestinal (GI) disorders such as organic and functional GI disorders. This critical review was conducted to evaluate fatigue measures that have been used in these patients. A systematic search using six databases (PubMed, PsycINFO, EMBASE, CINAHL, ProQuest, and Cochrane Review) was conducted from January 2000 to June 2014, and evaluations and reviews of fatigue instruments were performed by two independent reviewers (author and medical librarian). Fourteen instruments from 25 studies were identified. Ten instruments were solely focused on fatigue and four were multisymptom instruments. The average quality score of the 14 instruments was 10.7 (range, 6-14) out of 14. There were five instruments with high overall scores based on usability/feasibility, clinical/research utility, and psychometric properties (3 fatigue-specific and 2 multisymptom). There are valid and reliable measures that are currently available to assess fatigue in noncancer GI patients. Utilization of these common measures may assist clinicians (GI healthcare providers) and researchers to better understand the impact of fatigue in these patients. The instruments with low-quality scores cannot be chosen for routine use without further validation.

Primary Biliary Cholangitis: Medical and Specialty Pharmacy Management Update

BACKGROUND

Chronic liver disease and cirrhosis are a leading cause of morbidity and mortality in the United States. Primary biliary cholangitis (PBC), previously known as primary biliary cirrhosis and which has been designated an orphan condition, is a chronic autoimmune disease resulting in the destruction of the small bile ducts in the liver. Without effective treatment, disease progression frequently leads to liver failure and death. Until May 2016, the only FDA-approved treatment for PBC was ursodiol (UDCA), an oral hydrophilic bile acid, which can slow progression of liver damage due to PBC. However, 1 out of 3 patients taking UDCA has an inadequate biochemical response, leading to increased risk of disease progression, liver transplantation, and mortality. Given this unmet clinical need, new therapies are in development for the treatment of PBC. To provide pharmacists with an overview of the latest research on the pathophysiology of PBC and potential new treatment options and to highlight medical and specialty pharmacy approaches to managing access to drugs to treat orphan diseases such as PBC, a 2-hour satellite symposium was presented in conjunction with the 2015 Academy of Managed Care Pharmacy (AMCP) Nexus meeting. Although obeticholic acid was approved by the FDA for the treatment of PBC in May 2016, this development occurred after the symposium presentation. The symposium was supported by an independent educational grant from Intercept Pharmaceuticals and was managed by Analysis Group. Robert Navarro, PharmD, moderated the CPE-accredited symposium titled "Medical and Specialty Pharmacy Management Update on Primary Biliary Cirrhosis." Expert panelists included Christopher L. Bowlus, MD; James T. Kenney, RPh, MBA; and Gary Rice, RPh, MS, MBA, CSP.

OBJECTIVE

To summarize the educational satellite symposium presentations and discussions.

SUMMARY

Autoimmune liver diseases, including PBC, are responsible for 15% of all liver transplants performed and an equal percentage of deaths related to liver disease. UDCA is the only FDA-approved therapy for treatment of PBC and is considered the standard of care. Nevertheless, many patients do not respond to UDCA, creating the need for new therapeutic options to improve clinical outcomes for PBC patients with inadequate response to treatment. While several agents are being studied in combination with UDCA, monotherapy with the novel agent obeticholic acid, a farnesoid X receptor agonist, has also shown promising results. Health plans are anticipated to assign any newly introduced therapy for the treatment of PBC to specialty pharmacy given its orphan disease status. This assignment enables the health plan to receive disease education, which is particularly important when new drugs are indicated for orphan diseases, and assistance with designing appropriate prior authorization criteria. The clinical value of any new therapeutic options that will inform formulary decisions and prior authorization criteria will be assessed based on evidence of efficacy, safety, and tolerability, among other factors, such as the potential to reduce or delay medical resource utilization (e.g., liver transplant). Key considerations for prior authorization of a new therapy will be determining which PBC patients are appropriate candidates for the new therapy and developing criteria for that determination. These are likely to include clinical diagnostic criteria and degree of response to prior treatment with UDCA. Initially, any new therapy would likely be positioned as noncovered until appropriate prior authorization criteria are established.

CONCLUSIONS

PBC is a chronic liver disease with significant morbidity and mortality, as well as a significant burden on the health care system if the disease progresses to the point at which a liver transplant is needed. Although UDCA, the current standard of care, has improved outcomes for many patients, others have an inadequate response to this treatment. This symposium discussed these issues and also addressed the overall treatment paradigm for orphan drug therapies, key implications for patient management, and the role of specialty pharmacy management and any associated needs both in general and specifically for new therapeutic options for PBC.

Fatigue in primary sclerosing cholangitis is associated with sympathetic over-activity and increased cardiac output

BACKGROUND & AIMS

Patients with primary sclerosing cholangitis (PSC) frequently highlight the impact of fatigue on their life quality. The study aims were to evaluate fatigue and its associations in PSC and investigate whether overt autonomic dysfunction contributes to the expression of fatigue.

METHODS

All PSC patients under active follow-up at a regional liver centre were sent disease- and symptom-assessment tools. Three control groups were utilized; unselected community controls, patients with inflammatory bowel disease (IBD) without PSC, and cholestatic controls with primary biliary cirrhosis (PBC). A representative subgroup of PSC patients and normal controls underwent formal autonomic assessment.

RESULTS

Symptom-assessment tools were returned by 40 non-transplanted patients. PSC patients had significantly worse fatigue than population controls (P = 0.005). Fatigue was significant compared to population controls whether or not patients had accompanying IBD, although was more marked in those with both PSC and IBD. In patients with PSC and IBD, fatigue severity and autonomic symptoms were significantly increased in those with prior significant surgical intervention. Clinically significant autonomic dysfunction was seen in 22.5% of PSC patients, and of those, 78% had significant fatigue. Neurally mediated hypotension was found in 60% of PSC patients compared to 8% in the control group. The PSC group had increased sympathetic activity and reduced parasympathetic activity.

CONCLUSION

Fatigue is a significant problem in a minority of PSC patients and appears to be associated with autonomic dysfunction. Fatigued PSC patients should be screened for autonomic dysfunction and targeting such dysfunction represents a potential approach to treatment which warrants further exploration.

Factors that reduce health-related quality of life in patients with primary sclerosing cholangitis

BACKGROUND & AIMS

Health-related quality of life (HRQL) is frequently reduced in patients with chronic liver disease, but there are limited data from patients with primary sclerosing cholangitis (PSC). We aimed to evaluate HRQL and its potential determinants in 2 population-based cohorts of patients with PSC and to study the prevalence of fatigue among these patients.

METHODS

Validated questionnaires were used to measure quality of life (the Short-Form 36 [SF-36] and the chronic liver disease questionnaire), fatigue (the fatigue impact scale), and psychological distress (the hospital anxiety and depression scale) in 182 PSC patients residing in Sweden or England. Results were compared with those from the general population (controls). Regression analysis was performed to identify factors independently associated with HRQL.

RESULTS

Patients with PSC had significantly lower scores from several areas of the SF-36, compared with controls (P < .05). Age (β = -0.62 to -0.21, P < .05) and systemic symptoms (β = 3.84-15.94, P < .05) such as pruritus were associated with lower scores from specific areas of the SF-36; serum level of alkaline phosphatase (β =-1.12 to -0.75, P < .05), and large-duct PSC (β = -15.35 to -10.05, P < .05) were associated with lower scores on mental health questionnaires. The proportion of patients with significant fatigue, depression, or anxiety did not differ between patients and controls (P > .05).

CONCLUSIONS

Quality of life is impaired in unselected patients with PSC. Fatigue does not seem to be a specific symptom of PSC. Older age, large-duct disease, and systemic symptoms seem to reduce HRQL in patients with PSC.

Primary biliary cirrhosis and Sjögren's syndrome: autoimmune epithelitis

Primary biliary cirrhosis (PBC) has been often coined a model autoimmune disease based on the homogeneity amongst patients, the frequency and similarity of antimitochondrial antibodies, including the highly directed immune response to pyruvate dehydrogenase (PDC-E2). A significant number of patients with PBC suffer from sicca and amongst these, there are patients who also have classic Sjögren's syndrome. Indeed, both PBC and Sjögren's syndrome are characterized by inflammation of target epithelial elements. Both diseases can be considered on the basis of a number of other related clinical aspects, including proposed unique apoptotic features of the target tissue, the role of secretory IgA, and the frequency with which both diseases overlap with each other. Indeed, PBC may be considered a Sjögren's syndrome of the liver, whereas Sjögren's syndrome can be equally discussed as PBC of the salivary glands. Dissection of the genetic predispositions for both diseases and especially the molecular basis of effector mechanisms, will become critical elements in developing new therapies.

Predicting fatigue in patients using home parenteral nutrition: a longitudinal study

Background

Home parenteral nutrition (HPN) is a life-saving therapy for patients with diseases that preclude adequate oral or enteral food intake. HPN has a large impact on daily life. Many patients suffer from fatigue and depression, and they experience limits in social activities. This all contributes to a lower quality of life.

Purpose

Fatigue is the most frequently mentioned problem in Dutch HPN patients. Therefore, we studied the prevalence, course and predictors of fatigue in these patients.

Methods

Patients completed questionnaires at baseline and follow-up (12 months later). Measurements included fatigue, depression, functional impairment, social support, self-efficacy, coping, anxiety and acceptance. Laboratory measures, including total bilirubin, creatinine, albumin and haemoglobin levels, were obtained from the medical records. Descriptive statistics, correlations and linear regression analysis were performed.

Results

The response rate was 71% (n = 75). Sixty-five per cent of the patients were severely fatigued (n = 49). Eighty-nine per cent experienced persistent fatigue. Baseline fatigue predicted 57% of the variance of fatigue at follow-up, and avoidance was responsible for 3% of the variance. No significant correlations between fatigue and laboratory measures were found. A cross-sectional analysis showed that 46% of the variance of fatigue was explained by functional impairment, self-efficacy and depression.

Conclusion

Severe fatigue is a persistent problem for HPN patients. Baseline fatigue was the strongest predictor of fatigue at follow-up. Functional impairment, self-efficacy and depression are strongly related to fatigue. Early recognition and treatment of fatigue are important.

Fatigue and physical activity levels in patients with liver cirrhosis

AIMS AND OBJECTIVES

This study aimed to explore the correlation between fatigue and physical activity in patients with liver cirrhosis.

BACKGROUND

Many patients with liver cirrhosis perceive lower physical functioning and more fatigue than non-cirrhotic individuals. To date, however, few studies have examined the relationship between fatigue and physical activity in this patient population.

DESIGN

This study used a correlation design. Participants were patients with liver cirrhosis recruited from the gastroenterology clinic of a teaching medical centre in Taiwan.

METHODS

Data were collected using a structured questionnaire, consisting of a fatigue scale and a seven-day Physical Activity Recall scale. spss version 13.0 software was used to analyse the data through statistical methods, including one-way analysis of variance, independent t-test and Pearson's correlations.

RESULTS

Patients participating in this study suffered from moderate-to-severe fatigue, and their engagement in physical activity of moderate or higher intensity was decreased. On average, fatigue had a moderate level of influence on physical activity. A significant negative correlation was found between the fatigue level and average seven-day physical activity level.

CONCLUSIONS

Patients with liver cirrhosis can experience severe fatigue, which may reduce their level of physical activity.

RELEVANCE TO CLINICAL PRACTICE

Early evaluation of the fatigue level and physical activity constraints in patients with liver cirrhosis should be conducted in the clinic or community. Individualised instructions for patient's physical activity should be provided.

Chronic fatigue is more prevalent in patients with inflammatory bowel disease than in healthy controls

BACKGROUND

Fatigue is a common symptom in chronic disease. Few studies, however, have focused on fatigue related to inflammatory bowel disease (IBD). The aim was to determine the prevalence of fatigue in IBD and to identify demographic and clinical factors that influence fatigue.

METHODS

Patients in remission and with mild and moderate IBD completed the Fatigue Questionnaire (FQ). Higher FQ scores indicate greater levels of fatigue. In addition, demographic and clinical variables were obtained. Corresponding FQ data from healthy controls (HC) are based on 2287 Norwegian citizens.

RESULTS

In total, 140 patients were included, mean age 43.9 years (SD 16.4), male/female = 61/79, ulcerative colitis (UC) / Crohn's disease (CD) = 92/48. Total fatigue (TF) was 14.4, 14.7, and 12.2 for UC, CD, and HC, respectively. Chronic fatigue (CF), defined as substantial fatigue with duration more than 6 months, was reported in 29% (14/48) of CD and 22% (20/92) of UC compared to 11% (260/2287) of HC (P < 0.001 for both diagnoses). Linear regression analysis confirmed hemoglobin values, present gastrointestinal symptoms, and altered sleep to be the most important predictors of CF.

CONCLUSIONS

Chronic fatigue is more common in patients with UC and CD compared with healthy controls. IBD symptoms, hemoglobin values, and altered sleep patterns are significant predictors of CF.

A short version of a HRQoL questionnaire for Italian and Japanese patients with Primary Biliary Cirrhosis

BACKGROUND

The available self-report questionnaire for the quality of life in patients with primary biliary cirrhosis (PBC-40) is currently validated only in the British population but it lacks an evaluation of its dimensionality.

AIMS

To validate the Italian and Japanese versions of PBC-40 and to assess the dimensionality of the original structure of PBC-40 by a confirmatory factor analysis. PBC-40 was translated to Italian and Japanese using the forward-backward method and then reviewed in focus groups in the framework of a large multicentric study.

METHODS

A sample of 290 patients with PBC (125 Italian and 165 Japanese) was administered two questionnaires previously validated for PBC-specific (PBC-40) and general quality of life (SF-36).

RESULTS

The confirmatory model failed to fit adequately the original hypothesized structure. A principal component analysis led to a seven-factor structure, with exclusion of 13 items characterized by lower load; PBC-27 questionnaire was the final instrument. The validity of the PBC-27 was supported by its strong correlation with the SF-36 scores.

CONCLUSION

We here propose an alternative structure of the quality of life questionnaire for PBC, namely PBC-27, which appears to be effective in detecting the impact of PBC on quality of life in Italian and Japanese patients.

The specificity of fatigue in primary biliary cirrhosis: evaluation of a large clinic practice

Quality of life is an important concern for patients with chronic liver disease. We sought to describe the frequency, severity, and associations of fatigue, in patients with primary biliary cirrhosis (PBC). We performed association testing between PBC-40 multidomain disease-specific quality of life responses and clinical findings. Three hundred twenty-seven patients from a single clinic with PBC (94% female, 92% AMA-positive) were evaluated. The average age was 57 years and average disease duration 7.2 years. Verbally reported fatigue was noted in 48% but present in the overwhelming majority on PBC-40 completion, with 44% having moderate or severe symptoms. Of those not complaining of fatigue clinically, 25% documented moderate or severe fatigue by questionnaire. Age had an inverse relationship with fatigue (P < 0.01), whereas body mass index (BMI) was positively associated (P < 0.01), as was the presence of pruritus (P < 0.001), sicca symptoms (P < 0.001), depression (P < 0.001), fibromyalgia (P < 0.004), and scleroderma (P < 0.05). For those with varices (P < 0.05) or cirrhosis clinically (P < 0.05), higher fatigue scores were noted, although those who initially presented with noncirrhotic disease had higher scores at the time of testing (P < 0.005). Fatigue was associated with greater use of prescription medication (P < 0.01), in particular for antipruritics (cholestyramine: P < 0.001; rifampin: P < 0.001), proton pump inhibitors (P < 0.002), beta-blockers (P < 0.02), and antidepressants (P < 0.001), whereas those taking calcium and vitamin D appeared less fatigued (P < 0.05). In a multivariate model, calcium and vitamin D use, BMI, stage of disease at diagnosis, as well as symptomatic fatigue or pruritus, were significant. Biochemical response to UDCA was not associated with lower fatigue scores.

CONCLUSION

Attempts at defining the biological basis of fatigue in patients with PBC, and improving its treatment, must account for its multifactoral causes.

Systematic review: fatigue in inflammatory bowel disease

BACKGROUND

Fatigue is common, disabling yet underappreciated, in patients with chronic diseases, including inflammatory bowel disease (IBD).

AIMS

To examine the literature and determine the prevalence and patterns of fatigue in IBD patients, to identify opportunities and directions for future research in this area.

METHODS

A systematic review using PubMed and Ovid Medline databases was conducted using search terms 'fatigue', 'Crohn', 'colitis' and 'inflammatory bowel disease'. A review of fatigue in other similar chronic diseases was also performed.

RESULTS

Ten studies were found to include data on fatigue in IBD patients; all were conducted between 1999 and 2009. However, only one study (in children) measured fatigue in IBD patients as a primary outcome. In patients in remission, the prevalence of fatigue in IBD patients ranges from 41 to 48%. Data are sparse and conflicting on whether fatigue severity is proportional to disease severity/activity.

CONCLUSIONS

Despite the clinical reality of fatigue, there are few published studies examining fatigue in IBD as a primary outcome. More data are needed on the prevalence, correlation between disease activity and fatigue severity, and putative pathogenic pathways involved in fatigue pathogenesis, before ultimately elucidating targeted therapies for fatigue in IBD patients.

Primary biliary cirrhosis: a 2010 update

Primary biliary cirrhosis (PBC) is a chronic inflammatory autoimmune disease that mainly targets the cholangiocytes of the interlobular bile ducts in the liver. The condition primarily affects middle-aged women. Without treatment, PBC generally progresses to cirrhosis and eventually liver failure over a period of 10-20 years. PBC is a rare disease with prevalence of less than 1/2000. PBC is thought to result from a combination of multiple genetic factors and superimposed environmental triggers. The contribution of the genetic predisposition is evidenced by the familial clustering. Several risk factors, including exposure to infectious agents and chemical xenobiotics, have been suggested. Ursodeoxycholic acid (UDCA) is currently the only FDA-approved medical treatment for PBC. When administered at doses of 13-15 mg/kg/day, a majority of patients with PBC have a normal life expectancy without additional therapeutic measures. One out of three patients does not adequately respond to UDCA therapy and may need additional medical therapy and/or liver transplantation. This review summarises current knowledge on the epidemiology, ethiopathogenesis, clinical, and therapeutic aspects of PBC.

Health-related quality of life in patients with different stages of liver disease induced by hepatitis C

OBJECTIVE

Patients with hepatitis C have been shown to have impaired health-related quality of life (HRQoL). The aim of this study was to determine HRQoL in patients in different stages of hepatitis C virus (HCV) and to compare HRQoL in HCV cirrhosis with non-HCV-induced cirrhosis.

MATERIAL AND METHODS

Out of 489 consecutive patients who fulfilled the inclusion criteria, 472 (96%) agreed to participate in the study: 158 patients with mild/moderate fibrosis with chronic hepatitis C (CHC group), 76 patients with HCV compensated cirrhosis (CC), 53 patients with HCV decompensated (DC) cirrhosis, 52 non-cirrhotic patients with sustained viral response (SVR), and a control group consisting of 32 patients with non-HCV CC and 101 with non-HCV DC who completed the Short Form-36 (SF-36) and EQ-5D questionnaire.

RESULTS

The CHC group had significantly lower SF-36 scores than healthy controls, with the exception of scores for the dimensions physical function and bodily pain. HCV patients with DC had lower scores in all SF-36 dimensions in comparison with those of the CHC group, as well as in physical and mental component summaries (p<0.001). In comparison with the CHC group, the HCV CC group had lower scores on the SF-36 general health dimension (p<0.05) and lower SF-36 physical component summary (PCS) scores (p<0.05). No major differences were seen in patients with HCV- and non-HCV-induced cirrhosis.

CONCLUSIONS

Impairment in HRQoL in patients with HCV was associated with the severity of liver disease, patients with decompensated cirrhosis exhibiting the highest impairment in HRQoL. The etiology of liver disease does not seem to be important in determining HRQoL in cirrhosis.

Fatigue measurements in patients with primary biliary cirrhosis and the risk of mortality during follow-up

BACKGROUND

Fatigue was recently suggested to predict an increased risk of mortality in a primary biliary cirrhosis (PBC) cohort during follow-up.

AIMS

To analyse the impact of fatigue on prognosis in PBC.

METHODS

Patients with PBC who had earlier completed the fatigue impact scale (FIS) were identified. Prognosis in terms of death and liver transplantation (Tx) was determined.

RESULTS

FIS values at baseline were analysed from 208 patients (192 females; median age 59 years (interquartile range 51-67), median follow-up of 5 years. Overall, 181 patients were alive at follow-up, 22 (12%) died and five (2.4%) underwent transplantation. FIS at baseline was 28 (12-47) and FIS at follow-up was 25 (8-64) (P<0.001; r=0.69). Among survivors, FIS at baseline was 27 (12-43), 36 (12-72) in those who died (P=0.059) and 99 (41-102) in those who underwent transplantation (P=0.0008). FIS at baseline was 44 (12-88) in patients with death and/or Tx vs. 27 (12-43) in survivors (P=0.003). Age [hazard ratio (HR) 1.1 (confidence interval (CI) 1.0-1.2)] and aspartate aminotransferase [HR 2.0 (CI 1.3-3.0)] were independently associated with decreased survival on multivariate analysis. FIS scores over 40 [HR 9.6 (CI 2.3-39.7)] and bilirubin [HR 4.8 (CI 2.8-8.2)] were independently associated with a poor outcome in patients who underwent Tx or had a liver-related death.

CONCLUSIONS

Fatigue seems to change little over time in PBC. Fatigue levels were higher at baseline in those who died or underwent Tx. High fatigue levels seem to be a predictor of risk of liver-related mortality and need for transplantation over time but not a predictor of non-liver-related mortality.

Quality of life in short-bowel syndrome: impact of fatigue and gastrointestinal symptoms

OBJECTIVE

Patients with short-bowel syndrome (SBS) have impaired health-related quality of life (QoL). However, comparisons of QoL data with the data on other chronic gastrointestinal diseases are not available. The aim of this study was to assess QoL in SBS patients compared with that in the general population and with patients with inflammatory bowel disease (IBD). The potential relation between fatigue and gastrointestinal symptoms and impaired QoL in these patients was also investigated.

MATERIAL AND METHODS

Four validated questionnaires were used to measure aspects of QoL (SF-36), psychological distress (hospital anxiety and depression scale, HAD), fatigue (fatigue impact scale, FIS), and gastrointestinal symptoms (gastrointestinal symptom rating scale, GSRS) in 26/28 patients (93%) attending a SBS clinic (median age 62 years, 15 F/11 M) at a tertiary referral center. Persons from the general population (n=286) as well as patients with IBD (n=41) of similar age and gender distribution as the SBS group acted as controls.

RESULTS

SBS patients had significantly lower SF-36 physical and mental component summaries than those in the general population as well as significantly lower SF-36 physical (p<0.05) but not mental (p>0.05) component summaries compared with those of IBD patients. Fatigue and gastrointestinal symptoms were more severe in SBS patients than in IBD patients (p>0.05). The SF-36 physical component summary was independently related to the physical FIS dimension (beta=-0.4, p=0.004), the GSRS eating dysfunction dimension (beta=-0.31, p=0.025), and opiate use (beta=-0.28, p=0.031), regardless of diagnosis (SBS or IBD).

CONCLUSIONS

Patients with SBS show poor QoL compared with that in the general population and also impairment of mainly physical health compared with that in patients with IBD. Fatigue and gastrointestinal symptoms are more severe in patients with SBS, which has an impact on QoL.

Predictors of subjective fatigue in chronic gastrointestinal disease

BACKGROUND

Fatigue is a common, but poorly understood symptom in patients with chronic gastrointestinal (GI) diseases.

AIM

To evaluate factors of importance for fatigue in patients with chronic GI diseases, and to compare it with fatigue in the general population.

METHODS

In all, 399 patients attending a GI out-patient clinic completed questionnaires assessing fatigue, sleep disturbances, psychological general well-being and GI symptom severity. The patients were divided into two diagnostic groups: functional GI disorders (n = 112) and organic GI diseases (n = 287). The severity of fatigue was also evaluated in an age- and gender-matched group of 399 individuals from the general population.

RESULTS

Both patient groups had more severe fatigue than controls and patients with functional GI disorders were more fatigued than patients with an organic GI disease. Fatigue was associated with psychological general well-being, GI symptom severity, gender, employment status and sleep disturbances. In a linear regression analysis, psychological general well-being (vitality, general health, self-control), sleep disturbances and employment status were independently associated with the severity of fatigue (adjusted R(2) = 55%).

CONCLUSIONS

Fatigue is a troublesome symptom in a subgroup of patients with chronic GI diseases. These patients have a high symptom burden as regards both GI and psychological symptoms, as well as sleep disturbances.

The unfinished business of primary biliary cirrhosis

In nearly every multifactorial human disease, there are three periods that characterize our understanding and definition. First, there is a period in which there is rapid accumulation of descriptive data. Second, there is a longer and slower period as information is obtained that redefines and expands basic and clinical knowledge that lacks the final and important area of understanding aetiology and therapeutic intervention. Third, which is much less common for most diseases, is the vigorous definition of pathobiology and treatment. These phases are well illustrated by our current understanding of primary biliary cirrhosis (PBC). The term PBC was first used nearly 60 years ago and for the first 40 or so years, the primary research efforts were directed at clinical definitions and pathology. Subsequently, with the advent of molecular biology, there began a rigorous dissection of the immune response and, in particular, a better understanding of anti-mitochondrial antibodies. These efforts have greatly helped in our understanding of not only the effector mechanisms of disease, but also the uniqueness of the primary target tissue, biliary epithelium. However, this research has still not led to successful translation for specific therapy.

Clinical features and management of primary biliary cirrhosis

Primary biliary cirrhosis (PBC), which is characterized by progressive destruction of intrahepatic bile ducts, is not a rare disease since both prevalence and incidence are increasing during the last years mainly due to the improvement of case finding strategies. The prognosis of the disease has improved due to both the recognition of earlier and indolent cases, and to the wide use of ursodeoxycholic acid (UDCA). New indicators of prognosis are available that will be useful especially for the growing number of patients with less severe disease. Most patients are asymptomatic at presentation. Pruritus may represent the most distressing symptom and, when UDCA is ineffective, cholestyramine represents the mainstay of treatment. Complications of long-standing cholestasis may be clinically relevant only in very advanced stages. Available data on the effects of UDCA on clinically relevant end points clearly indicate that the drug is able to slow but not to halt the progression of the disease while, in advanced stages, the only therapeutic option remains liver transplantation.

Fatigue in primary biliary cirrhosis

The autoimmune liver disease, primary biliary cirrhosis (PBC), is associated with debilitating fatigue in a significant proportion of patients. The pathogenesis of fatigue in PBC is unclear, but preliminary studies suggest it has central mechanisms and may have peripheral manifestations. Studies are beginning to elucidate the biological associates of fatigue in PBC, particularly sleep disturbance and autonomic dysfunction. Comprehensive studies investigating the pathogenesis of fatigue in PBC are urgently needed as are large-scale prospective outcome studies.

Fatigue in primary biliary cirrhosis: a possible role of comorbidities

BACKGROUND AND AIMS

Fatigue is considered to be a specific manifestation of primary biliary cirrhosis (PBC). Recent reports have, however, questioned these findings. Considering the high rate of comorbidities in PBC patients and the fact that fatigue is a multifactorial symptom, we hypothesized that it might also be due to nonhepatic causes. Our aim was to evaluate fatigue in PBC patients and its relationship with comorbidities and depression.

METHODS

We enroled 49 Italian PBC patients (44 women; mean age: 58.9 years, range: 21-73 years) and 30 matched healthy controls, who completed the Fatigue Impact Scale (FIS), Modified FIS (MFIS), Fatigue Severity Score (FSS) and Rand Medical Outcomes Study Depression Screener. Comorbidities and several clinical and biochemical data were investigated. Linear regression, analysis of variance and post-hoc analysis were applied.

RESULTS

Fatigue was higher in patients than in controls (FIS: 33 vs. 24; MFIS: 24 vs. 14; FSS: 3.3 vs. 1.9). Physical domain was significantly different in all the three questionnaires (FIS: P=0.05; MFIS: P=0.002; FSS: P=0.0002). Comorbidities (38% of patients) were independently associated with higher fatigue scores (FIS: 45; MFIS: 32; FSS: 3.3). Depressed patients (30%) were more fatigued, even if not always significantly (FIS: 43; MFIS: 29; FSS: 3.5), than controls and patients with no depression. Patients without comorbidities or depression (51%) did not have higher fatigue than controls (FIS: 20; MFIS: 17; FSS: 2.4).

CONCLUSIONS

Fatigue in patients with PBC was higher, but not always significantly, than in healthy controls. Comorbidities and depression might have played a role in its pathogenesis. Our data arouse doubts about the specificity of fatigue in PBC and the pathogenetic role of liver impairment.

Depression in patients with primary biliary cirrhosis and primary sclerosing cholangitis

BACKGROUND/AIMS

Former studies reported a high prevalence of depression in patients with primary biliary cirrhosis (PBC) and primary sclerosing cholangitis (PSC). These studies hypothesized that the presence of depression could explain the fatigue experienced by these patients.

METHODS

Our aim was to study the prevalence of depression in a Dutch population with PBC and PSC. In addition, to investigating the effects of using an additional diagnostic structured psychiatric interview, after screening with the Beck Depression Inventory (BDI), a self-report severity scale instrument used in former studies. Patients with PBC and PSC (n=92) completed the BDI. Patients with scores of 10 or higher (n=39) were interviewed using a structured psychiatric interview. Patients with scores lower than 10 were at random (30/53, 57%) also interviewed using a structured psychiatric interview.

RESULTS

Of the 92 patients that were included 42% had depressive symptoms according to the BDI. However, of these patients only 3.7% had a depressive syndrome according to the DSM-IV criteria as assessed with the structured psychiatric interview.

CONCLUSIONS

The prevalence of a depressive disorder in patients with PBC and PSC is not higher than in the general population. Fatigue in patients with PBC and PSC cannot be explained by depression.

Fatigue in irritable bowel syndrome: characterization and putative role of leptin

OBJECTIVES

Fatigue has received little attention in the irritable bowel syndrome. Emerging evidence exists that leptin may be involved in the pathogenesis of fatigue in several conditions. We aimed to evaluate the occurrence of fatigue and its characteristics in irritable bowel syndrome and to analyze the relationship between fatigue and leptin.

METHODS

We enrolled 51 consecutive irritable bowel syndrome patients and 22 healthy controls without fatigue. None of them were depressed. The Fatigue Impact Scale was used to evaluate fatigue.

RESULTS

In all, 62.7% of irritable bowel syndrome patients verbally expressed fatigue and rated more than 4 on the visual analog scale. The total score of fatigue was significantly higher in irritable bowel syndrome than in controls. In irritable bowel syndrome patients, but not in controls, a significant association was found between the total score of fatigue and leptin and this association was more pronounced in 32 irritable bowel syndrome patients who verbally expressed fatigue (r=0.60; P=0.0003). In irritable bowel syndrome, leptin correlated with fatigue independently from age, sex, fat mass and body mass index.

CONCLUSIONS

Our study shows that fatigue occurs in 62.7% of irritable bowel syndrome patients when systematically asked for. Fatigue influences all three domains of the Fatigue Impact Scale in irritable bowel syndrome, the most being the physical and the psychosocial domains. Fatigue is associated with circulating leptin levels independently from age, sex, fat mass and body mass index in irritable bowel syndrome. The metabolic sequence involved in the occurrence of fatigue remains to be determined.

Gastrointestinal symptoms in patients with liver cirrhosis: associations with nutritional status and health-related quality of life

OBJECTIVE

Gastrointestinal symptoms can lead to decreased food intake and thereby increased morbidity. There is a general lack of data on the prevalence of gastrointestinal symptoms and their potential association with malnutrition and health-related quality of life (QoL) in cirrhosis. Our aim was to prospectively evaluate gastrointestinal symptoms, malnutrition, and QoL in patients with cirrhosis.

MATERIAL AND METHODS

Two validated questionnaires were used to measure gastrointestinal symptoms (gastrointestinal symptom rating scale (GSRS)) and health-related QoL (SF-36) in 128 consecutive cirrhotics (mean age 57 years, Child-Pugh score 8.6, MELD score 13.2) at a tertiary referral center. The results were compared with those of controls from the general population. Nutritional status was assessed by anthropometry and estimation of recent weight change.

RESULTS

Compared to controls, cirrhotic patients showed higher gastrointestinal symptom severity (total GSRS score: 1.53, 95% CI 1.50-1.55 versus 2.21, 95% CI 2.04-2.38) and profound reductions in the SF-36 physical (47.0 95% CI 45.0-49.0 versus 37.9, 95% CI 35.7-40.1) and mental component summary scores (51.0 95% CI 49.0-53.0 versus 39.2 95% CI 36.7-41.6). There were no significant differences in any GSRS domain between patients with and those without malnutrition. Multivariate analysis showed that gastrointestinal symptom severity was associated with the Child-Pugh score (beta = 0.10, r<0.05), daily lactulose use (beta = 0.65, p<0.005), and the presence of gastrointestinal comorbidities (beta = 0.51, p<0.05). Negative weight change (beta = -0.72, p<0.05) and the SF-36 physical (beta = -4.26, p<0.005) and mental (beta = -4.53, p<0.005) summaries were independently related to gastrointestinal symptom severity.

CONCLUSIONS

Patients with cirrhosis show increased severity of gastrointestinal symptoms, which are associated with recent weight loss and impaired health-related QoL. The severity of gastrointestinal symptoms seems to be related to the severity of cirrhosis.

Muscle fatigue in women with primary biliary cirrhosis: Spectral analysis of surface electromyography

AIM

To evaluate the myoelectric manifestations of peripheral fatigability in patients with primary biliary cirrhosis in comparison to healthy subjects.

METHODS

Sixteen women with primary biliary cirrhosis without comorbidity and 13 healthy women matched for age and body mass index (BMI) completed the self-reported questionnaire fatigue impact scale. All subjects underwent surface electromyography assessment of peripheral fatigability. Anterior tibial muscle isometric voluntary contraction was executed for 20 s at 80% of maximal voluntary isometric contraction. During the exercise electromyographic signal series were recorded and root mean square (expression of central drive) as well as mean and median of electromyographic signal frequency spectrum (estimates of muscle fatigability) were computed. Each subject executed the trial two times. EMG parameters were normalized, then linear regression was applied and slopes were calculated.

RESULTS

Seven patients were fatigued (median fatigue impact scale score: 38, range: 26-66) and 9 were not fatigued (median fatigue impact scale score: 7, range: 0-17). The maximal voluntary isometric contraction was similar in patients (82, 54-115 N) and controls (87, 74-101 N), and in patients with high (81, 54-115 N) and low fatigue impact scale scores (86, 65-106 N). Root mean square as well as mean and median of frequency spectrum slopes were compared with the Mann-Whitney U test, and no significant difference was found between fatigued and non-fatigued patients and controls.

CONCLUSION

No instrumental evidence of peripheral fatigability can be found in women with primary biliary cirrhosis but no comorbidity, suggesting that fatigue in such patients may be of central origin.

Characterisation of the associations and impact of symptoms in primary biliary cirrhosis using a disease specific quality of life measure

BACKGROUND/AIMS

Primary biliary cirrhosis (PBC) patients experience significant impairment to quality of life (QOL). Studies to date examining relative contributions of different symptoms to QOL impairment in PBC, and biological associations have been limited by the unavailability of appropriate disease specific symptom quantification modalities.

METHODS

We applied the PBC-40, a recently developed, multi-domain disease specific QOL measure, to 54 PBC patients to explore the inter-relationship of different symptoms, their biological associations, and correlation with physical functioning measured by accelerometry.

RESULTS

Two discrete and unrelated symptom complexes in PBC were identified focused on fatigue (together with cognitive and emotional dysfunction and other symptoms) and itch, with social dysfunction associating with both complexes. We confirmed no correlation between symptom severity and biological parameters of disease severity. There was a strong inverse correlation between physical activity (assessed over 6 days) and fatigue (P<0.005), but not between physical activity and Itch. Patients averaging <7,500 steps per day had over 75% higher fatigue scores than patients averaging >7,500 steps.

CONCLUSIONS

We have demonstrated two independent symptom complexes in PBC centred around fatigue and itch, neither is associated with biological parameters of activity, and the fatigue-centred complex is associated with objective impairment of physical functioning.