Psychosocial assessment of functional gastrointestinal disorders in clinical practice

Effectiveness and safety of lubiprostone after switching from stimulant laxatives in elderly patients with chronic constipation

Background and Aim

Stimulant laxatives may cause electrolyte abnormalities, dehydration, and abdominal pain; their long-term use can lead to tolerance and subsequent refractory constipation. We investigated the effectiveness, safety, and quality of life after switching from stimulant laxatives to lubiprostone in elderly patients with chronic constipation (CC).

Methods

This multicenter, interventional, open-label, single-arm, before-and-after comparison study enrolled 99 Japanese patients aged 65-90 years with CC who took stimulant laxatives for ≥2 weeks prior to switching to lubiprostone monotherapy.

Results

The mean ± SD spontaneous defecations at Week 1 of 7.8 ± 6.2 times/week was not significantly different from that at baseline (8.3 ± 4.7). Spontaneous defecations were significantly reduced at Weeks 2 (-1.5 ± 4.0, P < 0.001) and 4 (-1.5 ± 3.7, P < 0.001). The Bristol Stool Form Scale score did not change from baseline (4.7 ± 0.9) at Weeks 1 (4.5 ± 1.3) or 4 (4.3 ± 1.3), but it did at Week 2 (4.3 ± 1.5, P < 0.05). The Patient Assessment of Constipation Quality of Life questionnaire score increased (0.36 ± 0.07, P < 0.001) after 28 days. Nausea was the only symptom that worsened from baseline and was the most frequently reported adverse drug reaction (15.2%).

Conclusion

Switching to lubiprostone monotherapy for CC was not associated with significant concerns in short-term spontaneous defecation frequency and safety, but it might affect the efficacy and patient quality of life over 2 weeks. Careful treatment strategies facilitating gradual switching to lubiprostone monotherapy may be needed in patients using stimulant laxatives.

Overlap of disorders of gut-brain interaction: a systematic review and meta-analysis

BACKGROUND

Rome criteria differentiate distinct types of disorders of gut-brain interaction (DGBI); also known as functional gastrointestinal disorders. Overlap of symptom categories frequently occurs. This systematic review and meta-analysis aimed to define the prevalence of DGBI overlap and compare overlap in population-based, primary care or tertiary care health settings. Furthermore, we aimed to compare symptom severity of psychological comorbidities in DGBI with and without overlap.

METHODS

For this systematic review and meta-analysis we searched MEDLINE (PubMed) and Embase electronic databases from inception until March 1, 2022, for original articles and conference abstracts of observational cross-sectional, case-controlled, or cohort design studies that reported the prevalence of DGBI overlap in adult participants (aged ≥18 years). We included only those studies where the diagnosis of DGBI was based on clinical assessment, questionnaire data, or specific symptom-based criteria. Studies were excluded if reporting on mixed populations of DGBI and organic diseases. Aggregate patient data were extracted from eligible published studies. The prevalence of DGBI overlap in all studies was pooled using the DerSimonian and Laird random effects model, and further analysis stratified by subgroups (care setting, diagnostic criteria, geographic region, and gross domestic product per capita). We also assessed the relationship between DGBI overlap with anxiety, depression, and quality of life symptom scores. This study was registered with PROSPERO (CRD42022311101).

FINDINGS

46 of 1268 screened studies, reporting on 75 682 adult DGBI participants, were eligible for inclusion in this systematic review and meta-analysis. Overall, 24 424 (pooled prevalence 36·5% [95% CI 30·7 to 42·6]) participants had a DGBI overlap, with considerable between-study heterogeneity (I²=99·51, p=0·0001). In the tertiary health-care setting, overlap among participants with DGBI was more prevalent (8373 of 22 617, pooled prevalence 47·3% [95% CI 33·2 to 61·7]) compared with population-based cohorts (11 332 of 39 749, pooled prevalence 26·5% [95% CI 20·5 to 33·4]; odds ratio 2·50 [95% CI 1·28 to 4·87]; p=0·0084). Quality of life physical component scores were significantly lower in participants with DGBI overlap compared with participants without overlap (standardised mean difference -0·47 [95% CI -0·80 to -0·14]; p=0·025). Participants with DGBI overlap had both increased symptom scores for anxiety (0·39 [95% CI 0·24 to 0·54]; p=0·0001) and depression (0·41 [0·30 to 0·51]; p=0·0001).

INTERPRETATION

Overlap of DGBI subtypes is frequent, and is more prevalent in tertiary care settings and associated with more severe symptom manifestations or psychological comorbidities. Despite the large sample size, the comparative analyses revealed substantial heterogeneity, and the results should be interpreted with caution.

FUNDING

National Health and Medical Research Council and Centre for Research Excellence.

A population-based study of associations between functional gastrointestinal disorders and psychosocial characteristics in Xi'an, China

BACKGROUND

Functional gastrointestinal disorders (FGIDs) are disorders with chronic and recurring gastrointestinal symptoms. This study investigated the prevalence of FGIDs, assessed the association between FGIDs and psychosocial factors, and identified potential risk factors for FGIDs in a population in Xi'an, China.

METHODS

Of 752 recruited residents in Xi'an, 720 were selected for an epidemiological survey using a cluster sampling method. All subjects were interviewed face-to-face to complete the Chinese version of ROME III FGIDs questionnaire, the Symptom Check-List-90, the Eysenck Personality Questionnaire, a Life Event Scale, and a questionnaire regarding personal childhood adversity. The prevalence of FGIDs and associations between FGIDs and psychosocial factors were determined using EpiData Software. Logistic regression analysis was performed to identify the potential risk factors for FGIDs.

KEY RESULTS

The prevalence of FGIDs in this sample population was 14.3% (103/720). There were 13 (1.8%) cases of overlap of different FGIDs. No significant difference in the prevalence of FGIDs was observed between men and women. Alcohol intake and smoking habits were significantly associated with the presence of FGIDs. The presence of FGIDs was significantly associated with psychological factors and influences such as personality type, life events, childhood adversity, and psychopathology. The potential risk factors for contracting FGIDs were certain life events, childhood adversity, somatization, and a hostile affect (P < 0.001).

CONCLUSIONS & INFERENCES

The prevalence of FGIDs and overlap syndrome in Xi'an, China was lower than that reported in other countries. There was a strong correlation between specific lifestyle habits and psychosocial characteristics and the presence of FGIDs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Personality traits and impaired health-related quality of life in patients with functional gastrointestinal disorders

BACKGROUND & AIMS

Negative affectivity and social isolation (Type D personality) are personality traits associated with poor health-related quality of life (HRQoL). We hypothesized these traits would be associated with impaired HRQoL and increased gastrointestinal symptom severity in functional gastrointestinal disorders.

METHODS

Data were collected from patients undergoing breath testing. Patients completed the Type D Scale-14, Gastrointestinal Symptoms Severity Index and Short-Form Health Survey 12.

RESULTS

Of 230 patients evaluated, 37% met criteria for Type D personality. Type D was associated with a decreased Mental Component score on the Short-Form Health Survey 12 (mean difference = -8.29; 95% confidence interval, 5.2-11.4; P < .001). On the Gastrointestinal Symptoms Severity Index, severity of symptoms was significantly higher in Type D patients compared with non Type D patients (P < .001).

CONCLUSIONS

Type D personality was associated with decreased perceived HRQoL and reporting of more severe gastrointestinal symptoms. Type D personality construct may be an important consideration when assessing HRQoL outcomes. Consideration of personality traits could improve risk stratification in research and clinical practice in this patient group.

[Neurological and psychiatric aspects of some gastrointestinal diseases]

The gastrointestinal tract is controlled by the independent enteric nervous system. It is also closely connected to the central nervous system, and bi-directional communication exists between them. The communication involves neural pathways as well as immune and endocrine mechanisms. The brain-gut axis plays a prominent role in the modulation of gut functions. Signals from different sources (e.g. sound, sight, smell, somatic and visceral sensations, pain) reach the brain. These inputs are modified by memory, cognition and affective mechanisms and integrated within the neural circuits of the central nervous system, spinal cord, autonomic and enteral nervous systems. These inputs can have physiologic effects, such as changes in motility, secretion, immune function, and blood flow to the gastrointestinal tract. One of the most important neurotransmitters is serotonin that plays a key role in the pathogenesis of the most common chronic functional gastrointestinal disorder: the irritable bowel syndrome. It is a biopsychosocial disease, resulting from the dysregulation of the brain-gut axis. Endogenous pain facilitation rather than inhibition, pathologic gradation of visceral perception and reduced threshold for pain are all evident in these patients. Abuse history is common in their anamnesis. Exaggerated conscientiousness, perfectionism, oversensitivity, feeling of deficiency in effectiveness, and higher demand for social parity, neuroticism and alexithymia have been detected among their constant personality features. Females are also characterized by gender role conflict and low assertiveness. Antidepressants and psychotherapy have important roles in their treatment. Also patients with inflammatory bowel disease are characterized by neuroticism and alexithymia and altered mother-child attachment is often described in their anamnesis. Autonomic neuropathy is a frequent and early neurological complication. Reflux disease and obstructive sleep apnea mutually generate each other and their severities significantly correlate. In the celiac disease the most common neurological manifestations are ataxia, peripheral neuropathy and myopathy. Up to 85% of patients with histologically proven coeliac disease have no gastrointestinal symptoms; consequently, measurement of antigliadin antibody titre is therefore vital in all cases of idiopathic ataxia. Complete resolution of neurological symptoms is the result of gluten-free diet.

Multicenter study of gastroenterologists' ability to identify anxiety and depression in a new patient encounter and its impact on diagnosis

AIM

Although gastroenterologists are frequently exposed to psychopathology few data exist regarding their ability to accurately assess anxiety and depression or the impact of their perceptions of anxiety and depression on diagnostic decisions. The aims of this study were to determine gastroenterologists' ability to correctly identify anxiety and depression in patients with gastrointestinal symptoms and to determine whether gastroenterologist perceptions of anxiety and depression affected postvisit diagnosis.

METHODS

One hundred fifty-nine consecutive patients making their initial visit to 3 university outpatient clinics were evaluated by 38 gastroenterologists and completed Hospital Anxiety and Depression Scale. Gastroenterologists rated their perceptions of patient anxiety and depression on 100-mm visual analog scales and indicated whether they thought the patient was clinically anxious or depressed. On the basis of the gastroenterologists' postvisit diagnosis, patients were entered into functional gastrointestinal disorder (FGID; n=28), symptom-based (SB) diagnosis (n=45), or organic disease (OD; n=86) groups.

RESULTS

Anxiety and depression were present in 40% and 20% of patients, respectively. Gastroenterologists' categorization of patients as having clinically significant anxiety and depression were poor with positive predictive values of 0.52 and 0.26, respectively. Patients perceived as anxious by their gastroenterologist were more than twice as likely to receive a FGID diagnosis.

CONCLUSIONS

Anxiety and depression were prevalent in the study population yet gastroenterologists did not accurately detect these conditions. However, gastroenterologists were more than twice as likely to diagnose patients whom they perceived as anxious as having an FGID, highlighting a need for improved psychosocial assessment in clinical practice and education to diminish misattributions regarding FGID.

The organisation of the stress response, and its relevance to chiropractors: a commentary

The stress response is a natural reaction by the body, against potentially harmful stimuli to enhance the chance for survival. Persistent activation of the stress response can cause changes to homeostatic mechanisms. The study of stress neurophysiology, in the evaluation of the manifestation of disease in the body, suggests that these chronic changes have detrimental effects on sub cortical structures. Furthermore, there is much scientific support for the notion that chronic activation of supraspinal systems will lead to maladaptation of homeostatic mechanisms, causing the impairment of processes within the body, and ultimately leading to visceral disorders. The chiropractic profession for many years has alluded to chronic change of neurophysiological pathways as a potential explanation of visceral disorders, but the profession has typically described these in terms of somatovisceral or viscerosomatic reflex activity. Change in supraspinal neurophysiological efferent activity is increasingly being used to explain "stress" related disease. The chiropractic profession should consider investigating such stress responses by conducting spinal manipulative therapy trials that evaluate supraspinal effects of manipulation. Such research may help elucidate key mechanisms associated with the change of visceral disorders noted by some chiropractors following manipulative therapy.

Attitudes of hand surgeons, hand surgery patients, and the general public regarding psychologic influences on illness

PURPOSE

Psychologic influences on illness are well recognized but infrequently addressed in the interactions of hand surgeons and patients. This study assessed the attitudes of hand surgery patients and hand surgeons regarding psychologic influences on illness and compared their attitudes with those of the general population.

METHODS

An 8-question survey regarding participant's attitudes toward psychologic influences on illness was given to the general public (people waiting in an airport), patients presenting to a hand surgery practice, and members of the American Society for Surgery of the Hand.

RESULTS

A total of 474 surgeons, 85 patients, and 42 public participants completed the survey. There were no notable differences between patients and the general public, but the surgeons' attitudes were markedly different from both patients and the general public with respect to 4 items: the surgeons underestimated the openness of patients and the general public to discussing psychologic influences and willingness to see a psychologist or psychiatrist; and they were more supportive than the general public or patients regarding the opinion that the placebo effect reflects the strong influence of psychologic factors in healing and that psychologic stress often is expressed as a physical complaint. The distribution of patient responses showed 2 subgroups with respect to the idea that psychologic stress often is expressed as a physical complaint and with regard to willingness to see a mental heath professional, reflecting that a subset of patients with a hand illness may be resistant to these concepts.

CONCLUSIONS

Hand surgery patients and the general public are not as aware of the psychologic influences on illness as are hand surgeons, but they are more willing to consider and discuss psychologic factors-and even psychologic treatment-than their surgeons realize. Surgeons' views may be colored by a few negative interactions with challenging patients, but a dialogue with our patients regarding the influence of psychologic issues on illness will be well received by most patients and may facilitate recovery.

Slow transit constipation: A functional disorder becomes an enteric neuropathy

Slow transit constipation has been traditionally considered and classified as a functional disorder. However, clinical and manometric evidence has been accumulating that suggests how most of the motility alterations in STC might be considered of neuropathic type.In addition, further investigations showed that subtle alterations of the enteric nervous system, not evident to conventional histological examination, may be present in these patients. In the present article we will discuss these evidences, and will try to put them in relation with the abnormal motor function of the large bowel documented in this pathological condition.