Impact of coexisting irritable bowel syndrome on symptoms and pathophysiological mechanisms in functional dyspepsia

Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction

In patients with disorders of gut-brain interaction (DGBI), overlapping non-gastrointestinal conditions such as fibromyalgia, headaches, gynaecological and urological conditions, sleep disturbances and fatigue are common, as is overlap among DGBI in different regions of the gastrointestinal tract. These overlaps strongly influence patient management and outcome. Shared pathophysiology could explain this scenario, but details are not fully understood. This overlap has been shown to be of great relevance for DGBI. In addition, symptoms considered to be caused by a DGBI could have a detectable organic cause, and in patients with a diagnosed organic gastrointestinal disease, symptoms not clearly explained by the pathology defining this organic disease are common. Thus, the aims of this Rome Foundation Working Team Report were to review the literature on overlapping conditions among patients with paediatric and adult DGBI and, based on the available epidemiological and clinical evidence, make recommendations for the current diagnostic and therapeutic approach, and for future research. Specifically, we focused on other DGBI in the same or different gastrointestinal anatomical region(s), DGBI overlap with organic bowel diseases in remission, and DGBI overlap with non-gastrointestinal, non-structural conditions.

Comparison of pancreatic enzyme abnormalities and protease-activated receptor-2-positive eosinophils in the duodenum of patients with functional dyspepsia-irritable bowel syndrome overlap with functional dyspepsia alone in Asian populations

BACKGROUND AND AIM

Some patients with functional gastrointestinal disorders exhibit pancreatic dysfunctions and pancreatic enzyme abnormalities. Thus, we aimed to clarify whether significant differences in clinical characteristics, prevalence of pancreatic enzyme abnormalities, duodenal inflammation, and protease-activated receptor 2 (PAR2) expression levels related to hypersensitivity exist between functional dyspepsia (FD) alone and FD-irritable bowel syndrome (IBS) overlap group.

METHODS

Ninety-three patients based on the Rome IV criteria, FD alone (n = 44) and FD overlapped with IBS (n = 49) group were enrolled. The patients scored their own clinical symptoms after consuming high-fat meals. Serum trypsin, PLA2, lipase, p-amylase, and elastase-1 levels were measured. PAR2, eotaxin-3, and TRPV4 mRNA levels in duodenum were determined using real-time polymerase chain reaction methods. PRG2- and PAR2 in the duodenum were evaluated using immunostaining.

RESULTS

FD score and global GSRS in patients with FD-IBS overlap were significantly higher than FD alone. Although the prevalence of pancreatic enzyme abnormalities in patients with FD alone was significantly (P < 0.01) higher than that in FD-IBS overlap, the ratio of aggravation of clinical symptoms following high-fat intake in patients with FD-IBS overlap was significantly higher (P = 0.007) than that in patients with FD alone. PAR2- and PRG2-double positive cells were localized in the degranulated eosinophils in the duodenum of patients with FD-IBS overlap. The number of PAR2- and PRG2-double positive cells in FD-IBS overlap was significantly (P < 0.01) higher than FD alone.

CONCLUSIONS

Pancreatic enzyme abnormalities and PAR2 expression on degranulated eosinophils infiltrations in the duodenum may be associated with the pathophysiology of patients with FD-IBS overlap in Asian populations.

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.

The role of psychological factors in functional gastrointestinal disorders: a systematic review and meta-analysis

PURPOSE

To systematically reevaluate the role of psychological factors in functional gastrointestinal disorders (FGIDs) and thus provide a scientific basis for the psychological treatment of FGIDs.

METHODS

A literature search was conducted using the PubMed, Embase, Web of Science, and Cochrane Library databases from January 2018 to August 2022 for researches on psychological factors affecting patients with functional gastrointestinal disorders. Meta-analysis was carried out with Stata17.0 after the screening, extraction, and evaluation of article quality.

RESULTS

The search included 22 articles with 2430 patients in the FGIDs group and 12,397 patients in the healthy controls. Meta-analysis showed anxiety [(pooled SMD = 0.74, 95%CI: 0.62 ~ 0.86, p < 0.000) (pooled OR = 3.14, 95%CI: 2.47 ~ 4.00, p < 0.000)], depression [(pooled SMD = 0.79, 95%CI: 0.63 ~ 0.95, p < 0.000) (pooled OR = 3.09, 95%CI: 2.12 ~ 4.52, p < 0.000)], mental disorders (pooled MD =  -5.53, 95%CI: -7.12 ~  -3.95, p < 0.05), somatization (pooled SMD = 0.92, 95%CI: 0.61 ~ 1.23, p < 0.000), and sleep disorders (pooled SMD = 0.69, 95%CI: 0.04 ~ 1.34, p < 0.05) are risk factors for functional gastrointestinal disorders.

CONCLUSION

There is a significant association between psychological factors and FGIDs. Interventions such as anti-anxiety drugs, antidepressants, and behavioral therapy are of great clinical significance in reducing FGIDs risk and improving prognosis.

Type 2 and type 17 effector cells are increased in the duodenal mucosa but not peripheral blood of patients with functional dyspepsia

Background

Functional dyspepsia is characterised by chronic symptoms of post-prandial distress or epigastric pain not associated with defined structural pathology. Increased peripheral gut-homing T cells have been previously identified in patients. To date, it is unknown if these T cells were antigen-experienced, or if a specific phenotype was associated with FD.

Objective

This study aimed to characterise T cell populations in the blood and duodenal mucosa of FD patients that may be implicated in disease pathophysiology.

Methods

We identified duodenal T cell populations from 23 controls and 49 Rome III FD patients by flow cytometry using a surface marker antibody panel. We also analysed T cell populations in peripheral blood from 37 controls and 61 patients. Where available, we examined the number of duodenal eosinophils in patients and controls.

Results

There was a shift in the duodenal T helper cell balance in FD patients compared to controls. For example, patients had increased duodenal mucosal Th2 populations in the effector (13.03 ± 16.11, 19.84 ± 15.51, p=0.038), central memory (23.75 ± 18.97, 37.52 ± 17.51, p=0.007) and effector memory (9.80±10.50 vs 20.53±14.15, p=0.001) populations. Th17 populations were also increased in the effector (31.74±24.73 vs 45.57±23.75, p=0.03) and effector memory (11.95±8.42 vs 18.44±15.63, p=0.027) subsets. Peripheral T cell populations were unchanged between FD and control.

Conclusion

Our findings identify an association between lymphocyte populations and FD, specifically a Th2 and Th17 signature in the duodenal mucosa. The presence of effector and memory cells suggest that the microinflammation in FD is antigen driven.

Gastroparesis and Functional Dyspepsia: Spectrum of Gastroduodenal Neuromuscular Disorders or Unique Entities?

Gastroparesis is defined by delayed gastric emptying in the absence of mechanical obstruction of the stomach. Patients experience symptoms of nausea, vomiting, abdominal pain, fullness, and early satiety. The recognition of the disorder has progressed due to availability of gastric emptying scintigraphy and advancements made in understanding its pathophysiology and treatment options. The clinical presentation and treatment of gastroparesis overlap with a more commonly recognized disorder of gut-brain interaction, functional dyspepsia. Recent studies have reenergized the discussion whether these two are separate entities or perhaps reflect a spectrum of gastroduodenal neuromuscular disorders. The societal guidelines conflict on the utility of gastric emptying scintigraphy in assessment of patients with upper gastrointestinal symptoms. A better appraisal of similarities and differences between gastroparesis and functional dyspepsia will allow targeted treatment for these disorders. This is particularly important as specific pharmacological and endoscopic treatment options are being developed for gastroparesis which are unlikely to be helpful for functional dyspepsia. This review makes the case for considering these disorders in a spectrum where identification of both would most ideally position us toward providing the optimal clinical care.

British Society of Gastroenterology guidelines on the management of functional dyspepsia

Functional dyspepsia (FD) is a common disorder of gut-brain interaction, affecting approximately 7% of individuals in the community, with most patients managed in primary care. The last British Society of Gastroenterology (BSG) guideline for the management of dyspepsia was published in 1996. In the interim, substantial advances have been made in understanding the complex pathophysiology of FD, and there has been a considerable amount of new evidence published concerning its diagnosis and classification, with the advent of the Rome IV criteria, and management. The primary aim of this guideline, commissioned by the BSG, is to review and summarise the current evidence to inform and guide clinical practice, by providing a practical framework for evidence-based diagnosis and treatment of patients. The approach to investigating the patient presenting with dyspepsia is discussed, and efficacy of drugs in FD summarised based on evidence derived from a comprehensive search of the medical literature, which was used to inform an update of a series of pairwise and network meta-analyses. Specific recommendations have been made according to the Grading of Recommendations Assessment, Development and Evaluation system. These provide both the strength of the recommendations and the overall quality of evidence. Finally, in this guideline, we consider novel treatments that are in development, as well as highlighting areas of unmet need and priorities for future research.

Helicobacter pylori Infection—A Risk Factor for Irritable Bowel Syndrome? An Updated Systematic Review and Meta-Analysis

Nowadays, the relationship between Helicobacter pylori infection (HPI) and irritable bowel syndrome (IBS) remains controversial. Objective: The aim of this study is to investigate the relationship between HPI and IBS through a systematic review and meta-analysis based on the current evidence. Methods: We performed a systematic literature search in electronic databases (PubMed, EMBASE, and the Cochrane library) by computer to identify all reports published before 8 August 2021. The odds ratio (OR) and confidence interval (CI) were calculated to evaluate the association between HPI and IBS. Subgroup analyses were conducted for further assessment and exploration of heterogeneity sources. In addition, we assessed publication bias through funnel plots, Egger’s test, and Begg’s test. Finally, we conducted a sensitivity analysis to evaluate the robustness of the results. Results: Thirteen studies with 13,173 participants were included in the meta-analysis. The pooled OR of the association between HPI and IBS was 1.03 (95% CI [0.80,1.31]; p = 0.84). The adjusted OR of the association between HPI and IBS after excluding the studies with confounding factors defined by our team was 1.29 (95% CI [1.03,1.62]; p = 0.03). We found a positive association between HPI and IBS-D (diarrhea subtype) (OR: 1.54; 95% CI [1.22,1.95]; p = 0.0003). The OR of the relationship between cytotoxin-associated gene A (Cag A) positive HPI and IBS was 4.3 (95% CI [0.51,36.17]; p = 0.18). Conclusions: The likelihood of HPI in IBS patients is relatively higher than that of non-IBS participants but not statistically significant, implying that HPI is not significantly associated with IBS, albeit we may underestimate this association. Moreover, we found a positive association between HPI and IBS-D. We also observed an increased likelihood of Cag-A positive HPI in IBS patients than that of non-IBS participants but not statistically significant.

Pilot Study of a Self-Administered Hypnosis Intervention for Functional Dyspepsia

BACKGROUND

Functional dyspepsia (FD) is a chronic disorder of the upper gastrointestinal tract that currently lacks substantially effective therapy options.

AIMS

To evaluate the feasibility and potential impact on FD symptoms and well-being of a fully automated gut-directed hypnosis intervention delivered via audio recordings.

METHODS

FD patients were enrolled at a single medical center and given access to a password-protected website where they completed 7 bi-weekly audio-recorded hypnosis sessions over a 3-month period. Study questionnaires including the Patient assessment of upper gastrointestinal symptom severity index, Short-Form Nepean Dyspepsia Index, the Visceral Sensitivity Index, and the Brief Symptom Inventory (BSI-18) were completed online pre-treatment, mid-treatment, post-treatment and at 3-month follow-up.

RESULTS

Of 23 enrolled patients (18 females; mean age = 38 years), 96% completed the entire treatment program and 3-month follow-up. Intention-to-treat analyses showed significant improvement at both end of treatment and 3-month follow-up in dyspepsia severity and quality of life, as well as in gut-specific anxiety and psychological distress. 68% of treatment completers reported that their FD symptoms were improved. Improvement in FD severity was significantly positively correlated with baseline PAGI-SYM total scores and BSI Global Severity Index scores.

CONCLUSIONS

The fully automated hypnosis audio treatment program, which requires no therapist or clinician involvement, demonstrated excellent feasibility and resulted in significant improvement in FD symptoms, quality of life and emotional well-being. The results indicate that the intervention has high potential as adjunctive therapy for FD and warrants further investigation in a randomized controlled trial.

Constipation in Patients With Symptoms of Gastroparesis: Analysis of Symptoms and Gastrointestinal Transit

BACKGROUND & AIMS

Constipation can be an important symptom in some patients with gastroparesis. The aims were to: 1) Determine prevalence of constipation and delayed colonic transit in patients with symptoms of gastroparesis; 2) Correlate severity of constipation to severity of symptoms of gastroparesis; and 3) Relate severity of constipation to GI transit delays assessed by gastric emptying scintigraphy (GES) and wireless motility capsule (WMC).

METHODS

Patients with symptoms of gastroparesis underwent gastric emptying scintigraphy (GES), wireless motility capsule (WMC) assessing gastric emptying, small bowel transit, and colonic transit, and questionnaires assessing symptoms using a modified Patient Assessment of Upper GI Symptoms [PAGI-SYM] and Rome III functional GI disorder questionnaire.

RESULTS

Of 338 patients with symptoms of gastroparesis, 242 (71.5%) had delayed gastric emptying by scintigraphy; 298 (88.2%) also met criteria for functional dyspepsia. Severity of constipation was severe/very severe in 34% patients, moderate in 24%, and none/very mild/mild in 42%. Increasing severity of constipation was associated with increasing symptoms of gastroparesis and presence of irritable bowel syndrome (IBS). Severity of constipation was not associated with gastric retention on GES or WMC. Delayed colonic transit was present in 108 patients (32% of patients). Increasing severity of constipation was associated with increasing small bowel transit time, colonic transit time, and whole gut transit time.

CONCLUSIONS

Severe/very severe constipation and delayed colon transit occurs in a third of patients with symptoms of gastroparesis. The severity of constipation is associated with severity of gastroparesis symptoms, presence of IBS, small bowel and colon transit delay, but not delay in gastric emptying. ClinicalTrials.gov Identifier: NCT01696747.

Sex and Gender Differences in Overlap Syndrome of Functional Gastrointestinal Disorder and Effect of Genetic Polymorphisms in South Korea: A Long-term Follow-up Study

BACKGROUND/AIMS

Overlap functional gastrointestinal disorder (FGID) is associated with more severe gastrointestinal symptoms and lower quality of life. The aim of this study is to evaluate clinical features of non-erosive reflux disease (NERD), functional dyspepsia, irritable bowel syndrome, their overlap in terms of sex and gender, and to assess the risk factors, including genetic polymorphisms.

METHODS

A total of 494 FGIDs and 239 controls were prospectively enrolled between 2004 and 2020. FGIDs were diagnosed based on the Rome III criteria and symptoms were evaluated using a questionnaire. Follow-up questionnaires were conducted to determine the change of symptoms during the 75.8-month mean observation period. Risk factors including genetic polymorphisms in neurotransmitter receptor (SLC6A4 5-HTTLPR, GNB3, ADRA2A, CCKAR, and TRPV1) and cytokine (TNFA and IL10) genes.

RESULTS

NERD was more prevalent in men, and functional dyspepsia in women. Overlap FGIDs (n = 239) were more prevalent than nonoverlap FGIDs (n = 255) in women (P = 0.019). Anxiety and depression scores were higher in the overlaps (P = 0.012 and P < 0.001, respectively). Symptoms were more frequent and severe in the overlap FGIDs than in the non-overlaps (P < 0.001). During followup, symptoms progressed more frequently in the overlap FGIDs, especially in patients with the L/S genotype of SLC6A4 5-HTTLPR and anxiety/depression.

CONCLUSIONS

Overlap FGID patients need attention given their association with anxiety/depression and more severe symptoms, especially in women. Genetic polymorphisms also may be associated with certain symptoms of overlap FGIDs.

Sex and Gender Differences in Overlap Syndrome of Functional Gastrointestinal Disorder and Effect of Genetic Polymorphisms in South Korea: A Long-term Follow-up Study

Background/Aims

Overlap functional gastrointestinal disorder (FGID) is associated with more severe gastrointestinal symptoms and lower quality of life. The aim of this study is to evaluate clinical features of non-erosive reflux disease (NERD), functional dyspepsia, irritable bowel syndrome, their overlap in terms of sex and gender, and to assess the risk factors, including genetic polymorphisms.

Methods

A total of 494 FGIDs and 239 controls were prospectively enrolled between 2004 and 2020. FGIDs were diagnosed based on the Rome III criteria and symptoms were evaluated using a questionnaire. Follow-up questionnaires were conducted to determine the change of symptoms during the 75.8-month mean observation period. Risk factors including genetic polymorphisms in neurotransmitter receptor (SLC6A4 5-HTTLPR, GNB3, ADRA2A, CCKAR, and TRPV1) and cytokine (TNFA and IL10) genes.

Results

NERD was more prevalent in men, and functional dyspepsia in women. Overlap FGIDs (n = 239) were more prevalent than non-overlap FGIDs (n = 255) in women (P = 0.019). Anxiety and depression scores were higher in the overlaps (P = 0.012 and P < 0.001, respectively). Symptoms were more frequent and severe in the overlap FGIDs than in the non-overlaps (P < 0.001). During follow-up, symptoms progressed more frequently in the overlap FGIDs, especially in patients with the L/S genotype of SLC6A4 5-HTTLPR and anxiety/depression.

Conclusions

Overlap FGID patients need attention given their association with anxiety/depression and more severe symptoms, especially in women. Genetic polymorphisms also may be associated with certain symptoms of overlap FGIDs.

Association between Helicobacter pylori infection and irritable bowel syndrome: a systematic review and meta-analysis

BACKGROUND

Helicobacter pylori infection and irritable bowel syndrome (IBS) negatively affect the quality of life. Some previous studies found that H. pylori infection should be positively associated with the risk of IBS, but others did not. The present study aims to clarify this association, and to further analyse whether H. pylori treatment can improve IBS symptoms.

MATERIALS AND METHODS

The PubMed, EMBASE, Cochrane library, Chinese National Knowledge Infrastructure, China Science and Technology Journal and Wanfang databases were searched. Meta-analysis was performed using a random-effect model. The pooled odds ratios (ORs)/risk ratios (RRs) and their 95% CIs were calculated. Heterogeneity was evaluated using the Cochran's Q test and I² statistics. Meta-regression analysis was used to explore the sources of heterogeneity.

RESULTS

Thirty-one studies with 21 867 individuals were included. Meta-analysis of 27 studies found that patients with IBS had a significantly higher risk of H. pylori infection than those without (OR=1.68, 95% CI 1.29 to 2.18; p<0.001). The heterogeneity was statistically significant (I^²=85%; p<0.001). Meta-regression analyses indicated that study design and diagnostic criteria of IBS might be the potential sources of heterogeneity. Meta-analysis of eight studies demonstrated that H. pylori eradication treatment had a higher improvement rate of IBS symptoms (RR=1.24, 95% CI 1.10 to 1.39; p<0.001). The heterogeneity was not significant (I^²=32%; p=0.170). Meta-analysis of four studies also demonstrated that successful H. pylori eradication had a higher improvement rate of IBS symptoms (RR=1.25, 95% CI 1.01 to 1.53; p=0.040). The heterogeneity was not significant (I^²=1%; p=0.390).

CONCLUSION

H. pylori infection is associated with an increased risk of IBS. H. pylori eradication treatment can improve IBS symptoms.

Review article: irritable bowel syndrome: natural history, bowel habit stability and overlap with other gastrointestinal disorders

Symptoms of irritable bowel syndrome (IBS) characteristically fluctuate over time. We aimed to review the natural history of IBS and IBS subgroups including bowel habit disturbances, and the overlap of IBS with other gastrointestinal disorders. The community incidence of IBS is approximately 67 per 1000 person years. The prevalence of IBS is stable over time because symptoms fluctuate and there is a portion who experience resolution of their GI symptoms similar in number to those developing new-onset IBS. The proportion who report resolution of symptoms varies amongst population-based studies from 17% to 55%. There is evidence of substantial movement between subtypes of IBS. For example in a clinical trial cohort, only one in four patients retained their baseline classification throughout the study periods, two in three moved between IBS-C (constipation) and IBS-M (mixed), while over half switched between IBS-D (diarrhoea) and IBS-M. The least stable group was IBS-M. There are very limited data on drivers of bowel habit change in IBS. There are emerging evidence fluctuations in intestinal immune activity might account for symptom variability over time. It is of clinical importance to recognise the substantial overlap of IBS symptoms with other gastrointestinal syndromes including gastro-oesophageal reflux disease. This is important to ensure the correct clinical diagnosis of IBS is made and patients are not over investigated. Knowledge of the natural history, stability of subgroups and overlap of IBS with other gastrointestinal conditions should be considered in therapeutic decision making.

Gender difference in the overlap of irritable bowel syndrome and functional dyspepsia: a prospective nationwide multicenter study in Korea

BACKGROUND

The overlap between functional dyspepsia (FD) and irritable bowel syndrome (IBS) is associated with more severe gastrointestinal (GI) symptoms and lower quality of life. However, the gender differences in FD-IBS overlap remain unclear. This study aimed to investigate the gender differences in patients with FD-IBS overlap.

METHODS

Controls and cases were prospectively enrolled from July 2019 to June 2020 at nine tertiary referral centers. The patients underwent esophagogastroduodenoscopy, and their symptoms were evaluated using a questionnaire including GI symptom-related items and the Hospital Anxiety Depression Scale (HADS). FD and IBS were diagnosed according to the Rome IV criteria, and the clinical characteristics of the FD-IBS overlap group were compared with those of the FD-only or IBS-only group.

RESULTS

Among 667 subjects (334 healthy controls, 168 with FD-only, 37 with IBS-only, 128 with FD-IBS overlap), the FD-IBS overlap group (19.2%) showed a higher rate of preference for dairy products, a higher rate of history of Helicobacter pylori eradication, and higher HADS scores than the non-overlap group (P < 0.05). In the FD-IBS overlap group, men complained of reflux symptom and loose/watery stools more than women (P < 0.05), whereas women showed more severe GI symptoms, especially epigastric pain/burning symptoms, and higher depression scores than men (all P < 0.05).

CONCLUSIONS

FD-IBS overlap patients are associated with severe upper GI symptoms and depression compared to non-overlap patients. Moreover, women with FD-IBS overlap experience more severe GI and depression symptoms than men.

Association between Malnutrition and Quality of Life in Elderly Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a progressive articular disease. In addition to damaging the joints, it may cause multiple organ complications, and considerably impair the patient’s functioning. Elderly patients with RA report pain, fatigue, mood disorders, sleep disorders and insomnia, accompanied by weakness, poor appetite, and weight loss. All these factors combined have an adverse effect on the patient’s perceived quality of life (QoL). Due to the chronic nature of RA and the high risk of malnutrition in this patient group, the present study investigated QoL, activities of daily living, and frailty syndrome severity in relation to MNA (Mini Nutritional Assessment) questionnaire scores among elderly RA patients. The study included 98 patients (aged over 60) diagnosed with RA per the ARA (American Rheumatism Association) criteria. The following standardized instruments were used: WHOQoL-BREF for QoL, the Edmonton Frail Scale for frailty syndrome severity, MNA for nutritional status assessment, and MMSE (Mini-Mental State Examination) to assess any cognitive impairment. Medical data were obtained from hospital records. Patients with a different nutritional status differed significantly in terms of limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL). Higher levels of malnutrition were associated with greater limitations in activity. An adverse impact of lower body weight on cognitive function was also observed (dementia was identified in 33.33% of malnourished patients vs. 1.79% in patients with a normal body weight). Likewise, frailty was more common in malnourished patients (mild frailty syndrome in 33.3%, moderate in 16.67%, and severe in 16.67%). Malnourished patients had significantly lower QoL scores in all WHOQoL-BREF questionnaire domains than those with a normal body weight, and multiple-factor analysis for the impact of selected variables on QoL in each domain demonstrated that frailty was a significant independent determinant of poorer QoL in all domains: perceived quality of life (β = −0.069), perceived health (β = −0.172), physical domain (β = −0.425), psychological domain (β = −0.432), social domain (β = −0.415), environmental domain (β = −0.317). Malnutrition was a significant independent determinant of QoL in the “perceived health” domain (β = −0.08). In addition, regression analysis demonstrated the positive impact of male sex on QoL scores in the psychological (β = 1.414) and environmental domains (β = 1.123). Malnourished patients have a lower QoL than those with a normal body weight. Malnutrition adversely affects daily functioning, cognitive function, and the severity of frailty syndrome. Frailty syndrome is a significant independent determinant of poorer QoL in all WHOQoL BREF domains.

The water load test in school children and adolescents with functional gastrointestinal disorders

BACKGROUND/AIMS

We hypothesize that patients with functional gastrointestinal disorders (FGID) drink less water volume than healthy subjects during water load test. We evaluated and compared the water load test in students with and without FGID using the Rome III questionnaire.

METHODS

We performed the water load test in 142 students from two schools in Colombia. Students were diagnosed using the Spanish version of the Rome III questionnaire. Students drank water ad libitum for 3 min or until pain, satiety, or vomiting occurred. We correlated anthropometric variables with water volumes drunk. We recorded symptoms like pain and nausea, before and after the water load test.

RESULTS

We evaluated 142 students, with a mean age of 12.1 ± 0.2 years and 59.9% girls. Mean water volume drunk was 459 ± 22 mL. There was no significant difference between water volume drunk by students with and without FGID (466 ± 36 vs. 453 ± 27 mL, p = 0.108). We found a significant correlation between water volume drunk and gender, age, weight, height, and body mass index.

CONCLUSIONS

Students with and without FGID ingest similar volumes of water. Test adverse effects are minimal, and the test is safe to perform and well tolerated.

Herbal medicines in functional dyspepsia-Untapped opportunities not without risks

BACKGROUND

Contemporary treatments for functional dyspepsia have limitations. Herbal medicine has been suggested as adjunctive treatment. With growing scientific recognition and public interests, an in-depth review of this is timely.

AIMS/PURPOSE

To evaluate the therapeutic potential and problems that may be associated with the adoption of herbal medicines in functional dyspepsia.

METHODS

We reviewed the treatment landscape of functional dyspepsia and assessed the scientific community's interest in herbal medicine. Preclinical pharmacological and clinical trial data were reviewed for several herbal medicines available in the market. Challenges associated with adoption of herbal medicine in mainstream medicine were critically evaluated.

RESULTS

We found that herbal medicines frequently comprise a combination of herbs with multiple reported pharmacological effects on gastrointestinal motility and secretory functions, as well as cytoprotective and psychotropic properties. We identified a number of commercially available herbal products that have undergone rigorous clinical trials, involving large numbers of well-defined subjects, reporting both efficacy and safety for functional dyspepsia. Persisting concerns include lack of rigorous assessments for majority of products, toxicity, consistency of ingredients, dose standardizations, and quality control. We provide a quality framework for its evaluation.

CONCLUSIONS

We commend herbal medicine as a viable future option in managing functional dyspepsia. An attractive appeal of herbal medicine is the prospect to simultaneously target multiple pathophysiological mechanisms. Wider adoption and acceptance of herbal medicines in treatment algorithms of functional dyspepsia will require the application of the scientific rigor expected of chemical therapies, to all stages of their development and evaluation.

Differentiated approach to the choice of PPI in a patient with GERD in the practice of an outpatient (with a clinical case)

In recent years, functional disorders of the gastrointestinal tract (GIT) are quite common. The most significant functional disorders are functional dyspepsia (FD), which is widespread in the population. In addition, in the clinical practice of outpatient doctors, the proportion of combined variants or overlap of several types of functional disorders or a combination of functional disorders with organic pathology has increased. So, according to systematic reviews, the combined course of gastroesophageal reflux disease (GERD) and FD occurs in at least one third of patients. At the same time, the combined functional pathology of the gastrointestinal tract changes the clinical picture of GERD, which complicates differential diagnosis, leads to inadequate and multiple prescription of drugs and often low effectiveness of the prescribed therapy. All this negatively affects the quality of life of patients. The tactics of managing patients with the combined course of GERD and FD sometimes presents certain difficulties, since there are no available recommendations for pathogenetic therapy and preventive measures. To date, possible links in the pathogenesis of both GERD and FD have been studied and described, which predetermine certain approaches to the treatment of various variants of these two diseases. Drug therapy for GERD includes the appointment of proton pump inhibitors (PPIs), antireflux drugs. In FD therapy, prokinetics and/or PPIs are effective. A rational approach in the treatment of the intersection of GERD and FD is the appointment of a drug with a dual mechanism of action, which contains both a prokinetic and a PPI. An example of this approach is the appointment of omeprazole and domperidone. The use of this drug is presented in a clinical case.

The Association between Helicobacter pylori Infection and Irritable Bowel Syndrome: A Meta-Analysis

The association of Helicobacter pylori (H. pylori) infection with functional dyspepsia has been well studied. However, the data on the relationship between H. pylori infection and irritable bowel syndrome (IBS) are conflicting. This study aims to elucidate the association between H. pylori infection and IBS. PubMed, Cochrane Library, CINAHL and SCOPUS databases were searched to identify eligible English articles published up to December 2019. Cross-sectional studies, case–control studies and cohort studies reporting both prevalence of H. pylori infection and IBS were selected for the detailed review. The pooled odds ratio (ORs) and their 95% confidence interval (CI) were calculated. A total of 7269 individuals in four cross-sectional studies and six case-control studies were included. The prevalence of H. pylori infection ranged from 12.8% to 73.4% in the control group, and 9.7% to 72.1% in the IBS group. The combined OR for H. pylori infection was 1.10 (95% CI: 0.93–1.29, I²: 37.5%). In a subgroup analysis of IBS defined according to Rome criteria, the OR for H. pylori infection was 1.10 (95% CI: 0.93–1.30, I² = 31.7%). In this meta-analysis, H. pylori infection was not significantly associated with IBS. Well-designed studies are needed to identify the relationship between H. pylori infection and IBS.

Pathogenetic approach to the treatment of functional disorders of the gastrointestinal tract and their intersection: results of the Russian observation retrospective program COMFORT

BACKGROUND

The aim of this study was to investigate the efficacy and safety of the novel complex drug, consisting of released-active form of antibodies to S-100 protein, tumor necrosis factor-α and histamine, (Kolofort) under outpatient conditions in patients with functional dyspepsia (FD), irritable bowel syndrome (IBS), and FD-IBS overlap.

METHODS

The subjects of the observational noninterventional retrospective program were the data of 14,362 outpatient records of patients with diagnosed FD, IBS, and/or overlap, who were observed by gastroenterologists from November 01, 2017, through March 30, 2018, who received the drug Kolofort in monotherapy for 12 weeks, 2 tablets twice a day. To assess the presence and severity of symptoms of functional gastrointestinal disorders (FGID), the "7*7" questionnaire developed by a working group from the Russian Gastroenterological Association was used. The evaluated parameters included the proportion of patients: who had a 50% or more reduction in the total score; who have switched to the less severe category of the condition; who have switched to the "healthy" or "borderline ill" severity categories; and the change in the score in domains 1-7.

RESULTS

The final efficacy analysis included data from 9254 patients. A decrease in the total score by 50% or more was observed in 80.45% of patients with FD, 79.02% of patients with IBS, and in 83% of patients with both IBS and FD. Switch to a lower severity category of the condition at the end of therapy was noted in 93.35% of patients with FD, in 93.80% of cases in patients with IBS, and in 96.17% of cases in patients with a combination of IBS and FD. A total of 94 adverse events (AEs) were reported in 80 patients (0.65%).

CONCLUSION

The COMFORT program has demonstrated the positive effect of treatment in the majority of patients with IBS and FD and their combination in real clinical practice.

Is there an association between Helicobacter pylori infection and irritable bowel syndrome? A meta-analysis

BACKGROUND

Irritable bowel syndrome (IBS) is a prevalent and debilitating gastrointestinal condition. Research has reported persistent, low-grade mucosal inflammation and significant overlaps between patients with IBS and those with dyspepsia, suggesting a possible pathogenic role of Helicobacter pylori (H. pylori) in IBS. This study therefore aimed to provide the first systematic review and meta-analysis on the association between H. pylori infection and IBS.

AIM

To investigate the association between H. pylori infection and IBS.

METHODS

Using the keywords "H. pylori OR Helicobacter OR Helicobacter pylori OR infection" AND "irritable bowel syndrome OR IBS", a preliminary search of PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, Web of Science, Google Scholar and WanFang databases yielded 2924 papers published in English between 1 January 1960 and 1 June 2018. Attempts were also made to search grey literature.

RESULTS

A total of 13 clinical studies were systematically reviewed and nine studies were included in the final meta-analysis. Random-effects meta-analysis found a slight increased likelihood of H. pylori infection in patients with IBS, albeit this was not statistically significant (pooled odds ratio 1.47, 95% confidence interval: 0.90-2.40, P = 0.123). It must also be acknowledged that all of the available studies reported only crude odd ratios. H. pylori eradication therapy also does not appear to improve IBS symptoms. Although publication bias was not observed in the funnel plot, there was a high degree of heterogeneity amongst the studies included in the meta-analysis (I 2 = 87.38%).

CONCLUSION

Overall, current evidence does not support an association between IBS and H. pylori infection. Further rigorous and detailed studies with larger sample sizes and after H. pylori eradication therapy are warranted.

Overlap of Irritable Bowel Syndrome and Functional Dyspepsia in the Clinical Setting: Prevalence and Risk Factors

BACKGROUND

According to Rome IV criteria, functional dyspepsia (FD) and irritable bowel syndrome (IBS) are distinct functional gastrointestinal disorders (FGID); however, overlap of these conditions is common in population-based studies, but clinical data are lacking.

AIMS

To determine the overlap of FD and IBS in the clinical setting and define risk factors for the overlap of FD/IBS.

METHODS

A total of 1127 consecutive gastroenterology outpatients of a tertiary center were recruited and symptoms assessed with a standardized validated questionnaire. Patients without evidence for structural or biochemical abnormalities as a cause of symptoms were then categorized based upon the symptom pattern as having FD, IBS or FD/IBS overlap. Additionally, this categorization was compared with the clinical diagnosis documented in the integrated electronic medical records system.

RESULTS

A total of 120 patients had a clinical diagnosis of a FGID. Based upon standardized assessment with a questionnaire, 64% of patients had FD/IBS overlap as compared to 23% based upon the routine clinical documentation. In patients with severe IBS or FD symptoms (defined as symptoms affecting quality of life), the likelihood of FD/IBS overlap was substantially increased (OR = 3.1; 95%CI 1.9-5.0) and (OR = 9.0; 95%CI 3.5-22.7), respectively. Thus, symptom severity for IBS- or FD symptoms were significantly higher for patients with FD/IBS overlap as compared to patients with FD or IBS alone (p all < 0.01). Age, gender and IBS-subtype were not associated with overlap.

CONCLUSION

In the clinical setting, overlap of FD and IBS is the norm rather than the exception. FD/IBS overlap is associated with a more severe manifestation of a FGID.

Thailand Dyspepsia Guidelines: 2018

The management of dyspepsia in limited-resource areas has not been established. In 2017, key opinion leaders throughout Thailand gathered to review and evaluate the current clinical evidence regarding dyspepsia and to develop consensus statements, rationales, levels of evidence, and grades of recommendation for dyspepsia management in daily clinical practice based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline is mainly focused on the following 4 topics: (1) evaluation of patients with dyspepsia, (2) management, (3) special issues (overlapping gastroesophageal reflux disease/irritable bowel syndrome and non-steroidal anti-inflammatory drug/aspirin use), and (4) long-term follow-up and management to provide guidance for physicians in Thailand and other limited-resource areas managing such patients.

Rome Foundation Working Team Report on Post-Infection Irritable Bowel Syndrome

BACKGROUND & AIMS

The existence of postinfection irritable bowel syndrome (PI-IBS) has been substantiated by epidemiology studies conducted in diverse geographic and clinical settings. However, the available evidence has not been well summarized, and there is little guidance for diagnosis and treatment of PI-IBS. The ROME Foundation has produced a working team report to summarize the available evidence on the pathophysiology of PI-IBS and provide guidance for diagnosis and treatment, based on findings reported in the literature and clinical experience.

METHODS

The working team conducted an evidence-based review of publication databases for articles describing the clinical features (diagnosis), pathophysiology (intestinal sensorimotor function, microbiota, immune dysregulation, barrier dysfunction, enteroendocrine pathways, and genetics), and animal models of PI-IBS. We used a Delphi-based consensus system to create guidelines for management of PI-IBS and a developed treatment algorithm based on published findings and experiences of team members.

RESULTS

PI-IBS develops in about 10% of patients with infectious enteritis. Risk factors include female sex, younger age, psychological distress during or before acute gastroenteritis, and severity of the acute episode. The pathogenesis of PI-PBS appears to involve changes in the intestinal microbiome as well as epithelial, serotonergic, and immune system factors. However, these mechanisms are incompletely understood. There are no evidence-based, effective pharmacologic strategies for treatment of PI-IBS. We provide a consensus-based treatment algorithm, based on clinical presentation and potential disease mechanisms.

CONCLUSIONS

Based on a systematic review of the literature and team experience, we summarize the clinical features, pathophysiology (from animal models and human studies), and progression of PI-IBS. Based on these findings, we present an algorithm for diagnosis and treatment of PI-IBS based on team consensus. We also propose areas for future investigation.

Impact of concomitant dyspepsia and irritable bowel syndrome on symptom burden in patients with gastroesophageal reflux disease

BACKGROUND

Patients with gastroesophageal reflux disease (GERD) frequently report symptoms like dyspepsia or/and irritable bowel syndrome (IBS). The aim of the study was to investigate the impact of symptom overlap on GERD symptom burden. We also investigate whether GERD overlapping dyspepsia or/and IBS would have different clinical and psychological features as compared with GERD alone.

METHODS

A total of 2752 subjects were screened from a health check-up population. We compared the clinical and psychological factors among subjects with GERD alone and with overlap of two or all three diseases. All participants underwent an evaluation with questionnaires including Reflux Disease Questionnaire score, Pittsburgh Sleep Quality Index, Taiwanese Depression Questionnaire, and State-Trait Anxiety Inventory before receiving endoscopic exam.

RESULTS

Among the GERD population, we identified 26 with IBS (GERD-IBS), 60 with dyspepsia (GERD-D), and 25 subjects with overlap of all three conditions (GERD-D-IBS). GERD-D and GERD-D-IBS subjects had more severe GERD symptoms as compared subjects with GERD alone (p < 0.001). Subjects with overlapping dyspepsia or/and IBS showed a significant increase in the severity of depression and poorer sleep quality than subjects with GERD alone. Notably, anxiety scores did not differ significantly between subjects with overlapping diseases and GERD alone.

CONCLUSION

Our study demonstrates that disease overlap in GERD population is associated with greater symptom burden, higher depression and poorer sleep quality, but not with anxiety. This study highlights the importance of identifying overlapping conditions as a therapeutic strategy for better management of GERD.

Functional Dyspepsia and Severity of Psychologic Symptoms Associate With Postprandial Symptoms in Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS

Patients with irritable bowel syndrome (IBS) have an increased response of postprandial symptoms to a combined lactulose nutrient challenge test, compared with healthy volunteers. We investigated the associations among comorbid functional dyspepsia (FD), severity of psychologic symptoms, and breath test results in response to this test.

METHODS

We performed a prospective study of 205 patients with IBS (Rome III criteria), 94 of whom also had FD (IBS-FD), and 83 healthy volunteers in Sweden from 2008 through 2015. All participants completed a breath hydrogen test after a 400-mL liquid meal with 25 g lactulose. Gastrointestinal (GI) symptom severity was assessed using a graded scale and digestive comfort was recorded before the meal and every 15 minutes until 240 minutes after the meal. GI symptom scores over time were compared between groups using linear mixed models with anxiety, depression, and somatization as covariates.

RESULTS

Average levels of all GI symptoms varied over time among all groups (P < .0001). Patients with IBS-FD had higher levels of bloating (P = .004), abdominal pain (P = .005), and lower levels of digestive comfort (P < .01) than patients with only IBS. We observed a difference in increase in abdominal pain from baseline between IBS-FD and IBS groups (P = .013). Anxiety levels were associated with levels of all symptoms (all P < .025) except abdominal pain, which was associated with somatization severity (P < .0001). Furthermore, anxiety levels associated with level of exhaled hydrogen (P = .0042).

CONCLUSIONS

In a prospective study of patients with IBS, we found those with FD to have increased GI symptoms before and after a liquid meal with lactulose. Anxiety and somatization have an independent additional effect. The presence of comorbid FD and levels of psychologic symptoms affect reports of food-related symptoms in patients with IBS. ClinicalTrial.gov no: NCT01252550.

The Effect of Trimebutine on the Overlap Syndrome Model of Guinea Pigs

Background/Aims

Functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common gastrointestinal (GI) disorders and these patients frequently overlap. Trimebutine has been known to be effective in controlling FD co-existing diarrhea-dominant IBS, however its effect on overlap syndrome (OS) patients has not been reported. Therefore, we investigated the effect of trimebutine on the model of OS in guinea pigs.

Methods

Male guinea pigs were used to evaluate the effects of trimebutine in corticotropin-releasing factor (CRF) induced OS model. Different doses (3, 10, and 30 mg/kg) of trimebutine were administered orally and incubated for 1 hour. The next treatment of 10 μg/kg of CRF was intraperitoneally injected and stabilized for 30 minutes. Subsequently, intragastric 3 mL charcoal mix was administered, incubated for 10 minutes and the upper GI transit analyzed. Colonic transits were assessed after the same order and concentrations of trimebutine and CRF treatment by fecal pellet output assay.

Results

Different concentrations (1, 3, and 10 μg/kg) of rat/human CRF peptides was tested to establish the OS model in guinea pigs. CRF 10 μg/kg was the most effective dose in the experimental OS model of guinea pigs. Trimebutine (3, 10, and 30 mg/kg) treatment significantly reversed the upper and lower GI transit of CRF induced OS model. Trimebutine significantly increased upper GI transit while it reduced fecal pellet output in the CRF induced OS model.

Conclusions

Trimebutine has been demonstrated to be effective on both upper and lower GI motor function in peripheral CRF induced OS model. Therefore, trimebutine might be an effective drug for the treatment of OS between FD and IBS patients.

Definition, Pathogenesis, and Management of That Cursed Dyspepsia

Dyspepsia is an umbrella term used to encompass a number of symptoms thought to originate from the upper gastrointestinal tract. These symptoms are relatively nonspecific; not surprisingly, therefore, a myriad of conditions may present with any one or a combination of these symptoms. Therein lays the clinician's first challenge: detecting the minority who may have a potentially life-threatening disorder, such as gastric cancer, from a population whose symptoms are, for the most part, considered functional in origin. The second challenge lies in the definition and management of those individuals with functional dyspepsia (FD); the major focus of this review. The Rome process has addressed the issue of FD definition and a look back at the evolution of Rome criteria for this disorder illustrates the complexities that have so frustrated us. There has been no shortage of hypotheses to explain symptom pathogenesis in FD; initially focused on gastric sensorimotor dysfunction, these have now strayed well into the duodenum and have come to entertain such factors as immune responses and the microbiome. FD has proven to be an equally challenging area for therapeutics; while the staple approaches of acid suppression and eradication of Helicobacter pylori have some limited efficacy in select populations, strategies to ameliorate symptoms in the majority of sufferers based on presumed pathophysiology have largely foundered. Lacking a validated biomarker(s) FD continues to be an elusive target and is likely to remain so until we can better define the various phenotypes that it must surely contain.

Classification of pediatric functional gastrointestinal disorders related to abdominal pain using Rome III vs. Rome IV criterions

BACKGROUND

The primary purpose of this study was to compare Rome III and IV evaluation criteria for irritable bowel syndrome (IBS), functional dyspepsia (FD), and an overlap syndrome consisting of both IBS and FD by assessing the frequency of each diagnosis in a population of children with chronic abdominal pain. Frequencies of Rome IV FD subtypes of postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) were determined and FD/IBS overlap symptom associations were also assessed.

METHODS

We conducted a cross-sectional retrospective chart review of 106 pediatric patients who had completed standardized medical histories as part of their evaluation for chronic abdominal pain. The patients ranged from eight to 17 years of age and reported having abdominal pain at least weekly for 8 weeks. Patients whose evaluation revealed gastrointestinal disease were excluded. The patients' diagnoses were determined by a single pediatric gastroenterologist utilizing the specific criteria for Rome III and IV, respectively.

RESULTS

Patients were significantly more likely to be diagnosed with FD (84.9% vs. 52.8%), IBS (69.8% vs. 34%), and FD/IBS overlap (58.5% vs. 17.9%) by Rome IV criteria, as compared to Rome III criteria. With regard to Rome IV FD subtypes, 81.1% fulfilled criteria for PDS, 11.1% fulfilled criteria for EPS, 6.7% fulfilled criteria for both, and 1.1% did not fulfill criteria for either. Finally, we found an increased frequency of diarrhea and pain with eating in the overlap group compared to the non-overlap group of Rome III, while only an increased frequency of diarrhea was found in the overlap group compared to the non-overlap group of Rome IV.

CONCLUSIONS

Our data demonstrate that utilizing Rome IV criteria, as compared to Rome III, results in an increase in the diagnosis of FD, a two-fold increase in the diagnosis of IBS, and a three-fold increase in the diagnosis of FD/IBS overlap. Rome IV criteria appears to result in greater heterogeneity within diagnostic categories. It is important to determine whether Rome IV diagnoses are predictive of treatment response, and if so, whether assessing symptom variability within a diagnosis will enhance the ability to select patients for a particular treatment.

Gender differences in ghrelin, nociception genes, psychological factors and quality of life in functional dyspepsia

AIM

to evaluate gender differences in the aspect of ghrelin, nociception-related genes and psychological aspects and the quality of life (QoL) in Korean functional dyspepsia (FD) patients.

METHODS

Total of 191 persons were prospectively enrolled between March 2013 and May 2016 in Seoul National Bundang Hospital, and classified into control and FD group based on ROME III criteria. Questionnaire included assessment for dyspepsia symptoms, QoL and anxiety or depression. Preproghrelin and nociception genes in the gastric mucosa and plasma acyl/des-acyl ghrelin were measured.

RESULTS

Lower level of plasma acyl ghrelin in FD patients compared to control was significant only in male (15.9 fmol/mL vs 10.4 fmol/mL, P = 0.017). Significantly higher mRNA expressions of nerve growth factor and transient receptor potential vanilloid receptor 1 were observed in male (P = 0.002 and P = 0.014, respectively) than in female. In contrast, female FD patients had a higher anxiety and depression score than male FD (P = 0.029), and anxiety score was correlated with epigastric pain only in female FD patients (female: Spearman rho = 0.420, P = 0.037). The impairment of overall QoL was more prominent in female FD patients than male patients (5.4 ± 0.3 vs 6.5 ± 0.3, P = 0.020).

CONCLUSION

Gender differences of ghrelin and nociception-related genes in male and psychological factors in female underlie FD symptoms. More careful assessment of psychological or emotional status is required particularly for the female FD patients.

Clinical characteristics of functional dyspepsia depending on chemosensitivity to capsaicin

BACKGROUND

Augmented chemosensitivity to capsaicin has been demonstrated in approximately half of functional dyspepsia (FD) patients.

AIM

We determined clinical characteristics of FD patients with and without chemical hypersensitivity at baseline and after capsaicin ingestion for 4 weeks.

METHODS

N=49 outpatients with confirmed FD received an oral sensitivity test with 0.75 mg capsaicin at three occasions, before and after ingesting 0.25 mg capsaicin tid for 4 weeks. Symptomatic response to capsaicin allowed stratification to a capsaicin positive (chemosensitive) and a capsaicin negative (not chemosensitive) patient group. Symptom diaries were completed in the week before and during capsaicin ingestion.

RESULTS

A total of 53% FD had a positive capsaicin test, Crohnbach alpha was 0.85. Basic clinical characteristics were comparable in capsaicin positive and negative FD, but median daily aggregate upper gastrointestinal symptoms scores were significantly higher in capsaicin positive (median: 9.4; 5.4/11.7) than in capsaicin negative patients (6.6; 4.1/8.1) (P<.05). After capsaicin ingestion, upper gastrointestinal symptoms scores were reduced by -3.3 (-4.9/-1.9; P<.001) in capsaicin positive and -2.6 (-3.8/-0.3; P<.05) in capsaicin negative patients. Lower abdominal symptoms were comparable in capsaicin positive and negative patients at baseline (NS). After capsaicin ingestion lower gastrointestinal symptoms scores were reduced by -1.0 (-1.8/-0.1; P<.05) in capsaicin positive but not significantly altered (-0.6; -1.7/+0.9; NS) in capsaicin negative patients. After long-term capsaicin ingestion, the capsaicin test turned negative in 53% of chemosensitive patients (P<.01).

CONCLUSIONS

Differences in upper GI symptoms distinguished capsaicin positive and negative patients. Symptom improvement after long-term capsaicin ingestion was indirect proportional to the capsaicin test result.

Overlap between irritable bowel syndrome and functional dyspepsia including subtype analyses

BACKGROUND AND AIM

Coexistent gastrointestinal symptom profiles and prevalence or associated factors for the overlap between each functional dyspepsia (FD) and irritable bowel syndrome (IBS) group remain unclear. Thus, the aim of the present study was to evaluate the clinicodemographic features of FD, IBS, and IBS-FD overlap and assess the risk factors thereof, including subtype and genetic polymorphisms for IBS-FD.

METHODS

Consecutive patients were enrolled from the outpatient Gastroenterology clinics of Bundang Seoul National University Hospitals in Korea. All gastrointestinal symptoms occurring at least once per week in the previous 3 months were recorded. Diagnostic criteria of functional gastrointestinal disorders were based on the Rome III criteria. Risk factors including genetic polymorphisms of 5-HTTLPR and ADRA2A 1291 G alleles and CCK-1R intron 779T>C were assessed using a multivariate logistic regression model.

RESULTS

A total of 632 subjects (278 control subjects, 308 FD, 156 IBS, and 110 who met the criteria for both FD and IBS) were included in this study. Patients with IBS-FD overlap had more severe symptoms (such as bloating, nausea, vomiting, hard or lumpy stools, defecation straining, and a feeling of incomplete bowel movement) and higher depression scores compared with non-overlap patients. Single/divorced or widowed marital status, nausea, bloating, and a feeling of incomplete emptying after bowel movements were independent risk factors for IBS-FD overlap among IBS patients. In contrast, young age, depression, bloating, and postprandial distress syndrome were positively associated with IBS-FD overlap among FD patients. 5-HTTLPR L/L was a risk factor for the co-occurrence of IBS-C among FD patients (OR: 12.47; 95% CI: 2.00-77.75; P = 0.007).

CONCLUSIONS

Bloating was a risk factor for IBS-FD overlap. Patients with postprandial distress syndrome have a higher risk of coexisting IBS, particularly constipation-dominant IBS.

The Effect of Peripheral CRF Peptide and Water Avoidance Stress on Colonic and Gastric Transit in Guinea Pigs

Functional dyspepsia (FD) and irritable bowel syndrome (IBS) are common gastrointestinal (GI) diseases; however, there is frequent overlap between FD and IBS patients. Emerging evidence links the activation of corticotropin releasing factor (CRF) receptors with stress-related alterations of gastric and colonic motor function. Therefore, we investigated the effect of peripheral CRF peptide and water avoidance stress (WAS) on upper and lower GI transit in guinea pigs. Dosages 1, 3, and 10 μg/kg of CRF were injected intraperitoneally (IP) in fasted guinea pigs 30 minutes prior to the intragastric administration of charcoal mix to measure upper GI transit. Colonic transits in non-fasted guinea pigs were assessed by fecal pellet output assay after above IP CRF doses. Blockade of CRF receptors by Astressin, and its effect on GI transit was also analyzed. Guinea pigs were subjected to WAS to measure gastrocolonic transit in different sets of experiments. Dose 10 μg/kg of CRF significantly inhibited upper GI transit. In contrast, there was dose dependent acceleration of the colonic transit. Remarkably, pretreatment of astressin significantly reverses the effect of CRF peptide on GI transit. WAS significantly increase colonic transit, but failed to accelerate upper GI transit. Peripheral CRF peptide significantly suppressed upper GI transit and accelerated colon transit, while central CRF involved WAS stimulated only colonic transit. Therefore, peripheral CRF could be utilized to establish the animal model of overlap syndrome.

Multiple functional gastrointestinal disorders linked to gastroesophageal reflux and somatization: A population-based study

BACKGROUND

It is unknown why functional gastrointestinal disorders (FGIDs) overlap and limited information exists on risk factors for those with overlap. Our aim was to estimate the prevalence of combinations of FGIDs including reflux (FGIDs-gastroesophageal reflux [GER]), and evaluate potential risk factors for people with multiple disorders in a representative US community.

METHODS

A population-based study was conducted by mailing a valid GI symptom questionnaire to an age- and gender-stratified random sample of residents of Olmsted County, MN. Rome III definitions were used to identify people with FGIDs, and GER was defined by weekly or more frequent heartburn or acid regurgitation. The prevalence of people meeting multiple symptom complexes was estimated. Moreover, potential risk factors for people with multiple disorders were evaluated.

KEY RESULTS

A total of 3548 people provided data for each of the necessary symptom questions (mean age: 61±16 years, 54% female). Among these 3548 subjects, 2009 (57%) had no FGIDs-GER, 906 (26%) had a pure FGID-GER, 372 (10%) had 2 FGIDs-GER, and 261 (7%) had 3 or more FGIDs-GER. Somatization as assessed by a higher Somatic Symptom Checklist score (OR=3.3, 95% CI [2.7,4.1]) was associated with an increased odds for those with 3 or more FGIDs-GER compared to subjects with a pure FGID-GER adjusting for age and gender.

CONCLUSIONS AND INFERENCES

Symptom complex overlap is common rather than rare in the community. GER is an integral symptom complex associated with both upper and lower FGIDs. Somatization is a strong risk factor for multiple FGIDs.

Fecal incontinence in irritable bowel syndrome: Prevalence and associated factors in Swedish and American patients

BACKGROUND

Fecal incontinence (FI) is a prevalent but poorly recognized problem in the general population with profound negative effects on daily life. The prevalence of FI in irritable bowel syndrome (IBS) and its association with clinical, demographic, and pathophysiological factors remain largely unknown.

METHODS

One US (n=304) and one Swedish (n=168) patient cohort fulfilling Rome III criteria for IBS completed Rome III diagnostic questions on FI and IBS symptoms, and questionnaires on IBS symptom severity, quality of life, anxiety and depression, and work productivity impairment. The patients also underwent assessments of colorectal sensitivity and motility.

KEY RESULTS

Fecal incontinence ≥ one day per month was reported by 19.7% (USA) and 13.7% (Sweden) of IBS patients. These proportions rose to 43.4% and 29.8% if patients with less frequent FI were included. Fecal incontinence prevalence was higher in older age groups, with a clear increase above age 40. Irritable bowel syndrome patients with FI reported greater overall IBS symptom severity, more frequent and loose stools, and greater urgency. Negative effects of FI on quality of life, psychological distress, and work productivity were demonstrated. No associations were found between colorectal physiology and FI.

CONCLUSIONS & INFERENCES

Fecal incontinence is common in IBS patients, and similar to previous general population reports, the major risk factors for FI in IBS are older age, rectal urgency, and loose, frequent stools. When IBS patients have comorbid FI, the impact on quality of life, psychological symptoms, and work impairment appears greater.

Somatic Complaints Are Significantly Associated with Chronic Uninvestigated Dyspepsia and Its Symptoms: A Large Cross-sectional Population Based Study

Background/Aims

Somatization may influence persistence and severity of symptoms in gastrointestinal diseases. Some studies suggest that somatization is associated with chronic uninvestigated dyspepsia (CUD); however, the association is unclear. We aimed to determine the association between the profiles of somatic complaints with CUD and its symptoms.

Methods

In a cross-sectional study conducted on 4763 Iranian adults, somatic complaints were assessed using a comprehensive 31-items questionnaire. Patients with CUD were identified by the Rome III diagnostic criteria. Profiles of somatic complaints were derived from factor analysis. Logistic regression analysis was used to assess the relationship between extracted profiles with CUD and its symptoms.

Results

CUD, bothersome postprandial fullness, early satiation, and epigastric pain or burning was identified in 723 (15.2%), 384 (8.1%), 302 (6.3%), and 371 (7.8%) of the study population. The frequency of all 31 somatic complaints was significantly higher in patients with CUD compared with controls (P < 0.001), and the most frequent was severe fatigue (45.1%). The profiles of somatic complaints were extracted in 4 domains, including “psychological”, “gastrointestinal”, “neuro-skeletal”, and “pharyngeal-respiratory”. The psychological (OR, 1.49; 95% CI, 1.44–1.54), gastrointestinal (OR, 2.22; 95% CI, 2.09–2.37), neuro-skeletal (OR, 1.52; 95% CI, 1.44–1.59), and pharyngeal-respiratory (OR, 2.09; 95% CI, 1.94–2.25) profiles were significantly associated with greater odds of CUD.

Conclusions

CUD and its symptoms are strongly associated with higher levels of somatic complaints and their related extracted profiles. This perhaps explains that why it can be difficult to treat, however further prospective investigations are required to confirm these associations.

Upper gastrointestinal symptoms in autoimmune gastritis: A cross-sectional study

Autoimmune gastritis is often suspected for its hematologic findings, and rarely the diagnosis is made for the presence of gastrointestinal symptoms. Aims of this cross-sectional study were to assess in a large cohort of patients affected by autoimmune gastritis the occurrence and the pattern of gastrointestinal symptoms and to evaluate whether symptomatic patients are characterized by specific clinical features.Gastrointestinal symptoms of 379 consecutive autoimmune gastritis patients were systematically assessed and classified following Rome III Criteria. Association between symptoms and anemia pattern, positivity to gastric autoantibodies, Helicobacter pylori infection, and concomitant autoimmune disease were evaluated.In total, 70.2% of patients were female, median age 55 years (range 17-83). Pernicious anemia (53.6%), iron deficiency anemia (34.8%), gastric autoantibodies (68.8%), and autoimmune disorders (41.7%) were present. However, 56.7% of patients complained of gastrointestinal symptoms, 69.8% of them had exclusively upper symptoms, 15.8% only lower and 14.4% concomitant upper and lower symptoms. Dyspepsia, subtype postprandial distress syndrome was the most represented, being present in 60.2% of symptomatic patients. Univariate and multivariate analyses showed that age <55 years (OR 1.6 [CI:1-2.5]), absence of smoking habit (OR 2.2 [CI:1.2-4]), and absence of anemia (OR 3.1 [CI:1.5-6.4]) were independent factors associated to dyspepsia.Autoimmune gastritis is associated in almost 60% of cases with gastrointestinal symptoms, in particular dyspepsia. Dyspepsia is strictly related to younger age, no smoking, and absence of anemia.

The overlap of upper functional gastrointestinal disorders with irritable bowel syndrome in Chinese outpatients: A multicenter study

BACKGROUND AND AIM

Irritable bowel syndrome (IBS) is a common functional bowel disease, and the overlap with upper functional gastrointestinal disorders (FGIDs) is popular. However, the coexistent upper GI symptom profiles, upper FGID spectra, and related risk factors among IBS subjects remain unclear in mainland of China.

METHODS

Consecutive patients from the outpatient gastroenterology clinics of three tertiary hospitals in China were enrolled in this multicenter study. All upper GI symptoms occurring at least once a week in the last 3 months were recorded. Diagnostic criteria of functional esophageal, gastroduodenal disorders and IBS were based on Rome III criteria. Risk factors were assessed using a multivariate logistic regression model.

RESULTS

Of the 8906 consecutive patients, 751 patients met Rome III criteria for IBS and 735 IBS patients participated in the interview. Postprandial fullness (30.6%), belching (27.1%), and regurgitation (21.8%) were the three most prevalent upper GI symptoms in IBS. Functional dyspepsia (FD, 36.7%), belching disorders (27.1%), and functional heartburn (16.3%) were the three most frequent upper FGID in IBS patients. Female sex, divorced or widowed versus married status, defecation straining, reduced bowel movement, mixed IBS, abdominal distention, mild abdominal pain, moderate discomfort were positively associated with IBS-FD overlap. Female sex, drinking, moderate discomfort, and mild to moderate distension were independent risk factors for IBS-belching disorder overlap.

CONCLUSIONS

The study provides detailed overlap spectra of upper FGID with IBS. Mixed IBS is an important risk factor for IBS-FD overlap, which deserved more concern.

Prevalence of overlap syndromes and symptoms in pediatric functional dyspepsia

Background

The purpose was to evaluate the overlap frequency of irritable bowel syndrome (IBS), gastroesophageal reflux disease (GERD), and overactive bladder syndrome (OBS), as well as other gastrointestinal and systemic symptoms, in functional dyspepsia (FD). Additionally, we sought to determine whether adult Rome III FD subtypes were uniquely related to overlap syndromes or symptoms.

Methods

The study was a retrospective review of 100 consecutive pediatric patients, age 8–17 years, diagnosed with FD. All had completed a standardized medical history including gastrointestinal and systemic symptoms as well as specific symptoms related to GERD and OBS. The frequency of overlap with IBS, GERD, and OBS were determined for the whole group and for those fulfilling adult FD subtype criteria. Individual symptoms were also compared by FD subtype.

Results

Overlap IBS was present in 33 % of the FD patients. At least one GERD symptom was present in 74 % of patients with 41 % reporting heartburn. At least one OBS symptom was present in 44 % of patients with 29 % reporting urinary urgency. Other than pain, the most common reported gastrointestinal symptom was nausea (86 %). Systemic symptoms were common. Overlap syndromes/symptoms did not vary by FD subtype. Postprandial distress syndrome was associated with pain with eating, weight loss, and waking at night to have a stool.

Conclusions

FD is a heterogeneous condition in children and adolescents with significant variability in the presence of gastrointestinal and non-gastrointestinal symptoms and overlap syndromes. Varying symptom profiles need to be accounted for and analyzed in studies involving subjects with FD.

The ultrasound meal accommodation test in 509 patients with functional gastrointestinal disorders

AIM

The Ultrasound Meal Accommodation Test (UMAT) is a clinical test used to assess gastric accommodation, gastric emptying, and visceral sensitivity. It has been used as a clinical tool at Haukeland University Hospital, Bergen for more than 20 years.

MATERIAL AND METHODS

Five-hundred and nine patients were retrospectively evaluated, 71% females, and 51% were referred from other hospitals or specialists. The aim was to explore the usefulness of UMAT in patients with suspected functional GI disorders (FGID).

RESULTS

One hundred and sixty patients were diagnosed with functional dyspepsia (FD), and 154 patients were diagnosed with irritable bowel syndrome (IBS). The overlap between IBS and FD was 41%. In 36% of FD patients, ultrasound assessment showed impaired gastric accommodation. Of 262 patients filling out all required fields for the FD diagnosis (ROMA II and III), 198 (74%) met the criteria for FD, but only 91 (34%) were later diagnosed with FD by an experienced clinician.

CONCLUSIONS

By combining ultrasonography, the symptom response to a standardized meal, and psychological assessment, the UMAT is useful in diagnosis and management of patients with FGID.

The latent structure of the functional dyspepsia symptom complex: a taxometric analysis

OBJECTIVES

Rome III introduced a subdivision of functional dyspepsia (FD) into postprandial distress syndrome and epigastric pain syndrome, characterized by early satiation/postprandial fullness, and epigastric pain/burning, respectively. However, evidence on their degree of overlap is mixed. We aimed to investigate the latent structure of FD to test whether distinguishable symptom-based subgroups exist.

METHODS

Consecutive tertiary care Rome II FD patients completed the dyspepsia symptom severity scale. Confirmatory factor analysis (CFA) was used to compare the fit of a single factor model, a correlated three-factor model based on Rome III subgroups and a bifactor model consisting of a general FD factor and orthogonal subgroup factors. Taxometric analyses were subsequently used to investigate the latent structure of FD.

KEY RESULTS

Nine hundred and fifty-seven FD patients (71.1% women, age 41 ± 14.8) participated. In CFA, the bifactor model yielded a significantly better fit than the two other models (χ² difference tests both p < 0.001). All symptoms had significant loadings on both the general and the subgroup-specific factors (all p < 0.05). Somatization was associated with the general (r = 0.72, p < 0.01), but not the subgroup-specific factors (all r < 0.13, p > 0.05). Taxometric analyses supported a dimensional structure of FD (all CCFI<0.38).

CONCLUSIONS AND INFERENCES

We found a dimensional rather than categorical latent structure of the FD symptom complex in tertiary care. A combination of a general dyspepsia symptom reporting factor, which was associated with somatization, and symptom-specific factors reflecting the Rome III subdivision fitted the data best. This has implications for classification, pathophysiology, and treatment of FD.

Enhanced sympathetic nerve activity induced by neonatal colon inflammation induces gastric hypersensitivity and anxiety-like behavior in adult rats

Gastric hypersensitivity (GHS) and anxiety are prevalent in functional dyspepsia patients; their underlying mechanisms remain unknown largely because of lack of availability of live visceral tissues from human subjects. Recently, we demonstrated in a preclinical model that rats subjected to neonatal colon inflammation show increased basal plasma norepinephrine (NE), which contributes to GHS through the upregulation of nerve growth factor (NGF) expression in the gastric fundus. We tested the hypothesis that neonatal colon inflammation increases anxiety-like behavior and sympathetic nervous system activity, which upregulates the expression of NGF to induce GHS in adult life. Chemical sympathectomy, but not adrenalectomy, suppressed the elevated NGF expression in the fundus muscularis externa and GHS. The measurement of heart rate variability showed a significant increase in the low frequency-to-high frequency ratio in GHS vs. the control rats. Stimulus-evoked release of NE from the fundus muscularis externa strips was significantly greater in GHS than in the control rats. Tyrosine hydroxylase expression was increased in the celiac ganglia of the GHS vs. the control rats. We found an increase in trait but not stress-induced anxiety-like behavior in GHS rats in an elevated plus maze. We concluded that neonatal programming triggered by colon inflammation upregulates tyrosine hydroxylase in the celiac ganglia, which upregulates the release of NE in the gastric fundus muscularis externa. The increase of NE release from the sympathetic nerve terminals concentration dependently upregulates NGF, which proportionately increases the visceromotor response to gastric distention. Neonatal programming concurrently increases anxiety-like behavior in GHS rats.

Novel pharmacological therapies for irritable bowel syndrome

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder, which represents a major cost to healthcare services. Current pharmacological treatment includes fibre supplements, antispasmodics, laxatives, loperamide and antidepressants. This article reviews the novel pharmacological treatments already or recently approved for patients with IBS-C (lubiprostone, linaclotide) and IBS-D (alosetron, ramosetron, rifaximin, eluxadoline). Furthermore, results for drugs in development (plecanatide, ibudutant and ebastine) or used in chronic constipation or for other indications, with potential application in IBS (prucalopride, elobixibat, mesalazine, ondansetron and colesevelam) are also reviewed.

Noninflammatory upregulation of nerve growth factor underlies gastric hypersensitivity induced by neonatal colon inflammation

Gastric hypersensitivity is one of the key contributors to the postprandial symptoms of epigastric pain/discomfort, satiety, and fullness in functional dyspepsia patients. Epidemiological studies found that adverse early-life experiences are risk factors for the development of gastric hypersensitivity. Preclinical studies found that neonatal colon inflammation elevates plasma norepinephrine (NE), which upregulates expression of nerve growth factor (NGF) in the muscularis externa of the gastric fundus. Our goal was to investigate the cellular mechanisms by which NE upregulates the expression of NGF in gastric hypersensitive (GHS) rats, which were subjected previously to neonatal colon inflammation. Neonatal colon inflammation upregulated NGF protein, but not mRNA, in the gastric fundus of GHS rats. Western blotting showed upregulation of p110γ of phosphatidylinositol 4,5-bisphosphate 3-kinase (PI3K), phosphoinositide-dependent kinase-1 (PDK1), pAKT(Ser473), and phosphorylated 4E-binding protein (p4E-BP1)(Thr70), suggesting AKT activation and enhanced NGF protein translation. AKT inhibitor MK-2206 blocked the upregulation of NGF in the fundus of GHS rats. Matrix metalloproteinase 9 (MMP-9), the major NGF-degrading protease, was suppressed, indicating that NGF degradation was impeded. Incubation of fundus muscularis externa with NE upregulated NGF by modulating the protein translation and degradation pathways. Yohimbine, an α2-adrenergic receptor antagonist, upregulated plasma NE and NGF expression by activating the protein translation and degradation pathways in naive rats. In contrast, a cocktail of adrenergic receptor antagonists suppressed the upregulation of NGF by blocking the activation of the protein translation and degradation pathways. Our findings provide evidence that the elevation of plasma NE induces NGF expression in the gastric fundus.

Epidemiology of Functional Gastrointestinal Disorders in Japan and in the World

Functional gastrointestinal disorders (FGIDs), represented by functional dyspepsia (FD) and irritable bowel syndrome (IBS), are a group of disorders that include variable combinations of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities. FGIDs account for a significant percentage of patients seen in primary care settings with abdominal symptoms. Although the definition of FGIDs can easily affect the prevalence, the prevalences of dyspepsia/FD and IBS diagnosed by the Rome III criteria in the general population are 5.3–20.4% and 1.1–29.2%, respectively. Recent reports of FD and IBS defined by the Rome III criteria indicated a female predominance. Regarding the subtype prevalence of FD, postprandial distress syndrome was more prevalent than epigastric pain syndrome (5.6–13.9% vs 0.9–9.5%). The subtype prevalence of IBS is characterized by male predominance for IBS with diarrhea and female predominance for IBS with constipation. Factors affecting the development of FGIDs such as epidemiological factors including genetic and environmental factors, are important. Gene polymorphisms are involved in the development of FGIDs. The prevalence differs among races and geographic areas. Foods may affect the development of FGIDs, but the causal relationships between food and FGIDs are not conclusive. The symptoms often regress and appear in the course of these entities. Building a favorable patient-doctor relationship is effective for controlling symptoms of FGIDs. Physicians should explain that FGIDs are highly prevalent conditions, impair the patients’ quality of life even without evident underlying organic causes and are not life-threatening conditions to ensure patients’ understanding.