Fatigue: a distressing symptom for patients with irritable bowel syndrome

Patients' experiences of dietary changes during a structured dietary intervention for irritable bowel syndrome

BACKGROUND

Diet plays an important role in management of gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). Restrictive diets have gained popularity as treatment for IBS, but no studies have examined the patients' experiences of implementing such diets. Thus, the present study aimed to explore the experience of patients with IBS undergoing a structured dietary intervention.

METHODS

Using inductive content analysis, semi-structured interviews were conducted in 19 patients with IBS, who were recruited from a randomised controlled trial evaluating two different restrictive diets for 4 weeks: a diet low in total carbohydrates; and a diet low in fermentable oligo-, di- and monosaccharides and polyols (i.e., FODMAP) combined with traditional IBS dietary advice.

RESULTS

Three main themes developed from the qualitative analysis and together they describe the dietary intervention as supportive, as well as the dietary changes as challenging and contributing to reflection. Patients found the dietary support effective in both initiating and adhering to their dietary changes. Despite the support, the implementation of the diet was perceived as challenging when it interfered with other important aspects of their lives. However, going through the dietary change process, the patients began to reflect on their eating behaviours, which enabled individual dietary adjustments. The adjustments that patients maintained were not only a result of alleviation of GI symptoms, but also based on personal preferences.

CONCLUSIONS

Patients with IBS undergoing restrictive diets appear to benefit from structured support. However, considering the individual patient's life situation and personal preferences, individualised dietary options should be encouraged to achieve long-term dietary changes.

Faecal microbiota transplantation (FMT) in Norwegian outpatients with mild to severe myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): protocol for a 12-month randomised double-blind placebo-controlled trial

INTRODUCTION

The observed alteration of the intestinal microbiota in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and the effect of transferring a healthy gut flora from a faecal donor using a faecal microbiota transplantation (FMT) will be explored in this trial.

METHODS AND ANALYSIS

This is a protocol for a randomised, double-blind, placebo-controlled, parallel-group, single-centre trial, with 12 months follow-up. 80 participants will be included and randomised (1:1:2) to either donor FMT (from two different donors) or placebo (autologous FMT). Participants will be included by the International Clinical Criteria for ME/CFS. The clinical measures of ME/CFS and disease activity include Modified DePaul Questionnaire, Fatigue Severity Scale (FSS), Hospital Anxiety and Depression Scale (HADS), 36-Item Short Form Health Survey (SF-36), ROMA IV criteria, Food Frequency Questionnaire, Repeatable Battery for the Assessment of Neuropsychological Status, heart rate variability testing and reports on the use of antibiotics and food supplements, as well as biobanking of blood, urine and faeces.The primary endpoint is proportion with treatment success in FSS score in donor versus autologous FMT group 3 months after treatment. Treatment success is defined as an FSS improvement of more than 1.2 points from baseline at 3 months after treatment. Adverse events will be registered throughout the study.

ETHICS AND DISSEMINATION

The Regional Committee for Medical Research Ethics Northern Norway has approved the study. The study has commenced in May 2019. Findings will be disseminated in international peer-reviewed journal(s), submitted to relevant conferences, and trial participants will be informed via phone calls.

TRIAL REGISTRATION NUMBER

NCT03691987.

The Epidemiology of Bile Acid Diarrhea in Denmark

OBJECTIVE

Bile acid diarrhea (BAD) is a socially debilitating disease with frequent bowel movements, urgency, and fecal incontinence as the main symptoms. It is caused by excessive bile acid levels in the colon and is most commonly treated with bile acid sequestrants. It is estimated that 1-2% of the population suffers from the disease, but only a fraction of these are properly diagnosed with the gold standard ⁷⁵selenium-homotaurocholic acid (SeHCAT) test. Here, we use nationwide registries to describe the demographic characteristics of individuals suffering from BAD in Denmark.

METHODS

Since the International Classification of Diseases diagnosis code for BAD was not used until 2021, we identified the BAD population by referral to SeHCAT testing followed by a prescription of a bile acid sequestrant (colestyramine, colestipol or colesevelam) within 365 days. The study period was from 2003 to 2021.

RESULTS

During the study period, a total of 5264 individuals with BAD were identified with large differences between the five regions in Denmark. The number of prescriptions of colestyramine and colesevelam, the number of SeHCAT tests, and the number of individuals diagnosed with BAD increased during the study period. The BAD population had more co-morbidities and more health care contacts as well as lower levels of education and income compared with age- and sex-matched controls from the general population.

CONCLUSION

Using the Danish registries, we identified a BAD population, which seems to be inferior in health care and socio-economic parameters compared with the Danish general population.

Age Differences in Core Symptoms and Symptom Relationships in Patients With Irritable Bowel Syndrome: A Network Analysis

INTRODUCTION

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction, characterized by symptoms of abdominal pain and changes in bowel habits. It often co-occurs with extraintestinal somatic and psychological symptoms. However, the nature of the interrelationships among these symptoms is unclear. Although previous studies have noted age differences in IBS prevalence and specific symptom severity, it remains unknown whether specific symptoms and symptom relationships may differ by age.

METHODS

Symptom data were collected in 355 adults with IBS (mean age 41.4 years, 86.2% female). Network analysis was used to examine the interrelationships among 28 symptoms and to identify the core symptoms driving the symptom structure between young (≤45 years) vs older (>45 years) adults with IBS. We evaluated 3 network properties between the 2 age groups: network structure, edge (connection) strength, and global strength.

RESULTS

In both age groups, fatigue was the top core symptom. Anxiety was a second core symptom in the younger age group, but not the older age group. Intestinal gas and/or bloating symptoms also exerted considerable influences in both age groups. The overall symptom structure and connectivity were found to be similar regardless of age.

DISCUSSION

Network analysis suggests fatigue is a critical target for symptom management in adults with IBS, regardless of age. Comorbid anxiety is likely an important treatment focus for young adults with IBS. Rome V criteria update could consider the importance of intestinal gas and bloating symptoms. Additional replication with larger diverse IBS cohorts is warranted to verify our results.

A psychological symptom based machine learning model for clinical evaluation of irritable bowel syndrome

Background: Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by recurrent abdominal pain associated with alterations  in stool form and/or stool frequency. Co-morbidities such as anxiety, depression, fatigue, and insomnia are frequently reported by patients suffering from IBS. Identification of these symptoms should thus be an integral part of an IBS assessment.      However, an optimal tool to screen for core psychological symptoms in IBS is still  missing. Here, we aim to develop a psychological symptom based machine learning model to efficiently help clinicians to identify patients suffering from IBS. Methods: We developed a machine learning workflow to select the most significant psychological features associated with IBS in a dataset including 49 patients with IBS and 35 healthy controls. These features were used to train three different types of machine learning models: logistic regression, decision trees and support vector machine classifiers; which were validated on a holdout validation dataset and an unseen test set. The performance of these models was compared in terms of balanced accuracy scores. Results: A logistic regression model including a combination of symptom features associated with anxiety and fatigue resulted in a balanced accuracy score of 0.93 (0.81-1.0) on unseen test data and outperformed the other comparable models. The same model correctly identified all patients with IBS in a test set (recall score 1) and misclassified one non-IBS subject (precision score 0.91). A complementary post-hoc leave-one-out cross validation analysis including the same symptom features showed similar, but slightly inferior results (balanced accuracy 0.84, recall 0.88, precision 0.86). Conclusions: Inclusion of machine learning based psychological evaluation can complement and improve existing clinical procedure for diagnosis of IBS.

Incongruent Views of Functioning between Patients and Gastroenterologists: A Mixed Methods Study

Gastrointestinal patients, especially those diagnosed with functional digestive disorders (FGIDs), usually present a complex clinical picture that poses a challenge for their management in primary care. The main objective of the current research was to examine the relationship of the congruence of the perception of severity and quality of life between gastroenterologists and their patients with psychological distress and the helping attitude experienced by the latter attended in primary care centres. Additionally, we wanted to explore patients' and practitioners' perceptions. We performed a cross-sectional study with a total of 2261 patients (1562 analysed) that attended three primary care centres. Patients completed questionnaires that measured physical functioning, distress, and perception of helping attitude. Gastroenterologists registered the functional status of each participating patient. Patients were then invited to take part in the qualitative part of the study if they were considered to have incongruent views on their functioning with their gastroenterologist. In total, 52 patients took part in one of eight focus groups. Additionally, four individual interviews were carried out with three gastroenterologists and one consultation-liaison psychiatrist specialised in FGIDs. Both incongruence and functional diagnosis correlated with distress. However, incongruent views between patients and gastroenterologists explained more variance. Statistically significant differences in patients' helping attitude perception were detected between diagnostic but no incongruence groups. In the second stage of the study, a total of five themes were identified from the patient focus groups and the gastroenterologist interviews: illness-emotional and personal problems, disease-health system interaction, health system, intervention, and patients. The current research allowed us to confirm that incongruence in the perception of severity and quality of life between gastroenterologists and patients is related to psychological distress and that this occurs in a multifactorial context where the characteristics of the disorder interact with those of the health system.

Maintaining work life under threat of symptoms: a grounded theory study of work life experiences in persons with Irritable Bowel Syndrome

Background

Irritable Bowel Syndrome (IBS) is a highly prevalent functional gastrointestinal disorder. Earlier studies have shown that IBS can limit the ability to perform at work and lead to absenteeism. However, few studies focus on work life experiences based on patients’ narratives. The purpose of this study was to construct a theory for how persons with IBS maintain their work life.

Methods

A qualitative study was performed using constructivist grounded theory. Semi-structured interviews with 15 women and 8 men with IBS (26–64 years of age) were conducted. Fourteen participants worked full-time, six worked part-time and three were on sick leave. The interviews were transcribed verbatim and coded line-by-line, incident-by-incident and thereafter focused coding was done. From the data and codes, categories were generated. Finally, a core category was constructed explaining the process of maintaining work life when living with IBS.

Results

Balancing work life while being under threat of symptoms constituted of four categories, being prepared, restricting impact, reconciling and adjusting. Persons with IBS restricted the impact of IBS on work by using strategies and upholding daily routines and strived to being prepared by exerting control over work life. These ongoing processes served to limit the influence of IBS on work by symptoms being less intense, perceived as less frequent, or not as bothersome. Reconciling IBS with work life was understood as a successful outcome from being prepared and restricting impact but was also influenced by the individual’s outlook on life. Adjusting to other people at work interfered with the strategies of being prepared, restricting impact, and reconciling, leaving persons with IBS more susceptible to symptoms.

Conclusions

This study deepens the understanding of the work situation for persons with IBS. Health care professionals can use the results of this study in the dialogue with the patient discussing work ability and sick leave. The results imply that although balancing work life under threat of symptoms can be a struggle, there are strategies that persons with IBS and employers together can initiate and use to reduce impact on work on several different levels.

Central sensitization and severity of gastrointestinal symptoms in irritable bowel syndrome, chronic pain syndromes, and inflammatory bowel disease

BACKGROUND

Central sensitization has been suggested as an explanation of the wide range of gastrointestinal and extraintestinal symptoms commonly seen in irritable bowel syndrome (IBS). In this study, the presence and level of central sensitization, and its association to gastrointestinal (GI) symptoms were explored in IBS in comparison with control groups.

METHODS

We investigated patients with IBS (n = 215), chronic pain disorders (n = 36), and inflammatory bowel disease (IBD) (n = 40) and volunteers without chronic diseases (n = 112). The Central Sensitization Inventory (CSI) was translated and validated in Swedish and used together with the Highly Sensitive Person (HSP) scale to measure the presence and level of central sensitization. Furthermore, severity of GI symptoms (GSRS-IBS and IBS-SSS), and anxiety and depression (HAD) were determined.

KEY RESULTS

The Swedish translation of CSI demonstrated excellent validity. Central sensitization, defined by validated cut-off levels for CSI and HSP, was common in the whole cohort (40% and 28%) and in IBS (57% and 35%). Study participants with central sensitization had more severe GI symptoms, anxiety and depression, than participants without central sensitization. Strong associations were seen between CSI and GI symptom severity in the whole cohort (GSRS-IBS: partial η²  = 0.455, p < 0.001; IBS-SSS: partial η²  = 0.408, p < 0.001), with decreasing strength in patients with chronic pain, IBD, IBS, and volunteers.

CONCLUSION AND INFERENCES

Central sensitization was common in IBS and associated with GI symptom severity, but with stronger associations in chronic pain disorders and IBD. This implies that other mechanisms may be of equal or greater importance for GI symptom severity in IBS.

Central sensitization in burning mouth syndrome: a practical approach using questionnaires

OBJECTIVES

Some experts have suggested that burning mouth syndrome (BMS) should be included in the family of central sensitivity syndromes, a group of similar medical disorders linked by the central sensitization (CS) mechanism. Our objective is to assess the presence of CS in patients with BMS by performing a clinical examination and administering questionnaires to measure the generalized extent of pain, the presence of associated symptoms, and the number of other concurrent chronic pain conditions.

STUDY DESIGN

We conducted a case-control study in 82 subjects (40 patients with BMS and 42 controls). Patients with BMS were diagnosed using The International Classification of Headache Disorders 3rd edition, beta version (ICHD-IIIβ) criteria. The Widespread Pain Index (WPI) and Symptom Severity (SS) Score questionnaires were used to determine the degree of central sensitivity. The number of other concurrent chronic pain conditions was determined with the Neblett inventory.

RESULTS

Data indicative of CS show a statistically significant association with BMS. Both SS Score and Widespread Pain Index scores higher in patients with BMS. Additionally, patients with BMS reported a significantly higher number of other central sensitivity syndromes.

CONCLUSIONS

Patients with BMS could present a CS component as well as other chronic pain conditions. The use of questionnaires may be useful to determine the degree of central sensitivity in patients with BMS.

Cumulative Effect of Psychological Alterations on Gastrointestinal Symptom Severity in Irritable Bowel Syndrome

INTRODUCTION

Psychological alterations are common and considered important for symptom generation in irritable bowel syndrome (IBS). However, the possible cumulative effect of having multiple psychological alterations on gastrointestinal (GI) symptom severity in IBS is largely unknown.

METHODS

Patients with IBS (Rome IV) completed validated questionnaires assessing GI symptoms (Gastrointestinal Symptom Rating Scale, IBS version and IBS Severity Scoring System), personality traits (Big Five), posttraumatic stress and psychological alterations, anxiety (Generalized Anxiety Disorder 7-item scale and State-Trait Anxiety Inventory), depression (Patient Health Questionnaire, 9-item version), fatigue (Multidimensional Fatigue Inventory), pain catastrophizing, somatization (Patient Health Questionnaire, 12-item version), stress (Perceived Stress Scale), and GI-specific anxiety (Visceral Sensitivity Index). Of the 18 possible psychological factors, those with significant associations with GI symptom severity, corrected for multiple comparisons, were identified. The associations between increasing number of psychological alterations (validated cutoff values or uppermost tertile) and the severity of GI symptoms were analyzed with linear trend analyses.

RESULTS

In total, 106 patients with IBS (Rome IV criteria) were included (72 [68%] women, median age of 35 [interquartile range: 26-45] years). Psychological alterations were common and overlap among these factors were frequently seen. Five psychological factors (physical fatigue, GI-specific anxiety, perceived stress, pain catastrophizing, and trait anxiety) demonstrated significant, noncollinear associations with GI symptom severity. With increasing number of these psychological alterations, a gradual increase was seen in the overall severity of GI symptoms (Gastrointestinal Symptom Rating Scale, IBS version: partial η = 0.268, P < 0.001; IBS Severity Scoring System: partial η = 0.219, P < 0.001, both large effect sizes).

DISCUSSION

Distinct associations were seen between the severity of GI symptoms and individual, as well as an increasing number of psychological alterations. This highlights the importance of understanding different psychological alterations for the disease burden in IBS (visual abstract, Supplementary Digital Content 1, http://links.lww.com/AJG/B756).

Fatigue in irritable bowel syndrome is associated with plasma levels of TNF-α and mesocorticolimbic connectivity

Irritable bowel syndrome (IBS) is a symptom-based disorder of gut-brain interactions generating abdominal pain. It is also associated with a vulnerability to develop extraintestinal symptoms, with fatigue often reported as one of the most disturbing. Fatigue is related to brain function and inflammation in several disorders, however, the mechanisms of such relations in IBS remain elusive. This study aimed to elucidate fatigue and its association with a resting state network of mesocorticolimbic regions of known importance in fatigue, and to explore the possible role of circulating TNF-α levels in IBS and healthy controls (HC). Resting state functional magnetic resonance imaging (fMRI) was conducted in 88 IBS patients and 47 HC of similar age and gender to investigate functional connectivity between mesocorticolimbic regions. Further, fatigue impact on daily life and plasma levels of the proinflammatory cytokine tumor necrosis factor-α (TNF-α), of known relevance to immune activation in IBS, were also measured. The selected mesocorticolimbic regions indeed formed a functionally connected network in all participants. The nucleus accumbens (NAc), in particular, exhibited functional connectivity to all other regions of interest. In IBS, fatigue impact on daily life was negatively correlated with the connectivity between NAc and dorsolateral prefrontal cortex bilaterally (left p = 0.019; right p = 0.038, corrected for multiple comparisons), while in HC, fatigue impact on daily life was positively correlated to the connectivity between the right NAc and anterior middle insula in both hemispheres (left p = 0.009; right p = 0.011). We found significantly higher levels of TNF-α in IBS patients compared to HC (p = 0.001) as well as a positive correlation between TNF-α and fatigue impact on daily life in IBS patients (rho = 0.25, p = 0.02) but not in HC (rho = -0.13, p = 0.37). There was no association between functional connectivity in the mesocorticolimbic network and plasma levels of TNF-α in either group In summary, this novel multimodal study provides the first evidence that the vulnerability to fatigue in IBS is associated with connectivity within a mesocorticolimbic network as well as immune activation. These findings warrant further investigation, both peripherally and potentially with measurements of central immune activation as well.

Brief Behavioral Therapy for Insomnia in Patients with Irritable Bowel Syndrome: A Pilot Study

BACKGROUND

Up to 60% of patients with irritable bowel syndrome (IBS) report fatigue and 50% meet criteria for clinical insomnia. Recent studies have demonstrated a relationship between poor sleep and next-day IBS symptoms. However, no study to-date has evaluated behavioral therapy to treat poor sleep in IBS.

AIMS

The aim of the current pilot study is to test feasibility of behavioral therapy for insomnia among patients with IBS and poor sleep.

METHODS

This randomized controlled pilot study tested the feasibility of administering brief behavioral therapy for insomnia (BBT-I) to patients with IBS who report poor sleep. Participants were randomized to BBT-I or self-monitoring control. Exploratory analyses evaluated group differences after 4 weeks of treatment.

RESULTS

A total of 25 participants were randomized to the study, 13 to BBT-I and 12 to the control group. Three participants dropped out of the treatment group. Satisfaction with treatment was high. At follow-up, there were significant differences between groups in measures of sleep quality and insomnia severity. There were trends toward significance in IBS severity score, with 40% of the BBT-I sample reporting clinically meaningful drop in symptoms compared to 17% of the control group. Similar trends were observed with belly pain and global improvement scores.

CONCLUSIONS

This pilot study demonstrates feasibility/acceptability of a brief behavioral therapy for patients with IBS and poor sleep. Additionally, this study provides preliminary evidence to suggest that treatment of sleep difficulties in patients with IBS may improve IBS symptom outcomes. Future, larger randomized controlled studies are needed.

The effect of fecal microbiota transplantation on IBS related quality of life and fatigue in moderate to severe non-constipated irritable bowel: Secondary endpoints of a double blind, randomized, placebo-controlled trial

BACKGROUND

Severity in irritable bowel syndrome (IBS) is associated to impaired quality of life and fatigue. Fecal microbiota transplantation (FMT) induces significant relief in gastro-intestinal related complaints. The objective was to evaluate the effect of FMT on the secondary endpoints: IBS-related quality of life and fatigue in patients with non-constipated IBS.

METHOD

In this double-blind randomized placebo-controlled, parallel-group, single-center study, we enrolled patients with non-constipated IBS, defined by the ROME 3 criteria. We randomly assigned participants (2:1) in blocks of six to active or placebo FMT. Responder in fatigue and quality of life were defined as a decrease of 20 points in total Fatigue Impact Scale score, and improvement of 14 points in the IBS-quality of life questionnaire, respectively. In a modified-intention-to-treat population, we excluded participants who did not undergo treatment or who were diagnosed with any other disease by pinch biopsies during the treatment procedure.

FINDINGS

Between Jan1, and Oct 30, 2015, we recruited 90 participants and randomly assigned them to active treatment (n = 60) or placebo (n = 30). Three participants did not undergo FMT and four were excluded after diagnosis of microscopic colitis, leaving 83 for final modified intention-to-treat analysis (55 in the active treatment group and 28 in the placebo group). Significant improvement in QoL (Odds ratio (OR) 3,801; confidence interval (CI) = 1,309-11,042 p = 0.011) and fatigue (OR = 4,398; CI = 1,175-16,468 and p = 0,020) was found at six months. Absence of other self reported functional disorders and presence of depression at baseline is suggested to predict a lasting effect of FMT in QoL and fatigue, respectively.

INTERPRETATION

FMT induced significant relief in quality of life and fatigue. Results suggest a lasting effect of FMT in subgroups that should be further investigated in future studies. Funding Helse Nord, Norway and the Norwegian Centre of Rural Medicine, University of Tromsø, Norway.

Pain Severity and Vitamin D Deficiency in IBD Patients

Background: Pain and vitamin D deficiency are common in inflammatory bowel disease (IBD). Disease activity, fatigue, frequent relapses, prior surgery and psychological factors all seem to influence the experience of pain in IBD. Vitamin D deficiency has been associated with muscle and skeletal pain. This study aimed to determine whether there is an association between vitamin D deficiency and severity of pain in patients with IBD, and to investigate the influence of other socio-demographic and psychological variables on the experience of pain. Methods: Patients with IBD were recruited from nine hospitals in Norway in a multicenter cross-sectional study. The Brief Pain Inventory (BPI) questionnaire was used to measure pain. Disease activity was assessed using clinical disease activity indices, C-reactive protein (CRP) and fecal calprotectin. Regression models were fitted to explore a possible association between 25-hydroxyvitamin D and pain severity. Results: Of 407 patients included in the analyses, 229 (56%) had Crohn’s disease (CD) and 178 (44%) had ulcerative colitis (UC). Vitamin D deficiency was present in half (203/407) of patients. Presence of pain was reported by 76% (309/407). More severe pain was associated with female gender and increased disease activity scores, but not with increased CRP or fecal calprotectin. In CD, patients without prior intra-abdominal surgery reported more severe pain. In multivariate analyses, there was no association between 25-hydroxyvitamin D and pain severity. Conclusions: In this study, no significant association between pain severity and vitamin D deficiency was revealed in patients with IBD.

Anxiety and depression in irritable bowel syndrome: Exploring the interaction with other symptoms and pathophysiology using multivariate analyses

BACKGROUND

Anxiety or depression, in other words, psychological distress, are common comorbidities in patients with irritable bowel syndrome (IBS), but their interaction with pathophysiological factors and other symptoms are unclear.

METHODS

Patients with IBS (Rome III criteria), thoroughly characterized regarding pathophysiology (colonic transit time, visceral sensitivity, and autonomic nervous system [ANS] function), symptom profile (IBS severity, somatic symptoms, gastrointestinal [GI]-specific anxiety and fatigue), and quality of life, were explored for differences regarding pathophysiology and symptoms between patients with and without reported psychological distress in univariate and multivariate analyses (Principal Component Analysis [PCA] with Hotelling's T² and Orthogonal Partial Least Squares-Discriminant Analysis [OPLS-DA]).

KEY RESULTS

When using Hospital Anxiety and Depression Scale score ≥8 as cut-off score, including both borderline and clinically significant cases, 345 (44.9%) out of 769 IBS patients reported anxiety, and 198 (25.7%) depression. In univariate analyses, patients reporting psychological distress demonstrated more severe GI and non-GI symptoms, fatigue, GI-specific anxiety and lower quality of life, and differences for some pathophysiological measures. IBS patients with and without reported psychological distress showed significant differences between the multivariate means in symptom reporting (PCA; both P < 0.001), and in pathophysiological measures in patients with and without anxiety (P = 0.018). Visceral hypersensitivity, altered ANS function, more severe GI-specific anxiety, fatigue, and higher somatic non-GI symptoms were the factors that most strongly separated patients with and without psychological distress (OPLS-DA).

CONCLUSIONS AND INFERENCES

Reported anxiety and depression are common in IBS patients, and our study demonstrates that they are interwoven in the complex pathophysiological and clinical picture of IBS.

Gastrointestinal symptoms - an illness burden that affects daily work in patients with IBS

Background

Irritable Bowel Syndrome (IBS) is a chronic gastrointestinal disorder characterised by recurrent abdominal pain and disturbed bowel habits and unclear aetiology. IBS is also associated with psychosocial factors, impaired quality of life and lost work productivity. This study sought to determine whether the association between IBS and lost work productivity might be accounted for by poor coping strategies and loss of confidence in the healthcare system.

Methods

Case–control design was employed sampling IBS and non-gastrointestinal (non-GI) primary healthcare seekers in a defined region in Sweden. Non-GI patients were of similar age and sex distribution to the IBS patients. Questionnaires applied in this study included instruments designed to measure confidence in the social security system and in the community, as well as questions about whether gastrointestinal problems might affect working life and Sense of coherence (SOC) questionnaire. The study’s primary hypothesis was evaluated via an a priori path model.

Results

Statistically significant differences were found between IBS cases (n = 305) and controls (n = 369) concerning abdominal pain or discomfort affecting everyday performance at work (p <  0.0001). IBS cases also showed significantly lower (p = 0.001) confidence in public healthcare. The study’s hypothesis was supported with the finding of a statistically significant indirect association via poor coping strategies, although the indirect associations were lesser in magnitude than the direct association.

Conclusions

This study found a clear association between clinically diagnosed IBS status and interference in work by gastrointestinal symptoms in which sense of coherence might be of importance.

Experiences of the effects of physical activity in persons with irritable bowel syndrome (IBS): a qualitative content analysis

OBJECTIVE

Increased physical activity has been tested among patients with irritable bowel syndrome (IBS) in a randomized trial which demonstrated improvement in gastrointestinal (GI) symptoms. The patients' experiences of the effects of physical activity on IBS symptoms are unknown. This knowledge is necessary to enable suitable support from health care professionals. The aim of this study was therefore to explore patients' experiences of the effects of physical activity.

MATERIALS AND METHODS

Deep interviews were conducted with 15 patients (10 women and 5 men) aged 31-78 years. Their IBS had lasted for 10-57 years. The transcribed interviews were analyzed through a qualitative content analysis.

RESULTS

The analysis of the material revealed three themes; GI symptoms, extra-intestinal symptoms, and quality of life (QOL). In relation to GI symptoms, the patients discussed how physical activity affected these symptoms and how they used physical activity to normalize and control their GI symptoms. Extra-intestinal symptoms were also affected by physical activity, and the patients described how they experienced a general bodily wellbeing as well as improved mood and energy in relation to physical activity. In terms of QOL, the patients discussed their perspectives on physical activity as giving them achievements, being pleasurable, and being strengthening of the self.

CONCLUSIONS

Our results emphasize the importance of taking into account the patient's experiences of the effects of physical activity when coaching patients with IBS to be physically active. Using a person-centred approach incorporating, the patient's own experiences and resources is the key to successfully promoting physical activity in the clinic.

Association of Fatigue With TPH2 Genetic Polymorphisms in Women With Irritable Bowel Syndrome

Fatigue is the most common extraintestinal symptom in women with irritable bowel syndrome (IBS). Genetic polymorphisms of monoamines are associated with fatigue in many chronic diseases. In this pilot exploratory study, the primary aim was to determine whether genetic polymorphisms of tryptophan hydroxylase ( TPH1/TPH2), serotonin reuptake transporter ( SERT), or catechol-O-methyltransferase ( COMT) are associated with fatigue in women with IBS. Additionally, analysis explored whether these genetic associations with fatigue would be present when controlling for abdominal pain, psychological distress, feeling stressed, and sleepiness during the day. Secondary analysis of two randomized controlled trial baseline data sets in Caucasian women with IBS ( N = 185) was conducted. Participants kept a daily diary with one dimension (i.e., severity) for each of the 26 symptoms, including fatigue, for 28 days prior to randomization. DNA samples were tested for single-nucleotide polymorphisms (SNPs) of TPH1 (four SNPs) /TPH2 (one SNP), SERT (one SNP), and COMT (one SNP). Analysis of covariance was used to examine associations of percentage of diary days with moderate to very severe symptoms with genetic polymorphisms. Only one SNP, TPH2 rs4570625, was significantly associated with fatigue ( p = .005). T-allele (low functional) carriers of TPH2 (i.e., G/T or T/T genotypes) reported a greater percentage of days with moderate to very severe fatigue than G/G homozygotes ( p = .001). Reduced synthesis of tryptophan in the central nervous system may contribute to reports of fatigue in women with IBS. Understanding genetic risk factors for fatigue may elucidate preemptive strategies to reduce fatigue in individuals with IBS.

Work Productivity and Activity Impairment in Irritable Bowel Syndrome (IBS): A Multifaceted Problem

OBJECTIVES

Patients with irritable bowel syndrome (IBS) are more likely to be both absent from and impaired at work compared to non-IBS patients. We investigated the impact of IBS on work productivity and activity impairment and the relationship to disease specific and general health measures.

METHOD

In total, 525 patients with IBS completed questionnaires assessing work productivity and activity impairment, IBS symptom severity, IBS-related quality of life and GI-specific anxiety. In addition, 155 of the patients completed questionnaires assessing severity of somatic symptoms, depression, anxiety and fatigue. Uni- and bivariate analyses were performed, as well as linear regression to determine factors independently associated with the work productivity and activity impairment measures.

RESULTS

Of employed patients, 24.3% reported absenteeism and 86.8% reported presenteeism because of their IBS. With increasing severity of IBS symptoms and GI-specific anxiety, higher degrees of work impairment were seen. Work productivity impairment in IBS was also associated with low quality of life. GI-specific anxiety was independently associated with absenteeism (R² = 0.23; p < 0.05), IBS-symptom severity and general fatigue with presenteeism (R² = 0.40; p < 0.05), IBS-symptom severity, general fatigue and GI-specific anxiety with overall work loss (R² = 0.50; p < 0.05), and IBS symptom severity and somatic symptoms with activity impairment (R² = 0.38; p < 0.05).

CONCLUSION

Work impairment is a substantial problem in patients with IBS. A combination of IBS and somatic symptom severity, fatigue and psychological factors influence patients' ability to be present, active and productive at work. Based on this, a multidimensional treatment approach for patients with IBS seems logical.

Fatigue and its associated factors in microscopic colitis

BACKGROUND

Fatigue is a well-recognized symptom in patients with inflammatory bowel disease and irritable bowel syndrome (IBS), and has been associated with psychological comorbidity and impaired quality of life in both. However, features associated with fatigue in patients with microscopic colitis (MC) are less clear.

MATERIALS AND METHODS

We conducted a cross-sectional survey of patients with a new diagnosis of MC including levels of anxiety, depression, somatization, quality of life, and IBS-type symptoms. Levels and impact of fatigue were assessed using the Inflammatory Bowel Disease Fatigue self-assessment scale. Mean scores were compared against various patient characteristics, and were also correlated with anxiety, depression, somatization, and quality-of-life scores.

RESULTS

In total, 129 patients with MC diagnosed between 2010 and 2015 returned completed postal questionnaires. Common histological subtypes were collagenous colitis (53.5%, n = 69) and lymphocytic colitis (38.8%, n = 50). Higher mean fatigue severity and impact scores were associated with the presence of irritable-bowel-syndrome-type symptoms, abnormal levels of anxiety and depression, and high levels of somatization (p < 0.0001 for all), but those reporting ongoing symptoms attributable to MC did not report significantly higher scores. There were significant positive correlations between total anxiety, depression, or somatization scores and fatigue severity and impact scores, and significant negative correlations with quality-of-life measures (p < 0.001 for all).

CONCLUSIONS

Fatigue in MC appears to be associated with reporting IBS-type symptoms, psychological comorbidity and impaired quality of life. It may therefore represent an important target for treatment.

Fatigue is not associated with vitamin D deficiency in inflammatory bowel disease patients

AIM

To investigate if vitamin D deficiency is associated with fatigue in patients with inflammatory bowel disease (IBD).

METHODS

IBD patients were recruited from nine hospitals in the southeastern and western regions of Norway to participate in a multicenter cross-sectional study lasting from March 2013 to April 2014. Data were collected by interviews, from medical records and laboratory tests. The Fatigue Questionnaire (FQ) was used to measure fatigue. Linear and logistic regression models were applied to explore the possible association between vitamin D deficiency and total fatigue scores and chronic fatigue, respectively. The analyses were adjusted for age, gender, disease activity, depressive symptoms and sleep disturbance.

RESULTS

In total, 405 patients were included in the analyses, of which 227 (56%) had Crohn’s disease (CD) and 178 (44%) had ulcerative colitis (UC). Vitamin D deficiency (< 50 nmol/L) was present in half (203/405) of the patients. Chronic fatigue was reported by 116 (29%) of all included patients with substantial fatigue reported by 194 (48%). Vitamin D levels were neither associated with total fatigue nor with chronic fatigue. Higher total fatigue scores and chronic fatigue were both associated with increased disease activity scores in patients with UC and CD, but not with increased CRP or fecal calprotectin. In UC patients, female gender was associated with fatigue in the univariate analysis, but no such difference was found when adjusted for elevated disease activity scores. Sleep disturbance and more depressive symptoms were associated with total fatigue scores in both UC and CD patients, but with chronic fatigue only in CD patients.

CONCLUSION

In this study, no significant association between fatigue and vitamin D deficiency in IBD patients was revealed.

Altered levels of cytokines in patients with irritable bowel syndrome are not correlated with fatigue

Introduction

A considerable number of patients with gastrointestinal complaints attributable to irritable bowel syndrome (IBS) have shown evidence of immune activation. Fatigue is also frequently reported by IBS patients and the condition is considered as a common comorbidity of IBS. Therefore, it is interesting to see whether these two conditions share the same pathophysiological mechanism.

Aims

To investigate the potential role of cytokine profiles in patients with IBS and the relationship between cytokine profiles and fatigue.

Materials and methods

Thirty-eight patients with IBS (32 females, 6 males, age range 18-70 years) and 22 healthy individuals (control group) (17 females, 5 males, age range 24-42 years) were included. IBS was diagnosed according to Rome III criteria, and severity of IBS symptoms and fatigue were evaluated using the Irritable Bowel Syndrome-Severity Scoring System (IBS-SSS) and Fatigue Impact Scale (FIS), respectively. FIS scores of 25 or higher were defined as fatigue. Blood samples were also taken, and the Luminex^® platform (Cytokine Human Ultrasensitive Magnetic 10-Plex Panel) was used for quantifying human cytokines' profile (granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin [IL]-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, and tumor necrosis factor [TNF]-α) in serum.

Results

The serum levels of IL-5, IL-6, IL-10, and TNF-α were significantly higher in patients with IBS compared to healthy controls (p=0.003, p=0.011, p=0.007, and p=0.02, respectively). Conversely, serum levels of cytokine IL-1β were significantly higher in the control group (p=0.03). The findings were consistent when comparing nonatopic patients with controls. Fatigue was demonstrated in 84.2% of the IBS patients. Scores of IBS-SSS were not significantly correlated with FIS scores (r=0.2, p=0.19), and they were not significantly different in patients with FIS scores >25 compared to patients with FIS scores <25 (p=0.11). None of the cytokine levels were significantly different in IBS patients with FIS scores >25 compared to IBS patients with FIS scores <25. Moreover, the cytokine levels in participants did not vary significantly between patients with diarrhea, constipation, or mixed bowel habits in multiple comparisons of patients.

Conclusions

The cytokines IL-5, IL-6, IL-10, and TNF-α may contribute to the development of IBS. However, serum levels of cytokines were not significantly different in IBS patients with fatigue compared with IBS patients without fatigue. Thus, the significance of cytokine levels may be less important than anticipated in search of common underlying mechanisms, and other factors should be explored in future studies.

Incidence of irritable bowel syndrome and chronic fatigue following GI infection: a population-level study using routinely collected claims data

OBJECTIVES

To investigate the occurrence of postinfectious IBS in routine outpatient care, comparing different types of GI infection and its interaction with psychosomatic comorbidity.

DESIGN

Retrospective cohort study using routinely collected claims data covering statutorily insured patients in Bavaria, Germany. Cases were defined as patients without prior record of functional intestinal disorder with a first-time diagnosis of GI infection between January 2005 and December 2013 and classed according to the type of infection. Each case was matched by age, sex and district of residence to a patient without history of GI infection. Prior psychological disorder (depression, anxiety or stress reaction disorder) was assessed in the 2 years prior to inclusion. Proportional hazards regression models were used to estimate the HRs for GI infection and psychological disorder. Chronic fatigue syndrome (CFS) was assessed as a comparator outcome.

RESULTS

A total of 508 278 patients with first diagnosis of GI infection were identified, resulting in a matched cohort of 1 016 556 patients. All infection types were associated with an increased risk of IBS (HR: 2.19-4.25) and CFS (HR 1.35-1.82). Prior psychological disorder was a distinct risk factor for IBS (HR: 1.73) and CFS (HR: 2.08). Female sex was a further risk factor for both conditions.

CONCLUSION

Psychological disorder and GI infections are distinct risk factors for IBS. The high incidence of non-specific GI infection suggests that postinfectious IBS is a common clinical occurrence in primary care. Chronic fatigue is a further significant sequela of GI infection.

Validation of Fatigue Impact Scale with various item sets - a Rasch analysis

PURPOSE

Fatigue is a symptom in patients with chronic gastrointestinal (GI) and liver diseases. Different instruments have been developed to assess the severity of fatigue and the 40-item Fatigue Impact Scale (FIS) is among the most widely used. Shorter versions of FIS include the 21-item Modified Fatigue Impact Scale (MFIS), and an eight-item version for everyday use. The study aimed to assess construct validity, reliability, and sufficiency of the raw score of the original FIS with 40 items, and examine the sufficiency of the 21 items from the Modified scale and the eight items of the Daily Fatigue Impact Scale (D-FIS), all of which are embedded in the 40-item scale.

METHODS

Patients with chronic GI or liver disease (n = 354) completed the FIS with 40 items. The majority (57%) was under the age of 55 years and approximately half were females (48%). Various item sets of FIS were derived which showed fit to the Rasch model.

RESULTS

Local dependency and multidimensionality in FIS and the 21-item Modified scale were resolved with a testlet solution but the D-FIS showed local dependency and multidimensionality and differential item functioning (DIF) still remained. Two new item sets fulfilling unidimensionality and no DIF are suggested, one with 15 items and a six-item scale for daily use. The transformation table shows score-interval scale estimates for all these item sets.

CONCLUSIONS

Both the FIS and the Modified scale can be used to measure fatigue albeit requiring some adjustment for DIF. The eight-item D-FIS is more problematic, and its summed score is not valid. Alternative 15- and 6-item versions presented in this paper can offer valid summed scores, and the transformation table allows transformation of raw scores and comparisons across all versions. Implications for rehabilitation The Fatigue Impact Scale and the Modified Fatigue Impact Scale can be used to measure fatigue after adjustments for differential item functioning. Alternative 15- and 6-item versions of Fatigue Impact Scale offer valid summed scores. The summed score for the Daily Fatigue Impact Scale is not valid. A transformation table with raw scores and Rasch transformed interval scale metric makes it possible to compare scores derived from the Fatigue Impact Scale, the Modified Fatigue Impact Scale and the proposed 15- and 6-item versions of Fatigue Impact Scale for research and/or clinical use.

Psychological distress, iron deficiency, active disease and female gender are independent risk factors for fatigue in patients with ulcerative colitis

Background

Patients with ulcerative colitis often report fatigue.

Objectives

To investigate prevalence of and risk factors for fatigue in patients with ulcerative colitis with active disease and during deep remission.

Methods

In this cross-sectional study, disease activity was evaluated with endoscopy and calprotectin, and patients were classified as having active disease (n = 133) or being in deep remission (n = 155). Blood samples were analysed to assess anaemia, iron deficiency and systemic immune activity. Patients completed questionnaires to assess fatigue, psychological distress, gastrointestinal symptoms and quality of life.

Results

The prevalence of high fatigue (general fatigue ≥ 13, Multidimensional Fatigue Inventory) was 40% in the full study population. Among patients with high fatigue, female gender and iron deficiency were more prevalent, and these patients had more severe disease activity and reported higher levels of anxiety, depression and decreased quality of life compared with patients with no/mild fatigue. A logistic regression analysis identified probable psychiatric disorder (odds ratio (OR) (confidence interval) 6.1 (3.1-12.2)), iron deficiency (OR 2.5 (1.2-5.1)), active disease (OR 2.2 (1.2-3.9)) and female gender (OR 2.1 (1.1-3.7)) as independent risk factors for high fatigue. Similar results were found concerning psychological distress, gender and quality of life, but immune markers did not differ in patients in deep remission with high vs. no/mild fatigue.

Conclusions

Probable psychiatric disorder, iron deficiency, active disease and female gender are independent risk factors for high fatigue in patients with ulcerative colitis. Low-grade immune activity does not seem to be the cause of fatigue among patients in deep remission.