Impact of Psychological Comorbidity on the Prognosis of Irritable Bowel Syndrome

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.

Clinical Trial: Study to Investigate the Efficacy and Safety of the Alpha-2-Delta Ligand PD-217,014 in Patients With Irritable Bowel Syndrome

INTRODUCTION

Despite the emergence of drugs to treat irritable bowel syndrome (IBS), improving abdominal pain can still be challenging. α2δ ligands, such as gabapentin and pregabalin, are sometimes used off-label to tackle this problem. However, evidence for efficacy is limited, and no large-scale studies have been published.

AIM

To study the efficacy of the α2δ ligand PD-217,014 in IBS.

METHODS

This multi-centre, double-blind, randomised, placebo-controlled, parallel group study randomised participants with Rome II-defined IBS to 150 or 300 mg b.d. of PD-217,014 or placebo b.d. for 4 weeks. The primary efficacy endpoint was responder, defined as having adequate relief of abdominal pain/discomfort for ≥ 50% of the active treatment period. Key secondary endpoints were change from baseline in abdominal pain, bloating, stool frequency/consistency, and global assessment of IBS symptoms.

RESULTS

We randomised 330 participants [aged 19-73 years; 209 (65%) female] satisfying Rome II criteria, 322 (98%) were treated, and of whom 271 (84%) completed the study. In this study, 321 satisfied Rome IV criteria. Neither dose of PD-217,014 improved the percentage of participants reporting adequate relief of abdominal pain/discomfort compared with placebo, either using the Rome II-defined total cohort or Rome II and IV IBS bowel habit sub-types. There were similar observations for secondary endpoints, and no association between abdominal pain or anxiety levels at baseline with participant improvement. PD-217,014 was generally well tolerated.

CONCLUSION

This first large, dose-ranging trial examining the efficacy of PD-217,014 showed no significant efficacy in participants with IBS or bowel habit sub-types, irrespective of their pain and anxiety levels.

Serotoninergic Mechanisms of Action in the Relaxant Properties of Saccharomyces boulardii CNCM I-745 on the Intestine

BACKGROUND

Perturbations of intestinal serotonergic neurotransmission seem to be involved in bowel dysmotility associated with irritable bowel syndrome (IBS) with diarrhea. Oral administration of probiotics is an emerging strategy to improve IBS symptoms, possibly via influencing local serotonin metabolism and neurotransmission. In the present study, we evaluated the effects of the yeast Saccharomyces boulardii CNCM I-745 (S. boulardii) on intestinal motility and serotonergic receptors.

METHODS

Isolated rat ileum was contracted in a cumulative concentration way by serotonin (5-HT), various 5-HT agonists or by acetylcholine to determine their effective concentration 50% (EC50). Single concentrations of S. boulardii or 5-HT antagonists were added before agonists to identify the receptors targeted by S. boulardii.

RESULTS

The serotonin antagonists 5-HT1A WAY100635, 5-HT2A ketanserin and 5-HT4 GR113808 inhibited 5-HT-induced contractions in a concentration-dependent manner. S. boulardii between 0.05 and 1.5 mg/mL increased the EC50 value of 5-HT suggesting an inhibitory effect against serotonin-induced contraction. Ileum contractions induced by the serotonin agonist 5-HT1 carboxamidotryptamine or by the serotonin agonist 5-HT2 alpha-methyl-5-HT were significantly reduced by S. boulardii at 1.5 mg/mL. The yeast did not affect acetylcholine-induced ileum contraction.

CONCLUSION

S. boulardii CNCM I-745 possesses relaxant properties on the rat ileum involving the inhibition of 5-HT and more specifically 5-HT1A and 5-HT2A/2B/2C receptor-induced contractions. These data suggest that the attenuation of 5-HT-induced ileal contractions by S. boulardii represents a probable mechanism of action sustaining its efficacy in patients affected by IBS with diarrhea.

Somatization Mediates the Relationship Between Childhood Trauma and Pain Ratings in Patients with Irritable Bowel Syndrome

GOALS

To identify potential mechanisms by which childhood trauma may lead to the adult development of abdominal symptoms in patients with irritable bowel syndrome (IBS).

BACKGROUND

Patients with IBS frequently report a history of childhood trauma. The pathophysiology by which abdominal pain arises in patients with IBS is multidimensional, consisting of both peripheral factors, such as altered motility, inflammation, and bacterial overgrowth, as well as central factors, such as psychological distress and neuro-hormonal dysregulation.

STUDY

Adult psychological factors (anxiety, depression, and somatization) were examined to determine if they mediate the relationship between retrospective reports of childhood trauma and current adult IBS abdominal symptoms in a study of 436 patients (M age=41.6, 79% F) meeting Rome III diagnosis criteria. Childhood trauma was measured using retrospective questions assessing physical and sexual abuse. Psychological factors in adulthood were measured with the subscales of the Brief Symptom Inventory-18. Outcome variables included adult IBS symptoms of abdominal pain, bloating, and satisfaction with bowel habits from the IBS Symptoms Severity Scale.

RESULTS

Results indicated that somatization mediated the relationship between childhood abuse and abdominal pain and bloating but not bowel satisfaction.

CONCLUSIONS

This study provides insight into the multifactorial nature of IBS-associated abdominal pain in patients with a history of childhood trauma, elucidating the need for a trauma-informed treatment approach for patients with histories of abuse.

Potential Risk Factors of Disorders of Gut-Brain Interaction in Undergraduates and Postgraduates: Partially Mediated by Life Stress and Lifestyle

INTRODUCTION

This study aimed to investigate the prevalence of disorders of gut-brain interaction (DGBI) and life stress in college students, and explore risk factors of DGBI in college students and the role of life stress.

METHODS

A total of 2,578 college students filled up validated questionnaires assessing GI symptoms, lifestyle, and life stress. Participants were diagnosed as DGBI based on the Rome III criteria. Multivariate ordinal logistic regression analysis and mediation effect model were employed to explore potential risk factors of DGBI and the mediating role of life stress and lifestyle in DGBI.

RESULTS

A total of 437 of 2,578 (17.0%) college students were diagnosed with DGBI. College students with DGBI had higher levels of life stress, including eight specific categories. Females (1.709 [1.437, 2.033]), staying up late (1.519 [1.300, 1.776]), and life stress (1.008 [1.006, 1.010]) were risk factors for DGBI, while postgraduates (0.751 [0.578, 0.976]) and regular diet (0.751 [0.685, 0.947]) were protective factors. Males and poor family economic were associated with a higher risk of DGBI after controlling stress, while an association between grade and DGBI was mediated by stress, regular diet, and sleep habits.

CONCLUSION

DGBI was common among college students. Life stress and lifestyle were associated with DGBI and mediated partial association between grade and DGBI in college students. More attention should be paid to undergraduates.

Organization of Neurogastroenterology and Motility units with a multidisciplinary, patient-centered perspective

Neurogastroenterology and Motility is a Gastroenterology subspecialty dealing with the management of gastrointestinal (GI) motor diseases and disorders of gut-brain interaction (DGBI). Both types of conditions may impair the nutritional status of patients - In the case of motility disorders, because deficient gastrointestinal motility may impair appropriate food digestion and absorption; in DGBI because development of gastrointestinal symptoms may impair appropriate patient nutrition. In both cases, different studies have shown that patients start restrictive diets on their own, without supervision of a dietician, which leads to nutritional deficits in many cases. Likewise, psychological factors like stressful situations or anxiety may trigger gastrointestinal symptoms in these patients, mainly in those with DGBI. Recent studies comparing a patient-centered approach that includes medical treatment, dietary modifications, and behavioural interventions with gastroenterologist-only standard care have shown a greater proportion of improved symptoms, psychological status, and quality of life, as well as reduced costs in patients allocated to the multidisciplinary treatment arm. In conclusion, there is growing evidence in favour of dietary and behavioural interventions by specialized professionals, coupled with appropriate medical evaluation and treatment by a gastroenterologist. Hence the importance of developing reference units in which comprehensive, individualized management may be offered. Multidisciplinary models improve clinical outcomes and patient satisfaction, which should result in a reduction of direct and indirect costs.  .

The role of cognitive emotion regulation strategies in predicting the resilience, symptom severity, and quality of life of patients with irritable bowel syndrome

BACKGROUND

Psychosocial stressors contribute to the development of irritable bowel syndrome (IBS) and exacerbate the symptoms. The capability to cope with stress is an essential element in the management of IBS. This study assessed nine cognitive emotion regulation strategies (CERS) and their role in predicting symptom severity, quality of life (QOL), and resilience in IBS subjects.

METHODS

The scores regarding nine subscales of CERS were obtained by cognitive emotion regulation questionnaire (CERQ) and compared between study patients based on the severity and subtypes of IBS using one-way ANOVA. To evaluate the predictive role of CERS, logistic regression was performed. The correlation between CERS and the QOL was assessed by Pearson correlation analysis. The score of resilience was measured by Connor-Davidson Resilience Scale (CD-RISC).

RESULTS

We recruited 100 patients diagnosed with IBS based on ROME IV criteria. Among nine subscales of CERS, patients with more severe symptoms scored higher in catastrophizing (p < 0.001) and blaming others (p = 0.015) while lower in positive reappraisal (p = 0.028). Blaming others was the only predictor of resilience and severity of IBS in our patients (odds ratio (OR): -2.103, p=0.028, and OR:1.715, p = 0.049, respectively). We observed significant negative correlations between the quality of life and rumination (r= -0.202, p=0.044), self-blame (r= -0.241, p=0.016), catastrophizing (r= -0.342, p<0.001), and blaming others (r= -0.219, p=0.028).

CONCLUSION

Maladaptive strategies are more common in IBS patients with more severe symptoms and have negative correlations with the QOL. Blaming others has the potential to predict the resilience and severity of symptoms in IBS patients.

The gut microbiome in disorders of gut-brain interaction

Functional gastrointestinal disorders (FGIDs), chronic disorders characterized by either abdominal pain, altered intestinal motility, or their combination, have a worldwide prevalence of more than 40% and impose a high socioeconomic burden with a significant decline in quality of life. Recently, FGIDs have been reclassified as disorders of gut-brain interaction (DGBI), reflecting the key role of the gut-brain bidirectional communication in these disorders and their impact on psychological comorbidities. Although, during the past decades, the field of DGBIs has advanced significantly, the molecular mechanisms underlying DGBIs pathogenesis and pathophysiology, and the role of the gut microbiome in these processes are not fully understood. This review aims to discuss the latest body of literature on the complex microbiota-gut-brain interactions and their implications in the pathogenesis of DGBIs. A better understanding of the existing communication pathways between the gut microbiome and the brain holds promise in developing effective therapeutic interventions for DGBIs.

Irritable bowel syndrome and mental health comorbidity - approach to multidisciplinary management

Irritable bowel syndrome (IBS) affects 5-10% of the global population. Up to one-third of people with IBS also experience anxiety or depression. Gastrointestinal and psychological symptoms both drive health-care use in people with IBS, but psychological comorbidity seems to be more important for long-term quality of life. An integrated care approach that addresses gastrointestinal symptoms with nutrition and brain-gut behaviour therapies is considered the gold standard. However, best practice for the treatment of individuals with IBS who have a comorbid psychological condition is unclear. Given the rising prevalence of mental health disorders, discussion of the challenges of implementing therapy for people with IBS and anxiety and depression is critical. In this Review, we draw upon our expertise in gastroenterology, nutrition science and psychology to highlight common challenges that arise when managing patients with IBS and co-occurring anxiety and depression, and provide recommendations for tailoring clinical assessment and treatment. We provide best practice recommendations, including dietary and behavioural interventions that could be applied by non-specialists and clinicians working outside an integrated care model.

Antibiotics and Probiotics for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a disorder of a gut-brain interaction characterised by abdominal pain and a change in stool form or frequency. Current symptom-based definitions and the classification of IBS promote heterogeneity amongst patients, meaning that there may be several different pathophysiological abnormalities leading to similar symptoms. Although our understanding of IBS is incomplete, there are several indicators that the microbiome may be involved in a subset of patients. Techniques including a faecal sample analysis, colonic biopsies, duodenal aspirates or surrogate markers, such as breath testing, have been used to examine the gut microbiota in individuals with IBS. Because of a lack of a clear definition of what constitutes a healthy gut microbiota, and the fact that alterations in gut microbiota have only been shown to be associated with IBS, a causal relationship is yet to be established. We discuss several hypotheses as to how dysbiosis may be responsible for IBS symptoms, as well as potential treatment strategies. We review the current evidence for the use of antibiotics and probiotics to alter the microbiome in an attempt to improve IBS symptoms. Rifaximin, a non-absorbable antibiotic, is the most studied antibiotic and has now been licensed for use in IBS with diarrhoea in the USA, but the drug remains unavailable in many countries for this indication. Current evidence also suggests that certain probiotics, including Lactobacillus plantarum DSM 9843 and Bifidobacterium bifidum MIMBb75, may be efficacious in some patients with IBS. Finally, we describe the future challenges facing us in our attempt to modulate the microbiome to treat IBS.

Irritable Bowel Syndrome and the Gut Microbiome: A Comprehensive Review

Irritable Bowel Syndrome (IBS) is a functional disorder of the gastrointestinal tract characterized by abdominal pain and altered bowel habits. It has a prevalence of 10 to 25% in the United States and has a high disease burden, as evidenced by reduced quality of life, decreased work productivity and increased healthcare utilization and costs. IBS has been associated with several intra-intestinal and extra-intestinal conditions, including psychiatric comorbidities. Although the pathophysiology of IBS has not been fully elucidated, it involves dysregulation of communication between the brain and gut (brain–gut axis) which is associated with alterations in intestinal motility, gut permeability, visceral hypersensitivity and gut microbiota composition. The purpose of this article is to review the role the gut microbiota plays in the pathophysiology of IBS, understand factors that affect the gut microbiome and explore the microbiome as a target of treatment.

Prevalence and impact of faecal incontinence among individuals with Rome IV irritable bowel syndrome

BACKGROUND

Little is known about faecal incontinence (FI) in individuals with irritable bowel syndrome (IBS).

AIMS

To compare characteristics of people with IBS reporting FI, compared with people with IBS who do not report FI.

METHODS

We collected demographic, gastrointestinal and psychological symptoms, healthcare usage, direct healthcare costs, impact on work and activities of daily living, and quality of life data from individuals with Rome IV-defined IBS. We asked participants about FI, assigning presence or absence according to Rome-IV criteria.

RESULTS

Of 752 participants with Rome IV IBS, 202 (26.9%) met Rome IV criteria for FI. Individuals with FI were older (p < 0.001), more likely to have IBS-D (47.0% vs. 39.0%, p = 0.008), and less likely to have attained a university or postgraduate level of education (31.2% vs. 45.6%, p < 0.001), or to have an annual income of ≥£30,000 (18.2% vs. 32.9%, p < 0.001). They were more likely to report urgency (44.6% vs. 19.1%, p < 0.001) as their most troublesome symptom and a greater proportion had severe IBS symptom scores, abnormal depression scores, higher somatic symptom-reporting scores or higher gastrointestinal symptom-specific anxiety scores (p < 0.01 for trend for all analyses). Mean health-related quality of life scores were significantly lower among those with, compared with those without, FI (p < 0.001). Finally, FI was associated with higher IBS-related direct healthcare costs (p = 0.002).

CONCLUSIONS

Among individuals with Rome IV IBS, one-in-four repo rted FI according to Rome IV criteria. Physicians should ask patients with IBS about FI routinely.

Factors associated with lower disease-specific and generic health-related quality of life in Rome IV irritable bowel syndrome

BACKGROUND

Little is known about associations with reduced quality of life in irritable bowel syndrome (IBS) or impact of IBS on quality of life compared with other chronic conditions.

METHODS

We collected demographic, gastrointestinal and psychological symptoms, healthcare usage, direct healthcare costs, impact on work and activities of daily living data from 752 individuals with Rome IV-defined IBS. We used the irritable bowel syndrome quality of life (IBS-QOL) and the EQ-5D-5L questionnaires to examine characteristics associated with lower quality of life.

RESULTS

The mean IBS-QOL among all 752 individuals with Rome IV IBS was 48.4 (SD 22.3) and the mean EQ-5D score was 0.570 (SD 0.283), the latter being comparable to people with stroke, leg ulcers or chronic obstructive pulmonary disease. Lower levels of both disease-specific and generic quality of life were associated with severe IBS symptom scores, abnormal anxiety or depression scores, and higher somatoform symptom-reporting and gastrointestinal symptom-specific anxiety scores (p < 0.001 for all analyses). Those with lower quality of life had significantly higher healthcare usage and direct healthcare costs and more impairment in work and activities of daily living (p < 0.01 for all analyses). Avoidance of alcohol, lower educational level, abnormal anxiety, depression or somatoform symptom-reporting scores, and impairment in social leisure activities, home management or maintaining close relationships were all independently associated with lower quality of life.

CONCLUSION

IBS has a substantial impact on the quality of life of those affected, and worse than observed in some severe chronic organic conditions.

Anxiety and depression in Indian patients with irritable bowel syndrome: A meta-analysis

BACKGROUND

Functional gastrointestinal disorders (FGIDs), including irritable bowel syndrome (IBS), are associated with psychological abnormalities, such as anxiety and depression. Though the data on this are plenty in global literature, Indian data are sparse. We performed a systematic review and meta-analysis of Indian data on anxiety and depression among patients with IBS to estimate their pooled prevalence and to identify the shortcomings so that future areas of research can be identified.

METHOD

A comprehensive literature search was performed for studies applying tests for psychological issues in patients with IBS. After applying prospectively decided exclusion criteria, the eligible papers were examined using a meta-analysis approach for the prevalence of anxiety and depression in IBS patients using different tests. The odds ratios (OR) of anxiety and depression among subjects with IBS were calculated compared to controls.

RESULTS

Of seven studies (590 IBS patients and 1520 controls) included in the meta-analysis, the pooled OR of anxiety was 8.060 (95% confidence interval [CI] 4.007-16.213) as compared to controls (random-effect model). The pooled OR of depression was 7.049 (95% CI 3.281-15.147) compared to controls (random-effect model). There was significant heterogeneity in the included studies.

CONCLUSION

The current meta-analysis shows that the patients with IBS from India have eightfold greater risks of anxiety and sevenfold greater risks of depression than the controls. However, most of these data were from tertiary urban centers, and hence, there might be recruitment bias over-estimating the frequency.

Symptom management needs of patients with irritable bowel syndrome and concurrent anxiety and/or depression: A qualitative study

AIMS

To understand the experiences and needs of symptom management among individuals with irritable bowel syndrome and concurrent symptoms of anxiety and/or depression.

DESIGN

This study used a qualitative descriptive research design.

METHODS

Individuals with a diagnosis of irritable bowel syndrome and concurrent symptoms of anxiety and/or depression participated were recruited through an online ResearchMatch and a listserv. Semi-structured interviews focused on symptoms and experiences with symptom management interventions conducted from June to August 2020. Interviews were transcribed and data were analysed based on thematic analysis.

RESULTS

Twelve individuals participated in this study; all reported current irritable bowel syndrome and anxiety/depression symptoms. The data analysis cumulated with three themes related to symptom management: (a) irritable bowel syndrome negatively impacts physical and mental well-being; (b) a trial and error approach to symptom management; and (c) challenges with healthcare professionals supporting symptom management including negative interactions with healthcare professionals and lack of nutritional expertize and support.

CONCLUSION

There is a need for individualized approaches which consider patients' current symptoms of anxiety and depression, previous experiences with the trial-and-error process and consideration for intervention delivery methods.

IMPACT

There is a limited qualitative research focusing on the experiences of individuals with irritable bowel syndrome and concurrent symptoms of anxiety and/or depression. This research highlights the need for individualized approaches to enhance symptom management that acknowledges patients' psychological state and past negative experiences with providers and prior dietary regimens.

Latent class analysis does not support the existence of Rome IV functional bowel disorders as discrete entities

BACKGROUND

Previously, we used latent class analysis (LCA) to identify novel subgroups in people with irritable bowel syndrome (IBS). There are four other functional bowel disorders that, although characterized as discrete disorders, overlap considerably with, and fluctuate to, IBS. These might instead be conceptualized as a milder form of IBS. We explored this hypothesis using LCA in a cohort of people with non-IBS functional bowel disorders.

METHODS

We collected demographic, symptom, and psychological health data from 1375 adults in the community who self-identified as having IBS and identified individuals meeting Rome IV criteria for any non-IBS functional bowel disorder. We performed LCA to identify specific subgroups (clusters). We followed participants up at 12 months to reassess gastrointestinal and psychological heath and also gather data about healthcare utilization and impact of symptoms.

KEY RESULTS

811 people met Rome IV criteria for IBS and 558 Rome IV criteria for another functional bowel disorder (76 (5.5%) functional constipation; 198 (14.5%) functional diarrhea; 129 (9.5%) functional abdominal bloating or distension; and 155 (11.4%) unspecified functional bowel disorder). LCA in these 558 people identified five clusters defined by a combination of gastrointestinal symptoms and the extent of psychological co-morbidity. However, correlation between these clusters and the Rome IV functional bowel disorder diagnoses was poor and 75% of people were classified as having mild IBS using our previous IBS-derived model. By 12 months, one-third of people had fluctuated and met criteria for IBS. Clusters with high psychological burden had a poorer prognosis, with higher rates of medical consultation, medication use, and greater impact of symptoms on daily life.

CONCLUSIONS AND INFERENCES

The functional bowel disorders may be better characterized as a spectrum of IBS rather than separate disorders. Adopting this pragmatic stance may help to simply diagnosis, treatment, and recruitment of patients to research trials.

Patient satisfaction after remotely delivered gut-directed hypnotherapy for irritable bowel syndrome during the COVID-19 era: implications for future practice

Objective

Gut-directed hypnotherapy (GDH) is an evidence-based treatment for irritable bowel syndrome (IBS). Adoption of remote GDH has been accelerated by the COVID-19 pandemic. We aimed to evaluate patient experience and satisfaction following remote GDH.

Design

On completing 12 sessions of remote GDH via Skype using the Manchester protocol, patients with refractory IBS completed a feedback form on their experience. The proportion reporting positive outcomes (≥30% improvement in global IBS symptoms or abdominal pain, satisfaction, recommendation to family/friends) were compared by patient factors (age, gender, proximity, preferences).

Results

Of 52 patients completing the feedback form, 27 (52%) indicated that they would have opted for remote over face-to-face GDH, regardless of the pandemic situation. On a five-point scale (5=easy), patients rated the platform easy-to-use (mean 4.5±0.8) without impairment of communication (mean rating 4.6±0.8). Following remote GDH, 30/52 (58%) reported ≥30% global IBS symptom improvement, and 24/52 (46%) reported ≥30% pain reduction. 90% would recommend remote GDH to others. Only 39% felt they would have benefitted more from face to face. Those who would have chosen remote GDH regardless of the pandemic were more likely to be satisfied (p=0.01). Age, gender and proximity did not influence outcomes, satisfaction and likelihood of recommending remote GDH to others. Difficulties during remote sessions were infrequent in both those that were satisfied, and those that would have preferred face to face.

Conclusion

These data support the need to continue developing remote GDH in the post-COVID era but suggest that there is still a role for face-to-face GDH, with patient choice being an important factor.

Impact of Rome IV irritable bowel syndrome on work and activities of daily living

BACKGROUND

Few studies have demonstrated the impact of irritable bowel syndrome (IBS) on work and activities of daily living.

METHODS

We collected demographic, gastrointestinal symptom, psychological health and quality of life data from 752 adults with Rome IV-defined IBS. We used the work productivity and activity impairment questionnaire for irritable bowel syndrome and the work and social adjustment scale to examine the degree of both impairment at work and in activities of daily living, as well as factors associated with these.

RESULTS

Of 467 individuals who were employed, 133 (28.5%) reported absenteeism, 373 (85.6%) presenteeism and 382 (81.8%) overall work impairment. A mean of 1.97 hours of work per week was lost due to IBS. Extrapolating this across the entire UK, we estimate that between 72 and 188 million hours of work are lost per year due to IBS in individuals of working age. Among all 752 participants, 684 (91.0%) reported any activity impairment with 220 (29.3%) reporting impairment in home management, 423 (56.3%) in social leisure activities, 207 (27.5%) in private leisure activities, and 203 (27.0%) in maintaining close relationships. Severe IBS, higher levels of anxiety, depression, somatization and gastrointestinal symptom-specific anxiety, and lower levels of IBS-related quality of life were associated with impairment in both work and activities of daily living.

CONCLUSION

Patients with IBS experience a substantial impact on their work and activities of daily living because of their IBS. Future studies should assess the impact of medical interventions on the ability to work and participate in social activities.

Direct healthcare costs of Rome IV or Rome III-defined irritable bowel syndrome in the United Kingdom

BACKGROUND

Previous studies have demonstrated a substantial economic impact of irritable bowel syndrome (IBS).

AIMS

To provide contemporaneous estimates of direct healthcare costs of IBS in the United Kingdom.

METHODS

We collected demographic, gastrointestinal and psychological symptoms, quality of life and healthcare usage data from adults with Rome IV or Rome III IBS in the United Kingdom. We calculated the mean annual direct healthcare costs of IBS per person and used contemporaneous IBS prevalence data, together with census data, to estimate annual direct costs of IBS. We also examined predictors of higher costs.

RESULTS

The mean annual direct cost of IBS per person among 752 individuals with Rome IV IBS was £556.65 (SD £1023.92) and £474.16 (SD £897.86) for 995 individuals with Rome III IBS. We estimate the annual direct healthcare cost of IBS in the United Kingdom is £1.27 billion if the Rome IV criteria are used to define IBS, and £2.07 billion using Rome III. Among individuals with Rome IV IBS, mean annual costs were higher in those with opiate use (£907.90 vs £470.58, p < 0.001), more severe symptoms (p < 0.001 for trend), a shorter duration of IBS (1 year, £1227.14 vs >5 years £501.60, p = 0.002), lower quality of life (p < 0.001 for trend), and higher depression, somatisation and gastrointestinal symptom-specific anxiety scores (P < 0.001 for trend for all).

CONCLUSION

We estimate annual direct healthcare costs of IBS of between £1.3 and £2 billion in the United Kingdom.

Endometriosis and irritable bowel syndrome: similarities and differences in the spectrum of comorbidities

STUDY QUESTION

Do the spectrum and prevalence of comorbidities of endometriosis and irritable bowel syndrome (IBS) overlap?

SUMMARY ANSWER

Despite several overlapping symptoms, the most significantly associated comorbidities of endometriosis and IBS are different and are rather related to the organ systems primarily involved in the index diagnosis.

WHAT IS KNOWN ALREADY

Endometriosis and IBS both have several similar unspecific symptoms, such as recurrent abdominal pain, cramping and anxiety, and both diseases affect young women and are associated with a number of comorbidities causing a poor quality of life. However, a detailed study, revealing the full spectrum of endometriosis and IBS comorbidities in the same study population, is lacking.

STUDY DESIGN, SIZE, DURATION

This article presents a retrospective in silico analysis of the data from a large nationwide biobank-based cohort consisting of 121 773 women. After excluding all first- and second-degree relatives, the data of up to 65 421 women were analyzed.

PARTICIPANTS/MATERIALS, SETTING, METHODS

International Classification of Disease-10 diagnosis main codes associated with endometriosis (N80) and IBS (K58) diagnoses were identified from the Estonian Biobank dataset by linking with the Estonian Health Insurance Fund and other relevant registries. The associations between N80 and K58 and other diagnosis codes were tested using logistic regression, adjusting for age at recruitment and 10 genetic principal components to account for potential population stratification. Bonferroni correction was applied to account for multiple testing.

MAIN RESULTS AND THE ROLE OF CHANCE

Both women with endometriosis and IBS suffered from more conditions compared to the control group, with 226 and 428 diagnosis codes statistically significantly more frequent in women with respective diagnosis compared to controls. Women suffering from both conditions had 275 significantly associated comorbidities. A remarkable proportion of women with IBS or endometriosis suffered also from endometriosis (9.0%) or IBS (13.6%), respectively. In endometriosis, the most prevalent diagnoses were related to diseases of the genitourinary system (33 N-category codes) and in women with IBS, the most associated diagnoses were related to digestive disorders and gastrointestinal tract (52 codes from K-category). Among the most significant diagnoses in endometriosis were uterine leiomyomas (D25), menstrual disorders (N92) and infertility (N97) (P < 1 × 10-315 for all), and in IBS, lactose intolerance (E73), gastritis and duodenitis (K29) and functional dyspepsia (K30) were in the top list of most significant comorbidities (P < 1 × 10-315 for all).

LIMITATIONS, REASONS FOR CAUTION

The information about the severity stages of endometriosis and subtypes of IBS was not available for analysis. The findings may not be fully extrapolated to all female populations, because all participants were from one geographic area and had good access to health services.

WIDER IMPLICATIONS OF THE FINDINGS

These findings support previous studies that have found a high prevalence of pre-selected comorbidities in women with endometriosis and IBS. However, taking into account the differences in the full spectrum of comorbidities of endometriosis and IBS may aid in diagnosing these disorders. Women and healthcare providers need to be aware that women with endometriosis are at high risks of complications during pregnancy and should be carefully monitored.

STUDY FUNDING/COMPETING INTEREST(S)

This research was funded by the Estonian Research Council (grant PRG1076), Horizon 2020 innovation grant (ERIN, grant no. EU952516), Enterprise Estonia (grant no. EU48695), MSCA-RISE-2020 project TRENDO (grant no. 101008193) and by the European Union through the European Regional Development Fund (Projects no. 2014-2020.4.01.15-0012 and no. 2014-2020.4.01.16-0125). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Functional bowel disorders with diarrhoea: Clinical guidelines of the United European Gastroenterology and European Society for Neurogastroenterology and Motility

Irritable bowel syndrome with diarrhoea (IBS‐D) and functional diarrhoea (FDr) are the two major functional bowel disorders characterized by diarrhoea. In spite of their high prevalence, IBS‐D and FDr are associated with major uncertainties, especially regarding their optimal diagnostic work‐up and management. A Delphi consensus was performed with experts from 10 European countries who conducted a literature summary and voting process on 31 statements. Quality of evidence was evaluated using the grading of recommendations, assessment, development, and evaluation criteria. Consensus (defined as >80% agreement) was reached for all the statements. The panel agreed with the potential overlapping of IBS‐D and FDr. In terms of diagnosis, the consensus supports a symptom‐based approach also with the exclusion of alarm symptoms, recommending the evaluation of full blood count, C‐reactive protein, serology for coeliac disease, and faecal calprotectin, and consideration of diagnosing bile acid diarrhoea. Colonoscopy with random biopsies in both the right and left colon is recommended in patients older than 50 years and in presence of alarm features. Regarding treatment, a strong consensus was achieved for the use of a diet low fermentable oligo‐, di‐, monosaccharides and polyols, gut‐directed psychological therapies, rifaximin, loperamide, and eluxadoline. A weak or conditional recommendation was achieved for antispasmodics, probiotics, tryciclic antidepressants, bile acid sequestrants, 5‐hydroxytryptamine‐3 antagonists (i.e. alosetron, ondansetron, or ramosetron). A multinational group of European experts summarized the current state of consensus on the definition, diagnosis, and management of IBS‐D and FDr.

[Functional gastrointestinal disorders]

Approximately 50 % of chronic gastrointestinal symptoms in primary care can be attributed to functional gastrointestinal disorders (FGID). The most frequent gastrointestinal disorders are functional dyspepsia and irritable bowel syndrome. FGID are heterogenous with regards to the amount of symptoms and associated patient's impairment as well as to the underlying pathophysiological mechanisms. The biopsychosocial model of FGID assumes that biological, psychological and social factors interact in the predisposition to and in the initiation and course of FGID. The Rome Foundation defines FGID as disorders of the brain-gut interaction.Some physicians are hesitant to diagnose FGID due to the lack of specific biomarkers and/or structural changes in the gastrointestinal tract. In addition, some FGID to not respond well to conventional medications. Some patients are reluctant to accept the diagnosis of a FGID because they are afraid that a serious somatic disease has been missed and/or to be diagnosed as mentally ill.The use of interdisciplinary evidence-based guidelines for diagnosis and management of FGID can increase the certainty of diagnosis and the therapeutic options for physicians. In addition, these guidelines include recommendations how to explain the disorder and the management to the patient to establish a trustful doctor-patient relationship.FGID are diagnosed by the history of a typical cluster of symptoms and by guideline - recommended exclusion of somatic gastrointestinal disorders. FGID should be managed according to the main symptoms, the associated impairment and patients' preferences in a graduated approach by education and by dietary, pharmacological and psychological treatments.

Willingness to accept risk with medication in return for cure of symptoms among patients with Rome IV irritable bowel syndrome

BACKGROUND

Some drugs for irritable bowel syndrome (IBS) have serious side effects.

AIMS

To examine the willingness of individuals with IBS to accept risks with medication in return for symptom cure.

METHODS

We collected demographic, gastrointestinal symptoms, psychological health, quality of life and impact on work and daily activities data from 752 adults with Rome IV-defined IBS. We examined median willingness to accept death in return for cure with a hypothetical medication using a standard gamble, according to these variables.

RESULTS

Participants would accept a median 2.0% (IQR 0.0%-9.0%) risk of death in return for a 98.0% (IQR 91.0%-100.0%) chance of permanent symptom cure. The median accepted risk of death was higher in men (5.0% vs 2.0%, P < 0.001), those with continuous abdominal pain (4.0% vs 1.0%, P < 0.001), more severe symptoms (P = 0.005 for trend), abnormal depression scores (P < 0.001 for trend), higher gastrointestinal symptom-specific anxiety (P < 0.001 for trend), and lower IBS-related quality of life (P < 0.001 for trend). Those willing to accept above median risk of death were more likely to be male (17.1% vs 9.1%, P < 0.001), take higher levels of risks in their daily life (P = 0.008 for trend), and report continuous abdominal pain (53.1% vs 39.4%, P < 0.001), and had higher depression (P = 0.004 for trend) and lower quality of life (P < 0.001 for trend) scores.

CONCLUSION

Patients are willing to accept significant risks in return for cure of their IBS symptoms.

Characteristics of, and natural history among, individuals with Rome IV functional bowel disorders

BACKGROUND

Little is known about the natural history of functional bowel disorders using Rome IV criteria. We examined these issues in a longitudinal follow-up study.

METHODS

We collected complete demographic, gastrointestinal symptom, and psychological comorbidity data at baseline from 1372 adults who met Rome IV criteria for one of the five functional bowel disorders. At 12 months, we collected data regarding gastrointestinal symptoms, psychological comorbidity, consultation behavior, and treatment commenced. We examined prognosis and stability of all five functional bowel disorders.

KEY RESULTS

At baseline, 811 (59.1%) individuals met Rome IV criteria for irritable bowel syndrome (IBS), 76 (5.5%) functional constipation (FC), 199 (14.5%) functional diarrhea (FDr), 130 (9.5%) functional abdominal bloating or distension (FABD), and 156 (11.4%) unspecified functional bowel disorder (UFBD). In total, 782 (57.0%) were successfully followed up. Individuals with IBS at baseline were significantly more likely to report symptoms compatible with anxiety, depression, or somatoform-type behavior (p < 0.001 for all analyses) at baseline and follow-up compared with those with the other four functional bowel disorders. IBS was the most stable functional bowel disorder; 319 (70.6%) of 452 participants still met criteria for IBS at 12 months, compared with 14 (34.1%) of 41, 43 (35.5%) of 121, 26 (33.8%) of 77, and 37 (40.7%) of 91 for FC, FDr, FABD, and UFBD, respectively (p < 0.001).

CONCLUSIONS AND INFERENCES

Individuals with Rome IV-defined IBS exhibited higher levels of anxiety, depression, or somatoform-type symptom reporting. IBS was the most stable and the likeliest disorder that the other four functional bowel disorders would fluctuate to.

The symptom burden of Irritable Bowel Syndrome in tertiary care during the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic caused unprecedented disruption to healthcare services worldwide with well-documented detrimental effects on mental health. Patients with refractory disorders of gut-brain interaction such as Irritable Bowel Syndrome (IBS) seen in tertiary care tend to exhibit higher levels of psychological comorbidity, but the impact of the pandemic on IBS symptom severity in tertiary care is unknown.

METHODS

As part of routine clinical care, consecutive tertiary referrals with refractory IBS patients prospectively completed a series of baseline questionnaires including IBS symptom severity score (IBS-SSS), non-colonic symptom score, Hospital Anxiety and Depression (HAD), and Illness impact scores. The symptom severity questionnaire data were compared for consecutive patients seen in tertiary care 12 months before and after the onset of COVID-19 pandemic restrictions.

KEY RESULTS

Of 190 consecutive tertiary referrals with IBS, those seen during the pandemic had greater IBS severity (IBS-SSS: 352 vs. 318, p = 0.03), more severe extra-intestinal symptoms (non-colonic score: 269 vs. 225, p = 0.03), sleep difficulties (p = 0.03), helplessness and loss of control (p = 0.02), but similar HAD-Anxiety (p = 0.96) and HAD-Depression (p = 0.84) scores. During the pandemic, unmarried patients (p = 0.03), and keyworkers (p = 0.0038) had greater IBS severity.

CONCLUSIONS AND INFERENCES

This study has shown for the first time that patients seen in tertiary care with refractory IBS during the COVID-19 pandemic had a significantly higher symptom burden emphasizing the importance of gut-brain axis in IBS. Furthermore, lack of support and perceived loss of control appear to be contributory factors.

Review article: current and future treatment approaches for pain in IBS

BACKGROUND

Abdominal pain is a core symptom of IBS and a primary driver of care seeking. Visceral hypersensitivity is a key pathophysiological mechanism and therapeutic target for pain in IBS, with components of peripheral and central sensitisation and psychological factors.

AIM

To review current and future treatment approaches specifically for the pain component of IBS.

METHODS

Pubmed search terms included combinations of irritable bowel, pain, visceral hypersensitivity, novel, new, emerging, future and advances.

RESULTS

Established non-pharmacological treatments for IBS pain include the low FODMAP diet, probiotics and psychological interventions, especially hypnotherapy. Tricyclics remain the best evidenced pharmacological approach with GCC agonists, tenapanor, lubiprostone, eluxadoline and 5HT3 antagonists second line according to patient characteristics and availability. Less well-evidenced current options include anti-spasmodics, peppermint oil, SSRIs, SNRIs, alpha 2 delta ligands, melatonin and histamine antagonists. Patients are vulnerable to iatrogenesis and harmful approaches to be avoided include opioids and unwarranted surgical interventions. For severe pain, the concept of augmentation with combined gut-brain neuromodulators and psychotherapy in a multi-disciplinary setting is considered. A plethora of molecular targets and ligands are emerging from pre-clinical studies, together with early clinical evidence for a range of pharmacological, dietary, neurostimulation and novel psychological treatment delivery methods which are reviewed. The history of such emerging approaches, however, merits both caution and optimism in equal measure.

CONCLUSIONS

Despite good in-roads and emerging options, the management of abdominal pain remains one of the biggest challenges and research priorities for patients with IBS.

Illness perception and health care use in individuals with irritable bowel syndrome: results from an online survey

BACKGROUND

Individual illness perception is known to influence a range of outcome variables. However, little is known regarding illness perception in irritable bowel syndrome (IBS) and its relation to the use of the health care system. This study hypothesised a relationship between illness perception and inappropriate health care use (under-, over- and misuse).

METHODS

An internet-based, cross-sectional study in participants affected by IBS symptoms was carried out (April - October 2019) using open questions as well as validated standardized instruments, e.g. the illness perception questionnaire revised (IPQ-R) and its subscales. Sub-group comparisons were done non-parametrically and effect sizes were reported. Potential predictors of (1) conventional health care utilisation and (2) utilisation of treatment approaches with lacking or weak evidence regarding effectiveness in IBS were examined with logistic regression analyses and reported as odds ratio (OR) and 95% confidence interval.

RESULTS

Data from 513 individuals were available. More than one-third (35.7%) of participants were classified as high utilisers (> 5 doctor visits during the last year). Several indicators of inappropriate health care use were detected, such as a low proportion of state-of-the-art gynaecological evaluation of symptoms (35.0% of women) and a high proportion of individuals taking ineffective and not recommended non-steroidal antirheumatic drugs for IBS (29.4%). A majority (57.7%) used treatment approaches with lacking or weak evidence regarding the effectiveness in IBS (e.g. homeopathy). Being a high utiliser as defined above was predicted by the perceived daily life consequences of IBS (IPQ-R subscale "consequences", OR = 1.189 [1.100-1.284], p ≤ 0.001) and age (OR = 0.980 [0.962-0.998], p = 0.027). The use of treatment approaches with lacking or weak evidence was forecasted by the perceived daily life consequences (OR = 1.155 [1.091-1.223], p ≤ 0.001) and gender (reference category male: OR = 0.537 [0.327-0.881], p = 0.014), however effect sizes were small.

CONCLUSIONS

Daily life consequences, perceived cure and personal control as aspects of individual disease perception seem to be related to individuals' health care use. These aspects should be a standard part of the medical interview and actively explored. To face inappropriate health care use patients and professionals need to be trained. Interdisciplinary collaborative care may contribute to enhanced quality of medical supply in IBS.