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Thiruvengadam NR, Saumoy M, Schaubel DE, Cotton PB, Elmunzer BJ, Freeman ML, Varadarajulu S, Kochman ML, Coté GA. Rise in First-Time ERCP For Benign Indications >1 Year After Cholecystectomy Is Associated With Worse Outcomes. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00309-4. [PMID: 38599308 DOI: 10.1016/j.cgh.2024.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND & AIMS Greater availability of less invasive biliary imaging to rule out choledocholithiasis should reduce the need for diagnostic endoscopic retrograde cholangiopancreatography (ERCP) in patients who have a remote history of cholecystectomy. The primary aims were to determine the incidence, characteristics, and outcomes of individuals who undergo first-time ERCP >1 year after cholecystectomy (late-ERCP). METHODS Data from a commercial insurance claim database (Optum Clinformatics) identified 583,712 adults who underwent cholecystectomy, 4274 of whom underwent late-ERCP, defined as first-time ERCP for nonmalignant indications >1 year after cholecystectomy. Outcomes were exposure and temporal trends in late-ERCP, biliary imaging utilization, and post-ERCP outcomes. Multivariable logistic regression was used to examine patient characteristics associated with undergoing late-ERCP. RESULTS Despite a temporal increase in the use of noninvasive biliary imaging (35.9% in 2004 to 65.6% in 2021; P < .001), the rate of late-ERCP increased 8-fold (0.5-4.2/1000 person-years from 2005 to 2021; P < .001). Although only 44% of patients who underwent late-ERCP had gallstone removal, there were high rates of post-ERCP pancreatitis (7.1%), hospitalization (13.1%), and new chronic opioid use (9.7%). Factors associated with late-ERCP included concomitant disorder of gut-brain interaction (odds ratio [OR], 6.48; 95% confidence interval [CI], 5.88-6.91) and metabolic dysfunction steatotic liver disease (OR, 3.27; 95% CI, 2.79-3.55) along with use of anxiolytic (OR, 3.45; 95% CI, 3.19-3.58), antispasmodic (OR, 1.60; 95% CI, 1.53-1.72), and chronic opioids (OR, 6.24; 95% CI, 5.79-6.52). CONCLUSIONS The rate of late-ERCP postcholecystectomy is increasing significantly, particularly in patients with comorbidities associated with disorder of gut-brain interaction and mimickers of choledocholithiasis. Late-ERCPs are associated with disproportionately higher rates of adverse events, including initiation of chronic opioid use.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University Health, Loma Linda, California; Center for Endoscopic Innovation, Research, and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Monica Saumoy
- Center for Digestive Health, Penn Medicine Princeton Medical Center, Plainsboro, New Jersey
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter B Cotton
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, South Carolina
| | - Martin L Freeman
- Division of Gastroenterology and Hepatology, University of Minnesota School of Medicine, Minneapolis, Minnesota
| | | | - Michael L Kochman
- Center for Endoscopic Innovation, Research, and Training, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology and Hepatology, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Gregory A Coté
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, Oregon
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Huang J, Chen T, Zhang J, Ma X, Wang F, Tang X. Overlapping Symptoms of Functional Gastrointestinal Disorders: Current Challenges and the Role of Traditional Chinese Medicine. Am J Chin Med 2023:1-25. [PMID: 37183682 DOI: 10.1142/s0192415x23500398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Several functional gastrointestinal disorders (FGIDs) have overlapping symptoms, and, consequently, developing treatment strategies based on symptomatology poses a challenge for the clinical management of complex FGIDs. The significant overlap in the symptoms of FGIDs caused by the shared pathophysiological mechanisms is both a challenge and an excellent target for therapeutic development, since treatment strategies focused on shared pathophysiological mechanisms can treat the associated underlying diseases rather than just alleviating the primary symptoms. Owing to its multi-targeted approach, traditional Chinese medicine (TCM) has garnered immense interest worldwide; however, the quality of the data demonstrating its effectiveness is generally weak. Additionally, the causal link between the intrinsic mechanisms of action of TCM and its clinical benefits remains obscure. Systems biology is characterized by holistic and dynamic research, which corresponds to the holistic, multi-targeted, and syndrome-based approach of TCM. Therefore, high-throughput analysis techniques can be employed to describe and comprehend the genesis and progression of diseases, as well as the impacts of TCM on the organism, which may aid in elucidating the pathogenic mechanisms of the diseases as well as the mechanism of action of TCM.
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Affiliation(s)
- Jinke Huang
- Department of Gastroenterology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
| | - Ting Chen
- Department of Gastroenterology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
- Institute of Digestive Diseases, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
| | - Jiaqi Zhang
- Department of Gastroenterology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
- Institute of Digestive Diseases, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
| | - Xiangxue Ma
- Department of Gastroenterology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
- Institute of Digestive Diseases, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
| | - Fengyun Wang
- Department of Gastroenterology, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
- Institute of Digestive Diseases, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
| | - Xudong Tang
- Institute of Digestive Diseases, Xiyuan Hospital of China Academy of Chinese Medical Sciences, Beijing 100091, P. R. China
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Erdrich S, Hawrelak JA, Myers SP, Vuyisich M, Harnett JE. Investigating the association between the symptoms of women with Fibromyalgia, Digestive function, and markers of the microbiota of the Gastrointestinal Tract (The FIDGIT Study): study protocol. BMC Musculoskelet Disord 2023; 24:150. [PMID: 36849949 PMCID: PMC9969038 DOI: 10.1186/s12891-023-06259-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 02/20/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Fibromyalgia a common idiopathic condition affecting around 1.4% of adults globally. Its signature symptom is chronic widespread pain, with a constellation of somatic and psychological symptoms. Fibromyalgia is associated with significant reductions in quality of life, yet to date there is no biochemical marker for its diagnosis. Previous studies have indicated a strong association with gastrointestinal dysfunction, and more recently, alterations to the gut microbiome. No studies have examined the inter-relationship between fibromyalgia, gastrointestinal dysfunction, and the microbiome. This prospective observational case-controlled study will gather data on gastrointestinal function, dietary intake, fermentation patterns of ingested carbohydrates, and symptoms commonly associated with fibromyalgia. These will be evaluated alongside human gene expression and metatranscriptomic analysis of the oral and faecal microbiome. METHODS Adult women aged ≥18 years diagnosed with fibromyalgia and/or meeting ACR 2016 criteria, and healthy family or age-matched controls will be recruited from the community. From consenting participants, we will collect detailed survey information and samples of blood, urine, stool, saliva, and breath. DISCUSSION This is the first prospective study examining interactions between digestive function, human gene expression, and the gut microbiome together with general, and fibromyalgia-specific, symptoms experienced by New Zealand women. This exploration will allow an in-depth understanding of clinically relevant factors that are associated with fibromyalgia and will guide further research and contribute to improved management of this poorly understood condition. TRIAL REGISTRATION The study was approved by the New Zealand Health and Disability Committee (HDEC) (ref: 20/CEN/197) and registered with the Australia and New Zealand Clinical Trials Registry (ANZCTR), registration number ACTRN12620001337965. Written consent will be obtained after providing participants with detailed information about the procedures. Access to data will be restricted to the immediate research team, and all samples and survey data will be deidentified and coded before analysis.
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Affiliation(s)
- Sharon Erdrich
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia.
| | - Jason A Hawrelak
- College of Health and Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Stephen P Myers
- National Centre for Naturopathic Medicine, Faculty of Health, Southern Cross University, Lismore, New South Wales, Australia.,NatMed Research, Evans Head, New South Wales, Australia
| | - Momchilo Vuyisich
- Viome Life Sciences Inc, Seattle, Washington, United States of America
| | - Joanna E Harnett
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, New South Wales, Australia
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Zia JK, Lenhart A, Yang PL, Heitkemper MM, Baker J, Keefer L, Saps M, Cuff C, Hungria G, Videlock EJ, Chang L. Risk Factors for Abdominal Pain-Related Disorders of Gut-Brain Interaction in Adults and Children: A Systematic Review. Gastroenterology 2022; 163:995-1023.e3. [PMID: 35716771 PMCID: PMC9509486 DOI: 10.1053/j.gastro.2022.06.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/06/2022] [Accepted: 06/08/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Many studies have assessed risk factors of irritable bowel syndrome (IBS) and other abdominal pain-related disorders of gut-brain interaction (AP-DGBI); however, the role of these factors is unclear due to heterogeneous study designs. The aim of this systematic review was to extensively evaluate the literature and determine clinical risk and protective factors for the presence and persistence of AP-DGBI in children and adults. METHODS A PubMed search identified studies investigating potential risk and protective factors for AP-DGBI in adults and children. Inclusion criteria included fully published studies with a control group; exclusion criteria included poor-quality studies (using a validated scale). For each factor, the proportion of studies that found the factor to be a risk factor, protective factor, or neither was summarized. The number of studies, diagnostic criteria, number of subjects, and average study quality rating provided further context. Whenever possible, a meta-analysis generated pooled odds ratios or mean difference. RESULTS The systematic review included 348 studies. Female sex, gastroenteritis, abuse, stress, psychological disorders, somatic symptoms, and poor sleep were consistent risk factors for developing AP-DGBI in adults and children. In adults, additional risk factors included obesity, smoking, and increased use of medical resources. Protective AP-DGBI factors in adults included social support and optimism; no studies for protective factors were found for children. CONCLUSIONS There are multiple risk factors for AP-DGBI in adults and children. These include female sex, gastroenteritis, abuse, stress, poor sleep, obesity, psychological disorders, and somatic symptoms. Additional studies are needed in children, on protective factors, and on factors associated with persistence of AP-DGBI.
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Affiliation(s)
- Jasmine K. Zia
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington
| | - Adrienne Lenhart
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Pei-Lin Yang
- School of Nursing, National Defense Medical Center, Taipei, Taiwan
| | - Margaret M. Heitkemper
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, Washington
| | - Jason Baker
- Division of Gastroenterology and Hepatology, Michigan Medicine, Ann Arbor, Michigan
| | - Laurie Keefer
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Miguel Saps
- Division of Pediatrics Gastroenterology, Hepatology and Nutrition, Miller School of Medicine, University of Miami, Miami, Florida
| | - Callie Cuff
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Gregory Hungria
- Division of Pediatrics Gastroenterology, Hepatology and Nutrition, Miller School of Medicine, University of Miami, Miami, Florida
| | - Elizabeth J. Videlock
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California.
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Shah A, Fairlie T, Brown G, Jones MP, Eslick GD, Duncanson K, Thapar N, Keely S, Koloski N, Shahi M, Walker MM, Talley NJ, Holtmann G. Duodenal Eosinophils and Mast Cells in Functional Dyspepsia: A Systematic Review and Meta-Analysis of Case-Control Studies. Clin Gastroenterol Hepatol 2022; 20:2229-2242.e29. [PMID: 35123088 DOI: 10.1016/j.cgh.2022.01.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS This study explored the link between duodenal eosinophils and mast cells in patients with functional dyspepsia (FD). METHODS MEDLINE (PubMed) and Embase electronic databases were searched until June 2021 for case-control studies reporting duodenal eosinophils and mast cells in FD. Pooled standardized mean difference (SMD), odds ratio, and 95% CIs of duodenal eosinophils and mast cells in FD patients and controls were calculated, using a random-effects model. RESULTS Twenty-two case-control studies with 1108 FD patients and 893 controls were identified. Duodenal eosinophils (SMD, 1.29; 95% CI, 0.85-1.73; P = .0001) and mast cells (SMD, 2.11; 95% CI, 1.14-3.07; P = .0001) were increased in FD patients compared with controls. Substantial heterogeneity was found (I2 = 93.61, P = .0001; and I2 = 96.69, P = .0001, respectively) and visual inspection of funnel plots confirmed publication bias. Degranulation of duodenal eosinophils was significantly higher in FD patients compared with controls (odds ratio, 3.78; 95% CI, 6.76-4.48; P = .0001), without statistically significant heterogeneity. We conducted a sensitivity analysis for duodenal eosinophils, by including only high-quality studies, and the results remained unchanged (SMD, 1.73; 95% CI, 1.06-2.40; P = .0001), with substantial heterogeneity. Postinfectious FD patients had increased duodenal eosinophils compared with controls (SMD, 3.91; 95% CI, 1.32-6.51; P = .001) and FD patients without any history of infection (SMD, 1.42; 95% CI, 0.88-1.96; P = .001). Helicobacter pylori-negative FD patients had significantly higher duodenal eosinophils compared with controls (SMD, 3.98; 95% CI, 2.13-5.84; P = .0001), with substantial heterogeneity. No significant difference in duodenal eosinophils was seen according to FD subtypes. CONCLUSIONS This meta-analysis suggests a link between duodenal microinflammation and FD. However, the quality of evidence is very low, largely owing to the unexplained heterogeneity and serious risk of publication bias in all comparative analyses. Thus, causality remains uncertain and further studies are required.
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Parker S, Palsson O, Sanders DS, Simren M, Sperber AD, Törnblom H, Urwin H, Whitehead W, Aziz I. Functional Gastrointestinal Disorders and Associated Health Impairment in Individuals with Celiac Disease. Clin Gastroenterol Hepatol 2022; 20:1315-1325.e4. [PMID: 34298190 DOI: 10.1016/j.cgh.2021.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/28/2021] [Accepted: 07/15/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Individuals with celiac disease (CD) can experience persisting gastrointestinal symptoms despite adhering to a gluten-free diet (GFD). This may be due to functional gastrointestinal disorders (FGIDs), although there is little data on its prevalence and associated factors. METHODS An online health questionnaire was completed by adult members of Celiac UK in October 2018. The survey included validated questions on Rome IV FGIDs, nongastrointestinal somatic symptoms, anxiety, depression, quality of life, health care use, GFD duration, and its adherence using the celiac dietary adherence test score (with a value ≤ 13 indicating optimal adherence). The prevalence of FGIDs and associated health impairment in the celiac cohort was compared against an age- and sex-matched population-based control group. RESULTS Of the 863 individuals with CD (73% female; mean age, 61 years), all were taking a GFD for at least 1 year, with 96% declaring that they have been on the diet for 2 or more years (2-4 years, 20%; ≥5 years, 76%). The adherence to a GFD was deemed optimal in 61% (n = 523), with the remaining 39% (n = 340) nonadherent. Those adhering to a GFD fulfilled criteria for a FGID in approximately one-half of cases, although this was significantly lower than nonadherent subjects (51% vs 75%; odds ratio [OR], 2.0; P < .001). However, the prevalence of FGIDs in GFD-adherent subjects was significantly higher than in matched population-based controls (35%; OR, 2.0; P < .001). This was accounted for by functional bowel (46% vs 31%; OR, 1.9; P < .0001) and anorectal disorders (14.5% vs 9.3%; OR, 1.7; P = .02) but not functional esophageal (7.6% vs 6.1%; P = .36) or gastroduodenal disorders (8.7% vs 7.4%; P = .47). Finally, GFD-adherent subjects with FGIDs were significantly more likely than their counterparts without FGIDs to have abnormal levels of anxiety (5% vs 2%; OR, 2.8; P = .04), depression (7% vs 2%; OR, 3.6; P = .01), somatization (31% vs 8%; OR, 5.1; P < .0001), and reduced quality of life (P < .0001). CONCLUSION One in 2 people with CD, despite having been on a GFD for a number of years and demonstrating optimal adherence, have ongoing symptoms compatible with a Rome IV FGID. This is 2-fold the odds of FGIDs seen in age- and sex-matched controls. The presence of FGIDs is associated with significant health impairment, including psychological comorbidity. Addressing disorders of gut-brain interaction might improve outcomes in this specific group of patients.
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Affiliation(s)
- Sophie Parker
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Olafur Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - David S Sanders
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Heidi Urwin
- Coeliac UK, High Wycombe, Buckinghamshire, United Kingdom
| | - William Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
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Drossman DA, Chang L, Deutsch JK, Ford AC, Halpert A, Kroenke K, Nurko S, Ruddy J, Snyder J, Sperber A. A Review of the Evidence and Recommendations on Communication Skills and the Patient-Provider Relationship: A Rome Foundation Working Team Report. Gastroenterology 2021; 161:1670-1688.e7. [PMID: 34331912 DOI: 10.1053/j.gastro.2021.07.037] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/12/2021] [Accepted: 07/19/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Over several decades, changes in health care have negatively impacted meaningful communication between the patient and provider and adversely affected their relationship. Under increasing time pressure, physicians rely more on technology than face-to-face time gathering data to make clinical decisions. As a result, they find it more challenging to understand the illness context and fully address patient needs. Patients experience dissatisfaction and a diminution of their role in the care process. For patients with disorders of gut-brain interaction, stigma leads to greater care dissatisfaction, as there is no apparent structural basis to legitimize the symptoms. Recent evidence suggests that practical communication skills can improve the patient-provider relationship (PPR) and clinical outcomes, but these data are limited. METHODS The Rome Foundation convened a multidisciplinary working team to review the scientific evidence with the following aims: a) to study the effect of communication skills on patient satisfaction and outcomes by performing an evidence-based review; b) to characterize the influence of sociocultural factors, health care system constraints, patient perspective, and telehealth on the PPR; c) to review the measurement and impact of communication skills training on these outcomes; and d) to make recommendations to improve communication skills training and the PPR. RESULTS Evidence supports the fact that interventions targeting patient-provider interactions improve population health, patient and provider experience, and costs. Communication skills training leads to improved patient satisfaction and outcomes. The following are relevant factors to consider in establishing an effective PPR: addressing health care system constraints; incorporating sociocultural factors and the role of gender, age, and chronic illness; and considering the changing role of telehealth on the PPR. CONCLUSIONS We concluded that effective communication skills can improve the PPR and health outcomes. This is an achievable goal through training and system change. More research is needed to confirm these findings.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Center for Education and Practice of Biopsychosocial Care, Drossman Gastroenterology, and the Rome Foundation, Chapel Hill, North Carolina.
| | - Lin Chang
- Vatche and Tamar Manoukian Division of Digestive Diseases, G. Opopenbhemer Center for Neurobiology of Stress and Resilience, David Geffen School of Medicine at University of California-Los Angeles, Los Angeles, Calfornia
| | - Jill K Deutsch
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK; Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, UK
| | - Albena Halpert
- Gastroenterology,Harvard University Health Services, Boston, Massachusetts
| | - Kurt Kroenke
- Regenstrief Institute, Indiana University School of Medicine, Indianapolis, Indiana
| | - Samuel Nurko
- Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts
| | - Johannah Ruddy
- Center for Education and Practice of Biopsychosocial Care and Rome Foundation, Raleigh, North Carolina
| | - Julie Snyder
- Gastrointetinal Psychology Service, Boston University, Harvard Medical School, Boston, Massachusetts
| | - Ami Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Baumgartner M, Lang M, Holley H, Crepaz D, Hausmann B, Pjevac P, Moser D, Haller F, Hof F, Beer A, Orgler E, Frick A, Khare V, Evstatiev R, Strohmaier S, Primas C, Dolak W, Köcher T, Klavins K, Rath T, Neurath MF, Berry D, Makristathis A, Muttenthaler M, Gasche C. Mucosal Biofilms Are an Endoscopic Feature of Irritable Bowel Syndrome and Ulcerative Colitis. Gastroenterology 2021; 161:1245-1256.e20. [PMID: 34146566 PMCID: PMC8527885 DOI: 10.1053/j.gastro.2021.06.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Irritable bowel syndrome (IBS) and inflammatory bowel diseases result in a substantial reduction in quality of life and a considerable socioeconomic impact. In IBS, diagnosis and treatment options are limited, but evidence for involvement of the gut microbiome in disease pathophysiology is emerging. Here we analyzed the prevalence of endoscopically visible mucosal biofilms in gastrointestinal disease and associated changes in microbiome composition and metabolism. METHODS The presence of mucosal biofilms was assessed in 1426 patients at 2 European university-based endoscopy centers. One-hundred and seventeen patients were selected for in-depth molecular and microscopic analysis using 16S ribosomal RNA gene amplicon-sequencing of colonic biopsies and fecal samples, confocal microscopy with deep learning-based image analysis, scanning electron microscopy, metabolomics, and in vitro biofilm formation assays. RESULTS Biofilms were present in 57% of patients with IBS and 34% of patients with ulcerative colitis compared with 6% of controls (P < .001). These yellow-green adherent layers of the ileum and right-sided colon were microscopically confirmed to be dense bacterial biofilms. 16S-sequencing links the presence of biofilms to a dysbiotic gut microbiome, including overgrowth of Escherichia coli and Ruminococcus gnavus. R. gnavus isolates cultivated from patient biofilms also formed biofilms in vitro. Metabolomic analysis found an accumulation of bile acids within biofilms that correlated with fecal bile acid excretion, linking this phenotype with a mechanism of diarrhea. CONCLUSIONS The presence of mucosal biofilms is an endoscopic feature in a subgroup of IBS and ulcerative colitis with disrupted bile acid metabolism and bacterial dysbiosis. They provide novel insight into the pathophysiology of IBS and ulcerative colitis, illustrating that biofilm can be seen as a tipping point in the development of dysbiosis and disease.
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Affiliation(s)
- Maximilian Baumgartner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Michaela Lang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria,Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, Vienna, Austria
| | - Hunter Holley
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria,Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, Vienna, Austria
| | - Daniel Crepaz
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, Vienna, Austria
| | - Bela Hausmann
- Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, Vienna, Austria,Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Petra Pjevac
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, Vienna, Austria,Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, Vienna, Austria
| | - Doris Moser
- Department of Cranio-Maxillofacial and Oral Surgery, Medical University of Vienna, Vienna, Austria
| | - Felix Haller
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Fabian Hof
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Andrea Beer
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Orgler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Adrian Frick
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Vineeta Khare
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Rayko Evstatiev
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Susanne Strohmaier
- Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria
| | - Christian Primas
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | | | - Kristaps Klavins
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Timo Rath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen, Germany
| | - Markus F. Neurath
- Ludwig Demling Endoscopy Center of Excellence, Division of Gastroenterology, Friedrich-Alexander-University, Erlangen, Germany
| | - David Berry
- Centre for Microbiology and Environmental Systems Science, Department of Microbiology and Ecosystem Science, Division of Microbial Ecology, University of Vienna, Vienna, Austria,Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, Vienna, Austria
| | - Athanasios Makristathis
- Joint Microbiome Facility of the Medical University of Vienna and the University of Vienna, Vienna, Austria,Division of Microbiology, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Markus Muttenthaler
- Faculty of Chemistry, Institute of Biological Chemistry, University of Vienna, Vienna, Austria,Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
| | - Christoph Gasche
- Division of Gastroenterology and Hepatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria; Loha for Life, Center for Gastroenterlogy and Iron Deficiency, Vienna, Austria.
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9
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Lindfors P, Axelsson E, Engstrand K, Störsrud S, Jerlstad P, Törnblom H, Ljótsson B, Simrén M, Ringström G. Online Education Is Non-Inferior to Group Education for Irritable Bowel Syndrome: A Randomized Trial and Patient Preference Trial. Clin Gastroenterol Hepatol 2021; 19:743-751.e1. [PMID: 32289541 DOI: 10.1016/j.cgh.2020.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/03/2020] [Accepted: 04/03/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Structured education can reduce symptoms in patients with irritable bowel syndrome (IBS), but the availability of such interventions is limited and online formats could facilitate their dissemination. We compared the effectiveness of Internet-delivered vs face-to-face education in patients with IBS, hypothesizing that the online format would not be inferior. METHODS We conducted 2 trials of Internet-delivered vs face-to-face group education (3 weeks) at a gastroenterology outpatient clinic in Sweden. In the first trial, 141 patients with IBS were assigned randomly (1:1) to either Internet-delivered or face-to-face education, from August 2016 through June 2017. In the second trial, 155 patients with IBS were allowed to choose whether to receive education via the Internet or face to face, from August 2017 through September 2018. Patients completed questionnaires before, during, and after education. The primary outcome measure was the irritable bowel syndrome severity scoring system, which measures IBS severity on a scale from 0 to 500, based on abdominal pain, bloating, dissatisfaction with bowel habits, and interference with life. The primary test of noninferiority adhered to the intent-to-treat principle and concerned the difference in change up to 6 months after education, tested using the 1-sided CI for the time by group interaction in a linear mixed model fitted on data from the randomized controlled trial. A secondary per-protocol analysis used data from all treatment completers in both trials. The noninferiority margin was 40 points on the irritable bowel syndrome severity scoring system. RESULTS In the primary analysis, patients who received face-to-face education had an average reduction in irritable bowel syndrome severity score that was 12.2 points more than that of patients who received Internet education (1-sided 95% CI upper bound, 38.4). In the per-protocol analysis, patients who received face-to-face education reduced their average irritable bowel syndrome severity score by 14.7 points more than patients who received Internet education (95% CI upper bound, 35.5). Face-to-face education had significantly higher credibility and produced a significantly larger increase in self-rated knowledge, although most patients preferred Internet-delivered education. Between-group effects on secondary symptoms were small. CONCLUSIONS Based on the comparison of Internet-delivered vs face-to-face education for IBS, the upper bound of the CI for the difference in change up to 6 months after education was within the noninferiority margin of 40 points. We therefore conclude that Internet-delivered education is noninferior to face-to-face education. Future research should focus on increasing within-group effects. ClinicalTrials.gov no: NCT03466281.
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10
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Abstract
Functional gastrointestinal disorders (FGIDs) are a highly prevalent group of heterogeneous disorders, and their diagnostic criteria are symptom-based, with the absence of anatomical and biochemical abnormalities of the gastrointestinal tract. Chronic visceral symptoms are common both in patients with an identifiable organic disease but also in FGID patients. Patients suffering from upper gastrointestinal functional disorders typically present with various symptoms such as early satiety, postprandial fullness, bloating, nausea, vomiting, and epigastric pain. Considering their increasing prevalence, difficulties in diagnosis, and low quality of life, FGIDs have become an emerging problem in gastroenterology. We aimed to provide an updated summary of pathways involved in visceral sensitization. We examined the recent literature searching for evidence of the most important studies about the mechanisms underlying gastrointestinal symptom generation and sensitization.
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Affiliation(s)
- Alina Suciu
- Second Medical Department "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Stefan-Lucian Popa
- Second Medical Department "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania
| | - Dan-Lucian Dumitrascu
- Second Medical Department "Iuliu Hatieganu" University of Medicine and Pharmacy Cluj-Napoca, Romania
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11
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McNaughton DT, Andreasson A, Ljótsson B, Beath AP, Hush JM, Talley NJ, Ljunggren G, Schmidt PT, Agréus L, Jones MP. Effects of Psychology and Extragastrointestinal Symptoms on Health Care Use by Subjects With and Without Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2020; 18:847-854.e1. [PMID: 31323378 DOI: 10.1016/j.cgh.2019.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy about whether psychological factors (anxiety and depression) increase health care seeking by patients with irritable bowel syndrome (IBS). We investigated whether psychological factors increase health care seeking by patients with IBS and the effects of extragastrointestinal (extra-GI) symptoms. METHODS We performed a population-based prospective study of health care use over a 12-year period in Sweden. From 2002 through 2006, 1244 subjects were selected randomly for an examination by a gastroenterologist and to complete questionnaires, including the Rome II modular questionnaire. Psychological factors were measured with the valid Hospital Anxiety and Depression scale and extra-GI symptoms were measured with a symptom checklist. Responses from 1159 subjects (57% female; mean age, 48.65 y) were matched with health records in 2016 (164 were classified as having IBS based on Rome II criteria). RESULTS The overall association between depression or anxiety and health care use varied in subjects with and without IBS at baseline. The presence of extra-GI symptoms strengthened the relationship between anxiety and depression and prospective psychiatric visits for subjects with IBS and without IBS (incidence rate ratio, 1.14-1.26). Extra-GI symptoms did not alter the association of anxiety or depression with use of GI or extra-GI health care. CONCLUSIONS In a population-based study in Sweden, we found that individuals with high baseline anxiety or depression were more likely to seek psychiatric health care, but not GI or extra-GI health care, in the presence of extra-GI symptoms at baseline. Patients with IBS might benefit from more thorough assessments that examine extra-GI and psychological symptoms, to reduce health care utilization.
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Affiliation(s)
| | - Anna Andreasson
- Department of Psychology, Macquarie University, Sydney, NSW, Australia; Stress Research Institute, Stockholm University, Stockholm, Sweden; Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Brjánn Ljótsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Alissa P Beath
- Department of Psychology, Macquarie University, Sydney, NSW, Australia
| | - Julia M Hush
- Department of Health Professions, Macquarie University, Sydney, NSW, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Gunnar Ljunggren
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden; Public Healthcare Services Committee Administration, Stockholm County Council, Stockholm, Sweden
| | - Peter T Schmidt
- Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lars Agréus
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
| | - Michael P Jones
- Department of Psychology, Macquarie University, Sydney, NSW, Australia.
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12
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Aziz I, Palsson OS, Whitehead WE, Sperber AD, Simrén M, Törnblom H. Epidemiology, Clinical Characteristics, and Associations for Rome IV Functional Nausea and Vomiting Disorders in Adults. Clin Gastroenterol Hepatol 2019; 17:878-86. [PMID: 29857155 DOI: 10.1016/j.cgh.2018.05.020] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 05/08/2018] [Accepted: 05/20/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Functional nausea and vomiting disorders (FNVDs) are classified as chronic nausea and vomiting syndrome (CNVS) or cyclic vomiting syndrome (CVS)-CVS includes cannabinoid hyperemesis syndrome. We investigated the population prevalence of FNVDs, their characteristics, and associated factors. METHODS In the year 2015, an Internet cross-sectional health survey was completed by 5931 adults in the general populations of 3 English-speaking countries; 2100 participants were in the United States, Canada, or the United Kingdom. Quota-based sampling was used to generate demographically balanced and population-representative samples. The survey collected data on demographics, health care visits, medications, somatic symptom severity, quality of life, and symptom-based diagnostic criteria for Rome IV FNVDs as well as for irritable bowel syndrome and functional dyspepsia. Subsequent comparisons were made between Rome IV FNVD subjects and individuals without FNVDs (controls). RESULTS Overall, 2.2% of the population (n = 131) fulfilled symptom-based diagnostic criteria for Rome IV FNVDs: the United States (3%) had a greater prevalence than Canada (1.9%) or the United Kingdom (1.8%) (P = .02). The prevalence of CNVS was similar among the countries, ranging from 0.8% to 1.2%. However, the prevalence of CVS was higher in the United States (2%) than in Canada (0.7%) or the United Kingdom (1%) (P = .03). The proportion of subjects with CVS taking cannabis did not differ significantly among countries (P = .31), although the 7 cases of cannabinoid hyperemesis syndrome were in the United States. A significantly higher proportion of subjects with CVS reported a compulsive need for hot water bathing to alleviate emetic symptoms than subjects with CNVS (44% vs 19%; P = .03); this behavior was independent of cannabis but augmented by its use. Subjects with FNVDs had significantly greater health impairment and health care utilization than controls. On multivariate analysis, independent factors associated with FNVDs were younger age, increasing somatic symptom severity, lower quality of life, presence of irritable bowel syndrome, and functional dyspepsia. However, on subgroup analysis, somatic symptom severity was associated with CVS but not CNVS, whereas poor quality of life was associated with CNVS but not CVS. CONCLUSIONS Based on a cross-sectional health survey of adults in the general populations of 3 English-speaking countries, approximately 2% of subjects meet symptom-based criteria for Rome IV FNVDs and have considerable health impairments. Hot water bathing to alleviate emetic symptoms is reported for all FNVDs, and is perpetuated by cannabis use.
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13
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Clevers E, Tack J, Törnblom H, Ringström G, Luyckx K, Simrén M, Van Oudenhove L. Development of Irritable Bowel Syndrome Features Over a 5-year Period. Clin Gastroenterol Hepatol 2018; 16:1244-1251.e1. [PMID: 29510214 DOI: 10.1016/j.cgh.2018.02.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/25/2018] [Accepted: 02/25/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There are few data from longitudinal studies of the gastrointestinal and psychologic features of irritable bowel syndrome (IBS). We studied within-person correlations among features of IBS, along with progression of gastrointestinal (GI) symptoms and quality of life, and factors associated with changes over time. METHODS We performed a longitudinal study of 276 patients with IBS in Sweden (70% female; ages, 19-76 years) who completed questionnaires, each year for 5 years, about their GI symptom severity, quality of life, GI-specific anxiety, general anxiety, depression, and coping resources. We performed within-person correlation analyses, latent class growth analysis, and random-intercept cross-lagged panel analysis. RESULTS Within-person correlations with GI symptom severity were strongest for quality of life (r = -0.56) and GI-specific anxiety (r = 0.47). Progression of GI symptom severity was defined based on 3 classes; the class with the highest mean levels of GI, depression, and (GI-specific) anxiety symptoms at baseline did not improve over the 5-year period, contrary to the other classes. GI-specific anxiety was associated with an increase in GI symptom severity and decrease in quality of life 1 year later (P < .05) but other features of IBS were not. CONCLUSIONS In a 5-year study of patients with IBS in Sweden, we found 3 classes of GI symptom development. We found levels of GI-specific anxiety to associate with GI symptom severity and quality of life 1 year later. Clinicians should be aware of GI-specific anxiety in patients with IBS, to identify patients at risk for lack of long-term symptom improvement with standard medical treatment.
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Affiliation(s)
- Egbert Clevers
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium; Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Hans Törnblom
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gisela Ringström
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Koen Luyckx
- Faculty of Psychology and Educational Sciences, School Psychology and Child and Adolescent Development, KU Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Gawron AJ, Bielefeldt K. Risk of Pancreatitis Following Treatment of Irritable Bowel Syndrome With Eluxadoline. Clin Gastroenterol Hepatol 2018; 16:378-384.e2. [PMID: 28804032 DOI: 10.1016/j.cgh.2017.08.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 08/01/2017] [Accepted: 08/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The Food and Drug Administration approved eluxadoline for the treatment of diarrhea-predominant irritable bowel syndrome despite cases of pancreatitis in early stage trials. We investigated the frequency of pancreatitis attributed to eluxadoline in postmarketing surveillance. METHODS We extracted reports on eluxadoline submitted to the Federal Adverse Event Reporting System from January through September 2016. We collected data on patient age and sex, event date, reporting entity (consumer, physician, pharmacist, legal worker, or other), medications, dosages, presumed role in the event (coinciding, primary, or secondary suspect), treatment indication, and outcome (death, life threatening, hospitalization, disability, or other).We compared data for eluxadoline with data from antidiarrheals, oxycodone, and rifaximin using the κ2 test, Kruskal-Wallis rank test, and analysis of variance; findings with P < .05 were considered statistically significant. RESULTS Pancreatitis accounted for 16.4% of the 597 reports of adverse events linked to eluxadoline; 53 cases required hospitalization. Pancreatitis was listed as treatment complication of other agents in significantly lower proportions of cases (loperamide, 0.3%; diphenoxylate, 0.4%; oxycodone, 0.2%; rifaximin, 0.5%), with 75% of these submissions not considering the agent as causal. CONCLUSIONS In an analysis of reports on eluxadoline submitted to the Federal Adverse Event Reporting System, we confirmed a previously reported risk of pancreatitis associated with eluxadoline. The need for hospitalization in at least half of these instances and a recent report of 2 fatalities should prompt reassessments of the agent's risk-benefit ratio.
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Affiliation(s)
- Andrew J Gawron
- Gastroenterology Section, George E. Wahlen VA Medical Center, Salt Lake City, Utah; Division of Gastroenterology, Hepatology, and Nutrition, University of Utah, Salt Lake City, Utah; Salt Lake City Specialty Care Center of Innovation, Salt Lake City, Utah
| | - Klaus Bielefeldt
- Gastroenterology Section, George E. Wahlen VA Medical Center, Salt Lake City, Utah.
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Drossman DA, Tack J, Ford AC, Szigethy E, Törnblom H, Van Oudenhove L. Neuromodulators for Functional Gastrointestinal Disorders (Disorders of Gut-Brain Interaction): A Rome Foundation Working Team Report. Gastroenterology 2018; 154:1140-1171.e1. [PMID: 29274869 DOI: 10.1053/j.gastro.2017.11.279] [Citation(s) in RCA: 206] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/13/2017] [Accepted: 11/24/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Central neuromodulators (antidepressants, antipsychotics, and other central nervous system-targeted medications) are increasingly used for treatment of functional gastrointestinal disorders (FGIDs), now recognized as disorders of gut-brain interaction. However, the available evidence and guidance for the use of central neuromodulators in these conditions is scanty and incomplete. In this Rome Foundation Working Team report, a multidisciplinary team summarized available research evidence and clinical experience to provide guidance and treatment recommendations. METHODS The working team summarized the literature on the pharmacology of central neuromodulators and their effects on gastrointestinal sensorimotor function and conducted an evidence-based review on their use for treating FGID syndromes. Because of the paucity of data for FGIDs, we included data for non-gastrointestinal painful disorders and specific symptoms of pain, nausea, and vomiting. This information was combined into a final document comprising a synthesis of available evidence and recommendations for clinical use guided by the research and clinical experience of the experts on the committee. RESULTS The evidence-based review on neuromodulators in FGID, restricted by the limited available controlled trials, was integrated with open-label studies and case series, along with the experience of experts to create recommendations using a consensus (Delphi) approach. Due to the diversity of conditions and complexity of treatment options, specific recommendations were generated for different FGIDs. However, some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship. CONCLUSIONS Based on systematic and selectively focused review and the consensus of a multidisciplinary panel, we have provided summary information and guidelines for the use of central neuromodulators in the treatment of chronic gastrointestinal symptoms and FGIDs. Further studies are needed to confirm and refine these recommendations.
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Affiliation(s)
- Douglas A Drossman
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Center for Education and Practice of Biopsychosocial Care and Drossman Gastroenterology, Chapel Hill, North Carolina.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Alexander C Ford
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, United Kingdom; Leeds Gastroenterology Institute, St James's University Hospital, Leeds, United Kingdom
| | - Eva Szigethy
- Departments of Psychiatry and Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hans Törnblom
- Departments of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
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Rodriguez-Urrutia A, Eiroa-Orosa FJ, Accarino A, Malagelada C, Azpiroz F. The role of incongruence between the perceived functioning by patients and clinicians in the detection of psychological distress among functional and motor digestive disorders. J Psychosom Res 2017; 99:112-119. [PMID: 28712415 DOI: 10.1016/j.jpsychores.2017.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/06/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Previous research on gastrointestinal and other medical conditions has shown the presence of incongruence between self- and clinician-reported functioning and its relation with psychopathology. The main objective of this study was to test whether inconsistencies between clinician- and self-assessed functionality can be used to detect psychopathology among patients diagnosed of motor or functional gastrointestinal disorders. METHODS One hundred and three patients from a gastroenterology inpatient unit were included in this study. All patients underwent clinical assessment, including intestinal manometry, Rome III criteria for functional gastrointestinal disorders, and psychological and psychiatric evaluation. Patients with suspected gastroparesis underwent a scintigraphic gastric emptying test. Definitive diagnoses were made at discharge. RESULTS Patients with higher levels of incongruence differed in various sociodemographic (age, educational level, work activity and having children) and psychopathological (all SCL-90-R subscales except anxiety and hostility) characteristics. Using general lineal models, incongruence was found to be the variable with stronger relations with psychopathology even when controlling for diagnosis. Interactions were found between incongruence and diagnosis reflecting a pattern in which patients with functional disorders whose subjective evaluation of functioning is not congruent with that of the clinician, have higher levels of psychopathology than patients with motor disorders. CONCLUSIONS Incongruence between clinician and self-reported functionality seems to be related to higher levels of psychopathology in patients with functional disorders. These findings underscore the need for routine psychosocial assessment among these patients. Gastroenterologists could use the concept of incongruence and its clinical implications, as a screening tool for psychopathology, facilitating consultation-liaison processes.
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Affiliation(s)
- Amanda Rodriguez-Urrutia
- Consultation-Liaison Psychiatry Unit, Department of Psychiatry, University Hospital Vall d'Hebron, CIBERSAM, Spain; Department of Psychiatry and Legal Medicine, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain.
| | - Francisco José Eiroa-Orosa
- Section of Personality, Evaluation and Psychological Treatment, Department of Clinical Psychology and Psychobiology, School of Psychology, University of Barcelona, Spain.
| | - Anna Accarino
- Digestive System Research Unit, University Hospital Vall d'Hebron, CIBEREHD, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Carolina Malagelada
- Digestive System Research Unit, University Hospital Vall d'Hebron, CIBEREHD, Barcelona, Spain
| | - Fernando Azpiroz
- Digestive System Research Unit, University Hospital Vall d'Hebron, CIBEREHD, Barcelona, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
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17
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Jones MP, Tack J, Van Oudenhove L, Walker MM, Holtmann G, Koloski NA, Talley NJ. Mood and Anxiety Disorders Precede Development of Functional Gastrointestinal Disorders in Patients but Not in the Population. Clin Gastroenterol Hepatol 2017; 15:1014-1020.e4. [PMID: 28087404 DOI: 10.1016/j.cgh.2016.12.032] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/26/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Understanding the interactions between brain and gastrointestinal disorders requires analysis of the order of disease onset. We analyzed data from 2 independent studies to determine the proportion of individuals with diagnoses of functional gastrointestinal disorders (FGIDs) before diagnoses of mood or anxiety disorders (gut to brain), and vice versa (brain to gut). METHODS We collected data from a retrospective study of 4966 patients diagnosed with a FGID (irritable bowel syndrome, dyspepsia, or constipation) and mood or anxiety disorder at general practices in the United Kingdom (health care seekers) over an average period of 13.1 years; we recorded which diagnosis appeared first and compared these with patients' sex and socioeconomic factors. We also collected data from a population study of 1002 randomly selected individuals in Australia (non-heath care seekers) followed from 1997 through 2009; we determined whether subjects were free of either FGID or an anxiety or mood disorder at baseline but developed either one after a 12-year follow-up period. RESULTS Among the 4966 health care seekers, 3279 patients were diagnosed with a mood or anxiety disorder before an FGID (ratio of 2:1). This ratio increased with socioeconomic disadvantage. The time period between diagnosis of mood or anxiety disorder and FGID was longer (median, 3.5 years) than time period between diagnosis of an FGID and a mood or anxiety disorder (median, 1.8 years). Among non-heath care seekers (population study), equal proportions were diagnosed with a mood or anxiety disorder before versus after an FGID. CONCLUSIONS In an analysis of data from a study of patients and a population-based study of individuals with these diagnoses, we found 2-fold more patients to receive a diagnosis of a mood or anxiety disorder before an FGID, but equal proportions of individuals in the population to be diagnosed with the mood or anxiety disorder before versus after an FGID. Among patients, the mood or anxiety disorder was on average diagnosed more than 3 years before the FGID, offering opportunity for prevention. Our findings support a role for adverse socioeconomic factors in development of FGIDs in patients with psychological disorders.
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Affiliation(s)
- Michael P Jones
- Psychology Department, Macquarie University, North Ryde, New South Wales, Australia.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Division of Gastroenterology, University of Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, Division of Gastroenterology, University of Leuven, Leuven, Belgium; University Psychiatric Centre, Liaison Psychiatry, University Hospital Gasthuisberg, Leuven, Belgium
| | - Marjorie M Walker
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Gerald Holtmann
- Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Natasha A Koloski
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia; Department of Gastroenterology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Nicholas J Talley
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
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Klem F, Wadhwa A, Prokop L, Sundt W, Farrugia G, Camilleri M, Singh S, Grover M. Prevalence, Risk Factors, and Outcomes of Irritable Bowel Syndrome After Infectious Enteritis: A Systematic Review and Meta-analysis. Gastroenterology 2017; 152:1042-1054.e1. [PMID: 28069350 PMCID: PMC5367939 DOI: 10.1053/j.gastro.2016.12.039] [Citation(s) in RCA: 249] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 12/29/2016] [Accepted: 12/30/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Foodborne illness affects 15% of the US population each year, and is a risk factor for irritable bowel syndrome (IBS). We evaluated risk of, risk factors for, and outcomes of IBS after infectious enteritis. METHODS We performed a systematic review of electronic databases from 1994 through August 31, 2015 to identify cohort studies of the prevalence of IBS 3 months or more after infectious enteritis. We used random-effects meta-analysis to calculate the summary point prevalence of IBS after infectious enteritis, as well as relative risk (compared with individuals without infectious enteritis) and host- and enteritis-related risk factors. RESULTS We identified 45 studies, comprising 21,421 individuals with enteritis, followed for 3 months to 10 years for development of IBS. The pooled prevalence of IBS at 12 months after infectious enteritis was 10.1% (95% confidence interval [CI], 7.2-14.1) and at more than 12 months after infectious enteritis was 14.5% (95% CI, 7.7-25.5). Risk of IBS was 4.2-fold higher in patients who had infectious enteritis in the past 12 months than in those who had not (95% CI, 3.1-5.7); risk of IBS was 2.3-fold higher in individuals who had infectious enteritis more than 12 months ago than in individuals who had not (95% CI, 1.8-3.0). Of patients with enteritis caused by protozoa or parasites, 41.9% developed IBS, and of patients with enteritis caused by bacterial infection, 13.8% developed IBS. Risk of IBS was significantly increased in women (odds ratio [OR], 2.2; 95% CI, 1.6-3.1) and individuals with antibiotic exposure (OR, 1.7; 95% CI, 1.2-2.4), anxiety (OR, 2; 95% CI, 1.3-2.9), depression (OR, 1.5; 95% CI, 1.2-1.9), somatization (OR, 4.1; 95% CI, 2.7-6.0), neuroticism (OR, 3.3; 95% CI, 1.6-6.5), and clinical indicators of enteritis severity. There was a considerable level of heterogeneity among studies. CONCLUSIONS In a systematic review and meta-analysis, we found >10% of patients with infectious enteritis develop IBS later; risk of IBS was 4-fold higher than in individuals who did not have infectious enteritis, although there was heterogeneity among studies analyzed. Women-particularly those with severe enteritis-are at increased risk for developing IBS, as are individuals with psychological distress and users of antibiotics during the enteritis.
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Affiliation(s)
- Fabiane Klem
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN,Universidade Federal do Paraná, Curitiba, Paraná, Brazil
| | - Akhilesh Wadhwa
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Larry Prokop
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Wendy Sundt
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Gianrico Farrugia
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Michael Camilleri
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, San Diego, CA
| | - Madhusudan Grover
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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Ha EK, Jang H, Jeong SJ. Therapeutic Response for Functional Abdominal Pain in Children with Occult Constipation: Laxatives versus Prokinetic Drugs. J Korean Med Sci 2017; 32:102-107. [PMID: 27914138 PMCID: PMC5143280 DOI: 10.3346/jkms.2017.32.1.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 10/05/2016] [Indexed: 12/12/2022] Open
Abstract
The relationship between functional abdominal pain (FAP) and occult constipation (OC) in children who did not meet the Rome III criteria for constipation has rarely been reported. This study aimed to estimate the prevalence of OC in patients with FAP and to compare the effectiveness of prokinetic drugs and laxatives for FAP and OC. Pediatric outpatients (n = 212; aged 4-15 years) who satisfied the Rome III criteria for childhood FAP were divided into 2 groups based on Leech scores: group 1 < 8; group 2 ≥ 8. Group 2 received either prokinetic drugs or laxatives and pain severity was assessed after 2 weeks, 1 month, and 3 months. A total 52.4% (111/212) of patients had OC in this study. More patients who received laxatives had reduced pain scores compared with those who received prokinetic drugs. Those treated with laxatives in group 2 had a better response than those treated with prokinetic drugs throughout the study period (P < 0.001, P < 0.001, and P = 0.002 after 2 weeks, 1 month, and 3 months, respectively). OC was frequently encountered in children with FAP. Laxatives can be more effective than prokinetic drugs for relieving symptoms of FAP in children with a Leech score ≥ 8 and suspected OC.
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Affiliation(s)
- Eun Kyo Ha
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Homin Jang
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Su Jin Jeong
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea.
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Ceunen E, Zaman J, Weltens N, Sarafanova E, Arijs V, Vlaeyen JWS, Van Oudenhove L, Van Diest I. Learned Fear of Gastrointestinal Sensations in Healthy Adults. Clin Gastroenterol Hepatol 2016; 14:1552-1558.e2. [PMID: 27155550 DOI: 10.1016/j.cgh.2016.04.035] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/18/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastrointestinal symptom-specific fear and anxiety are important determinants of gastrointestinal symptom perception. We studied learning of fear toward innocuous gastrointestinal sensations as a putative mechanism in the development of gastrointestinal symptom-specific fear and anxiety. METHODS Fifty-two healthy subjects (26 women) received 2 types of esophageal balloon distention at a perceptible but nonpainful intensity (conditioned stimulus [CS], the innocuous sensation) and at a painful intensity (unconditioned stimulus [US]). Subjects were assigned randomly to 1 of 2 groups. During the learning phase, the innocuous CS preceded the painful US in the experimental group (n = 26). In the control group (n = 26), on the contrary, the US never followed the CS directly. During a subsequent extinction phase, both groups received only CS distention-the painful US was no longer administered. Indexes of fear learning toward the innocuous CS distention included the skin conductance response, fear-potentiated startle (measured by the eye-blink electromyogram), and self-reported expectancy of the US. RESULTS During the learning phase, only the experimental group learned to fear the innocuous gastrointestinal CS, based on the increase in US expectancy (compared with the control group, P = .04), increased skin conductance response (compared with the control group, P = .03), and potentiated startle reflex (compared with the control group, P = .001) in response to the CS. The differences between the experimental and control groups in US expectancy and skin conductance, but not fear-potentiated startle, disappeared during the extinction phase. CONCLUSIONS Fear toward innocuous gastrointestinal sensations can be established through associative learning in healthy human beings. This may be an important mechanism in the development of fear of gastrointestinal symptoms, implicated in the pathophysiology of functional gastrointestinal disorders.
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Affiliation(s)
- Erik Ceunen
- Health Psychology, KU Leuven, Leuven, Belgium
| | - Jonas Zaman
- Health Psychology, KU Leuven, Leuven, Belgium
| | - Nathalie Weltens
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Ekaterina Sarafanova
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Vicky Arijs
- Health Psychology, KU Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- Health Psychology, KU Leuven, Leuven, Belgium; Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands
| | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Center for Gastrointestinal Disorders, Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
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21
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Irvine EJ, Tack J, Crowell MD, Gwee KA, Ke M, Schmulson MJ, Whitehead WE, Spiegel B. Design of Treatment Trials for Functional Gastrointestinal Disorders. Gastroenterology 2016; 150:1469-1480.e1. [PMID: 27147123 DOI: 10.1053/j.gastro.2016.02.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 12/19/2022]
Abstract
This article summarizes recent progress and regulatory guidance on design of trials to assess the efficacy of new therapies for functional gastrointestinal disorders (FGIDs). The double-masked, placebo-controlled, parallel-group design remains the accepted standard for evaluating treatment efficacy. A control group is essential, and a detailed description of the randomization process and concealed allocation method must be included in the study report. The control will most often be placebo, but for therapeutic procedures and for behavioral treatment trials, respectively, a sham procedure and control intervention with similar expectation of benefit, but lacking the treatment principle, are recommended. Investigators should be aware of, and attempt to minimize, expectancy effects (placebo, nocebo, precebo). The primary analysis should be based on the proportion of patients in each treatment arm who satisfy a treatment responder definition or a prespecified clinically meaningful change in a patient-reported outcome measure. Data analysis should use the intention-to-treat principle. Reporting of results should follow the Consolidated Standards for Reporting Trials guidelines and include secondary outcome measures to support or explain the primary outcome and an analysis of harms data. Trials should be registered in a public location before initiation and results should be published regardless of outcome.
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Affiliation(s)
- E Jan Irvine
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute and Department of Medicine, St Michael's Hospital, Toronto, Canada
| | - Jan Tack
- Departments of Clinical and Experimental Medicine and Gastroenterology, Translational Research Center for Gastrointestinal Disorders, University Hospital KU Leuven, Leuven, Belgium.
| | - Michael D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
| | - Kok Ann Gwee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Meiyun Ke
- Peking Union Medical College Hospital, Center of FGID and MGID, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Max J Schmulson
- Facultad de Medicina, Universidad Nacional Autónoma de México, Laboratorio de Hígado, Páncreas y Motilidad, Unidad de Investigación en Medicina Experimental, Hospital General de México, Mexico City, Mexico
| | | | - Brennan Spiegel
- Cedars-Sinai Health System, Cedars-Sinai Center for Outcomes Research and Education, Los Angeles, California
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Mazaheri M. Difficulties in Emotion Regulation and Mindfulness in Psychological and Somatic Symptoms of Functional Gastrointestinal Disorders. Iran J Psychiatry Behav Sci 2015; 9:e954. [PMID: 26834811 PMCID: PMC4733315 DOI: 10.17795/ijpbs-954] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/28/2015] [Accepted: 09/16/2015] [Indexed: 12/14/2022]
Abstract
Background: Negative emotions are the best predictors for psychological and physical health. Objectives: We aimed to investigate the role of difficulties in emotion regulation and mindfulness on psychological and somatic symptoms of patients with functional gastrointestinal disorders (FGID). Patients and Methods: In this cross-sectional study, the studied sample was selected using census method. A total of 167 patients with FGID completed a demographic questionnaire, difficulties in emotion regulation scale (DERS), mindful attention awareness scale (MAAS), depression, anxiety and stress scale (DASS), and gastrointestinal symptom rating scale (GSRS). To examine the relationship between studied variables, Pearson correlation coefficients and multiple regression analyses were used. Results: The findings of the study indicate that difficulties in emotion regulation and mindfulness are significantly correlated to both increased psychological and somatic symptoms. Some factors of difficulties in emotion regulation positively predicted those symptoms. Among these factors, only lack of awareness was not significantly correlated with both symptoms as well as decreased mindfulness. Conclusions: The findings suggest some potential targets to reduce symptoms. Patients with FGID may benefit from treatments that facilitate emotional experience, functional status, and ability to control impulsive behaviors and behave according to the goals when experiencing negative emotions.
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Affiliation(s)
- Mina Mazaheri
- Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
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23
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Aghayousefi A, Oraki M, Mohammadi N, Farzad V, Daghaghzadeh H. Reliability and Validity of the Farsi Version of the Somatosensory Amplification Scale. Iran J Psychiatry Behav Sci 2015; 9:e233. [PMID: 26576173 PMCID: PMC4644620 DOI: 10.17795/ijpbs-233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/15/2014] [Accepted: 12/20/2014] [Indexed: 01/12/2023]
Abstract
Background: The somatosensory amplification scale (SSAS) is a 10-item self-report instrument designed to assess a tendency to experience normal somatic and visceral sensations as intense, noxious, and disturbing. Objectives: The present study investigated the reliability and validity of the SSAS, developed by Barsky et al. (1988), in the Iranian population. Materials and Methods: The study was carried out on 240 patients with functional gastrointestinal disorders and 30 healthy persons selected by convenience sampling from 2013 to 2014. The patients completed the SSAS, the somatization subscale of the symptom checklist-90-revised (SCL-90-R som), and the modified somatic perception questionnaire (MSPQ), whereas the healthy persons completed just the SSAS. Results: Exploratory factor analysis indicated that the one-factor solution, accounting for 29.42% of the variance, explained that the SSAS items were represented by one global dimension. The SSAS had acceptable internal consistency (α = 0.78) and good test-retest reliability (r = 0.80). The item-to-scale correlations varied from 0.17 to 0.55. Item 2 had the lowest item-total score correlation (r = 0.17), and the α coefficient for the SSAS exceeded when this item was deleted. The convergent validity of the SSAS with somatization was shown with a significant correlation between the SSAS, SCL-90-R som (r = 0.36), and MSPQ scores (r = 0.52). Discriminant validity analysis showed no significant difference in the SSAS between the patient and control groups (P > 0.05) and non-specificity of the SSAS for patients. Conclusions: In sum, the SSAS has acceptable reliability and validity for the Iranian population and the scale measures the same the original scale, namely somatosensory amplification.
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Affiliation(s)
| | - Mohammad Oraki
- Department of Psychology, Payame Noor University, Tehran, IR Iran
| | - Narges Mohammadi
- Psychosomatic Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
| | | | - Hammed Daghaghzadeh
- Integrative Functional Gastroenterology Research Center, Isfahan University of Medical Sciences, Isfahan, IR Iran
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Ly HG, Weltens N, Tack J, Van Oudenhove L. Acute Anxiety and Anxiety Disorders Are Associated With Impaired Gastric Accommodation in Patients With Functional Dyspepsia. Clin Gastroenterol Hepatol 2015; 13:1584-91.e3. [PMID: 25869636 DOI: 10.1016/j.cgh.2015.03.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 03/19/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Functional dyspepsia (FD) is associated with impaired gastric accommodation, as well as gastric hypersensitivity, delayed emptying, and psychosocial comorbidities. In healthy people, acute anxiety impairs gastric accommodation, which is traditionally quantified as the average increase in gastric volume after a meal over 1 hour. However, this quantification approach does not address the complex time course of the gastric accommodation response to a meal. We modeled gastric accommodation in patients with FD as a function of postprandial time, to investigate whether it is associated with psychosocial factors (state anxiety, anxiety disorder, depression) and gastric sensorimotor function (sensitivity, emptying). METHODS We studied gastric sensorimotor function in 259 consecutive patients diagnosed with FD based on Rome II at the University Hospitals Leuven from January 2002 through February 2009. Subjects underwent a gastric barostat and breath test; psychiatric comorbidity was assessed by questionnaires. Subjects completed the State-Trait Anxiety Inventory to measure levels of state anxiety immediately before and after gastric barostat analysis. The time course of the accommodation response was analyzed using mixed models. Psychological and sensorimotor variables were added to the model as continuous (state anxiety) or dichotomous (gastric sensitivity and emptying, anxiety disorders, depression) covariates, including their interaction with the time effects. RESULTS In subjects with FD, delayed emptying (β = 50.3 ± 15.9; P = .002) and lower state anxiety (β = -1.7 ± 0.7; P = .012) were associated with an upward shift of the accommodation curve. There was a significant interaction between comorbid anxiety disorder and linear (β = 8.2 ± 3.5; P = .02), quadratic (β = -0.4 ± 0.1; P = .004), and cubic (β = 0.005 ± 0.002; P = .002) effects of time: patients with a comorbid anxiety disorder had significantly slower initial increases in gastric volume to a lower maximum, and a slower return to baseline, compared with patients without anxiety disorder. Depression and gastric sensitivity were not associated significantly with gastric accommodation. CONCLUSIONS In patients with FD, state anxiety and comorbid anxiety disorders are associated with impaired accommodation; gastric emptying also is associated with accommodation in these patients. These findings help elucidate the complex interactions between psychological processes and disorders, gastric sensorimotor dysfunction, and symptom reporting in patients with FD.
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Abstract
Ingestion of food has long been linked with gut symptoms, and there is increasing interest in using diet in the management of patients with irritable bowel syndrome (IBS). The West has developed an intense interest in specialized, restrictive diets, such as those that target multiple food groups, avoid gluten, or reduce fermentable oligo-, di-, and mono-saccharides and polyols. However, most gastroenterologists are not well educated about diets or their effects on the gut. It is important to understand the various dietary approaches, their putative mechanisms, the evidence that supports their use, and the benefits or harm they might produce. The concepts behind, and delivery of, specialized diets differ from those of pharmacologic agents. High-quality research is needed to determine the efficacy of different dietary approaches and the place of specific strategies.
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Affiliation(s)
- Peter R Gibson
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia.
| | - Jane Varney
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Sreepurna Malakar
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
| | - Jane G Muir
- Department of Gastroenterology, Monash University and Alfred Health, Melbourne, Victoria, Australia
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Weijenborg PW, de Schepper HS, Smout AJPM, Bredenoord AJ. Effects of antidepressants in patients with functional esophageal disorders or gastroesophageal reflux disease: a systematic review. Clin Gastroenterol Hepatol 2015; 13:251-259.e1. [PMID: 24997325 DOI: 10.1016/j.cgh.2014.06.025] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 06/01/2014] [Accepted: 06/18/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with functional esophageal disorders present with symptoms of chest pain, heartburn, dysphagia, or globus in the absence of any structural abnormality. Visceral hypersensitivity is a feature of these functional disorders, and might be modulated by antidepressant therapy. We evaluated evidence for the efficacy of antidepressant therapy for symptoms associated with esophageal visceral hypersensitivity in patients with functional esophageal disorders or gastroesophageal reflux disease (GERD). METHODS We performed a systematic search of the Cochrane Comprehensive Trial Register, MEDLINE, and EMBASE (through February 2014). We analyzed relevant randomized, placebo-controlled trials reporting the effect of antidepressant therapy on experimentally induced esophageal sensation or intensity, or frequency of heartburn, chest pain, dysphagia, or globus. RESULTS The search strategy identified 378 articles; 15 described randomized controlled trials that were eligible for inclusion. In addition, 1 conference abstract and 2 case reports were included, providing the best available evidence on specific symptoms. Esophageal pain thresholds increased by 7% to 37% after antidepressant therapy. Antidepressant therapy reduced functional chest pain over a range from 18% to 67% and reduced heartburn in patients with GERD over a range of 23% to 61%. One study included patients with globus and none of the studies included patients with functional heartburn or functional dysphagia. CONCLUSIONS Based on a systematic review, antidepressants modulate esophageal sensation and reduce functional chest pain. There is limited evidence that antidepressants benefit a subgroup of patients with GERD. More controlled trials are needed to investigate the effects of antidepressants on functional esophageal disorders.
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Affiliation(s)
- Pim W Weijenborg
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Heiko S de Schepper
- Department of Gastroenterology and Hepatology, Universitair Ziekenhuis Antwerpen, Antwerpen, Belgium
| | - André J P M Smout
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
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Horst S, Shelby G, Anderson J, Acra S, Polk DB, Saville BR, Garber J, Walker LS. Predicting persistence of functional abdominal pain from childhood into young adulthood. Clin Gastroenterol Hepatol 2014; 12:2026-32. [PMID: 24732284 PMCID: PMC4195814 DOI: 10.1016/j.cgh.2014.03.034] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 03/24/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Pediatric functional abdominal pain has been linked to functional gastrointestinal disorders (FGIDs) in adulthood, but little is known about patient characteristics in childhood that increase the risk for FGID in young adulthood. We investigated the contribution of gastrointestinal symptoms, extraintestinal somatic symptoms, and depressive symptoms in pediatric patients with functional abdominal pain and whether these predicted FGIDs later in life. METHODS In a longitudinal study, consecutive new pediatric patients, diagnosed with functional abdominal pain in a subspecialty clinic, completed a comprehensive baseline evaluation of the severity of their physical and emotional symptoms. They were contacted 5 to 15 years later and evaluated, based on Rome III symptom criteria, for abdominal pain-related FGIDs, including irritable bowel syndrome, functional dyspepsia, functional abdominal pain syndrome, and abdominal migraine. Controlling for age, sex, baseline severity of abdominal pain, and time to follow-up evaluation, multivariable logistic regression was used to evaluate the association of baseline gastrointestinal, extraintestinal somatic, and depressive symptoms in childhood with FGID in adolescence and young adulthood. RESULTS Of 392 patients interviewed an average of 9.2 years after their initial evaluation, 41% (n = 162) met symptom criteria for FGID; most met the criteria for irritable bowel syndrome. Extraintestinal somatic and depressive symptoms at the initial pediatric evaluation were significant predictors of FGID later in life, after controlling for initial levels of GI symptoms. Age, sex, and abdominal pain severity at initial presentation were not significant predictors of FGID later in life. CONCLUSIONS In pediatric patients with functional abdominal pain, assessment of extraintestinal and depressive symptoms may be useful in identifying those at risk for FGID in adolescence and young adulthood.
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Affiliation(s)
- Sara Horst
- Department of Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Grace Shelby
- Department of Psychology and Human Development, Peabody College, Vanderbilt University, Nashville, TN
| | - Julia Anderson
- Department of Pediatric Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - Sari Acra
- Department of Pediatric Gastroenterology, Hepatology, & Nutrition, Vanderbilt University Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
| | - D. Brent Polk
- Department of Pediatrics, University of Southern California and Children’s Hospital Los Angeles, Nashville, TN
| | - Benjamin R. Saville
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Judy Garber
- Department of Psychology and Human Development, Peabody College of Vanderbilt University, Nashville, TN
| | - Lynn S. Walker
- Division of Adolescent and Young Adult Health, Department of Pediatrics, Vanderbilt University School of Medicine & Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN
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Cheung CKY, Lee YY, Chan Y, Cheong PK, Law WT, Lee SF, Sung JJY, Chan FKL, Wu JCY. Decreased Basal and postprandial plasma serotonin levels in patients with functional dyspepsia. Clin Gastroenterol Hepatol 2013; 11:1125-9. [PMID: 23591288 DOI: 10.1016/j.cgh.2013.03.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 03/19/2013] [Accepted: 03/19/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with diarrhea-predominant irritable bowel syndrome (IBS) have been found to have increased postprandial levels of serotonin (5-HT). Functional dyspepsia (FD) and IBS have been proposed to have common methods of pathogenesis, but little is known about the role of 5-HT in FD. METHODS We measured postprandial levels of 5-HT in 54 patients with FD (based on Rome III criteria) and 28 asymptomatic healthy individuals (controls). Patients with gastroesophageal reflux disease and IBS as their predominant symptom were excluded. After an overnight fast, the subjects drank a liquid meal (Ensure; 1.06 kcal/mL at 30 mL/min) and underwent a (13)C-octanoic acid breath test to measure gastric emptying times. Blood samples were collected at 0, 30, 60, 90, and 120 minutes after the liquid meal for the 5-HT assay. RESULTS Thirty-five patients with FD (65%) had postprandial distress syndrome, and 6 (11%) had a combination of postprandial distress syndrome and epigastric pain syndrome. There were no differences in rates of gastric emptying between patients with FD (103.6 ± 19.4 minutes) and controls (83.1 ± 4.0 minutes; P = .30). However, patients with FD had lower caloric intake (823.40 ± 44.1 kcal) than controls (1021 ± 68.2 kcal; P = .026). Patients with FD also had lower basal (P = .03) and postprandial plasma levels of serotonin at 30 minutes (P = .04), 60 minutes (P = .01), 90 minutes (P = .02), and 120 minutes (P = .002) than controls, as well as area under the curve values over the 120-minute time period (P = .005). Repeated-measures analysis of variance correlated 5-HT level with FD (P < .001). CONCLUSIONS In contrast to patients with diarrhea-predominant IBS, those with FD have decreased basal and postprandial plasma levels of 5-HT. These findings indicate that the pathogenic mechanism of FD differs from that of diarrhea-predominant IBS, and that strategies to alter 5-HT levels or activity might be developed to treat patients with FD.
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Affiliation(s)
- Cynthia K Y Cheung
- Institute of Digestive Disease, the Chinese University of Hong Kong, Hong Kong, China
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Saps M, Nichols-Vinueza D, Dhroove G, Adams P, Chogle A. Assessment of commonly used pediatric stool scales: a pilot study. Rev Gastroenterol Mex 2013; 78:151-8. [PMID: 23948097 DOI: 10.1016/j.rgmx.2013.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Revised: 04/11/2013] [Accepted: 04/17/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND The Bristol Stool Form Scale (BSFS) and a modified child-friendly version (M-BSFS) are frequently used in clinical practice and research. These scales have not been validated in children. 3-D stool scale models may be better adapted to the child's development. AIMS To assess the usefulness of the BSFS, M-BSFS, and a newly developed 3-D stool scale in children. METHODS Fifty children were asked to rank the picture cards of the BSFS and 3-D models from hardest to softest and to match the pictures with descriptors for each stool type. RESULTS Thirty percent of the children appropriately characterized the stools as hard, loose, or normal using the BSFS vs. 36.6% with the 3-D model (p=0.27). Appropriate correlation of stools as hard, loose, or normal consistency using the BSFS vs. the 3-D model by age group was: 6 to 11-year-olds, 27.5% vs. 33.3% (p=0.58) and 12 to 17-year-olds, 32.1% vs. 39.5% (p=0.41). Thirty-three percent correlated the BSFS pictures with the correct BSFS words, 46% appropriately correlated with the M-BSFS words, and 46% correlated the 3-D stool models with the correct wording. CONCLUSIONS The BSFS and M-BSFS that are widely used as stool assessment instruments are not user-friendly for children. The 3-D model was not found to be better than the BSFS and the M-BSFS.
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Affiliation(s)
- M Saps
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Ann & Robert H Lurie Children's Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
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Soylu OB. Clinical findings of functional and secondary constipation in children. Iran J Pediatr 2013; 23:353-6. [PMID: 23795262 PMCID: PMC3684484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2012] [Accepted: 12/22/2012] [Indexed: 11/05/2022]
Abstract
OBJECTIVE We aimed to evaluate clinical features and follow-up data of children with functional and secondary constipation. METHODS Hospital records of 335 constipated children were evaluated. Children were divided into 2 groups as functional and secondary, and were compared with regard to clinical and anthropometric data. FINDINGS Of 335 children (M/F 167/168, mean age 4.3±3.5 years) 91% had functional constipation (group 1). Family history of constipation was significantly higher in group 1. Malnutrition was found in 18% of group 1, 56% in group 2 (p < 0.001). CONCLUSION If a constipated child has a family history of constipation but does not have failure to thrive and constipation begins at an older age, functional constipation is more probable.
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Affiliation(s)
- Ozlem Bekem Soylu
- Corresponding Author:Address: Ozlem Bekem Soylu, MD, Camlicay Mahallesi 5182 sokak No: 12/A, 35315, Urla, Izmir, Turkey. E-mail:
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Monajemzadeh M, Kalantari M, Yaghmai B, Shekarchi R, Mahjoub F, Mehdizadeh M. Hirschsprung's Disease: a Clinical and Pathologic Study in Iranian Constipated Children. Iran J Pediatr 2011; 21:362-6. [PMID: 23056814 PMCID: PMC3446185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 09/06/2010] [Accepted: 01/01/2011] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Hirschsprung's disease (HD) is a complex disorder resulting from absence of ganglion cells in the bowel wall leading to functional obstruction and bowel dilatation proximal to the affected segment. The aim of our study was to evaluate rectal biopsies from constipated children in different age groups to see in which age it is more likely to encounter HD to avoid unnecessary rectal biopsy. METHODS Records of all children with chronic constipation undergoing a rectal biopsy to exclude HD were obtained from the files of Children's Medical Center in Tehran, Iran. A detailed retrospective demographic review, including age of beginning of signs and symptoms was made of all cases. FINDINGS Totally, 172 biopsies were taken from 168 children in a five year period, of which 127 cases (75%) had HD. The mean age of constipated patients at biopsy was 39 months and the mean age of patients with proven HD was 18 months. Males were affected more than females. Congenital anomalies associated with HD were found in 9.6%. In 85 (91%) cases constipation had begun in neonatal period. CONCLUSION Our data supports previous studies that if constipation begins after the neonatal period, the child is unlikely to have HD. In neonates delay in meconium passage is the most important clinical sign of HD.
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Affiliation(s)
- Maryam Monajemzadeh
- Department of Pathology, Tehran University of Medical Sciences, Tehran, Iran,Pediatrics Center of Excellence, Children's Medical Center, Tehran, Iran,Corresponding Author: Address: Pathology Ward, Children Medical Center Hospital, Keshavarz Boulevard,Tehran, Iran. E-mail:
| | - Mehdi Kalantari
- Pediatrics Center of Excellence, Children's Medical Center, Tehran, Iran,Department of Pediatric Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Bahareh Yaghmai
- Pediatrics Center of Excellence, Children's Medical Center, Tehran, Iran,Department of Pediatric, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Shekarchi
- Department of Pathology, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Mahjoub
- Department of Pathology, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrzad Mehdizadeh
- Pediatrics Center of Excellence, Children's Medical Center, Tehran, Iran,Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran
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