Benjamin Cassell

The impact of psychiatric and extraintestinal comorbidity on quality of life and bowel symptom burden in functional GI disorders

Functional gastrointestinal disorders (FGID) patients report poor health‐related quality of life (HRQOL) and experience high rates of psychiatric and extraintestinal functional disorder (EIFD) comorbidity. The independent influence of these comorbidities on HRQOL and symptom burden remains unknown. We sought to determine whether FGID with mood or EIFD comorbidity have poorer HRQOL and greater GI symptom burdens; to determine the influence of comorbidities on HRQOL in FGID independent of bowel symptoms.

The impact of abuse and mood on bowel symptoms and health‐related quality of life in irritable bowel syndrome (IBS)

Irritable bowel syndrome (IBS) is a common abdominal pain disorder without an organic explanation. Abuse histories (physical, sexual, emotional) are prevalent in IBS. While abuse relates to mood disorders (depression and anxiety) also common in IBS, the influence of abuse on gastrointestinal (GI) symptoms and health‐related quality of life (HRQOL) and its independence from psychological symptom comorbidity has not been studied.

Genetic variation in the beta-2 adrenergic receptor (ADRB2) predicts functional gastrointestinal diagnoses and poorer health-related quality of life

The beta‐2 adrenergic receptor (ADRB2) is an important target for epinephrine, a neurotransmitter in pain signalling. ADRB2 haplotypes affect receptor expression and ligand response, and have been linked to painful non‐GI disorders.

Effects of disturbed sleep on gastrointestinal and somatic pain symptoms in irritable bowel syndrome

Sleep disturbances are common, and perhaps are even more prevalent in irritable bowel syndrome (IBS).

Beliefs about GI medications and adherence to pharmacotherapy in functional GI disorder outpatients.

Objectives:Pharmacotherapy is a mainstay in functional gastrointestinal (GI) disorder (FGID) management, but little is known about patient attitudes toward medication regimens. Understanding patient concerns and adherence to pharmacotherapy is particularly important for off-label medication use (e.g., antidepressants) in FGID.Methods:Consecutive tertiary GI outpatients completed the Beliefs About Medications questionnaire (BMQ). Subjects were categorized as FGID and structural GI disease (SGID) using clinician diagnoses and Rome criteria; GI-specific medications and doses were recorded, and adherence to medication regimens was determined by patient self-report. BMQ domains (overuse, harm, necessity, and concern) were compared between FGID and SGID, with an interest in how these beliefs affected medication adherence. Psychiatric measures (depression, anxiety, and somatization) were assessed to gauge their influence on medication beliefs.Results:A total of 536 subjects (mean age 54.7±0.7 years, range 22–100 years; n=406, 75.7% female) were enrolled over a 5.5-year interval: 341 (63.6%) with FGID (IBS, 64.8%; functional dyspepsia, 51.0%, ≥2 FGIDs, 38.7%) and 142 (26.5%) with SGID (IBD, 28.9%; GERD, 23.2%). PPIs (n=231, 47.8%), tricyclic antidepressants (TCAs) (n=167, 34.6%), and anxiolytics (n=122, 25.3%) were common medications prescribed. FGID and SGID were similar across all BMQ domains (P>0.05 for overuse, harm, necessity, and concern). SGID subjects had higher necessity-concern framework (NCF) scores compared with FGID subjects (P=0.043). FGID medication adherence correlated negatively with concerns about medication harm (r=−0.24, P<0.001) and overuse (r=−0.15, P=0.001), whereas higher NCF differences predicted medication compliance (P=0.006). Medication concern and overuse scores correlated with psychiatric comorbidity among FGID subjects (P<0.03 for each). FGID patients prescribed TCAs (n=142, 41.6%) expressed a greater medication necessity (17.4±0.4 vs. 16.2±0.4, P=0.024) and found their GI regimen to be more helpful (P=0.054). FGID subjects not on TCAs expressed a greater apprehension about medication overuse (10.7±0.3 vs. 9.7±0.2, P=0.002) on the BMQ.Conclusions:FGID subjects report medication necessity and concern scores comparable to patients with SGID but have negative perceptions about medications, particularly in the presence of psychiatric comorbidity; these factors may affect treatment adherence and willingness to initiate neuromodulator regimens.

Gastrointestinal Bleeding Following Left Ventricular Assist Device (LVAD) Implantation: Taking the Pulse of the Problem

Over the course of the last decade, implantation of left ventricular assist devices (LVADs) has become an increasingly popular treatment strategy for patients with advanced heart failure, both as a bridge to heart transplantation and as a ‘‘destination’’ therapy. The first generation of LVADs, based on a pulsatile mechanism, was plagued by poor reliability and high infection and thrombosis rates, leading to the development of smaller and more reliable continuous-flow (CF) LVADs. Following the introduction of CF-LVADs, postimplantation survival rates improved to as high as 50–75 % at 2 years [1]. Not surprisingly, CF-LVAD implantation rates have grown exponentially. With the rapidly expanding use of LVADs, it has become clear that long-term mechanical circulatory support is associated with gastrointestinal (GI) bleeding, now considered one of the more common and recalcitrant longterm complications following LVAD implantation, with a recent meta-analysis reporting the prevalence of GI bleeding near 30 % [2]. While the scope of the problem is well described, the pathogenesis of GI bleeding following LVAD implantation is still uncertain. Most studies report that GI bleeding was far more prevalent in patients supported by CF rather than pulsatile LVADs [3]. Continuous, non-pulsatile flow of blood through the vasculature differs from the normal physiologic state, with significant pathophysiologic implications. An important concept for CF-LVADs is the pulsatility index, a measure of the variation in pulse pressure representing the contribution of the native heart to the cardiac output. Interestingly, most prior studies have reported an inverse relationship between the pulsatility index and the risk of GI bleeding, patients with more pulsatile blood flow less likely to bleed [3, 4]. Although the pathophysiologic link between non-pulsatile flow and an increased propensity to bleed remains incompletely understood, recent investigation has uncovered several potential contributing factors such as the development of an acquired von Willebrand disorder in LVAD patients [5], apparently related to the continuous-flow pattern, similar to patients with aortic stenosis and Heyde’s syndrome [5]. In this issue of Digestive Diseases and Sciences, Jabbar et al. [6] report a single-center, retrospective cohort study describing the incidence and outcomes of GI bleeding in patients during long-term support with CF-LVADs, representing one of the largest published experiences to date. The authors reviewed the records of 112 patients who were followed for a median of 12 months after implantation of the Heart Mate II continuous-flow LVAD. Overall, GI bleeding was reported in 39 % of patients, with the first episode typically occurring within 2 months of implantation. As in most prior reports, GI bleeding was overt in a majority of cases (73 %), and the source of bleeding identified with upper endoscopy in 61 % of patients. Gastro-duodenal erosive disease (erosions or ulcers) was the most frequently observed bleeding lesions, accounting for 38 % of events, followed by angioectasia. Although endoscopic therapy was performed in 39 % of patients, endoscopic therapy did not influence the rate of recurrent GI bleeding. Multivariable analysis identified elevated right heart pressures and post-LVAD ejection fraction as risk factors for GI bleeding. Overall, the findings of this study are in line with comparable other recent reports. The most clinically relevant & Vladimir M. Kushnir vkushnir@wustl.edu

Do Consultants Follow-Up on Tests They Recommend? Insights From an Academic Inpatient Gastrointestinal Consult Service

Background Inpatient care is a fundamental part of gastroenterology training and involves the recommendation, performance, and interpretation of diagnostic tests. However, test results are not always communicated to patients or treating providers. We determined the process of communication of test results and recommendations in our inpatient gastroenterology (GI) consult service.

Mo1278 Review of Systems and Medication Allergies Predict Presence and Severity of Functional GI Disorders (FGIDs)

Background: IBS is a common functional GI syndrome with a prominent pain component. History of physical, sexual, and/or emotional abuse is more prevalent among IBS sufferers. Previously we reported that abuse is linked to more severe and frequent IBS symptoms and poorer health related quality of life (HRQOL). If abuse experiences heighten brain neurocircuitry sensitivity to pain experiences as has been suggested (Ringel Y et al Gastroenterol 2008), this study then sought to examine the effects of an abuse history on rates of functional GI disorder (FGID) diagnoses, non-GI diagnoses, and recent pain symptoms among an IBS population; further, we aimed to determine whether experiences of multiple forms of abuse resulted in greater likelihood of developing functional GI and non-GI complaints. Methods: Consecutive GI outpatients were invited to complete ROME III Research Diagnostic Questionnaire to establish FGID criteria. Self-report questionnaires on abuse history (Life-Stress Questionnaire) were obtained, with a focus on physical, sexual, and emotional abuse. IBS patients with histories of any form of these abuse experiences were defined as IBS+/Abuse+. Recent non-GI somatic symptoms (PHQ-12), and historical somatic pain diagnoses (e.g., fibromyalgia, headache, chronic back pain) were recorded. 272 ROMEdefined IBS subjects (50.1±0.9 yrs, 81% female) were identified, and reported greater rates of abuse compared to a non-IBS comparator group (n=246): physical (18.1% vs 6.6%), sexual (15.5% vs 7.4%), and emotional (31.7% vs 16.9%) (p 1 form of abuse. Compared to IBS subjects without abuse histories (IBS+/Abuse-), IBS+/Abuse+ subjects had greater total numbers of ROME diagnoses (2.5±0.3 vs 2.1±0.3, p=0.10), non-GI pain diagnoses (1.9±0.2 vs. 0.9±0.08, p<0.001), and more recent somatic symptoms (9.6±0.5 vs. 7.7±0.4, p=0.001). All forms of abuse experiences imposed similar risk of functional syndromes. An additive effect of multiple forms of abuse was observed, such that greater numbers non-GI pain disorders (F=13.5, p<0.001) and somatic symptom complaints (F=5.8, p=0.001) were noted with the experience of multiple forms of abuse. This additive effect was not relevant to the number of ROME diagnoses recorded, however (F=0.69, p=0.55). Conclusions: Abuse experiences common in IBS patients are associated with reports of greater non-GI symptoms, historical somatic diagnoses, and to a lesser extent additional FGID diagnoses in IBS patients; these relationships are particularly robust when multiple forms of abuse have been experienced. These observations provide indirect evidence of an enhanced susceptibility to both GI and somatic functional disorders following abuse.

Mo1276 Abuse Histories Predict Greater Functional GI and Pain Comorbidities in Irritable Bowel Syndrome (IBS) Patients

Background: IBS is a common functional GI syndrome with a prominent pain component. History of physical, sexual, and/or emotional abuse is more prevalent among IBS sufferers. Previously we reported that abuse is linked to more severe and frequent IBS symptoms and poorer health related quality of life (HRQOL). If abuse experiences heighten brain neurocircuitry sensitivity to pain experiences as has been suggested (Ringel Y et al Gastroenterol 2008), this study then sought to examine the effects of an abuse history on rates of functional GI disorder (FGID) diagnoses, non-GI diagnoses, and recent pain symptoms among an IBS population; further, we aimed to determine whether experiences of multiple forms of abuse resulted in greater likelihood of developing functional GI and non-GI complaints. Methods: Consecutive GI outpatients were invited to complete ROME III Research Diagnostic Questionnaire to establish FGID criteria. Self-report questionnaires on abuse history (Life-Stress Questionnaire) were obtained, with a focus on physical, sexual, and emotional abuse. IBS patients with histories of any form of these abuse experiences were defined as IBS+/Abuse+. Recent non-GI somatic symptoms (PHQ-12), and historical somatic pain diagnoses (e.g., fibromyalgia, headache, chronic back pain) were recorded. 272 ROMEdefined IBS subjects (50.1±0.9 yrs, 81% female) were identified, and reported greater rates of abuse compared to a non-IBS comparator group (n=246): physical (18.1% vs 6.6%), sexual (15.5% vs 7.4%), and emotional (31.7% vs 16.9%) (p 1 form of abuse. Compared to IBS subjects without abuse histories (IBS+/Abuse-), IBS+/Abuse+ subjects had greater total numbers of ROME diagnoses (2.5±0.3 vs 2.1±0.3, p=0.10), non-GI pain diagnoses (1.9±0.2 vs. 0.9±0.08, p<0.001), and more recent somatic symptoms (9.6±0.5 vs. 7.7±0.4, p=0.001). All forms of abuse experiences imposed similar risk of functional syndromes. An additive effect of multiple forms of abuse was observed, such that greater numbers non-GI pain disorders (F=13.5, p<0.001) and somatic symptom complaints (F=5.8, p=0.001) were noted with the experience of multiple forms of abuse. This additive effect was not relevant to the number of ROME diagnoses recorded, however (F=0.69, p=0.55). Conclusions: Abuse experiences common in IBS patients are associated with reports of greater non-GI symptoms, historical somatic diagnoses, and to a lesser extent additional FGID diagnoses in IBS patients; these relationships are particularly robust when multiple forms of abuse have been experienced. These observations provide indirect evidence of an enhanced susceptibility to both GI and somatic functional disorders following abuse.