Enrique Rey

Symptoms of gastro-oesophageal reflux: prevalence, severity, duration and associated factors in a Spanish population

Aim : To measure the prevalence of gastro‐oesophageal reflux symptoms and to identify associated factors in a representative sample of the Spanish population.

Myenteric antiplexus antibodies and class II HLA in achalasia.

Achalasia, a motor disorder of the esophagus, is accompanied by autoimmune phenomena that could be playing a role in the pathogenesis of the disease. Our objective was to establish the genotypic frequency of the HLA-DR and DQ alleles in patients with achalasia and to establish their relationship with the presence of myenteric antiplexus antibodies in our geographic area. A total of 92 patients diagnosed with achalasia and two control groups with 275 healthy subjects were studied for HLA typing and 40 for autoantibodies determination. The myenteric antiplexus antibodies were positive in 50 patients (54.3%) and in 3 healthy subjects (7.5%) (P < 0.001). The patients showed a significantly higher frequency of DQA1*0103 and DQB1*0603 than was found in the controls. The heterodimer DQA1*0103–DQB1*0603 was increased in the patients [odds ratio (OR) = 2.57]. In regard to the association between the HLA DQA1 and DQB1 alleles and the antiplexus antibodies, these antibodies were found in greater prevalence in those patients with the DQA1*0103 and DQB1*0603 alleles, and the differences were statistically significant (OR = 3.17 and OR = 5.82, respectively). All of the women and 66.7% of the men with achalasia and the DQB1*0603 allele or the DQA1*0103–DQB1*0603 heterodimer were positive for antibodies.

Irritable bowel syndrome: Novel views on the epidemiology and potential risk factors

Symptoms consistent with the irritable bowel syndrome are remarkably frequent around the world. Irritable bowel syndrome prevalence ranges from 2.1% to 22%, depending on criteria used. Women are more frequently affected than men, but the reasons remain obscure; irritable bowel syndrome occurs in all age groups but there appears to be a modest decline in prevalence with advancing age again for unknown reasons. The incidence of irritable bowel syndrome per year has been estimated at approximately 1.5% in community subjects; annually only 0.2% of population will be diagnosed with irritable bowel syndrome. The natural history of irritable bowel syndrome is characterized by symptomatic flare ups and by a high rate of transition to other functional gastrointestinal diseases over the long term. Well recognized risk factors for irritable bowel syndrome include psychological distress and gastroenteritis. However, the association of psychological distress in some cases may reflect confounding factors and might be explained at least in part by cytokine production. Familial aggregation of irritable bowel syndrome occurs, and while the environment is key, twin studies generally support a genetic component in irritable bowel syndrome explaining up to 20% of the variability. Prior surgery may increase risk of irritable bowel syndrome. Early childhood trauma may be important; a low birth weight, nasogastric suction at birth, childhood abuse, and low socioeconomic status may carry an increased risk of suffering with irritable bowel syndrome as an adult. The role of diet remains uncertain but under-studied.

Onset and risk factors for fecal incontinence in a US community.

OBJECTIVES:The natural history of fecal incontinence (FI) in community subjects is uncertain and the onset rate is unknown. The aim of the study is to estimate the prevalence, new-onset rate, and risk factors for FI in community subjects.METHODS:A random sample of 2,400 community subjects aged ⩾50 years was surveyed in 1993, using a validated questionnaire. Responders were recontacted in 2003. FI was defined as self-reported problems with leakage of stool. Onset rate was calculated as the proportion of subjects without FI who became new cases. Logistic regression models were constructed to identify predictive factors for developing FI and changes in bowel habit associated with the onset of FI.RESULTS:Overall, 1,540 (64%) subjects responded to the initial survey, and 674 (44%) of them responded to the second survey a median of 9 (8.8–9.5) years later. The prevalence of FI in the first survey was 15.3% (13.4–17.3%). In the second survey, 37 reported incident FI; thus, the onset rate of FI was 7.0% (5.0–9.6) per 10 years. Predictive factors at baseline for the onset of FI were self-reported diarrhea (odds ratio (OR)=3.8 (1.5, 9.4)), incomplete evacuation (OR=3.4 (1.2, 9.8)), and pelvic radiation (OR=5.1 (1.01, 25.9)). Development of urgency was the primary predictor among the set of predictors reflecting changes in bowel symptoms that were associated with the onset of FI (OR=24.9 (10.6, 58.4)).CONCLUSIONS:The onset rate of FI is approximately 7% per 10 years in community subjects aged ⩾50 years. Prevention may be possible if bowel habit is appropriately managed in high-risk individuals.

Gastroesophageal reflux symptoms during and after pregnancy: a longitudinal study.

BACKGROUND AND AIMS:Prevalence of gastroesophageal reflux symptoms (GERS) increases during pregnancy, but there are no longitudinal studies on western populations examining their incidence in each trimester. Our aim was to describe the natural history of GERS in pregnancy and to ascertain whether pregnancy might be associated with a higher risk of developing GERS 1 yr postpartum.METHODS:Pregnant women (<12 wk gestation) and age-matched controls were included. A telephone survey was conducted, covering pregnant women at 12, 24, and 36 wk of gestation and at 1 yr postpartum, using a validated questionnaire. Controls were interviewed at baseline and 21 months later.RESULTS:Data on 263 pregnant women were analyzed. Incidence of GERS was 25.8% (95% confidence interval [CI] 20.1–31.1%) in the first trimester, 24.3% (95% CI 18.1–30.6%) in the second, and 25.5% (95% CI 18.2–32.8%) in the third. Factors associated with developing GERS in the first trimester were South American origin (odds ratio [OR] 2.75, 95% CI 1.30–5.84) and prepregnancy occasional GERS (OR 3.00, 95% CI 1.35–6.66). Risk factors of GERS in the third trimester were cumulative weight gain during pregnancy (OR 1.18, 95% CI 1.04–1.32) and prepregnancy occasional GERS (OR 3.79, 95% CI 1.08–13.24). Incidence of frequent GERS at 1 yr postpartum was higher in pregnant versus control women (4.7% vs 1.3%, P < 0.05).CONCLUSIONS:Incidence of GERS is similar across the three trimesters of pregnancy. Accumulated weight gain during pregnancy is associated with a higher risk of GERS in the third trimester. Pregnancy might constitute a risk factor for developing GERS 1 yr postpartum.

Association between weight gain and symptoms of gastroesophageal reflux in the general population

BACKGROUND AND AIM:Excess weight is a risk factor of gastroesophageal reflux symptoms (GERS) in population-based studies but it is unknown to what extent short-term weight gain (occurring in months) is associated with the development of GERS. Our aim is to examine the association of weight gain with GERS.METHODS:A phone interview was conducted with 2,500 persons aged 40–79 yr selected at random from the general population of Spain. The Gastroesophageal Reflux Questionnaire was used to identify the onset, frequency, and severity of GERS. We also assessed weight, height, and 1-yr weight change (classified as no weight gain, weight gain ≤5 kg, and weight gain >5 kg). We compared the frequency of new (less than 1 yr duration) and old (1 yr or more duration) GERS among weight change subgroups. The association between weight change and GERS was analyzed by logistic regression adjusting for BMI and other potential confounders.RESULTS:The prevalence of new and old GERS, respectively, was significantly (p < 0.05) higher in subjects with weight gain >5 kg (14.4% and 32.4%) than in those with weight gain ≤5 kg (8.2% and 27.5%) and no weight gain (5.4% and 22.5%). Subjects with a weight gain ≤5 kg showed an adjusted odds ratio (aOR) of 1.5 (95% confidence limits [CL]: 0.9–2.4) for new GERS and of 1.1 (95% CL: 0.8–1.4) for old GERS. Those with a weight gain >5 kg showed an aOR of 3.0 (95% CL: 1.6–6.0) for new GERS and of 1.3 (0.8–2.1) for old GERS.CONCLUSION:Weight gain is associated with GERS, independently of BMI.

Chronic Constipation, Irritable Bowel Syndrome With Constipation and Constipation With Pain/Discomfort: Similarities and Differences

OBJECTIVES:Some patients with chronic constipation (CC) have abdominal pain and discomfort (painful CC) without fulfilling the criteria for irritable bowel syndrome (IBS). Our aim was to investigate similarities and differences among nonpainful CC, painful CC, and CC in patients with IBS according to prevalence, individual symptoms, associated factors, and impact on health-related quality of life and use of medical resources.METHODS:We conducted a telephone survey of a random sample of the Spanish population (N=1500). Bowel symptoms were recorded using the Rome III questionnaire, health-related quality of life using the short form-12 (SF-12) and quality of live in constipation-20 (CVE-20) questionnaires, and self-reported constipation, lifestyle habits, and consultation behavior using an ad hoc questionnaire.RESULTS:The overall prevalence of CC was 19.2%, with prevalence by subgroups being 13.9% for nonpainful CC, 2.0% for painful CC, and 3.3% for CC in patients with IBS. CC was more prevalent among women at a ratio of 2.7:1. Subjects with painful CC and CC in patients with IBS were younger, reported more constipation, and had more symptoms than subjects with nonpainful CC. Age and physical activity were significantly associated with CC. Symptoms associated with consultation were abdominal pain and digitation. Nonpainful CC patients were more satisfied with laxative use than were the other subgroups. Subjects with CC showed a significant impairment in the physical and mental component of the SF-12 questionnaire.CONCLUSIONS:CC appears to be a spectrum; most patients do not have abdominal pain/discomfort but others (with otherwise quite similar characteristics) are patients with IBS or are out of any established diagnosis.

Prevalence of Hidden Gastroparesis in the Community: The Gastroparesis "Iceberg"

Background/Aims The prevalence of diagnosed gastroparesis is 24.2/100,000 inhabitants, but a large group of people with gastroparesis-like symptoms have never had a gastric emptying (GE) test. Some of them may have undiagnosed gastroparesis. Our aim was to estimate the prevalence of hidden gastroparesis in the community. Methods The study was conducted in 2 parts: (1) Patients referred for a scintigraphic GE test completed a validated questionnaire (Bowel Disease Questionnaire). Multiple linear regression models to predict 2 hours and 4 hours GE rates were developed. (2) A revised Bowel Disease Questionnaire was mailed to a random sample of 4,194 Olmsted County residents. GE rates were estimated with the models for each subject and delayed GE was considered when they were lower than normal values. Hidden gastroparesis was defined in community subjects with predicted delayed GE that had not been diagnosed with gastroparesis prior to the survey. Results The regression models for GE rates were constructed using data from 450 patients. In addition to age and gender, the symptoms found significant were nausea/vomiting, early satiety, upper abdominal pain, bloating, loss of appetite and weight loss more than 7 pounds. 2,298 (55%) community subjects returned a questionnaire. Five subjects were excluded due to a prior diagnosis of gastroparesis. When models were applied to the community survey data, 42 (1.8%) subjects were estimated to have delayed GE. Conclusions Delayed GE was estimated to occur in 1.8% of community subjects. Since the prevalence of diagnosed gastroparesis is low (0.02%), many subjects with gastroparesis may remain undiagnosed.

A Randomized, Double-Blind, Placebo-Controlled Trial of St John's Wort for Treating Irritable Bowel Syndrome

OBJECTIVES:St Johns wort (SJW) is known to effectively treat patients with mild-to-moderate depression. Antidepressants are frequently used to treat irritable bowel syndrome (IBS). To date, no study that examines the efficacy of SJW in IBS has been carried out. The aim of this study was to evaluate the efficacy of SJW in IBS after 12 weeks.METHODS:In this randomized, double-blind, placebo-controlled trial, 70 participants with an established diagnosis of IBS were randomized and assigned by concealed allocation to either SJW or placebo. Both treatment arms were balanced on symptom subtype. The primary end point was self-reported overall bowel symptom score (BSS) at 12 weeks. Secondary end points were individual BSS for diarrhea (D-BSS), constipation (C-BSS), pain or discomfort, and bloating; adequate relief (AR) of IBS on at least 50% of the last 4 weeks of therapy; and IBS quality-of-life score at 12 weeks.RESULTS:In all, 86% of the participants were women, and the median age was 42 years. Overall, 29% had C-IBS, 37% D-IBS, and 31% had mixed IBS. Both groups reported decreases in overall BSS from baseline, with the placebo arm having significantly lower scores at 12 weeks (P=0.03) compared with SJW. These patterns of improvement were mirrored in the secondary end points with the placebo group faring better than the SJW-treated group, with significant differences observed at week 12 for D-BSS (P=0.03) and percent with AR (P=0.02). A similar proportion of subjects in each treatment group (SJW: 51% vs. placebo: 54%) believed that the study drug they received decreased IBS life interferences (P=0.79).CONCLUSIONS:SJW was a less effective treatment for IBS than placebo.

Prevalence of Functional Gastrointestinal Disorders in Patients With Fibromyalgia and the Role of Psychologic Distress

BACKGROUND & AIMS Fibromyalgia is a rheumatologic disorder associated with somatic and psychologic conditions. Although fibromyalgia is associated with irritable bowel syndrome, its relationship with other functional gastrointestinal disorders (FGID) is unclear. We evaluated the prevalence of FGID in patients with fibromyalgia and the role of psychologic factors in this relationship. METHODS From a Spanish population, 100 patients with fibromyalgia and 100 matched controls completed the Rome II Integrative Questionnaire to assess the prevalence of FGID and the Symptom Checklist-90 Revised (SCL-90R) to evaluate psychologic distress. Patients completed the Fibromyalgia Impact Questionnaire to evaluate the overall impact of fibromyalgia and controls filled out the Chronic Widespread Pain Questionnaire to detect potential cases of fibromyalgia. RESULTS Ninety-three percent of the total study population was female, with a mean age of 50 years. We identified 6 cases of widespread pain among controls. The average Fibromyalgia Impact Questionnaire score for patients was 67.28 +/- 14.25. All gastrointestinal symptoms except for vomiting were more frequent in patients. Ninety-eight percent of patients with fibromyalgia had at least one FGID, compared with only 39% of controls. Fibromyalgia was correlated most highly with irritable bowel syndrome. Patients presented with significantly higher scores of psychologic distress than controls, especially those with fecal incontinence. CONCLUSIONS There is a prevalence of FGID in patients with fibromyalgia and a wider distribution of such symptoms along the gastrointestinal tract compared with controls. We propose that an increased degree of psychologic distress in these patients predisposes them to FGID, especially significant for anorectal syndromes.