Gisela Ringstrom

Gastrointestinal-specific anxiety : an important factor for severity of GI symptoms and quality of life in IBS

Background  Gastrointestinal (GI)‐specific anxiety (GSA) has been proposed to influence symptom severity and quality of life (QOL) in patients with irritable bowel syndrome (IBS). The Visceral Sensitivity Index (VSI) is a recently developed, reliable and valid measure of GSA. Our aim was to evaluate the association between GSA, GI symptom severity, and QOL in IBS patients.

Treatment With Hypnotherapy Reduces the Sensory and Motor Component of the Gastrocolonic Response in Irritable Bowel Syndrome

Objective Postprandial symptoms in irritable bowel syndrome are common and relate to an exaggerated motor and sensory component of the gastrocolonic response. We investigated whether this response can be affected by hypnotherapy. Methods We included 28 patients with irritable bowel syndrome refractory to other treatments. They were randomized to receive gut-directed hypnotherapy 1 hour per week for 12 weeks (N = 14) or were provided with supportive therapy (control group; N = 14). Before randomization and after 3 months, all patients underwent a colonic distension trial before and after a 1-hour duodenal lipid infusion. Colonic sensory thresholds and tonic and phasic motor activity were assessed. Results Before randomization, reduced thresholds after vs. before lipid infusion were seen in both groups for all studied sensations. At 3 months, the colonic sensitivity before duodenal lipids did not differ between groups. Controls reduced their thresholds after duodenal lipids for gas (22 ± 1.7 mm Hg vs. 16 ± 1.6 mm Hg, p < .01), discomfort (29 ± 2.9 mm Hg vs. 22 ± 2.6 mm Hg, p < .01), and pain (33 ± 2.7 mm Hg vs. 26 ± 3.3 mm Hg, p < .01), whereas the hypnotherapy group reduced their thresholds after lipids only for pain (35 ± 4.0 mm Hg vs. 29 ± 4.7 mm Hg, p < .01). The colonic balloon volumes and tone response at randomization were similar in both groups. At 3 months, baseline balloon volumes were lower in the hypnotherapy group than in controls (83 ± 14 ml vs. 141 ± 15 ml, p < .01). In the control group, reduced balloon volumes during lipid infusion were seen (141 ± 15 ml vs. 111 ± 19 ml, p < .05), but not after hypnotherapy (83 ± 14 ml vs. 80 ± 16 ml, p > .20). Conclusion Hypnotherapy reduces the sensory and motor component of the gastrocolonic response in patients with irritable bowel syndrome. These effects may be involved in the clinical efficacy of hypnotherapy in IBS.

Patients with Chronic Renal Failure Have Abnormal Small Intestinal Motility and a High Prevalence of Small Intestinal Bacterial Overgrowth

Background/Aims: Gastrointestinal (GI) symptoms are common among patients with chronic renal failure (CRF). The pathogenesis of these symptoms is probably multifactorial. Our aims were to assess gastric and small intestinal motility and the prevalence of small intestinal bacterial overgrowth (SIBO) in order to clarify possible pathophysiological mechanisms behind these symptoms in CRF patients. Methods: Twenty-two patients with CRF, 12 with GI symptoms and 10 without GI symptoms underwent antroduodenojejunal manometry. All patients with GI symptoms had diarrhea and half of them had abdominal pain, nausea and/or early satiety. Symptoms were unexplained by conventional investigations. Interdigestive motility was recorded for 5 h and postprandially for 1 h. Samples for culture from the small intestine were obtained through the manometry catheter. Results were compared with 34 healthy controls. Results: On manometry, 11 CRF patients demonstrated neuropathic-like abnormalities, with no significant difference between the patients with (7/12) and without (4/10) GI symptoms. SIBO was seen in 8 CRF patients (36%), 3 with and 5 without GI symptoms (p = 0.15). Six of eleven (55%) of the CRF patients with neuropathic-like abnormalities had SIBO, compared to 2/11 (18%) in those without abnormalities on conventional analysis (p = 0.07). The propagation velocity of phase III was significantly faster in CRF patients with GI symptoms compared to CRF patients without symptoms and healthy controls (21.4 (16.4–54.7) vs. 8.1 (4.6–9.6) and 10.8 (7.2–21.6) cm/min, p = 0.007 and p = 0.019, respectively). We found a higher proportion of retrograde pressure waves in late phase II in the proximal duodenum in patients with and without GI symptoms, than in healthy controls (29 (17–38) and 16 (14–42) vs. 8 (0–24)%, p < 0.0001 and p = 0.0005, respectively). The number of long clusters during the fasting recording was higher in both patient groups than in controls (9 (5–21) and 11 (7–15) vs. 4 (2–9)/5, p = 0.046 and p = 0.002, respectively). Conclusion: In the small intestine, abnormal motility and bacterial overgrowth are common in patients with chronic renal failure. These alterations correlate poorly with GI symptoms, but disturbed intestinal motility might explain diarrhea in some of these patients.

Structured patient education is superior to written information in the management of patients with irritable bowel syndrome: a randomized controlled study.

Objective Education and reassurance are proposed to be of great importance in the management of patients with irritable bowel syndrome (IBS), but few trials supporting this are available. Our aim was to compare the effects of a structured patient group education (IBS school) versus receiving written information in the form of an IBS guidebook, on knowledge, symptoms, and quality of life in IBS patients. Methods Patients with IBS according to the Rome II criteria were randomized to participate in the group education or to receive the guidebook. The effects were evaluated by self-administered questionnaires at 3 and 6 months after baseline. Results One hundred and forty-three patients – 71 in the guidebook group and 72 in the IBS school group – completed the study. Compared with the guidebook group, the patients in the education group showed greater reduction in IBS symptom severity and gastrointestinal (GI)-specific anxiety, as well as greater improvement in perceived knowledge of IBS. Several aspects of health-related quality of life were significantly improved after the group education, but not in the group who received the written information. Conclusion A structured patient group education is superior to written information to enhance knowledge of IBS, and improve GI symptoms and GI-specific anxiety in IBS patients.

Detection of inflammatory markers in stools from patients with irritable bowel syndrome and collagenous colitis

Objective. Irritable bowel syndrome (IBS) and collagenous colitis (CC) share chronically recurring symptoms of altered bowel habits associated with abdominal pain or discomfort. The aims of the present study were to investigate whether inflammatory markers could be detected in faeces from patients with IBS and CC, and to elucidate whether such analyses could be used as non-invasive tools to distinguish between these disorders. Material and methods. Stool samples were obtained from 18 patients with CC, 46 patients with IBS and 20 healthy controls (HC). Eosinophil protein X (EPX), myeloperoxidase (MPO), tryptase, interleukin-1 beta (IL-1β) and tumour necrosis factor alpha (TNFα) were measured in supernatants from processed faeces using immunoassays. Results. EPX levels were enhanced in faeces from CC patients (median 3.8 µg/g (0.47–16.2)) compared to patients with IBS (0.44 µg/g (0.25–1.8)), p<0.001, and HC (0.46 µg/g (0.21–1.3)), p<0.001. In addition, MPO was increased in CC patients (11.7 µg/g (2.0–124)) compared to IBS patients (1.7 µg/g (0.81–5.2)), p<0.01, and HC (2.5 µg/g (1.1–6.3)), p<0.05. Tryptase was found in 9/18 patients with CC, 6/46 with IBS and 1/19 HC. IL-1β was only enhanced in 2/11 CC patients and TNFα was not detected in any sample. Conclusions. Increased levels of EPX, MPO and tryptase were observed in stools from collagenous colitis patients, whereas the levels in IBS patients did not differ from healthy controls. Our data suggest that faecal markers could be used as part of the clinical work-up to determine which patients should be biopsied and evaluated for collagenous colitis.

Why do subjects with irritable bowel syndrome seek health care for their symptoms

Objective. Irritable bowel syndrome (IBS) is common in the population, but not all subjects seek professional health care for their symptoms. The aim of this study was to compare consulters in secondary/tertiary care with those in primary care and non-consulters by using questionnaires to investigate factors of importance for health-care seeking in IBS. Material and methods. The study included 218 subjects with IBS: 70 non-consulters, 53 patients from primary care and 95 from secondary/tertiary care. The subjects completed questionnaires on gastrointestinal (GI) and psychological symptoms, coping resources, health-related quality of life (HRQOL) and reasons for not seeking health care. Results. Consulters (primary and secondary/tertiary care combined) had poorer HRQOL, more severe psychological symptoms, higher levels of GI-specific anxiety and poor coping resources compared with non-consulters, but the GI symptom severity was similar. Mental health and poor social, emotional and physical functioning were independently predictive of being a health-care seeker (r2=0.41). Independent predictors for being a consulter in secondary/tertiary care were a high degree of anxiety, low scores on physical functioning, physical role and food (IBSQOL) (r2=0.65). Several non-consulters reported mild symptoms and ability to control symptoms as reasons for not seeking health care. Having a close relative with similar symptoms reduced the need to seek health care. Thirty-six non-consulters had sought alternative care or advice from friends and/or relatives about their GI symptoms. Conclusions. GI symptom severity alone cannot explain the illness behavior in IBS. HRQOL and psychological symptoms are important for experience of GI symptoms and the health-care seeking pattern in IBS.

Intervention to increase physical activity in irritable bowel syndrome shows long-term positive effects.

AIM To assess the long-term effects of physical activity on irritable bowel syndrome (IBS) symptoms and on quality of life, fatigue, depression and anxiety. METHODS Seventy-six patients from a previous randomized controlled interventional study on increased physical activity in IBS were asked to participate in this long-term follow-up study. The included patients attended one visit in which they filled out questionnaires and they underwent a submaximal cycle ergometer test. The primary end point was the change in the IBS Severity Scoring System (IBS-SSS) at baseline, i.e., before the intervention and at follow-up. The secondary endpoints were changes in quality of life, fatigue, depression and anxiety. RESULTS A total of 39 [32 women, median age 45 (28-61) years] patients were included in this follow-up. Median follow-up time was 5.2 (range: 3.8-6.2) years. The IBS symptoms were improved compared with baseline [IBS-SSS: 276 (169-360) vs 218 (82-328), P = 0.001]. This was also true for the majority of the dimensions of psychological symptoms such as disease specific quality of life, fatigue, depression and anxiety. The reported time of physical activity during the week before the visit had increased from 3.2 (0.0-10.0) h at baseline to 5.2 (0.0-15.0) h at follow-up, P = 0.019. The most common activities reported were walking, aerobics and cycling. There was no significant difference in the oxygen uptake 31.8 (19.7-45.8) mL per min per kg at baseline vs 34.6 (19.0-54.6) mL/min per kg at follow-up. CONCLUSION An intervention to increase physical activity has positive long-term effects on IBS symptoms and psychological symptoms.

Gastric electrical stimulation for intractable vomiting in patients with chronic intestinal pseudoobstruction

Abstract  Gastric electrical stimulation (GES) is effective for medically refractory nausea and vomiting in patients with idiopathic or diabetic gastroparesis (DGP). We studied whether GES has similar effects in chronic intestinal pseudoobstruction (CIP). Patients referred for chronic small bowel (SB) motor dysfunction requiring parenteral nutrition and having a weekly vomiting frequency (WVF) ≥7 refractory to prokinetics and antiemetics were included. Patients were implanted for high‐frequency GES 12 stimuli min−1, laparoscopy being the first‐line implantation procedure. Results were compared with those obtained in 11 DGP patients. Three patients with familial CIP and one patient with postsurgical CIP fulfilled the criteria. Gastric emptying was delayed in two and was normal in two patients. SB transit time was markedly delayed. Laparoscopy was used in three patients, one patient required laparotomy. During GES, WVF decreased from 24 (mean) before GES to 6.9 at 12 months and 7.5 at last visit. Vomiting reduction was 50–90% at last visit. For the DGP patients, WVF decreased from 23 before GES to 3.5 at 12 months and 3.5 (P < 0.01) at last visit. In patients with CIP and medically refractory vomiting, GES seems to have an anti‐vomiting effect comparable to that seen in patients with severe DGP. GES should be considered as a therapeutic option for these patients.

Effects of Duodenal Lipids on Gastric Sensitivity and Relaxation in Patients with Ulcer-Like and Dysmotility-Like Dyspepsia

Background/Aims: Functional dyspepsia (FD) according to Rome II is divided into ulcer-like dyspepsia (ULD) and dysmotility-like dyspepsia (DLD). The rationale behind this is the assumption that the underlying pathophysiology is different, but this is largely unexplored. Our aim was to elucidate the differences in gastric sensorimotor function in these subgroups of FD. 13 healthy controls (HC) and 20 patients with FD, 10 ULD and 10 DLD, were included. Methods: A feeding tube was placed fluoroscopically in the proximal duodenum and a barostat balloon was placed in the proximal stomach. Sensory thresholds to gastric distention for first sensation, bloating and discomfort were assessed before and after duodenal lipid infusion (2 kcal/min, 60 min). Results: Volume changes in the balloon were recorded as a measure of gastric tone. In FD patients, sensory thresholds in the fasting state were significantly lower than in HC, mostly due to gastric hypersensitivity in ULD. After lipid infusion, 95% of FD patients fell outside the normal range of HC for first sensation, bloating and/or discomfort, compared with 65% in the fasting state. Patients with ULD but not DLD had impaired fundic relaxation after duodenal lipids compared with HC. Conclusions: Investigating gastric sensorimotor function after duodenal lipid infusion, FD patients can accurately be differentiated from HC. Impaired fundic relaxation seems to be more common in patients with ULD.

A comparison of a short nurse-based and a long multidisciplinary version of structured patient education in irritable bowel syndrome.

Objective Structured multidisciplinary patient group education has positive effects on symptoms, health-related quality of life, and disease-related knowledge in patients with irritable bowel syndrome (IBS), but few studies comparing different forms of educational interventions are available. Our aim was to compare the effects of long multidisciplinary group education with a short nurse-based group education with regard to symptoms, knowledge, quality of life, and satisfaction with the intervention in IBS patients. Methods Patients with IBS according to the Rome II criteria were randomized to either short nurse-based or a long multidisciplinary-based education. The effects were evaluated by self-administered questionnaires at 3, 6, and 12 months after baseline, and compared between the groups. Results No differences in effects were detected in the between-group comparisons at any of the follow-up assessments. However, positive effects on symptoms, knowledge, quality of life, and satisfaction with the intervention were found in both the short and the long version. Conclusion A short, nurse-based educational intervention seems to be as efficacious as a longer multidisciplinary version. In both groups, positive effects on patients’ well-being were found to a similar extent. This is an important finding that, from a cost-effective perspective, could contribute toward an optimized management of patients with IBS.