Kevin W. Olden

Overlapping Upper and lower gastrointestinal symptoms in irritable Bowel syndrome patients with constipation or diarrhea

OBJECTIVES:Distinguishing between irritable bowel syndrome (IBS) and functional dyspepsia can be challenging because of the variations in symptom patterns, which commonly overlap. However, the overlap is poorly quantified, and it is equally uncertain whether symptom patterns differ in subgroups of IBS arbitrarily defined by primary bowel patterns of constipation (IBS-C) and diarrhea (IBS-D). We aimed to determine and to compare the distribution of GI symptoms, both, upper and lower, among IBS-C and IBS-D patients.METHODS:A total of 121 consecutive patients presenting with a diagnosis of IBS were grouped according to primary bowel symptoms as IBS-C (58 women and 18 men, mean age 47 ± 17 yr) or IBS-D (26 women and 19 men, mean age 47 ± 15 yr). The Hopkins Bowel Symptom Questionnaire, which includes a brief Quality of Life assessment, and the Hopkins Symptom Checklist 90-Revised were completed by all patients at intake.RESULTS:IBS-C patients reported significantly more overall GI symptoms when compared to patients with IBS-D (6.67 vs 4.62, respectively, p < 0.001). Abdominal pain patterns differed in patients with IBS-C versus IBS-D (lower abdominal pain: 40.8%vs 24.4%p = 0.05 and upper abdominal pain: 36.8%vs 24.4%, respectively). Bloating was substantially more common in IBS-C patients (75%) than in IBS-D (40.9%). There were no significant differences in personality subscales by IBS subgroup; however, somatization was positively associated with multiple symptom reports and was negatively correlated with quality of life.CONCLUSIONS:Upper GI symptoms consistent with functional dyspepsia were more frequent in IBS-C. Although there was considerable overlap of upper and lower GI symptoms in patients with IBS-C and IBS-D, the former had more frequent lower abdominal pain and bloating.

Effect of alosetron on bowel urgency and global symptoms in women with severe, diarrhea-predominant irritable bowel syndrome: Analysis of two controlled trials☆

BACKGROUND & AIMSnThe aim of this study was to assess the effect of alosetron on bowel urgency and irritable bowel syndrome (IBS) global improvement in diarrhea-predominant IBS (D-IBS).nnnMETHODSnWomen with a lack of satisfactory bowel urgency control at least 50% of the time during screening were randomized to receive alosetron 1 mg (n = 246) or placebo (n = 246) twice daily. The primary end point was the percentage of days with satisfactory control of bowel urgency. The response rate for the IBS global improvement scale (GIS) was a secondary end point. GIS responders were patients who recorded either moderate or substantial improvement in IBS symptoms relative to the way they felt before entering the study. Other end points included improvement in stool frequency, stool consistency, and percentage of days with incomplete evacuation. Further analyses were performed on a subset of patients who had at least 10 of 14 days during screening (>/=71% of days) with a lack of satisfactory control of bowel urgency.nnnRESULTSnPatients had severe chronic IBS symptoms, and 89% of patients had D-IBS. Alosetron resulted in a greater percentage of days with satisfactory control of urgency compared with placebo (69% vs. 56%, respectively, P < 0.001). Greater percentages of alosetron-treated patients were GIS responders at 4, 8, and 12 weeks compared with placebo (59% vs. 41%, 63% vs. 41%, and 68% vs. 46%, respectively, P < 0.001). Patients with more frequent urgency had similar results. Constipation occurred in 28% and 9% of subjects in the alosetron- and placebo-treated groups, respectively. No cases of ischemic colitis were reported.nnnCONCLUSIONSnAlosetron effectively manages bowel urgency and improves global symptoms in women with severe chronic D-IBS.

Psychosocial aspects of functional gastrointestinal disorders

Psychosocial factors, such as stress, abuse history, psychiatric disturbance, coping style, and learned illness behaviors, play an important role in functional GI disorders in terms of symptom experience and clinical outcome. These psychosocial factors are influenced by and influence GI symptoms in a bidirectional manner as mediated through the brain-gut axis (CNS and ENS pathways). Entering the patient encounter using a biopsychosocial approach and a care (versus cure) style can help avoid excessive diagnostic testing, and elicit crucial information about potential abuse history or psychiatric symptoms that can help guide therapy. Finally, for patients with severe, refractory symptoms, multicomponent treatment involving psychologic therapy, such as CBT, relaxation, or hypnotherapy, can be beneficial.

PSYCHOLOGIC AND PSYCHIATRIC ASPECTS OF GASTROINTESTINAL DISEASE

There has been an explosion in understanding of the psychosocial concomitants of functional gastrointestinal disorders. Detecting psychologic disturbance and eliciting a history of physical or sexual abuse are critical in suggesting comprehensive and efficacious treatment strategies for these patients. The challenge is to define further the use of psychopharmacologic agents, including the newer antidepressants, anticonvulsants, and anxiolytic agents, in the treatment of chronic functional gastrointestinal disorders. Further research to evaluate the usefulness of various forms of psychotherapeutic and behavioral interventions needs to be undertaken. Establishing a multicomponent treatment program delivered by a team of caregivers, each bringing their unique skills (internist, psychiatrist, psychologist, and others) to patients, must be based on further research on the efficacy of these modalities as opposed to empiric treatment.

Patient satisfaction with alosetron for the treatment of women with diarrhea-predominant irritable bowel syndrome.

OBJECTIVE:The efficacy and tolerability of alosetron in women with diarrhea-predominant irritable bowel syndrome (IBS) have been established in double-blind, placebo-controlled trials. However, the degree to which alosetron fulfills the needs of those suffering from IBS has not been thoroughly examined from the patients perspective. This randomized, double-blind, placebo-controlled study conducted in women with diarrhea-predominant IBS evaluated patients’ overall satisfaction with treatment as well as their satisfaction with respect to several specific medication attributes.METHODS:Patients randomized to receive either alosetron 1 mg b.i.d. (n = 532) or placebo (n = 269) were administered a questionnaire on which they rated on 7-point Likert scales their prestudy IBS treatment (at the screening visit) or study medication (on wk 12 or final study visit) with respect to overall satisfaction and 11 specific medication attributes.RESULTS:Whereas approximately 10% of patients were satisfied or very satisfied overall with prestudy IBS medication, 69% of patients were satisfied or very satisfied overall with alosetron and 46% with placebo (p < 0.001) at the end of 12 wk of therapy. The majority of alosetron-treated patients (61–87%) were satisfied or very satisfied with each of 11 specific medication attributes (p < 0.001 vs placebo for each attribute). Favorable satisfaction ratings for alosetron were assigned to the five medication attributes that patients considered to be most important, including relief of urgency (68% alosetron vs 41% placebo), speed of relief (71% vs 40%), time to return to normal activities (75% vs 49%), relief of abdominal pain (62% vs 44%), and prevention of return of urgency (68% vs 42%).CONCLUSIONS:Women with diarrhea-predominant IBS are satisfied with alosetron 1 mg b.i.d. treatment overall and also with respect to specific attributes of IBS medication they consider most important.

The psychological aspects of noncardiac chest pain

There is some evidence to support a psychosocial link to GERD,although it is a weak one. The little research that has been done in this area is, in general, poor and inconclusive. Better designed studies must be done. The elements that seem to offer the best possibilities for research in GERD are the psychological variables involved in care seeking and the variations between care seekers and non-care seekers. In addition, research on psychosocial predictors of response to proton pump inhibitors, prokinetic agents, and antidepressants and other pain-modulating drugs need to be better understood. The psychosocial link to NCCP is stronger with regard to panic disorder,but much research needs to be done. Despite the paucity of well done,rigorously controlled studies in NCCP patients, that there is a high prevalence of psychiatric disturbance in this group. Parental health and childhood trauma are intriguing areas for further research, particularly in light of the connection between abuse and IBS and other functional GI disorders.Finally, panic disorder has been established as an important comorbidity of NCCP. It also merits more research, particularly into the pathophysiology that may link these two disorders.

Colonic perforation in unsuspected amebic colitis.

Unsuspected amebic colitis presenting as inflammatory bowel disease, as in our patient, has been previously reported (4, 7, 8). Misdiagnosis, delay in antibiotic treatment, and institution of immunosuppression were the result of failure to identify the parasite in stool specimens and have resulted in suffering, morbidity, mortality, and surgery. In all previously reported cases, routine stool studies failed to identify E. histolytica (4, 7, 8). The correct diagnosis was only established after reviewing the surgical specimen or biopsies obtained endoscopically. Because the erroneous diagnosis of inflammatory bowel disease can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas with endemic E. histolytica (17). We recommend obtaining at least three stool specimens for microscopic examination, as well as testing for serum amebic antibody. Patients should submit fresh stool specimens directly to the laboratory to allow for prompt diagnostic evaluation. Such an approach might lead to the improved diagnosis of amebiasis.

Subtypes of anal incontinence associated with bowel dysfunction: clinical, physiologic, and psychosocial characterization.

BACKGROUNDWe hypothesized that functional anal incontinence with no structural explanation comprises distinct pathophysiologic subgroups that could be identified on the basis of the predominant presenting bowel pattern.METHODSConsecutive patients (n = 80) were prospectively grouped by bowel symptoms as 1) incontinence only, 2) incontinence + constipation, 3) incontinence + diarrhea, and 4) incontinence + alternating bowel symptoms. The Hopkins Bowel Symptom Questionnaire, the Symptom Checklist 90-R, and anorectal manometry were completed.RESULTSSignificant group differences were found between subcategories of incontinent patients on the basis of symptoms. Abdominal pain was more frequent in patients with altered bowel patterns. Patients with alternating symptoms reported the highest prevalence of abdominal pain, rectal pain, and bloating. Basal anal pressures were significantly higher in alternating patients (P = 0.03). Contractile pressures in the distal anal canal were diminished in the incontinent-only and diarrhea groups (P = 0.004). Constipated patients with incontinence exhibited elevated thresholds for the urge to defecate (P = 0.027). Dyssynergia was significantly more frequent in patients with incontinence and constipation or alternating bowel patterns.CONCLUSIONSDistinct patterns of pelvic floor dysfunction were identified in patient subgroups with anal incontinence, based on the presence or absence of altered bowel patterns. Physiologic assessments suggested different pathophysiologic mechanisms among the subgroups. The evaluation of patients with fecal incontinence should consider altered bowel function.

10 Are psychosocial factors of aetiological importance in functional dyspepsia

The causes of functional dyspepsia remain unclear. Research has linked other functional gastrointestinal disorders, particularly irritable bowel syndrome, to a history of physical or sexual abuse, psychosocial distress and certain psychiatric disorders. In functional dyspepsia, there is a possibility of certain psychiatric disorders, particularly alcohol abuse and eating disorders, indirectly influencing the development of functional dyspepsia-like symptoms. However, the literature on possible psychosocial correlates in functional dyspepsia is not as mature as the literature on irritable bowel syndrome. This paper critically reviews the psychosocial dimensions and implications for the psychotherapeutic treatment of functional dyspepsia.

Treatment of irritable bowel syndrome: new modalities for a new millennium.

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