Laurie Keefer

Controversies Revisited: A Systematic Review of the Comorbidity of Depression and Anxiety with Inflammatory Bowel Diseases.

Background:Although mental health concerns are known to occur commonly for those with inflammatory bowel diseases (IBD), the nature of this comorbid relationship has not been systematically reviewed to date. A review in 2007 identified 5 controversies regarding anxiety/depression rates and various comparators between and within IBD. We aimed to systematically analyze and critique the current evidence regarding this comorbidity, providing an update to the 5 controversies. Methods:Ebscohost Medline, CINAHL, Embase, and PsychINFO were searched between 2005 and 2014 using systematic review methodology. Controlled quantitative studies examining either symptoms or diagnoses of anxiety and depression in IBD were included in the review, with study quality assessed using a scale developed a priori to evaluate observational research. Results:(1) IBD versus healthy controls (pooled mean proportions) (n = 13 studies): anxiety 19.1% versus 9.6%, depression 21.2% versus 13.4%; (2) IBD inactive versus IBD active disease (n = 26): anxiety 28.2% versus 66.4%, depression 19.9% versus 34.7%; (3) ulcerative colitis versus Crohns disease (n = 28): anxiety 31% versus 37%, depression 22% versus 24.4%; (4) IBD versus other chronic medical conditions (n = 17): anxiety 41.9% versus 48.2%, depression 14.5% versus 28.4%; (5) onset of anxiety/depression before or after IBD onset (n = 2): adults more likely to develop anxiety/depression before IBD onset, but a substantial proportion develops depression after onset; an increased risk for children of developing anxiety/depression after IBD onset. Conclusions:The high rates of anxiety and depression for those with IBD, particularly when disease is active, warrant a systemic approach to screening and treatment.

Increased Risk for Persistent Intestinal Metaplasia in Patients With Barrett's Esophagus and Uncontrolled Reflux Exposure Before Radiofrequency Ablation

BACKGROUND & AIMS Radiofrequency ablation (RFA) is a safe alternative to esophagectomy for patients with dysplastic Barretts esophagus (BE). Although some studies have indicated that RFA is effective at eradicating dysplasia, most have found that RFA is not as effective in eradicating intestinal metaplasia. We investigated whether uncontrolled reflux is associated with persistent intestinal metaplasia after RFA. METHODS Thirty-seven patients with BE underwent RFA, high-resolution manometry, and 24-hour impedance-pH testing; they received proton pump inhibitors twice daily. Patients returned every 2 months for repeat treatment or standard surveillance. Patients were classified as complete responders (CRs) if all intestinal metaplasia was eradicated in fewer than 3 ablation sessions. We analyzed clinical parameters to identify factors associated with a CR or incomplete responder (ICR). RESULTS Among the 37 patients, 22 had a CR and 15 had an ICR. Mann-Whitney U tests revealed that length of BE, size of hiatal hernia, and frequency of reflux, but not acid reflux, differed between CRs and ICRs. CRs had fewer weakly acidic events than ICRs (29.5 vs 52; P < .05) and total reflux events (33.5 vs 60; P < .05), and a trend toward fewer weakly alkaline events (1.0 vs 5.0; P = .06). No other clinical or manometric features differed between groups. CONCLUSIONS Uncontrolled, predominantly weakly acidic reflux despite twice-daily proton pump inhibitor therapy before RFA increases the incidence of persistent intestinal metaplasia after ablation in patients with BE. Length of BE and size of hiatal hernia also were associated with persistent intestinal metaplasia after RFA.

Preliminary evidence supporting a framework of psychological adjustment to inflammatory bowel disease

Background: Adjustment to chronic disease is a multidimensional construct described as successful adaptation to disease‐specific demands, preservation of psychological well‐being, functional status, and quality of life. Inflammatory bowel disease (IBD) can be particularly challenging due to the unpredictable, relapsing and remitting course of the disease. Methods: All participants were patients being treated in an outpatient gastroenterology clinic at a university medical center. Participants completed a survey of questionnaires assessing illness perceptions, stress, emotional functioning, disease acceptance, coping, disease impact, and disease‐specific and health‐related quality of life. Adjustment was measured as a composite of perceived disability, psychological functioning, and disease‐specific and health‐related quality of life. Results: Participants were 38 adults with a diagnosis of either Crohns disease (45%) or ulcerative colitis (55%). We observed that our defined adjustment variables were strongly correlated with disease characteristics (r = 0.33–0.80, all P < 0.05), an emotional representation of illness (r = 0.44–0.58, P < 0.01), disease acceptance (r = 0.34–0.74, P < 0.05), coping (r = 0.33–0.60, P < 0.05), and frequency of gastroenterologist visits (r = 0.39–0.70, P < 0.05). Better adjustment was associated with greater bowel and systemic health, increased activities engagement and symptom tolerance, less pain, less perceived stress, and fewer gastroenterologist visits. All adjustment variables were highly correlated (r = 0.40–0.84, P < 0.05) and demonstrated a cohesive composite. Conclusions: The framework presented and results of this study underscore the importance of considering complementary pathways of disease management including cognitive, emotional, and behavioral factors beyond the traditional medical and psychological (depression and anxiety) components. (Inflamm Bowel Dis 2010)

The adult eosinophilic oesophagitis quality of life questionnaire: a new measure of health-related quality of life

Aliment Pharmacol Ther 2011; 34: 790–798

Development and Validation of the Rome IV Diagnostic Questionnaire for Adults

The Rome IV Diagnostic Questionnaires were developed to screen for functional gastrointestinal disorders (FGIDs), serve as inclusion criteria in clinical trials, and support epidemiological surveys. Separate questionnaires were developed for adults, children/adolescents, and infants/toddlers. For the adult questionnaire, we first surveyed 1,162 adults without gastrointestinal disorders, and recommended the 90th percentile symptom frequency as the threshold for defining what is abnormal. Diagnostic questions were formulated and verified with clinical experts using a recursive process. The diagnostic sensitivity of the questionnaire was tested in 843 patients from 9 gastroenterology clinics, with a focus on clinical diagnoses of irritable bowel syndrome (IBS), functional constipation (FC), and functional dyspepsia (FD). Sensitivity was 62.7% for IBS, 54.7% for FD, and 32.2% for FC. Specificity, assessed in a population sample of 5,931 adults, was 97.1% for IBS, 93.3% for FD, and 93.6% for FC. Excess overlap among IBS, FC, and FD was a major contributor to reduced diagnostic sensitivity, and when overlap of IBS with FC was permitted, sensitivity for FC diagnosis increased to 73.2%. All questions were understandable to at least 90% of individuals, and Rome IV diagnoses were reproducible in ¾ of patients after one month. Validation of the pediatric questionnaires is ongoing.

Biopsychosocial Aspects of Functional Gastrointestinal Disorders: How Central and Environmental Processes Contribute to the Development and Expression of Functional Gastrointestinal Disorders

In this paper, we provide a general framework for understanding the functional gastrointestinal disorders (FGID) from a biopsychosocial perspective. More specifically, we provide an overview of the recent research on how the complex interactions of environmental, psychological, and biological factors contribute to the development and maintenance of the FGID. We emphasize that considering and addressing all these factors is a conditio sine qua non for appropriate treatment of these conditions. First, we provide an overview of what is currently known about how each of these factors - the environment, including the influence of those in an individuals family, the individuals own psychological states and traits, and the individuals (neuro)physiological make-up - interact to ultimately result in the generation of FGID symptoms. Second, we provide an overview of commonly used assessment tools which can assist clinicians in obtaining a more comprehensive assessment of these factors in their patients. Finally, the broader perspective outlined earlier is applied to provide an overview of centrally acting treatment strategies, both psychological and pharmacological, which have been shown to be efficacious to treat FGID.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)

BACKGROUND Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE. OBJECTIVE To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment. DESIGN Open-label prospective cohort study of patients with GAVE refractory to APC. SETTING Academic tertiary referral center. PATIENTS GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence. INTERVENTIONS Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed. MAIN OUTCOME MEASUREMENTS Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications. RESULTS Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention. LIMITATIONS Single-center, single-operator, and nonrandomized design. CONCLUSIONS RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

Gender differences in psychological distress among patients with irritable bowel syndrome

OBJECTIVE We examined possible gender differences in psychological distress in a sample of treatment-seeking Irritable Bowel Syndrome (IBS) patients. METHODS A total of 341 IBS patients (238 females, 83 males) were studied. Structured psychiatric interviews were available on 250 participants. RESULTS We found significantly higher scores for females than males on the Beck Depression Inventory (BDI), Trait Anxiety of the State-Trait Anxiety Inventory (STAI), and Scales 2 and 3 of the MMPI. However, there were no differences in the percentages of the two samples meeting criteria for one or more Axis I psychiatric disorders, with 65.6% of the total sample meeting these criteria. CONCLUSION Gender differences in psychological distress appear to be a function of method of measurement.

Gut-directed hypnotherapy significantly augments clinical remission in quiescent ulcerative colitis

Psychotherapy is not routinely recommended for in ulcerative colitis (UC). Gut‐directed hypnotherapy (HYP) has been linked to improved function in the gastrointestinal tract and may operate through immune‐mediated pathways in chronic diseases.

Type, rather than number, of mental and physical comorbidities increases the severity of symptoms in patients with irritable bowel syndrome.

BACKGROUND & AIMS Irritable bowel syndrome (IBS) has significant mental and physical comorbidities. However, little is known about the day-to-day burden these comorbidities place on quality of life (QOL), physical and mental function, distress, and symptoms of patients. METHODS We collected cross-sectional data from 175 patients with IBS, which was diagnosed on the basis of Rome III criteria (median age, 41 years; 78% women), who were referred to 2 specialty care clinics. Patients completed psychiatric interviews, a physical comorbidity checklist, the IBS Symptom Severity Scale, the IBS-QOL instrument, the Brief Symptom Inventory, the abdominal pain intensity scale, and the Short Form-12 Health Survey. RESULTS Patients with IBS reported an average of 5 comorbidities (1 mental, 4 physical). Subjects with more comorbidities reported worse QOL after adjusting for confounding variables. Multiple linear regression analyses indicated that comorbidity type was more consistently and strongly associated with illness burden indicators than disease counts. Of 10,296 possible physical-mental comorbidity pairs, 6 of the 10 most frequent dyads involved specific conditions (generalized anxiety, depression, back pain, agoraphobia, tension headache, and insomnia). These combinations were consistently associated with greater illness and symptom burdens (QOL, mental and physical function, distress, more severe symptoms of IBS, and pain). CONCLUSIONS Comorbidities are common among patients with IBS. They are associated with distress and reduced QOL. Specific comorbidities are associated with more severe symptoms of IBS.