Miranda A. van Tilburg

Early Life Risk Factors That Contribute to Irritable Bowel Syndrome in Adults: A Systematic Review

BACKGROUND:Irritable bowel syndrome (IBS) is a common disorder that occurs in adults. The natural history of symptoms and risk factors that contribute to IBS may begin in childhood. The aim of this systematic review was to determine what early life factors contribute to the development of IBS in adolescents and adults.METHODS:A computer-assisted search of the PubMed database from 1966 to 2007 was performed. The selection criteria were: (a) studies conducted in adolescents or adults with IBS that (b) investigate premorbid factors occurring specifically during the childhood period and are (c) associated with the outcomes of symptoms, quality of life, health-care utilization, and interferences with work or disability.RESULTS:Twenty-five articles met inclusion criteria. The studies were categorized into articles examining the persistence of childhood gastrointestinal symptoms into adulthood, affluent childhood socioeconomic status and adult IBS, infantile and childhood trauma associated with the development of adult IBS, and social learning of illness behavior as predictors of adult IBS.CONCLUSION:Pediatricians should be aware of potentially modifiable childhood risk factors and should consider interventions such as early symptom management of recurrent functional abdominal pain with cognitive therapies and parent education about social learning of illness behavior. Early treatment may have a long-term impact. Research examining the effect of affluent childhood socioeconomic status and early childhood trauma in the evolution of functional gastrointestinal disorders may help identify causative factors of IBS.

Contributions of pain sensitivity and colonic motility to IBS symptom severity and predominant bowel habits.

OBJECTIVES:Irritable bowel syndrome (IBS) patients show pain hypersensitivity and hypercontractility in response to colonic or rectal distention. Aims were to determine whether predominant bowel habits and IBS symptom severity are related to pain sensitivity, colon motility, or smooth muscle tone.METHODS:One hundred twenty-nine patients classified as IBS with diarrhea (IBS-D, N = 44), IBS with constipation (IBS-C, N = 29), mixed IBS (IBS-M, N = 45), and unspecified IBS (IBS-U, N = 11) based on stool consistency, and 30 healthy controls (HC) were studied. A manometric catheter containing a 600-mL capacity plastic bag was positioned in the descending colon. Pain threshold was assessed using a barostat. Motility was assessed for 10 min with the bag minimally inflated (individual operating pressure [IOP]), 10 min at 20 mmHg above the IOP, and for 15-min recovery following bag inflation. Motility was also recorded for 30 min following an 810-kcal meal.RESULTS:Compared with HC, IBS patients had lower pain thresholds (medians 30 vs 40 mmHg, P < 0.01), but IBS subtypes were not different. IBS symptom severity was correlated with pain thresholds (rho =− 0.36, P < 0.001). During distention, the motility index (MI) was significantly higher in IBS compared with HC (909 ± 73 vs 563 ± 78, P < 0.01). Average barostat bag volume at baseline was higher (muscle tone lower) in HC compared with IBS-D and IBS-M but not compared with IBS-C. The baseline MI and bag volume differed between IBS-D and IBS-C and correlated with symptoms of abdominal distention and dissatisfaction with bowel movements. Pain thresholds and MI during distention were uncorrelated.CONCLUSIONS:Pain sensitivity and colon motility are independent factors contributing to IBS symptoms. Treatment may need to address both, and to be specific to predominant bowel habit.

Audio-Recorded Guided Imagery Treatment Reduces Functional Abdominal Pain in Children: A Pilot Study

OBJECTIVE: This study was designed to develop and to test a home-based, guided imagery treatment protocol, using audio and video recordings, that is easy for health care professionals and patients to use, is inexpensive, and is applicable to a wide range of health care settings. METHODS: Thirty-four children, 6 to 15 years of age, with a physician diagnosis of functional abdominal pain were assigned randomly to receive 2 months of standard medical care with or without home-based, guided imagery treatment. Children who received only standard medical care initially received guided imagery treatment after 2 months. Children were monitored for 6 months after completion of guided imagery treatment. RESULTS: All treatment materials were reported to be self-explanatory, enjoyable, and easy to understand and to use. The compliance rate was 98.5%. In an intention-to-treat analysis, 63.1% of children in the guided imagery treatment group were treatment responders, compared with 26.7% in the standard medical care–only group (P = .03; number needed to treat: 3). Per-protocol analysis showed similar results (73.3% vs 28.6% responders). When the children in the standard medical care group also received guided imagery treatment, 61.5% became treatment responders. Treatment effects were maintained for 6 months (62.5% responders). CONCLUSION: Guided imagery treatment plus medical care was superior to standard medical care only for the treatment of abdominal pain, and treatment effects were sustained over a long period.

Complementary and alternative medicine use and cost in functional bowel disorders: A six month prospective study in a large HMO

BackgroundFunctional Bowel Disorders (FBD) are chronic disorders that are difficult to treat and manage. Many patients and doctors are dissatisfied with the level of improvement in symptoms that can be achieved with standard medical care which may lead them to seek alternatives for care. There are currently no data on the types of Complementary and Alternative Medicine (CAM) used for FBDs other than Irritable Bowel Syndrome (IBS), or on the economic costs of CAM treatments. The aim of this study is to determine prevalence, types and costs of CAM in IBS, functional diarrhea, functional constipation, and functional abdominal pain.Methods1012 Patients with FBD were recruited through a health care maintenance organization and followed for 6 months. Questionnaires were used to ascertain: Utilization and expenditures on CAM, symptom severity (IBS-SS), quality of life (IBS-QoL), psychological distress (BSI) and perceived treatment effectiveness. Costs for conventional medical care were extracted from administrative claims.ResultsCAM was used by 35% of patients, at a median yearly cost of

Development and Validation of the Rome IV Diagnostic Questionnaire for Adults

200. The most common CAM types were ginger, massage therapy and yoga. CAM use was associated with female gender, higher education, and anxiety. Satisfaction with physician care and perceived effectiveness of prescription medication were not associated with CAM use. Physician referral to a CAM provider was uncommon but the majority of patients receiving this recommendation followed their physicians advice.ConclusionCAM is used by one-third of FBD patients. CAM use does not seem to be driven by dissatisfaction with conventional care. Physicians should discuss CAM use and effectiveness with their patients and refer patients if appropriate.

Which psychological factors exacerbate irritable bowel syndrome? Development of a comprehensive model

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.

Unexplained Gastrointestinal Symptoms After Abuse in a Prospective Study of Children at Risk for Abuse and Neglect

OBJECTIVE There is evidence that psychological factors affect the onset, severity and duration of irritable bowel syndrome (IBS). However, it is not clear which psychological factors are the most important and how they interact. The aims of the current study are to identify the most important psychological factors predicting IBS symptom severity and to investigate how these psychological variables are related to each other. METHODS Study participants were 286 IBS patients who completed a battery of psychological questionnaires including neuroticism, abuse history, life events, anxiety, somatization and catastrophizing. IBS severity measured by the IBS Severity Scale was the dependent variable. Path analysis was performed to determine the associations among the psychological variables, and IBS severity. RESULTS Although the hypothesized model showed adequate fit, post hoc model modifications were performed to increase prediction. The final model was significant (Chi(2)=2.2; p=0.82; RMSEA<.05) predicting 36% of variance in IBS severity. Catastrophizing (standardized coefficient (β)=0.33; p<.001) and somatization (β=0.20; p<.001) were the only two psychological variables directly associated with IBS severity. Anxiety had an indirect effect on IBS symptoms through catastrophizing (β=0.80; p<.001); as well as somatization (β=0.37; p<.001). Anxiety, in turn, was predicted by neuroticism (β=0.66; p<.001) and stressful life events (β=0.31; p<.001). CONCLUSION While cause-and-effect cannot be determined from these cross-sectional data, the outcomes suggest that the most fruitful approach to curb negative effects of psychological factors on IBS is to reduce catastrophizing and somatization.

Chronic Pain in Adolescents Is Associated With Suicidal Thoughts and Behaviors

PURPOSE Unexplained gastrointestinal symptoms are more common in adults who recall abuse as a child; however, data available on children are limited. The aim of this study was to investigate the association of childhood maltreatment and early development of gastrointestinal symptoms and whether this relation was mediated by psychological distress. METHODS Data were obtained from the Longitudinal Studies of Child Abuse and Neglect, a consortium of 5 prospective studies of child maltreatment. The 845 children who were observed from the age of 4 through 12 years were the subjects of this study. Every 2 years information on gastrointestinal symptoms was obtained from parents, and maltreatment allegations were obtained from Child Protective Services (CPS). At the age of 12 years children reported gastrointestinal symptoms, life-time maltreatment, and psychological distress. Data were analyzed by logistic regression. RESULTS Lifetime CPS allegations of sexual abuse were associated with abdominal pain at age 12 years (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.1–2.47). Sexual abuse preceded or coincided with abdominal pain in 91% of cases. Youth recall of ever having been psychologically, physically, or sexually abused was significantly associated with both abdominal pain and nausea/vomiting (range, OR = 1.5 [95% CI, 1.1–2.0] to 2.1 [95% CI, 1.5–2.9]). When adjusting for psychological distress, most effects became insignificant except for the relation between physical abuse and nausea/vomiting (OR = 1.5; 95% CI, 1.1–2.2). CONCLUSION Youth who have been maltreated are at increased risk for unexplained gastrointestinal symptoms, and this relation is partially mediated by psychological distress. These findings are relevant to the clinical care for children who complain of unexplained gastrointestinal symptoms.

Teaching diaphragmatic breathing for rumination syndrome.

UNLABELLED Adults who suffer from chronic pain are at increased risk for suicide ideation and attempts, but it is not clear whether adolescents with chronic pain are similarly at elevated risk. This study investigates whether chronic pain is associated with an increase in suicidal ideation/attempts independent of depression in a population sample of adolescents. We analyzed data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in the United States (N = 9,970). Most chronic pain was related to suicide ideation/attempt both in the last year (odds ratio [OR] 1.3-2.1) and during the subsequent year (OR 1.2-1.8). After controlling for depressive symptoms, headaches (OR = 1.3 last year, OR = 1.2 subsequent year) and muscle aches (OR = 1.3 last year) remained associated with suicide ideation but not suicide attempt. These findings show that chronic pain in adolescence is a risk factor for suicide ideation; this effect is partly but not fully explained by depression. Youth with comorbid depression and chronic pain are at increased risk of thinking about and attempting suicide. Clinicians should be alert to suicide ideation/attempt and comorbid depression in this at-risk population. PERSPECTIVE Adolescents who suffer from chronic pain are at increased risk for suicide ideation and attempt. Depressive symptoms account for the link between chronic pain and suicide attempt, but do not completely explain why adolescents with chronic pain show suicide ideation.

Direct Medical Costs of Constipation From Childhood to Early Adulthood: A Population-based Birth Cohort Study

Teaching Diaphragmatic Breathing for Rumination Syndrome Denesh K. Chitkara, M.D.,1 Miranda Van Tilburg, Ph.D.,1 William E. Whitehead, Ph.D.,1 and Nicholas J. Talley, M.D., Ph.D.2 1UNC Center for Functional GI and Motility Disorders, University of North Carolina School of Medicine, Chapel Hill, North Carolina; and 2Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Mayo Clinic and Mayo Foundation, Rochester, Minnesota