Saqib Mumtaz

Prevalence of, and predictors of, bile acid malabsorption in outpatients with chronic diarrhea.

Backgroundu2002 Many physicians do not consider the diagnosis of bile acid malabsorption in patients with chronic diarrhea, or do not have access to testing. We examined yield of 23‐seleno‐25‐homo‐tauro‐cholic acid (SeHCAT) scanning in chronic diarrhea patients, and attempted to identify predictors of a positive test.

Poor Correlation Between Clinical Disease Activity and Mucosal Inflammation, and the Role of Psychological Comorbidity, in Inflammatory Bowel Disease

OBJECTIVES:There is a move toward patient-reported outcome measures as end points in clinical trials of novel therapies for inflammatory bowel disease (IBD). However, the association between patient-reported symptoms and mucosal inflammation, and the influence of psychological factors, remains unclear. We examined this in a secondary care population.METHODS:Validated patient-reported disease activity indices were used to define clinically active disease in a cohort of 356 patients with ulcerative colitis (UC) or Crohn’s disease (CD). A fecal calprotectin ≥250u2009μg/g was used to define active mucosal inflammation. The hospital anxiety and depression scale (HADS) and patient health questionnaire (PHQ)-15 were used to assess for anxiety, depression, or somatization, respectively. Logistic regression analysis was performed to determine the association between symptoms, mucosal inflammation, and psychological comorbidity.RESULTS:Clinical disease activity was associated with mucosal inflammation in UC (odds ratio (OR) 3.36; 95% confidence interval (CI) 1.34–8.47) but not in CD (OR 1.69; 95% CI 0.74–3.83). Depression in UC (OR 1.21 per 1-point increase in HADS; 95% CI 1.02–1.44) and somatization in UC (OR 1.17 per 1-point increase in PHQ-15; 95% CI 1.03–1.33) and CD (OR 1.31 per 1-point increase in PHQ-15; 95% CI 1.13–1.52) were associated with clinical disease activity. Overall, patient-reported symptoms yielded poor positive predictive values for mucosal inflammation in both CD and UC.CONCLUSIONS:Patient-reported symptoms and the Harvey–Bradshaw index were poor predictors of mucosal inflammation in CD. Psychological comorbidity was associated with gastrointestinal symptom-reporting. A shift in the focus of IBD management toward one addressing both psychological and physical well-being is required.

High Prevalence of Idiopathic Bile Acid Diarrhea Among Patients With Diarrhea-Predominant Irritable Bowel Syndrome Based on Rome III Criteria

BACKGROUND & AIMSnSome studies have found that patients with idiopathic bile acid diarrhea (BAD) present with symptoms of diarrhea-predominant irritable bowel syndrome (D-IBS). However, these studies either were retrospective, did not define D-IBS according to current criteria, or included patients with chronic functional diarrhea. We performed a prospective study of the prevalence of idiopathic BAD in consecutive patients fulfilling the Rome III criteria for D-IBS.nnnMETHODSnWe analyzed data from 118 consecutive adult patients who fulfilled the Rome III criteria for D-IBS (mean age, 41.7 y; 72.9% female), seen at 2 gastroenterology clinics in the United Kingdom. We excluded patients with risk factors for BAD (previous history of cholecystectomy, terminal ileal Crohns disease, terminal ileal resection or right hemicolectomy, pelvic or abdominal radiotherapy, celiac disease, or microscopic colitis). Participants completed questionnaires at baseline (on demographics, hospital anxiety, somatization, and depression, as wellxa0as the patient health questionnaire-12 and the Short Form-36), and then received the (75)selenium homocholic acid taurine retention test. Retention of (75)selenium homocholic acid taurine 7xa0days after administration was used to identify patients with idiopathic BAD (mild BAD, 10%-14.9%; moderate BAD, 5.1%-9.9%; and severe BAD, ≤5%).nnnRESULTSnTwenty-eight patients were found to have BAD (23.7% of total), with similar percentages at each study site (25.3% and 20%; Pxa0= .54). Eight patients had mild BAD (28.6%), 8 patients had moderate BAD (28.6%), and 12 patients had severe BAD (42.8%). There was no statistical difference in age, sex, depression, patient health questionnaire-12 responses, or SF-36 scores between individuals with vs without BAD. However, patients with BAD had a higher mean body mass index than patients without BAD (31.6 vs 26.4; Pxa0= .003). Physical activity (based on the Short Form-36) was significantly lower in subjects with moderate (43.8) or severe BAD (41.7), compared with patients with mild BAD (87.5) (Pxa0= .046).nnnCONCLUSIONSnAlmost 25% of patients presenting with D-IBS have idiopathic BAD; most cases are moderate to severe. Guidelines should advocate testing to exclude BAD before patients are diagnosed with D-IBS.

Negative Effects on Psychological Health and Quality of Life of Genuine Irritable Bowel Syndrome–type Symptoms in Patients With Inflammatory Bowel Disease

BACKGROUND & AIMS Symptoms compatible with irritable bowel syndrome (IBS) are common in patients with inflammatory bowel disease (IBD), but it is unclear whether this relates to occult IBD activity. We attempted to resolve this issue in a secondary care population by using a cross‐sectional study design. METHODS We analyzed Rome III IBS symptoms, disease activity indices, and psychological, somatization, and quality of life data from 378 consecutive, unselected adult patients with IBD seen in clinics at St Jamess University Hospital in Leeds, United Kingdom from November 2012 through June 2015. Participants provided a stool sample for fecal calprotectin (FC) analysis; levels ≥250 &mgr;g/g were used to define mucosal inflammation. By using symptom data and FC levels we identified 4 distinct groups of patients: those with true IBS‐type symptoms (IBS‐type symptoms with FC levels <250 &mgr;g/g, regardless of disease activity indices), quiescent IBD (no IBS‐type symptoms with FC levels <250 &mgr;g/g, regardless of disease activity indices), occult inflammation (normal disease activity indices and FC levels ≥250 &mgr;g/g, regardless of IBS symptom status), or active IBD (abnormal disease activity indices with FC levels ≥250 &mgr;g/g, regardless of IBS symptom status). We compared characteristics between these groups. RESULTS Fifty‐seven of 206 patients with Crohns disease (27.7%) and 34 of 172 patients with ulcerative colitis (19.8%) had true IBS‐type symptoms. Levels of psychological comorbidity and somatization were significantly higher among patients with true IBS‐type symptoms than patients with quiescent IBD or occult inflammation. Quality of life levels were also significantly reduced compared with patients with quiescent disease or occult inflammation and were similar to those of patients with active IBD. By using FC levels ≥100 &mgr;g/g to define mucosal inflammation, we found a similar effect of IBS‐type symptoms on psychological health and quality of life. CONCLUSIONS In a cross‐sectional study, we identified a distinct group of patients with IBD and genuine IBS‐type symptoms in the absence of mucosal inflammation. These symptoms had negative effects on psychological well‐being and quality of life to the same degree as active IBD. New management strategies are required for this patient group.

Response to Levenstein and Prantera

To the Editor: We thank Drs Levenstein and Prantera for their insightful comments in response to our recently published manuscript (1,2). Our assertions were that clinical disease activity indices were poor predictors of mucosal inflammation in Crohn’s disease (CD) and only modest predictors of mucosal inflammation in ulcerative colitis, and that the presence of symptoms, independent of active inflammation, was associated with psychological comorbidity.

PTU-090 Prevalence and impact of irritable bowel type-symptoms in quiescent inflammatory bowel disease

Introduction The prevalence of symptoms compatible with irritable bowel syndrome (IBS) in inflammatory bowel disease (IBD) has been previously described.1However, the association between the presence of these symptoms and occult disease activity is less well known, as is the effect of these symptoms on psychological health. We conducted a cross-sectional survey examining these issues. Method Demographic and gastrointestinal symptom data were collected from 439 adult patients via the Rome III questionnaire. IBD activity was assessed via clinical scoring systems and faecal calprotectin (FC). Mood was assessed using the hospital anxiety and depression scale, whilst somatisation and quality of life data were collected using the patient health questionnaire-12 (PHQ-12) and SF-36 questionnaire respectively. Mean FC, as well as anxiety, depression and somatisation severity and quality of life were compared between CD and UC patients meeting Rome III criteria for IBS and those who did not. Results More patients with CD met criteria for IBS than UC (97 (42.4%) of 229 vs. 63 (30.9%) of 204 respectively, P = 0.01). In CD, there was no difference in anxiety (P = 0.106), depression (P = 0.156) or somatisation severity (P = 0.104) in patients with IBS-type symptoms versus those without. Mean quality of life scores for pain (P = 0.003) and general health (P = 0.009) were significantly lower in CD patients with IBS-type symptoms. In contrast, in UC anxiety severity was higher in those with IBS-type symptoms (P = 0.001), and there was a trend towards greater depression and somatisation severity in patients with IBS-type symptoms (P = 0.035 and P = 0.011 respectively). UC patients with IBS-type symptoms had significantly lower mean quality of life scores for role limitations due to physical health (P = 0.004), energy/fatigue (P = 0.003), emotional wellbeing (P = 0.002), social functioning (P = 0.006), pain (P < 0.001) and general health (P = 0.003). Mean FC levels were higher in those with IBS-type symptoms than those without in CD (543.3 vs. 444.9; P = 0.529) and UC (423.5 vs. 282.8; P = 0.368). There was no difference in the proportion of individuals with a normal FC in CD patients fulfilling criteria for IBS (12 (63.2%) of 19) than those not (31 (56.4%) of 55) (P = 0.605). The same was true in UC (7 (50%) of 14 vs. 38 (69.1%) of 55 (P = 0.181). Conclusion The prevalence of IBS-type symptoms is higher in CD than in UC. IBS-type symptoms are associated with more severe anxiety in UC patients and lower quality of life scores in both CD and UC. Whether such symptoms arise from occult disease activity, or true coexistence of IBS, remains unclear. Disclosure of interest None Declared. Reference Halpin SJ, Ford AC. Am J Gastroenterol. 2012;107(10):1474–82

PTU-089 Are clinical indices of inflammatory bowel disease activity superior to patient opinion at predicting activity as defined by faecal calprotectin?

Introduction The Harvey-Bradshaw index (HBI) and simple clinical colitis activity index (SCCAI) are clinical scoring systems used to estimate Crohn’s disease (CD), and ulcerative colitis (UC) activity, respectively. However, whether they are superior to the patient’s own opinion at predicting disease activity, defined by faecal biomarkers of inflammatory bowel disease (IBD) activity is unclear. We conducted a cross-sectional survey of IBD patients to assess these issues. Method Patient opinion as to whether they were, or were not experiencing a flare of disease was recorded in 245 patients. Active disease was defined as a HBI or SCCAI score of ≥5 for CD and UC respectively. Stool was collected for faecal calprotectin (FC) analysis by enzyme linked immunosorbent assay (Biohit, Finland), with patients dichotomised into those with or without active disease, using a FC of ≥200 µg/g of stool to define active disease. The sensitivity, specificity, positive and negative predictive values, and overall accuracy of patient opinion and clinical activity indices at predicting disease activity defined by FC was calculated. A ROC curve for HBI and SCCAI against disease activity defined by FC was used to calculate the AUC for each clinical assessment index. Mean FC was compared between those with and without active disease by patient opinion and clinical indices of IBD activity by independent samples t-test. Results The sensitivity, specificity, positive and negative predictive value, overall test accuracy and AUC for each test when used to predict disease activity defined by FC is illustrated in Table 1. In CD, mean FC was lower in patients with active disease defined by HBI than those without (381 vs. 472; P = 0.368), but higher in patients with active disease defined by patient opinion than those without (474 vs. 425; P = 0.711). In contrast, mean FC was significantly higher in UC patients with active disease defined by both patient opinion and SCCAI (919 vs. 381; P < 0.001 and 949 vs. 311; P < 0.001 respectively).Abstract PTU-089 Table 1 Performance of individuals IBD assessment tools Crohn’s disease Ulcerative colitis Patient opinion HBI Patient opinion SCCAI Sensitivity 0.17 0.37 0.45 0.54 Specificity 0.84 0.64 0.78 0.73 PPV 0.45 0.44 0.62 0.62 NPV 0.57 0.57 0.64 0.65 Accuracy 0.55 0.53 0.63 0.64 ROC AUC - 0.49 - 0.66 Conclusion The performance of clinical disease activity indices at predicting IBD activity was modest in UC and poor in CD when compared with faecal biomarkers of intestinal inflammation. Neither HBI nor SCCAI outperformed patient opinion in the assessment of disease activity. Faecal biomarker point of care testing may aid clinical decision making. Disclosure of interest None Declared.