Spencer D. Dorn

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Asymptomatic Neoplastic Pancreatic Cysts

This article has an accompanying continuing medical education activity on page e12. Learning Objective: At the conclusion of this exercise, the learner will understand the approach to counseling patients regarding the optimal method and frequency of radiologic imaging, indications for invasive tests like endoscopic ultrasonography (EUS) and surgery, select patients for follow-up after surgery, decide the duration of such follow-up, and decide when to stop surveillance for those with and without surgery.

American Gastroenterological Association Medical Position Statement on Constipation

This document presents the official recommendations of the American Gastroenterological Association (AGA) on onstipation. It was drafted by the AGA Institute Medical Poition Panel, reviewed by the Clinical Practice and Quality Mangement Committee, and approved by the AGA Institute Govrning Board. This medical position statement is published in onjunction with a technical review1 on the same subject, and nterested readers are encouraged to refer to this publication for n-depth considerations of topics covered by these questions. he technical review was begun before the AGA’s decision to dopt the GRADE system. However, a GRADE methodologist orked with the authors and panel to rank the quality of the vidence and strength of recommendations. The medical position statement presents information by ddressing clinically related questions and summarizing key oints from the technical review. When specific recommendaions about medical interventions or management strategies for atients with constipation are stated, the “strength of recomendation” and the “quality of evidence” are provided. The trength of recommendation is either judged as “weak” or strong” and quality of evidence is ranked as high, moderate, ow, or very low in accordance with GRADE criteria. Recomendations are highlighted by appearing within a text box. A trong recommendation implies that, based on available evience, the benefits outweigh risks and there is less variability in atient’s values and preferences. A weak recommendation imlies that benefits, risks, and the burden of intervention are ore closely balanced, or appreciable uncertainty exists in reards to patient’s values and preferences. Applying this aproach, high-quality evidence does not always result in strong ecommendations and, conversely, strong recommendations ay emerge from lower-quality evidence. Symptoms of constipation are extremely common; the prevlence is approximately 16% in adults overall and 33% in adults lder than 60 years. Many people seek medical care for constiation, but fortunately most do not have a life-threatening or isabling disorder and the primary need is for control of sympoms, although rare, life-threatening, or treatable conditions ust be excluded. If therapeutic trials of laxatives fail, specialzed testing should be considered. We suggest the following ractice guidelines for the symptom of constipation; our ratioale for these guidelines is supported by the accompanying echnical review. Constipation is a symptom that can rarely be associated with ife-threatening diseases. Current recommendations will relate o (1) rational and, where possible, more judicious diagnostic pproaches and (2) more rational and efficacious therapies that ill improve symptoms, both of which should have beneficial scal and logistic impacts on the health care system. Although he overall classification of chronic constipation into 3 categoies (ie, normal transit, isolated slow transit, and defecatory isorders) and several recommendations in this version are imilar to the prior version, there are 3 substantive changes. irst, these guidelines recommend assessment of colonic transit t a later stage, that is, only for patients who do not have a efecatory disorder or patients with a defecatory disorder that as not responded to pelvic floor retraining. Second, the evience supporting these recommendations has been evaluated sing the GRADE system, in which the strength of recommenation is rated as strong or weak and the quality of evidence is ated as high, moderate, low, or very low. Third, therapeutic ecommendations have been updated to include newer agents nd delete certain older agents.

Increased colonic pain sensitivity in irritable bowel syndrome is the result of an increased tendency to report pain rather than increased neurosensory sensitivity

Objective: The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors. Methods: Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion—that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI). Results: IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 (“mild” pain) vs 5.2 (“weak” pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = −0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = −0.26; p = 0.001) and BSI global score (r = −0.18; p = 0.035). Similar results were seen for the non-painful sensation of urgency. Conclusion: Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.

Inflammatory bowel disease is not a risk factor for cardiovascular disease mortality: Results from a systematic review and meta-analysis

OBJECTIVES: Inflammation in general, and C-reactive protein (CRP) in particular, are closely associated with atherosclerosis. Similarly, the risk of cardiovascular (CV) disease is increased in several systemic inflammatory diseases. The purpose of this study was to examine whether inflammatory bowel disease (IBD) increases CV mortality, an indirect surrogate for CV disease incidence.METHODS: A systematic review of studies on CV mortality rates in patients with IBD published between 1965 and 2006 was performed. Studies were included for analysis if they reported data on CV-disease-specific standardized mortality ratios (SMRs) for Crohns disease (CD) and/or ulcerative colitis (UC). A meta-analysis of SMRs from included studies was performed.RESULTS: The review ultimately included 11 studies. Overall there were 4,532 patients with CD and 9,533 patients with UC. SMR point estimates ranged from 0.7 to 1.5 for patients with CD and 0.6–1.1 for patients with UC. There was not a statistically significant increase in CV SMR for either CD or UC in any study. However, two studies demonstrated a statistically significant decrease in CV SMR for UC. Finally, the meta-SMR for CD was 1.0 (95% CI 0.8–1.1) and the meta-SMR for UC was 0.9 (95% CI 0.8–1.0).CONCLUSIONS: IBD is not associated with increased CV mortality. Although CV mortality is a suboptimal surrogate for CV disease incidence, this finding provides indirect evidence against an association between IBD and CV disease.

The development and validation of a new coeliac disease quality of life survey (CD-QOL).

Aliment Pharmacol Ther 31, 666–675

American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 American Gastroenterological Association Institute Guideline on the Management of Acute Diverticulitis 67 68 69 70 71 72 73 74 Neil Stollman, Walter Smalley, Ikuo Hirano, and AGA Institute Clinical Guidelines Committee

Irritable Bowel Syndrome Subtypes Defined by Rome II and Rome III Criteria are Similar

Background The implications of the Rome III recommendations to change the irritable bowel syndrome (IBS) subtype criteria for stool pattern are unknown. Aim (1) Determine the level of agreement between Rome II and Rome III subtypes and (2) compare the behaviors of Rome II and Rome III subtypes over time. Methods Female patients (n=148) with Rome II defined IBS were prospectively tracked over 5 consecutive 3-month periods. At baseline, bowel habit reports on questionnaires were used to subclassify patients into Rome II and Rome III subtypes. Over the subsequent 15 months, bowel habit reports on diary cards were used to subclassify patients based on previously derived surrogate criteria into Rome II and Rome III IBS subtypes. Results The level of agreement between Rome II and Rome III subtype assignments was quite high (86.5%; κ 0.79). The behavior of Rome II and Rome III subtypes over time was also similar in terms of subtype prevalence, subtype stability, and the proportion of subjects who met criteria for alternating irritable bowel syndrome. Conclusions Rome II and Rome III IBS subtypes are in high agreement and behave similarly over time. Therefore, studies that used Rome II subtype criteria and studies that will use Rome III criteria will define comparable populations.

Opioid-Induced Bowel Dysfunction: Epidemiology, Pathophysiology, Diagnosis, and Initial Therapeutic Approach

Opioids affect motor and sensory function throughout the gastrointestinal tract, and are frequently associated with a number of gastrointestinal symptoms including constipation, which impairs the quality of life and may limit the dose of opioid or result in discontinuation altogether. Patients with opioid-induced constipation should be assessed by careful history and physical examination, and in some cases where the diagnosis is unclear with select diagnostic tests. Few clinical studies have been conducted to assess the efficacy of various treatments. However, it is generally recommended that first-line therapy begin with opioid rotation, as well as with low-cost and low-risk approaches such as lifestyle changes, consumption of fiber-rich food, stool softeners, and laxatives.

American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Lynch Syndrome

Veterans Affairs Center for Clinical Management Research; Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Division of Gastroenterology, St Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; Departments of Family Medicine and Urology, University of Michigan Medical School, Ann Arbor, Michigan; and Division of Gastroenterology, McGill University, McGill University Health Centre, Montreal, Quebec, Canada

Psychosocial Factors Are More Important Than Disease Activity in Determining Gastrointestinal Symptoms and Health Status in Adults at a Celiac Disease Referral Center

BackgroundThe relative effects of clinical and psychosocial variables on outcome in celiac disease (CD) has not previously been reported. In adult patients with (CD), we studied the relationships among demographics, psychosocial factors, and disease activity with health-related quality of life (HRQOL), health care utilization, and symptoms.MethodsAmong 101 adults newly referred to a tertiary care center with biopsy-proven CD we assessed: (a) demographic factors and diet status; (b) disease measures (Marsh score, tissue transglutaminase antibody (tTG) level, weight change and additional blood studies); and (c) Psychosocial status (psychological distress, life stress, abuse history, and coping). Multivariate analyses were performed to predict HRQOL, daily function, self-reported health, number of physician visits, and GI symptoms (pain and diarrhea).ResultsImpaired HRQOL and daily function was associated with psychological distress and poorer coping. Self-report of poorer health was associated with poorer coping, longer symptom duration, lower education, and greater weight loss. More physician visits were associated with poorer coping, abnormal tTG levels, and milder Marsh classification. Greater pain scores were seen in those with higher psychological distress and greater weight loss. Finally, diarrhea was associated with greater psychological distress and poorer coping.ConclusionsIn patients presenting to a CD referral center, psychosocial factors more strongly affect health status and GI symptoms than disease measures.