Abnormalities of the electrogastrogram in functional gastrointestinal disorders

OBJECTIVE: Cutaneous electrogastrography records gastric electrical activity and detects gastric arrhythmias. Abnormalities of the electrogastrogram have been described in a variety of disorders, but their specificity and their prevalence in patients with functional gastrointestinal disorders has not been reported. The aim of this study was to assess the specificity of electrogastrography as well as the prevalence and pattern of abnormalities in functional dyspepsia and irritable bowel syndrome. METHODS: Electrogastrography was performed in 170 patients with functional dyspepsia, 70 patients with irritable bowel syndrome, 20 patients with gastroesophageal reflux disease, and 30 asymptomatic controls. The abnormal electrogastrogram was defined as <70% normal electrical activity either before or after a test meal. RESULTS: The electrogastrogram was abnormal in 36% of patients with functional dyspepsia and in 25% with irritable bowel syndrome who complained of concurrent dyspepsia. The electrogastrogram was normal in 93% of asymptomatic controls, 90% of patients with gastroesophageal reflux, and 92% of patients with irritable bowel syndrome who did not complain of dyspepsia. As a group, functional dyspepsia patients had a greater degree of tachygastrias both before (p < 0.02) and after (p < 0.01) a test meal. The electrical frequency after the test meal was also more unstable (p < 0.003). CONCLUSIONS: The electrogastrogram is abnormal in approximately 36% of functional dyspepsia patients and has a specificity of approximately 93%. Electrogastrography defines a subgroup of patients with functional dyspepsia and electrical rhythm disturbance. In irritable bowel syndrome, the electrogastrogram is usually abnormal only if concurrent dyspepsia is present.     

Incidence and significance of different types of connective tissue antibodies in adult and pediatric gastroenterological disorders.

The incidence of connective tissue antibodies was assessed in 3,000 adults and in 388 pediatric patients with gastroenterological disorders. Following a previous classification, connective tissue antibodies were distinguished in 5 different types, R1 and R2 reacting with reticulin components, KC with Kupffer cells, AC and Rs with intra- and extracellular mesenchymal antigens. R1 predominated in children and was observed only in patients with malabsorption; the great majority of them had celiac disease and an abnormal small bowel mucosa. Ac was rarely seen in children and occurred in several unrelated gastrointestinal diseases of the adult; its incidence, however, was significantly higher in disorders with idiopathic and secondary malabsorption. R2, KC and Rs were seen only occasionally in unrelated gastroenterological disorders without malabsorption. R1, therefore, seems to be strongly suggestive of a malabsorption syndrome with abnormal small bowel mucosa and AC is a nonspecific reaction occuring predominantly in primary and secondary malabsorption; the other connective tissue antibodies have no clinical significance in gastroenterological disorders.     

Sobreposición entre los trastornos funcionales de dolor abdominal y enfermedades orgánicas en niños

Functional abdominal pain disorders are highly prevalent in children. These disorders can be present in isolation or combined with organic diseases, such as celiac disease and inflammatory bowel diseases. Intestinal inflammation (infectious and non-infectious) predisposes children to the development of visceral hypersensitivity that can manifest as functional abdominal pain disorders, including irritable bowel syndrome. The new onset of irritable bowel syndrome symptoms in a patient with an underlying organic disease, such as inflammatory bowel disease, is clinically challenging, given that the same symptomatology may represent a flare-up of the inflammatory bowel disease or an overlapping functional abdominal pain disorder. Similarly, irritable bowel syndrome symptoms in a child previously diagnosed with celiac disease may occur due to poorly controlled celiac disease or the overlap with a functional abdominal pain disorder. There is little research on the overlap of functional abdominal disorders with organic diseases in children. Studies suggest that the overlap between functional abdominal pain disorders and inflammatory bowel disease is more common in adults than in children. The causes for these differences in prevalence are unknown. Only a handful of studies have been published on the overlap between celiac disease and functional abdominal pain disorders in children. The present article provides a review of the literature on the overlap between celiac disease, inflammatory bowel disease, and functional abdominal pain disorders in children and establish comparisons with studies conducted on adults.     

What the gastroenterologist does all day. A survey of a state society's practice.

Members of a state society of gastroenterologist collected information about their pattern of practice. Twenty-two of the 41 members voluntarily kept a list of 25 sequential new patients seen during the spring of 1973. Five hundred and fory-nine diagnoses were accumulated; 369 (67%) of these diagnoses were gastroenterological. The five most common gastroenterological diagnoses were: functional disorder, duodenal ulcer, hiatus hernia, biliary tract disease, and esophagitis. The five most common over-all diagnostic areas were: functional disorder, cardiovascular disease, "other" nongastroenterological diagnoses (including obesity), duodenal ulcer, and endocrine malfunction. Geographically dispersed gastroenterologists in Virginia make more than one-half of their primary diagnoses in the area of their subspecialty interest. The primary gastroenterological problems seen are "upper gut" lesions and biliary tract disease. These observations may be of value in planning education, training, or research activities, especially if verified by a broader sample of gastroenterological practitioners.     

The personality pattern of duodenal ulcer patients in relation to spontaneous ulcer healing and relapse

One hundred consecutive out-patients with duodenal ulceration from a hospital and a gastroenterological clinic were tested with the Minnesota Multiphasic Personality Inventory (MMPI). This was carried out in order to investigate whether neuroticism or other personality disorders were characteristics of duodenal ulcer patients, and whether the presence of such possible personality disorders might influence the prognosis of the disease. Neuroticism occurred in 53% of the patients, but only in 5% of controls (P less than 0.0001). Overall, personality disorders were present in 69% of the patients compared with 30% of the controls (P less than 0.0001). Neuroticism was connected with a high frequency of relapse (P less than 0.05) whereas failure of spontaneous ulcer healing had no certain relation to personality disorders. Patients with non-neurotic personality disorders had more frequently suffered stressful life events before entrance to the study (P less than 0.05) and, like the neurotic patients, they had lower ego-strength to cope with such events (P less than 0.05). The results indicate that personality assessments make it possible to distinguish between subgroups of duodenal ulcer patients with different course of the disease.     

Endokrine St?rungen und Verdauungstrakt

The endocrine system has a central and integrative role in maintaining whole body homeostasis in humans. Therefore, endocrine disorders consequently affect other organs, such as the digestive system. Gastrointestinal symptoms, such as swallowing disorders, abdominal pain, diarrhea or obstipation are common clinical problems in the general practice. Besides primary gastroenterological causes, such as achalasia, gastrointestinal malignancies or chronic inflammatory bowel disease, endocrine disorders have to be ruled out when searching for the correct diagnosis. Hyperparathyroidism or endocrine pancreatic tumors, for example, can be the cause for fulminant diarrhea. The correlation of endocrine and gastroenterological diseases can also be found in the associations of papillary thyroid carcinoma with familial adenomatous polyposis (FAP), multiple endocrine neoplasia with Hirschsprung??s disease and Hashimoto??s thyroiditis with celiac disease and chronic atrophic gastritis. Knowledge of these associations seems not only clinically important for establishing a correct diagnosis but also has consequences in the follow-up of patients, for example the diagnosis of medullary thyroid malignancy may precede the diagnosis of FAP and vice versa.     

Irritable bowel syndrome in general practice: an overview

BACKGROUND: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder that is frequently seen in gastroenterological practice. Population-based studies have shown that at any point in time IBS symptoms are present in about 3%-22% of the general Western population. In general practice, half of all new patients have functional disorders and IBS is responsible for about five consultations per week. General practitioners (GPs) manage the majority of IBS patients, but most knowledge (and research) is based on the smaller percentage of patients managed in secondary care. There is a paucity of literature on differences or similarities between these two groups with regard to clinical characteristics or diagnostic approach. METHODS: The literature published in English about IBS in general practice was reviewed. CONCLUSIONS: Irritable bowel syndrome is frequently encountered in primary care. Primary care IBS patients, compared to secondary care patients, are likely to be young, female and to have less severe symptoms. But this is only true for some symptoms; for example, non-abdominal complaints are equally reported in both groups. The disorder can be diagnosed safely using internationally agreed symptom-based criteria, such as the Rome II criteria. Additional diagnostic measures will be necessary to support the diagnosis in only a minority of situations. Many primary care IBS patients can be managed given adequate reassurance and education, frequently without additional pharmacological treatment.     

Organic and functional disorders in 2000 gastroenterology outpatients

To determine the relative frequency of different diseases and of functional gastrointestinal disorders among patients referred by general practitioners to a gastroenterology clinic, 2000 patients referred over a five-year period were studied. 980 had organic diseases, of which peptic ulcer, oesophagitis, and inflammatory bowel disease accounted for about half. 888 patients had functional disorders of the gastrointestinal tract, without any disease. Among these, various syndromes could be distinguished; abdominal pain with altered bowel habit (irritable bowel syndrome, spastic colon type) accounted for about half of these patients. More attention could profitably be directed towards understanding these common functional syndromes so that they can be more readily diagnosed and better managed.     

A unifying hypothesis for the functional gastrointestinal disorders: really multiple diseases or one irritable gut?

The functional gastrointestinal disorders are defined by the Rome criteria as a heterogeneous group of symptom-based conditions that have no structural or biochemical explanation. However, this definition now seems outdated, because structural and molecular abnormalities have begun to be recognized in subsets of patients with the irritable bowel syndrome (IBS), the prototypic functional bowel disease. A complex classification system based arbitrarily on symptom criteria does not fit in with a number of emerging facts. For example, the symptom overlap of IBS with gastroesophageal reflux disease is not due to chance, and the emergence of post-infectious IBS, dyspepsia, or both after Salmonella gastroenteritis fits better with a 1-disease model. A new paradigm seems to be needed. All of these disorders may arise after infection or gut inflammation, but the phenotype depends on localized neuromuscular dysfunction in the predisposed human host (the "irritable gut").     

Editorial: Can gluten contribute to irritable bowel syndrome?

Functional gastrointestinal disorders are the most common gastroenterological problem in our society. Changes in gut function, including pain perception, motility, and intestinal permeability, and low-grade inflammation have been described in patients with irritable bowel syndrome (IBS). The triggering factors for the described immunity and gut functional changes in patients with IBS are not completely understood. Similarly to post-infective IBS, some patients with IBS symptoms exhibit immunological evidence of gluten sensitivity but have no overt intestinal mucosal injury. They have symptoms that meet the diagnostic criteria for IBS and respond symptomatically to exclusion of gluten from the diet. Thus, gluten sensitivity may be involved in the pathogenesis of a subgroup of IBS patients. Unfortunately, there remain many unanswered questions regarding the mechanistic link between gluten sensitivity and functional gastrointestinal symptoms.     

Inflammatory bowel disease in ankylosing spondylitis

Routine detailed gastroenterological investigations were performed in a series of 47 ankylosing spondylitics. Evidence of chronic inflammatory bowel disease was found in eight patients, a prevalence of 17%. Unsuspected bowel disease was found in the absence of symptoms in three of these patients.     

Derivation and identification of questions that act as predictors of abdominal pain of musculoskeletal origin

OBJECTIVE: Although most causes of abdominal pain have a visceral origin, the musculoskeletal system must be considered when the cause is not obvious. This prospective study aimed to identify questions that would aid the diagnosis of patients with abdominal pain of musculoskeletal origin. DESIGN: Assessment of consecutive patients with abdominal pain recruited from gastroenterological outpatient clinics to develop diagnostic pointers to identify abdominal pain arising from musculoskeletal disorders. PARTICIPANTS: Subjects with benign abdominal pain, with or without a change in bowel habit, were recruited from gastroenterological clinics. Patients with inflammatory or neoplastic disease were excluded. SETTING: The study was conducted in the Physiotherapy Department, Addenbrooke's NHS Trust Hospital, Cambridge. MAIN OUTCOME MEASURES: A set of questions developed to indicate a musculoskeletal cause of a patient's abdominal symptoms.RESULTS The questions 'Does taking a deep breath aggravate your symptoms?' and 'Does twisting your back aggravate your symptoms?' had a significant positive indication of abdominal symptoms of musculoskeletal origin. The questions 'Has there been any change in bowel habit since onset of your symptoms?', 'Does eating foods aggravate your symptoms?' and 'Has there been any weight change since onset of symptoms?' had a significant negative indication for abdominal symptoms not of musculoskeletal origin. A combination of these questions gave 96% specificity and 67% sensitivity. CONCLUSION: These questions may help with the early identification of patients with abdominal pain of musculoskeletal origin and will be tested in further studies.     

Irritable bowel syndrome in general practice: prevalence, characteristics, and referral

BACKGROUND AND AIMS: Little is known about the prevalence, symptoms, diagnosis, attitude, and referral to specialists of patients with irritable bowel syndrome (IBS) in general practice. This study aimed to determine these characteristics. METHODS: 3111 patients attending 36 general practitioners (GPs) at six varied locations in and near Bristol, UK, were screened to identify those with a gastrointestinal problem. These patients (n=255) and their doctors were given questionnaires. Six months later the case notes were examined to reach criteria based diagnoses of functional bowel disorders. RESULTS: Of 255 patients with a gastrointestinal complaint, 30% were judged to have IBS and 14% other functional disorders. Compared with 100 patients with an "organic" diagnoses, those with IBS were more often women and more often judged by their GP to be polysymptomatic and to have unexplained symptoms. The majority of patients with IBS (58%) were diagnosed as such by the GP; 22% had other functional diagnoses. Conversely, among 54 patients diagnosed as having IBS by the GPs, the criteria based diagnosis was indeed functional in 91%; only one patient had organic disease (proctitis). More patients with IBS than those with organic disease feared cancer. In most some fear remained after the visit to the doctor. On logistic regression analysis, predictors of referral to a specialist (29% referred) were denial of a role for stress, multiple tests, and frequent bowel movements. CONCLUSIONS: Half the patients with gut complaints seen by GPs have functional disorders. These are usually recognised, and few patients are referred. In IBS, cancer fears often remain, suggesting unconfident diagnosis or inadequate explanation.     

Oral Crohn's disease: Is it a separable disease from orofacial granulomatosis? A review

Symptomatic oral Crohn's disease is comparatively rare. The relationship between orofacial granulomatosis, (where there is granulomatous inflammation and ulceration of the mouth in the absence of gastrointestinal disease) and true oral Crohn's disease is discussed along with the plethora of clinical oral disease presentations associated with both disorders and the differential diagnosis of oral ulceration in patients presenting to a gastroenterological clinic. Specific oral syndromes are outlined including the association between oral manifestations in Crohn's disease and the pattern of intestinal disease and their relationship to other recorded extraintestinal manifestations. The histological and immunological features of oral biopsies are considered as well as the principles of management of symptomatic oral disease. At present, it is suggested that both orofacial granulomatosis and oral Crohn's disease appear to be distinct clinical disorders.     

Irritable bowel syndrome in children: Pathogenesis,diagnosis and evidence-based treatment

Irritable bowel syndrome (IBS) is the commonest cause of recurrent abdominal pain (RAP) in children in both more developed and developing parts of the world. It is defined by the Rome III criteria for functional gastrointestinal disorders. It is characterized by abdominal pain that is improved by defecation and whose onset is associated with a change in stool form and or frequency and is not explained by structural or biochemical abnormalities. It is estimated that 10%-15% of older children and adolescents suffer from IBS. IBS can be considered to be a brain-gut disorder possibly due to complex interaction between environmental and hereditary factors. The diagnosis of IBS is made based on the Rome III criteria together with ruling out organic causes of RAP in children such as inflammatory bowel disease and celiac disease. Once the diagnosis of IBS is made, it is important to explain to the parents (and children) that there is no serious underlying disease. This reassurance may be effective treatment in a large number of cases. Lifestyle modifications, stress management, dietary interventions and probiotics may be beneficial in some cases. Although there is limited evidence for efficacy of pharmacological therapies such as antispasmodics and antidiarrheals; these have a role in severe cases. Biopsychosocial therapies have shown encouraging results in initial trials but are beset by limited availability. Further research is necessary to understand the pathophysiology and provide specific focused therapies.     

Splitting irritable bowel syndrome: from original Rome to Rome II criteria

OBJECTIVES: Diagnosis of irritable bowel syndrome (IBS) and other functional bowel disorders (FBD) is based on symptom evaluation. Clinical criteria have changed over time, yielding different proportions of subjects fulfilling diagnostic requirements. According to new diagnostic criteria (Rome II), subjects considered some years ago to have IBS no longer do so. The aim of this article is to evaluate how patients diagnosed as having IBS according to original Rome criteria have been split, and to which clinical diagnosis they belong today. METHODS: Two hundred and eleven subjects meeting original Rome IBS diagnostic criteria were studied: 65 also met Rome II criteria while 146 did not. Subjects were extracted from an epidemiological survey, using home-based personal interviews, on 2000 subjects randomly selected as representative of the Spanish population. Clinical complaints, personal well-being, resource utilization, and health-related quality of life (HRQOL) were compared. RESULTS: Of the subjects meeting original Rome but not Rome II criteria, the present diagnosis should be: 40%"minor" IBS (IBS symptoms of less than 12 wk duration), 37% functional constipation, 12% alternating bowel habit, 7% functional diarrhea, 3% functional abdominal bloating, and 1% unspecified functional bowel disorder (FBD). Thus, 52 subjects (36%) should not be diagnosed with IBS because they really had other FBD, 59 (40%) because of symptoms consistent with IBD diagnosis but not the required duration or frequency, and 35 (24%) because of symptoms consistent with some other FBD diagnosis but not meeting the required duration. Clinical complaints, personal well-being, resource utilization, and HRQOL were more severely affected in IBS than in other FBD as a group, and in "major" rather than in "minor" forms. CONCLUSIONS: Many subjects meeting original Rome criteria for IBS do not meet Rome II criteria: approximately one quarter of subjects do not have sufficient symptom duration or frequency to be diagnosed with IBS and almost half are now considered as having other ("major" or "minor") FBD.     

Psychological features are important predictors of functional gastrointestinal disorders in patients with eating disorders

OBJECTIVE: Gastrointestinal symptoms that occur without evidence of structural gastrointestinal disease are a well-recognized feature of patients with eating disorders (EDs). Despite this, the spectrum and predictors of specific functional gastrointestinal disorders (FGIDs), documented using standardized and validated questionnaires, have received little attention. The aims of the study were to describe the prevalence and type of FGIDs in patients suffering from anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS), and to determine the relationships between psychological features, eating-disordered attitudes and behaviours, demographic characteristics and the type and number of FGIDs present. MATERIAL AND METHODS: A total of 101 consecutive female patients admitted to an eating disorder unit (AN 44%, BN 22%, EDNOS 34%, mean age 21 years) completed the Rome II modular questionnaire and a range of other validated self-reported questionnaires detailing illness history, psychological features and eating and exercise behaviour. RESULTS: The criteria for at least one FGID were fulfilled by 98% of the sample. The most prevalent FGIDs were irritable bowel syndrome (IBS: 52%), functional heartburn (FH: 51%), functional abdominal bloating (31%), functional constipation (FC: 24%), functional dysphagia (23%) and functional anorectal pain disorder (FAno: 22%); 52% of the sample satisfied the criteria for at least three coexistent FGIDs. Psychological variables (somatization, neuroticism, state and trait anxiety), age and binge eating were significant predictors of specific, and > or =3 coexistent FGIDs. Other disordered eating characteristics, including body mass index, were not predictors. CONCLUSIONS: In patients with EDs, specific psychological traits predict FGID type and the presence of multiple coexistent FGIDs. These findings support the role of specific psychological features as important contributors to certain FGIDs.     

Reproductive disorders in women with celiac disease: effect of etiotropic therapy

The study included 132 women (average age 38.5 +/- 1.17 years) with HC observed in the CSRIG from 2000 to 2010. Comparison group consisted of 105 women (average age 38.7 +/- 1.6 years) mainly with functional bowel disorders (irritable bowel syndrome, functional constipation, functional meteorism, inert colon). Take into account the information relating to obstetric and gynecological history, Physical and laboratory signs of malabsorption syndrome (MS), studies of antibodies to alpha-gliadin immunoglobulin (IG), Class A (AHA) and tissue transglutaminase (AtTG). Reproductive disorders in women with celiac disease are significantly more frequently than in women with functional bowel disease. One of the causes of reproductive disorders in patients with HC might be malabsorption disorders of essential nutrients in the small intestine. The presence of reproductive disorders should be considered as a risk factor for celiac disease, so these women should be screened for celiac disease.     

Insights into normal and disordered bowel habits from bowel diaries

BACKGROUND: While symptom questionnaires provide a snapshot of bowel habits, they may not reflect day-to-day variations or the relationship between bowel symptoms and stool form. AIM: To assess bowel habits by daily diaries in women with and without functional bowel disorders. METHOD: From a community-based survey among Olmsted County, MN, women, 278 randomly selected subjects were interviewed by a gastroenterologist, who completed a bowel symptom questionnaire. Subjects also maintained bowel diaries for 2 wk. RESULTS: Among 278 subjects, questionnaires revealed diarrhea (26%), constipation (21%), or neither (53%). Asymptomatic subjects reported bowel symptoms (e.g., urgency) infrequently (i.e., <25% of the time) and generally for hard or loose stools. Urgency for soft, formed stools (i.e., Bristol form = 4) was more prevalent in subjects with diarrhea (31%) and constipation (27%) than in normals (16%). Stool form, straining to begin (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.7-10.2) and end (OR 4.7, 95% CI 1.6-15.2) defecation increased the odds for constipation. Straining to end defecation (OR 3.7, 95% CI 1.2-12.0), increased stool frequency (OR 1.9, 95% CI 1.02-3.7), incomplete evacuation (OR 2.2, 95% CI 1.04-4.6), and rectal urgency (OR 3.1, 95% CI 1.4-6.6) increased the odds for diarrhea. In contrast, variations in stool frequency and form were not useful for discriminating between health and disease. CONCLUSIONS: Bowel symptoms occur in association with, but are only partly explained by, stool form disturbances. These observations support a role for other pathophysiological mechanisms in functional bowel disorders.     

Sources of clinical referrals to an urban coloproctology unit in Italy

Prompt and appropriate referrals to colorectal surgeons result in better clinical and more cost-effective outcome: the question that then arises is how patients with large bowel diseases get in contact with the specialist. The aim of the present research was to investigate the sources of clinical referrals of 1000 patients attending a dedicated coloproctology unit. One thousand consecutive new patients attending the private Coloproctology Unit of Rome were prospectively evaluated from May 1995 through December 1999. For each patient, the following data were collected: age, gender, source of referral, and disease classified as benign anal diseases, neoplasms, functional disorders or inflammatory bowel disease (IBD). There were 569 patients with benign anal disease, 334 with functional disorders, 57 with neoplasms, and 40 with IBD. Sources of referral were: surgeons (32.6%), previous patients (23.6%), other specialists (22.8%), general practitioners (11.8) and others (9.2%). Overall, referrals from non-medical sources were 32.8%, whereas 67.2% of the cases were referred by other colleagues. Most of the referring specialists were surgeons or gastroenterologists, who sent 304 patients, whereas 9.4% of the cases were referred by other colorectal surgeons. Previous patients who were satisfactorily cured sent 23.6% of the cases. Only 1.1% of patients were referred by health insurance companies and 0.2% found the Unit through Internet. Colleagues who referred patients to the coloproctologist sent mainly cases with benign anal diseases and functional disorders. Few patients were referred for colorectal cancer and IBD as these diseases are routinely treated by general surgeons and their management is expensive in a private hospital for patients without insurance coverage. In conclusion, GPs, media, health insurance and Internet may be the most valuable targets of an information campaign, as their role as sources of referral was lower than expected.