Half-way through Digestive Disease Week 2015, I have decided to discontinue my little experiment that consisted of shortening my blogs here to a seven-sentence limit to make live-blogging feasible from the conference (see my earlier blog entry about that). In the first couple of days at DDW 2015 I was only able to squeeze in time for 2 blog entries (see below), even in the shorter format. I have concluded that things are just too busy at these conferences for me to blog meaningfully, and there is nothing I can do to change that if I want the meetings to be as incredibly productive for me as they have been. But that is why we do experiments – to learn something new. And I have learned that sharing information from DDW is only feasible for me in shorter tweet format. So I am now concentrating on highlighting key new and interesting information on FGIDs more actively on Twitter. instead Follow my stream there at @DrPalssonUNC to keep up with that. Twitter seems to be by far the most effective way for information to flow from the conference in real-time, and I will focus on participating in that information outpouring to give FGID info from the more emphasis.
It is widely recognized that fecal incontinence is a distressing health problem, but there is very little information in the literature on the psychological impact of this problem in the general community.
Today, I am presenting a Poster of Distinction here at Digestive Disease Week, with the findings of a community survey of a broad sample of U.S. adults that our team conducted to assess the psychological effects of having FI.
We compared the responses of 234 adults with FI (defined as accidental loss of liquid or solid stool at least once a month in the past 6 months) to those of a control sample of 328 subjects without FI, using a set of questionnaires that included multiple measures of Fecal Incontinence, a Quality of life measure (the FI-QOL Scale) and a psychological distress questionnaire(Brief Symptom Inventory – 18; or BSI-18).
We found that people with FI had significantly higher average scores (see Figure 1 below) on all dimensions of psychological distress (anxiety, depression, somatization and overall distress) on the BSI-18 questionnaire compared to those without FI symptoms), and that substantially higher proportion of FI sufferers scored in the clinically significantly distressed range on this questionnaire (BSI-GSI scores > 63) according to guidelines for BSI-18 interpretation (see Figure 2).
High psychological distress was a significant independent predictor, along with greater severity of fecal incontinence and younger age, in predicting the amount of quality-of-life impairment among the individuals with FI.
One must always be careful in assuming causality when interpreting the findings of a single-time assessment like we used here. However, these results strongly suggest that the burden of FI symptoms results in clinically significant levels of psychological distress for a substantial proportion of FI sufferers, with the majority of individuals with FI suffering from clinical levels of psychological distress, and it further seems that having FI at a relatively younger age adds to the burden of this health problem.
Olafur S. Palsson , Steve Heymen , William E. Whitehead . Fecal Incontinence is Associated with Clinically Significant Psychological Distress. DDW 2015 Sa1366
A large proportion of individuals with functional GI disorders such as IBS report significant levels of psychological distress (50-90% of people with IBS in clinical samples in fact have diagnosable affective disorder – less in community samples), but it generally been unclear whether this elevation in psychological symptoms is a cause or amplifier of GI symptoms or the result of the bowel symptoms.
In contrast, individuals with bowel symptoms of more organic nature, like inflammatory bowel disease (IBD), tend to have lower levels of psychological distress than functional GI patients.
In a study presented as a poster today, Saturday May 16, Piacentino and colleagues in Rome, Italy, examined the relationship of psychological symptoms on the SCL-90_R with bowel symptom severity in 75 IBS patients and 69 patients with inflammatory bowel disease (35 of those had ulcerative colitis and 34 had Crohn’s Disease).
In line with prior studies, they found that on average the IBS patients had significantly higher scores on psychological distress than those with IBD.
However, both group scored significantly higher than population norms for psychological symptoms, and for both groups, and there was a clear increase in psychological symptom level with increasing severity of bowel symptoms.
This pattern of findings suggest that the elevated psychological distress of many GI patients is driven to substantial degree by the the gastrointestinal symptoms, regardless of whether the symptoms are organic or functional in nature – probably the result from the added stress and life interference that those gut troubles produce – although a bi-directional relationship between symptoms and psychological symptoms certainly is likely as well.
Daria Piacentino , Monica Cesarini , Enrico Corazziari. Gastrointestinal patients’ psychopathological level is associated with symptom severity irrespectively of inflammatory bowel disease or irritable bowel syndrome diagnosis. DDW 2015 Sa2009.
The last three years when I have attended the annual Digestive Disease Week, I have endeavored to share on this blog some of the many new and interesting research findings on functional GI disorders presented at that meeting – information that I think may be of interest to patients with these disorders and the general public. You can see the results of this effort in the archive here below.
Although I have been happy enough with what I have been able to write, it has troubled me each year that I have only been able to write a few posts from the meeting – far less than I would like to share with my audience. I will readily admit that this is in part because I have been somewhat verbose in my blogs. The scientist in me tends to want to explain everything in detail with facts, figures and context. That kind of writing takes a lot of time, and it simply does not lend itself very well to live-blogging from a conference. The fact of the matter is that I never have nearly enough free hours at DDW to accomplish as much as I would like with such thorough blogging. The conference days are always an exciting and extremely busy time for me, filled with numerous meetings with research colleagues, presentations and poster sessions, receptions and dinners, leaving little time for writing.
In pondering this dilemma the other day, it struck me that it might be helpful if I limited myself strictly to a self-imposed shorter blog format – turned my blogging into mini-blogging – so that I could cover more topics more quickly in my live-blogging from these meetings.
The more I thought about it, the more I liked the idea of adopting short-format blogging, as a fun writing challenge for myself for DDW 2015. After a lot of consideration about how much space I would absolutely minimally need to cover the typical topics I want to share from DDW in a reasonable but brief way, I settled on a seven-sentence limit for my new experimental format. And to make it a bit more fun as a challenge for myself, I decided to set myself the absolute rule of writing each blog topic from this year’s DDW in exactly seven sentences: No more, and no less.
So that is what I will do, and I invite you to watch this blog during DDW 2015 (May 16-19) to see how I do with my personal writing experiment. I hope that my adoption of this self-imposed mini-blog format will enable me to share more of the wealth of interesting new FGID content that I learn about at the meeting in a readable and understandable manner. I will certainly welcome any feedback on this approach. And who knows? If it works well, it might even become my standard way of writing this blog from now on.
I always find it intriguing and encouraging when herbal and alternative medicine treatments that I have never known to be used for IBS are tested and show good promise in research studies. Yesterday, May 3 2014, a team of researchers from Essen, Germany presented the results of one such study at Digestive Disease Week 2014; a randomized controlled trial that indicates that poultices with caraway oil might be beneficial for reducing IBS symptoms and improving the quality of life of IBS sufferers. A poultice an old-fashioned time-honored form of treatment — a soft moist mass containing therapeutic herbal or chemical ingredients that is applied to the surface of the body. Poultices are for example often used to relieve pain, inflammation or swelling. I knew that caraway is an old and very useful medicinal plant with digestive benefits, from growing up in Iceland where it is cultivated and used (among other things to flavor the national strong Vodka-like spirit informally called Black Death). I had never known caraway oil to be used in poultices, however, or for IBS treatment.
The German research team conducted a well-designed trial. They treated 48 IBS patients with diarrhea-predominant and alternating bowel symptoms, and compared daily use of hot poultice of caraway oil for three weeks to daily use of hot or cold poultices with olive oil instead, each also for three weeks. Every patient used both the caraway treatment and the comparison interventions, in a random order, with a two-week recovery (wash-out) period between different treatment conditions.
The results clearly favored the hot caraway oil over the comparison interventions. Symptom severity was reduced much more on average from that treatment than the others, and a higher proportion of patients was deemed treatment responder with the caraway oil (43.9%) compared to hot (20.0%) or cold (18.9%) olive oil. Additionally, health-related quality of life, as measured by the IBS-QOL scale, improved significantly more with the caraway oil than the olive oil poultices.
In short, the results of this study seem to me to show tantalizing promise of a potentially valuable therapy for IBS patients. The main concern I have about this study is the possibility that caraway oil, which I believe has a sharp spice scent, may have seemed more “medicinal” to the patients than the olive oil interventions and therefore may have raised expectations of benefit and thereby caused a stronger placebo response than olive oil. However, the researchers mentioned in their abstract that they made adjustments for expectancy in their statistical analyses, so perhaps this was taken into account. I think it would be great to see further good-quality research done on these hot caraway oil poultices as possible useful therapy for IBS.
Sa1071 Jost Langhorst,Romy Lauche ,Anke Janzen, Rainer Lüdtke, Holger Cramer, Gustav J. Dobos. Efficacy of Caraway Oil Poultices in the Treatment of Irritable Bowel Syndrome – a Randomized Controlled Cross-Over Trial. Departments of Integrative Gastroenterology and Internal and Integrative Medicine, University Duisburg-Essen, Essen, Germany; Karl and Veronica Carstens-Foundation, Essen, Germany
Advances in technology and ever-decreasing cost of large-scale DNA analysis have made it possible in the past few years to conduct a census of the bacterial populations that live in different places inside individual human beings. A number of such studies have been done on IBS patients, and they are revealing that IBS patients may have an abnormal balance in their bacterial populations (more of certain bacteria types and less of others) compared to other people. This raises the possibility that such bacterial imbalance may be contributing to symptoms and, by extension, that these bacterial differences could be corrected to help improve IBS. And in fact, both treatment with probiotics (beneficial bacteria that are taken in capsules and are thought to restore balance in the bacterial population in the intestines) and treatment with antibiotics that mostly work within the bowel (neomycin and rifaximin) have shown clear positive effects on the symptoms of some IBS patients in multiple studies1,2. This provides indirect but persuasive evidence that bacteria play a definite role in IBS symptoms. However, much is still poorly understood about this phenomenon of bacterial abnormality in IBS. It is unclear, for example, which bacteria exactly are trouble-makers (apart from a couple of notorious offenders like Clostridium Difficile) or how they cause trouble.
The balance between different types of bacteria in IBS has typically been studied in stool samples, and that makes good sense since IBS is a bowel problem. But could bacterial imbalances also be present in other parts of the body in people with IBS? A study presented yesterday (Saturday May 3) at Digestive Disease Week 2014 in Chicago indicates that bacterial abnormalities are in fact present in the other end of the GI tract as well – in the mouths of IBS patients.
Fourie and colleagues at the National Institutes of Health in Bethesda, Maryland, collected samples of bacteria from the lining of the mouth cavity of 19 IBS patients and also from the same number of healthy controls who were matched to the IBS patients in height, weight, race and sex. They then ran whole microbiome DNA analysis on the samples to identify the types of bacteria present based on their genes, and then calculated how abundant different types of bacteria were in the mouths of IBS sufferers versus the healthy comparison subjects.
The team found that the people with IBS had significantly more of three bacteria types – Prevotellacea, Lachnospiraceae, and Rikenellaceae – compared to the healthy individuals. The latter two kinds of bacteria have already previously been found to be incresed in IBS according to the authors. The researchers further did some bowel stress test that involved swallowing a mixture of 4 types of sugars, and measured the stress hormone cortisol in the participants’ urine to evaluate the amount of stress response to this stimulation, and they discovered that the amount of Lachnospiraceae bacteria was related to the intensity of the body’s stress response to the sugar stress test. However, IBS patients (who had a higher concentration of that type of bacteria) had less stress response to the sugar stressor, so the meaning of that bacterial association is a bit ambiguous.
The significance of this study, even though it is small and the findings need to be replicated, is that it indicates that abnormal bacterial balance is probably not limited to the lower part of the GI tract in IBS, but is likely to be found all over in the GI tract – even in the parts furthest away from the small or large bowels where most biological and physiological investigations in IBS have been concentrated. As the authors suggest, sampling bacteria in the mouth could be a convenient way (compared to stool samples) to measure the microbe inbalances in IBS patients that could potentially be treated to improve their IBS symptoms.
Sa1185. Nicolaas H. Fourie, Dan Wang, Paul A. Smyser, Sarah Abey1, LeeAnne Sherwin, Bridgett Rahim-Williams, Wendy A. Henderson. Dysbiosis of the Mucosa-Adherent Microbiome in Patients With Irritable Bowel Syndrome. NINR & NIMHD, NIH DHHS, Bethesda, MD.
1. Ohman L, Simrén M. Intestinal microbiota and its role in irritable bowel syndrome (IBS). Curr Gastroenterol Rep. 2013 May;15(5):323. Review. PubMed PMID: 23580243
2. Cash BD. Emerging role of probiotics and antimicrobials in the management of irritable bowel syndrome. Curr Med Res Opin. 2014 Apr 14. [Epub ahead of print] PubMed PMID: 24666019
Functional dyspepsia (FD) is a common disorder characterized by symptoms that are often described as indigestion; unpleasant sensations in the middle of the abdomen, uncomfortable fullness after eating, and sometimes inability to eat normal-size meals. FD is a much-researched disorder, but surprisingly, no nationwide studies have been done in the U.S. to evaluate what proportion of adults actually meet formal criteria for FD as defined by the current Rome III diagnostic criteria. Moreover, little is known about how rates of dyspepsia differ among race or ethnic groups or between different age group in the American population.
Today (May 3, 2014) I presented in poster format at Digestive Disease Week 2014 in Chicago the results of statistical analyses that our research team carried out to estimate how common FD is in American adults. We used for this purpose data from the Rome Normative Gastrointestinal Symptom Survey that we conducted last year, and which was sponsored by the Rome Foundation. In this secure online survey, we obtained responses from a large group of adults across every state in the U.S. The survey included questions about the responders’ demographics, health history, and the whole Rome III Diagnostic Questionnaire that diagnoses all functional gastrointestinal disorders. To minimize bias due to the possibility that people with GI symptoms might be more interested than others in participating and therefore be over-represented in our sample, invitations to participate described the study as a physical symptoms survey but did not mention gastrointestinal symptoms. We also controlled how many participants in different demographic categories could participate, in order to ensure equal gender proportions and get enough minority participation for our sample to be similar to the U.S. population.
A total of 1,665 individuals ranging in age from 18-94 years completed our survey, but we then eliminated from our analysis dataset people who showed evidence of inconsistent survey answers (we included three repeat questions in the survey for quality-check purposes), leaving us with responses from 1,277 people suitable for analysis. We have used that sample to estimate how common different functional gastrointestinal disorders are in the U.S. population and whether they have different frequency in various subgroups of the population (like males vs. females or older individuals versus young). In today’s presentation we only reported such findings for FD, but we will also be presenting our results for IBS and fecal incontinence separately here at DDW on Tuesday. We found that 11.4% of the people who completed our survey met Rome III criteria for FD. However, to get a more accurate estimate of the national dyspepsia prevalence, we statistically adjusted (weighted) our calculations to make the sample match the national adult age, gender and race/ethnicity distribution in the 2010 U.S. Census. Doing this only altered our numbers slightly, resulting in an estimated overall national U.S. FD rate of 11.9%.
We also found that functional dyspepsia tended to be more common in women than men (13.0% versus 9.9%) but this actually did not quite reach statistical significance, so we cannot be confident about the sexes really being different in this regard. In both sexes, FD rates were lowest in the youngest and oldest age groups, and significantly higher at mid-life; see the Figure below. Dyspepsia prevalence was not significantly different in white (12.3%) hispanic (12.9%) and black (9.6%) respondents in our survey.
There are presently two recognized subtypes of FD, separated by difference in the symptom pattern. A surprising finding in our survey was that only 3 individuals in our whole sample (a mere 0.2%) met criteria for one of those sub-types, which is called Epigastric Pain Syndrome (defined primarily by pain in the upper gut, above the stomach). In contrast, most of the people (87%) in our survey who qualified for FD diagnosis based on their responses fit into the other subgroup, called Postprandial Distress Syndrome (meaning that they mostly have uncomfortable fullness after eating).
In summary, our analyses of responses to the FD diagnostic questions in this large nationwide survey give a clear picture for the first time of the prevalence of this disorder overall in the U.S. and in population subgroups, as it is defined by current Rome symptom criteria. Our results indicate that about 12% of American adults have this disorder, which makes it one of the most common of all gastrointestinal problems in the U.S.
Sa1335. Olafur S. Palsson, Miranda A. Van Tilburg, Brennan M. Spiegel, Jan F. Tack, Robin C. Spiller, Lynn S. Walker, Yunsheng Yang, William E. Whitehead. Uninvestigated Dyspepsia in the U.S. General Population: Results From the ROME Normative Gastrointestinal Symptoms Survey (RNGSS). Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, NC; Digestive Diseases, VA/UCLA, Los Angeles, CA; TARGID, University Hospitals of Gasthuisberg, Leuven, Belgium; Nottingham Digestive Diseases Centre Biomedical Research Unit, University of Nottingham, Nottingham, United Kingdom; Adolescent Medicine, Vanderbilt Children’s Hospital, Nashville, TN; Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China.