Functional dyspepsia--managing the conundrum.
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Dyspepsia↗
Biomedical subjects
George F Longstreth
Publications and source records attributed to George F Longstreth.
Functional bowel disorders.
Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.
Constipation↗
Results of computed tomography in family practitioners' patients with non-acute abdominal pain.
OBJECTIVES: The utility of abdominal computerized tomography (CT) for evaluating abdominal pain in non-emergency, primary care outpatients is unknown. Family practice patients commonly report abdominal pain. METHODS: We reviewed the records of health maintenance organization primary care outpatients <2 years after they had undergone CT for abdominal pain and assessed demographic variables, clinical and laboratory data, CT findings and final diagnoses. RESULTS: We studied 137 patients: age 58.1 +/- 16.1 years (mean +/- SD), 80 (58.4%) females. Fifty (36.5%) patients had > or =1 warning clinical or laboratory feature. Positive (etiologic) and negative CT reports and unrelated and multiple CT findings occurred in 16 (11.7%), 104 (75.9%), 16 (11.7%) and 1 (0.7%) patients, respectively. Positive findings occurred in 16 (32.0%) patients with > or =1 warning feature and 1 (1.2%) patient (including the 1 patient with multiple findings) with no warning feature (P < 0.0001). One (6.3%) unrelated finding led to treatment, ovariectomy for a benign tumor. Fifty-four (39.4%) patients had a final diagnosis. CONCLUSIONS: A majority of outpatients who had CT for abdominal pain received no diagnosis, and CT was rarely diagnostic for patients lacking a warning feature. Positive and unrelated CT findings were equally prevalent, and the latter were not beneficial.
Abdominal Pain↗
Diabetic thoracic polyradiculopathy.
Diabetic thoracic polyradiculopathy usually causes severe, chronic abdominal pain in patients with type 2 diabetes of variable duration. Other diabetic complications, weight loss and paretic abdominal wall protrusion are common. Sensory, motor and autonomic functions are affected. The diagnosis can be made from the characteristic history, physical examination findings, paraspinal electromyography, and other procedures. The differential diagnosis includes postherpetic neuralgia, abdominal wall pain, malignancy, and other spinal disorders. The pathology appears to be immune-mediated neurovasculitis resulting in ischemic injury. Traditional therapy is symptomatic, but recent pathological findings and clinical experience suggest that immunotherapy may be effective.
Abdominal Pain↗
Definition and classification of irritable bowel syndrome: current consensus and controversies.
The symptom-based taxonomy of IBS and other functional bowel disorders is based on defined individual symptoms and the co-occurrence of certain symptoms in individuals. Wording of survey questions to accurately reflect the symptoms can be difficult in English, but accomplishing it for non-English-speakers, especially residents of non-Western societies, is an even greater challenge that needs more attention. The potential for misdiagnosis and inappropriate management, including unnecessary surgery, under-scores the need for wider knowledge of typical IBS symptoms by physicians and the collaboration of primary and specialist physicians in patient care. Even though the evolving symptom classification is as evidence-based as its designers can make it, some arbitrariness is inevitable. Population prevalence rates vary widely, depending on diagnostic criteria and other factors, and further work is needed to determine which individuals detected in surveys consider themselves distressed enough to want medical care and why the remaining people do not feel this need. Clearly, more primary care patients should be studied. Physicians should assess clinical trials critically regarding patient recruitment methods and patient features that could influence whether the results are applicable to their patients. The instability of bowel habit subtypes suggests that relatively few patients should expect relief by taking the same motility-active drug regularly for a long time. Long-term, natural history studies of symptoms and health care use are needed. Discoveries of subtle morphologic pathology and disordered physiology are elucidating IBS pathophysiology further, which some experts believe will lead to a more objective, laboratory-based (organic) diagnosis and more effective therapy. The benefit patients will obtain from supplementing a traditional symptom-based, biopsychosocial approach with such findings remains to be determined. The symptom criteria have had important roles in epidemiological studies and characterizing subjects for clinical trials. Many practitioners, however,do not know the typical symptoms or use the criteria, and investigating how physicians diagnose IBS has received scanty attention. It is unknown how many physicians diagnose IBS by exclusion only after extensively testing patients with typical symptoms and no alarm features, but determining this could have important economic and safety implications. There has been little careful validation of the symptom criteria, especially with primary care patients, and no particular criteria are clearly superior for clinical practice,although the Manning and Rome I criteria have been most evaluated and are less restrictive than the Rome II criteria.
Humans↗
Severe irritable bowel and functional abdominal pain syndromes: managing the patient and health care costs.
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Abdominal Pain↗
Impact of irritable bowel syndrome on patients' lives: development and psychometric documentation of a disease-specific measure for use in clinical trials.
OBJECTIVE: To develop a disease-specific questionnaire to capture the impact of irritable bowel syndrome (IBS) and its treatment on patients' lives, the Irritable Bowel Syndrome Impact Scale (IBS-IS). PATIENTS AND METHODS: One hundred and fifty-five IBS patients participated (126 (81%) female; age (mean+/-SD) 45.5+/-12.4 years). We developed the initial 39 items from the literature, available IBS-specific instruments and input from physicians, nurses and patients. We deleted IBS-IS items with a high ceiling effect, items that measured a different construct and items showing a high correlation (r>0.90) with another item and with Rasch analysis, leaving 26 items. We then applied exploratory factor analysis to examine domain groupings. Subjects completed the IBS-IS instrument, the Gastrointestinal Symptom Rating Scale for IBS (GSRS-IBS), Short Form-36 (SF-36), Visceral Sensitivity Index (VSI), and Hospital Anxiety and Depression (HAD) scale. Internal consistency, construct validity and discriminate validity were assessed. RESULTS: The 26 items represented five domains: fatigue, impact on daily activities, sleep disturbance, emotional distress and eating habits. The internal consistency reliability for the domains was 0.87 to 0.96. Most associations between similar constructs in the IBS-IS, GSRS-IBS, SF-36, VSI, and HAD were >0.40. Each IBS-IS domain score decreased with increasing IBS symptom severity (P<0.05), and the patients scored >5 score units lower than a US general population scored on all eight SF-36 dimensions. CONCLUSION: The IBS-IS is a short, user-friendly instrument with excellent psychometric properties that has potential usefulness for clinical trials.
Activities of Daily Living↗
Chronic abdominal wall pain: clinical features, health care costs, and long-term outcome.
BACKGROUND & AIMS: Chronic abdominal wall pain (CAWP) often is misdiagnosed. We evaluated CAWP patients regarding diagnosis accuracy, clinical features, comorbidity, referral frequency, use of care, and long-term outcome. METHODS: We reviewed the records of all outpatients referred to a gastroenterologist in 5 years, recorded referral indications, and identified patients initially diagnosed with CAWP or irritable bowel syndrome (IBS). Charts of all CAWP patients were reviewed, and direct costs were estimated for abdominal pain-related physician visits and imaging studies during the 12 months before and 12 months after consultation. We appraised long-term pain status by telephone. RESULTS: Of 2709 patients, CAWP was diagnosed by physical examination in 137 patients; the diagnosis remained unchanged after 47.3 +/- 17.7 (mean +/- SD) months in 133 (97.1%) patients. Women predominated over men 4 to 1, pain was usually upper abdominal, had lasted 25.3 +/- 46.3 months, and obesity and painful comorbidities and depression were common. CAWP and IBS comprised 7.8% and 16.3% of symptomatic referrals, respectively. Prereferral, physicians rarely suspected CAWP and often prescribed therapy for acid-peptic disease. Postconsultation, primary care, emergency and specialist visits, and radiologic examinations markedly decreased (P < 0.001), and estimated annual costs decreased from $1133.87 +/- 953.37 to $541.33 +/- 989.04 (P < 0.0001). Therapy varied, and 44 (47.3%) patients had no pain at follow-up evaluation. CONCLUSIONS: CAWP is a common underrecognized disorder. Comorbidities are frequent, and health care use is high. Diagnosis is accurate and reduces health care costs. Over the long term, pain disappearance and persistence occurs in approximately equal proportions of patients.
Abdominal Pain↗
Irritable bowel syndrome and surgery: a multivariable analysis.
BACKGROUND & AIMS: Patients with irritable bowel syndrome (IBS) have high surgical rates. We investigated the demographic and medical factors independently associated with surgical histories of health examinees. METHODS: We applied multiple stepwise logistic regression analysis to self-completed questionnaire data from 89,008 examinees, assessing 6 surgeries as outcomes. We assessed questionnaire/physician record agreement of physician-diagnosed IBS and surgical history on 201 randomly selected examinees with > or =3 years of records. RESULTS: Questionnaire/record agreement for IBS and surgery was 83.6% (kappa = 0.68) and 95.5%-100.0% (kappa = 0.82-1), respectively. IBS was reported by 4587 examinees (5.2%) (1382 men [3.0%] and 3205 women [7.5%]). Subjects with and without IBS, respectively, reported the following surgical procedures: cholecystectomy, 569 (12.4%) versus 3428 (4.1%), P < 0.0001; appendectomy, 967 (21.1%) versus 9906 (11.7%), P < 0.0001; hysterectomy, 1063 (33.2%) versus 6751 (17.0%), P < 0.0001; back surgery, 201 (4.4%) versus 2436 (2.9%), P < 0.0001; coronary artery surgery, 127 (2.8%) versus 2033 (2.4%), P > 0.05; peptic ulcer surgery, 22 (0.5%) versus 277 (0.3%), P > 0.05. Among independent surgery associations, IBS was associated with cholecystectomy (adjusted odds ratio [OR], 2.09; 95% confidence interval [CI], 1.89-2.31; P < 0.0001), appendectomy (OR, 1.45; 95% CI, 1.33-1.56; P < 0.0001), hysterectomy (OR, 1.70; 95% CI, 1.55-1.87; P < 0.0001), and back surgery (OR, 1.22; 95% CI, 1.05-1.43; P = 0.0084). CONCLUSIONS: Health examinees with physician-diagnosed IBS report rates of cholecystectomy 3-fold higher, appendectomy and hysterectomy 2-fold higher, and back surgery 50% higher than examinees without IBS; IBS is independently associated with these surgical procedures.
Adult↗
Quality of life in managed care patients with irritable bowel syndrome.
The relationship between the severity of abdominal discomfort/pain and generic and disease-specific quality of life (QoL) was explored in patients with irritable bowel syndrome in an MCO. Subjects were stratified into four symptom-severity groups. Descriptive and multivariate analyses were used to examine the relationship of QoL to severity of abdominal discomfort/pain. Generic and disease-specific QoL scores declined as severity of abdominal discomfort/pain increased. The lowest 36-Item Short-Form Health Survey scores for respondents with the most severe abdominal discomfort/pain were for role physical (24.2 +/- 35.4) and vitality (33.7 +/- 19.2). In multivariate regression models controlling for age, sex, work status and education, severity of abdominal discomfort/pain was a significant independent predictor of QoL.
Female↗
Family practitioners' attitudes and knowledge about irritable bowel syndrome: effect of a trial of physician education.
BACKGROUND: Primary physicians care for most patients with irritable bowel syndrome (IBS), but data on their attitudes and knowledge about the disorder are limited to research in the UK. OBJECTIVE: The purpose of the present study was to assess US family practitioners' attitudes and knowledge about IBS and determine the effect of a single education class on these measures. METHODS: In a large health maintenance organization (HMO), a baseline group of family practitioners twice completed a questionnaire on attitudes and knowledge about IBS, 3 months apart. A class group completed it pre-class, immediately post-class and 3 months post-class. RESULT: Thirty-five physicians ranked IBS among five chronic, painful syndromes as highest in difficulty satisfying patients, tied with headache for highest in difficulty in practice strategy decision, second in time required, and fourth in diagnostic confidence and satisfaction in caring for patients. IBS and heartburn had widely separated rankings in all five attitudes. The correct answer rate on seven of 13 knowledge questions was <50%, and a majority did not identify the Rome II symptom criteria as typical and lacked other important knowledge. Of the 30 class physicians, the knowledge scores (mean +/- SD; maximum possible, 13) of 29 increased from 5.59 +/- 1.84 pre-class to 10.21 +/- 1.76 immediately post-class (P < 0.0001); 3 months later, the scores were lower (8.93 +/- 0.36) than post-class (P < 0.0001), but still higher than pre-class (P < 0.0001). Their attitude rankings were nearly identical pre-class and 3 months later (P > 0.05). In the 19 baseline physicians, IBS attitude rankings and knowledge scores did not change significantly over 3 months (P > 0.05). CONCLUSION: These US family practitioners had attitudes about IBS patients and lacked knowledge that could interfere with patient care. A single class improved short-term knowledge but had little effect on attitudes about IBS.
Adult↗
Irritable bowel syndrome, health care use, and costs: a U.S. managed care perspective.
OBJECTIVE: We performed an evaluation of patient symptoms, health care use, and costs to define the burden of illness of irritable bowel syndrome (IBS) and the relation to the severity of abdominal pain/discomfort in a large health maintenance organization. METHODS: All 6500 adult health maintenance organization members who had undergone flexible sigmoidoscopy in the year 2000 were mailed a questionnaire that elicited Rome I symptom criteria and severity ratings for abdominal pain/discomfort. Multiple health care use measures were obtained from various administrative databases. IBS patients were compared with a control group of non-IBS subjects, and analyses were adjusted for age and sex. RESULTS: We received 2613 (40.2%) responses. Compared with non-IBS subjects over 2 yr, IBS patients had more outpatient visits (medical, surgery, and emergency, p < 0.05), were hospitalized more often (p < 0.05), and had more total outpatient prescriptions (p < 0.05) and IBS-related prescriptions (p < 0.05). Over 1 yr, total costs were 51% higher in IBS patients, who also had higher costs for outpatient visits, drugs, and radiology and laboratory tests (p < 0.05). Total costs were increased by 35%, 52%, and 59% in IBS patients with mild, moderate, and severe symptoms of abdominal pain/discomfort compared with non-IBS subjects (p < 0.05). CONCLUSIONS: Using Rome I symptom criteria, we found that IBS is associated with a broad pattern of increased health care use and costs. The severity of abdominal pain/discomfort is a significant predictor of health care use and costs for patients with IBS compared with non-IBS subjects.
Adult↗
A questionnaire for the assessment of biliary symptoms.
OBJECTIVES: Gallstone disease is common and causes high health care costs, but a measure of symptomatic biliary disease for outcome studies is lacking. We aimed to develop a reproducible, valid, discriminative, disease-specific measure of biliary symptoms. METHODS: We created the self-report Biliary Symptoms Questionnaire (BSQ) by combining possible biliary symptoms with validated items for gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), and other disorders. We developed the final version through an iterative process and assessed reproducibility by the test-retest method, concurrent validity by comparing BSQ responses with symptoms obtained by structured interview, and discriminative validity by comparing BSQ-based diagnoses of biliary symptoms, GERD, and IBS with patients' final diagnoses. A shortened version (sBSQ) also underwent reproducibility testing. RESULTS: A total of 245 outpatients (mean age, 55.2 yr; 61% female) participated. Median completion times for the BSQ and sBSQ were 36 and 10 min, respectively. For the BSQ, median kappa values were 0.65 (range -0.03 to 0.95) for reproducibility and 0.61 (range 0.15-0.95) for concurrent validity. Using BSQ responses, investigators distinguished IBS and GERD 79-90% of the time. For the sBSQ, the median kappa value for reproducibility was 0.72 (range 0.32-0.86). CONCLUSIONS: The BSQ is reproducible and has good concurrent and discriminative validity for biliary symptoms. The abridged sBSQ has good reproducibility. These instruments may be useful in future outcome studies.
Adult↗
New developments in the diagnosis and treatment of irritable bowel syndrome.
Irritable bowel syndrome (IBS) is a common disorder with major health status and economic effects. Symptom criteria are of paramount importance in diagnosis, but differences among the Manning, Rome I, and Rome II criteria may lead to variable identification of people with the disorder. Practice guidelines are based on evidence and, to a greater degree, on consensus; therefore, experts vary on the specifics of ordering particular diagnostic tests. There is an overlap of IBS symptoms with those of celiac sprue, and selected patients should be tested for the latter disease. Symptom confusion with biliary pain and overlap with chronic pelvic pain could contribute to the predisposition of IBS patients to undergo cholecystectomy and hysterectomy. Development and documentation of effective therapy has been difficult, but depending on the selection of subgroups, there is evidence for usefulness of smooth muscle relaxants, loperamide, and antidepressants. Various forms of psychological therapy and new serotonin-modulating agents seem especially promising. The placebo effect of the physician-patient relationship has important therapeutic benefit.
Anti-Bacterial Agents↗
Colonoscopy and lower GI bleeding.
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Colonic Diseases↗