- Email: [email protected]
Excess surgery in irritable bowel syndrome (IBS)
FGID and 14% met criteria for multiple FGIDs. The remaining 17% did not meet the criteria for an), FGID. The most common diagnoses were irritable bowel syndrome (45%), functional dyspepsia (16%) and functional constipation (9%). Among patients who met criteria for irritable bowel syndrome (n = 48), 58.3% were constipation-predominant and 14.6% were diarrhea-predominant. Conclusions: A detailed study' of childhood RAP demonstrated that the majority of this patient population can be separated into FG1Ds based on symptoms outlined by the Pediatric Rome Criteria. This finding has implications for both clinical investigation and therapeutic intervention. The overlap among FG1Ds observed in 14% of the cases may' reflect the comorbidity also seen with these disorders in adults or may indicate that further refinement of the diagnostic criteria is necessary.
M1636
Comorbidity and Psychological Distress in Irritable Bowel Syndrome (1BS) Olatur S. Palsson, Rona L Levy, Michael Von Korff, Andrew Feld, Marsha J. Turner, William E. Whitehead We previously' (Gastro 2002,122(Suppl 1):A502) developed and validated the IBS-specific Recent Physical Symptoms Questionnaire (RPSQ) and Comorbid Medical Conditions Questionnaire (CMCQ) based on a systematic literature review We hypothesized that the excess comorhid medical cooditions and non-gastrointestinal symptoms seen in 1BS constitute somatization, that is, expresskm of psychological distress thmugb physieal symptoms (Gastro 2002;122(4):1140-56). Aims: (1) Test the hy'pothesis that comorbidity m IBS is related to anxiety and depression and (2) quantity' the impact of excess comorbidity on IBS symptom severity, disability, quality of fite and IBScelated health care utilization. Methods: The RPSQ and CMCQ were mchided in a marl survey completed by 1603 patients with functional bowel diagnoses in a large nortfiwestem US. health maintenance organization within 2 weeks of a clinic visit. The survey also included the IBS-QOL (Dig Dis Sci 1998;43:40011), the IBS Seventy Index (Aliment Pharmacol Tber 1997;11:395-402) the Brief Symptom Inventory' -18 (NCS Pearson, Inc.) attd questions about doctor's visits and disability days. Data from the 7g\5 IBS patients who met Rome II criteria were analyzed. Results: RPSQ # of non-gastrointestinal (non-GI) symptoms and CMCQ # of comorbid medical diagnoses were moderately intercorrelated (r= 49, p < 0001). Gender*adjusted BSI anxiety and depression scores were robustly correlated with gender-adjusted RPSQ (r = .50 and r = 4 0 , p<.0001) and CMCQ (r = 47 and r = .40, p < 0001) scores. In a multiple regression model, depression did not add to the contribution of anxiety to the variance m these comorbidity indices. Compared to uther IBS patients, high scorers (>1 standard deviation above the sample mean) on either comorbidity scale bad greater quality of li|e impairment, more than 3 times the number of disability days m the past year, and greater overall IBS symptom severity (p<.001 m all comparisons). High number of co-morbid medical diagnoses, but not nonspecific symptoms contributed to more frequent (p<.01) doctors' visits due to bowel symptoms in the past 6 montha Conclusions: Our results support the hypothesis that comorbidity in IBS is an expression of psychological distress. High number of co-morbid diagnoses and non*GI symptoms are related to a substantiaUy greater IBS morbidity, disability and worse quality ot lite. (Supported by RO1 DK31369, ROI HD36069 and a grant fi'om Novartis Pharmaceuticals Corp.)
M1639 Gender Differences in Plasma 5-Hydroxytryptamine (5-HT) Concentration in Diarrhoea Predominant Irritable Bowel Syndrome (d-IBS): Influence of the Menstrual Cycle Wendy Atkinson, Lesley A Houghton, Peter J. Whorwell, Paul Whitaker 1BS is more common in females than males (1) and a number of studies have suggested gender differences in both symptomatology and pathophysiology (2). However, these can also change with the menstrual cycle, as seen for example in female patients with d-IBS, who have higher post-prandial platelet depleted plasma (PDP) 5-HT concentrations during the hiteal compared with the menstrual phase of the menstrual cycle (3). The aim of this study was to compare PDP 5-HT concentrations in male patients with d-IBS (Rome II) with that seen in female d-IBS patients (Rome II) who were either in the hiteaI or menstrual phase of their menstrual cycle. Methods: PDP 5-HT concentration was assessed tbr 2 hours under fasting conditions and for 4 hours after a standard carbohydrate meal (457keal) in 11 male patients (aged 20-48 yrs), 12 female patients (aged 22-45 yrs) during menses and 39 female patients (aged 19-52 yrs) during the lnteal phase of the menstrual cycle. 5-HT concentration was measured by reverse-phase high performance liquid chromatography with fluorimetric detection. In addition, symptomatology was assessed throughout the study. Results: Male patients had higher PDP 5-HT concentrations under both fasting (35.3nmol/ l (mean)) and fed (64.0nmoH) conditions compared with female patients at menses (fasting: 26.8nmol/1, ratio male:female (95%Cl), 1.32 (0.62, 0.93), p=0.010; fed: 39.2nmogl, ratio male:female, 1.63 (0.34, lAD; p=0.101)). However, these differences were reduced when female patients were studied m the luteal phase of the cycle (fasting: 29.1nmolA, ratio male:female, 1.21 (0.66, 1.03), p=0.088; fed: 53.7nmol/[, ratio male:temale, 1.19 (0.56, 1.26), p=0.390). These results were not related to differences m s)~nptomatology under either tasting (males, 1.41(0.38, 321); female hiteal, 2.18 (1.42, 3.18); female menses, 2.58(1.18, 4.90)) or fed (4.71(2.12, 9.45); 5.14(3.35, 7.66); 5.29(3.21, 8.40)) conditions. Conclusions: Gender differences in PDP 5-HT concentration in patients with d-IBS are influenced by the phase of the menstrual cycle that the female patients are studied. Caution needs be applied when interpreting gender differences in IBS. (1)Drossman et al Dig Dis Sci 1993; 38: t569-80, (2)Chang et al Gastroenterol 2002; 123: 1686-1701, (3) Atkinson et al Gastroenterol 2002; 122 (No 4): M1489.
\ M1637
Excess Surgery in Irritable Bowel Syndrome (IBS) Andrew D Feld, Michael Von Korff, Rona L. Levy, Olatur S. Palsson, Marsha J Turner, William E, Whitehead Ptvvlous studies suggest that IBS patients receive excess numbers of hysterectomies (int J Clin Pract 2000;54:647-50), cholecystectomies (BrJ Surg 2000;87:1658-63), and appendectomies (S Air Med J 1986;70:91) Aim: To compare the incidence of selected surgical procedures in a large group of IBS patients and age-matched controls, bletbe, ds: Using the computerized inibrmation system of a large health maintenance organization, 3153 patients who received a diagnosis of IBS at one or more clinic visits during 1994 or 1995 (index visit) and 3153 age"and sex matched controls were identified (75% female, average age 52.7 years). These groups were cmnpared by Chi square for the frequenQ" of 8 selected surgical procedures occumng within a 4-year period linked to the index visit, plus the fi'equency of receiving at least one of these 8 operations in the same 4-years. Results: Significantly more ~IBS patients had at least one surgical procedure: females 9.9% vs. 5.6%, p
M1640 Diagnosis of Pelvic Floor Dyssynergia according to the Type of Attempted Defecation during Anorectal Manometry Js Lee, Ka Kwon, Hh Im, Kr Hwang, Sh Lee, Gy Jang, Sh Kim, Jy Jang, ls Jung, Bm 1(o, SI Hong, Cb Ryu, Jo Kim, Jy Cho, Ms Lee, Cs Shim, Bs Kim Aim:To compare th%chmcal and physiologic characteristics of each types of attempted defecation during ARM. Methods and Materials: We evaluated retrospectively data from 184 patients with functional constipation (mean age -+ SD, 47 -+ 15 yr; M:F = 51:133). Manometric pattern of attempted defecation was classified as five types. Type 0, adequate rectal pushing tbrce with adequate relaxation of AS (->20%); type 1, adequate rectal pushing force (->50 mmHg) with paradoxical increase m AS pressure; type 2, inadequate rectal pushing force with possible paradoxical increase in AS pressure; type 3, adequate rectal pushing force with absent or incomplete relaxation of AS (< 20%); type 4, inadequate rectal pushing force but adequate relaxation of AS. We compare the prevalence of PFD, clinical and physiologic data among the these types. Results: Number of patients classified as type 0, 1, 2, 3, 4 were 28 (15%), 88 (47.8%), 51 (27.7%), 1 (0.5%)and 16 (8.7%), respectively. Patients with PDF by Rome II were 50 out of 184 patients; 49 from type 1 (55.7%) and one from type 3 (100%). However, 17 out of 51 patients (33%) from type 2 and 5 out of 16 patients (31%) from type 4, showed puborectalis muscle indentation or incomplete relaxation of AS on defecogram, and evidence of incomplete evacuation from defecography, balIoon expulsion test, EMG, and transit study. They did not show"any evidence of neurulogie or skeletal muscle disorders despite of inadequate pushing force. Age of type 1 was older than type 2 (50.2_+ 13.7 vs. 43.1-+155, p<0.05), but sex ratio and clinical syp~ptoms failed to show significant difference among the types. Defecation index(D1) shows significant dilterences among the types except ty~pe 0 or I vs. tyTue 4 (median 0.88, 0.54, 0.25, and 0.67 in type 0, 1, 2, and 4 respectively, p<0.05) The differences of posterior anorectal angle (ARAstrammg-ARArestmg) did not show slgnifieant difterences (median 21.1 ~ 6.2 ~ 5.0~ 26.0~ 7.6~ in type 0, 1, 2, 3 and 4 respectively'). Conclusions: Many patients with type 1 and 3 of the attempted defecation dunng ARM in constipation patients, suggest PFD by Rome ll. Although the patients with type 2 and 4 did not fit with PFD by Rome II criteria because of inadequate pushing force, more than 30% of these patients strongly suggest PFD. Especially the patients with type 2 showed low DI and failure to widen the anorectal angle on straining, suggesting PFD. These finding suggests adequate rectal pushing force (rectal pressure > 50 mmHg) should not be an absolute criteria in the diagnosis of PFD.
M1638
Subtypes of Recurrent Abdominal Pain based on the Rome Criteria for Functional Gastrointestinal Disorders Lymr S. Walker, Tricia Lipam, John W. Greene, Karen Caines, John Stutts, D. Brent Polk, Arlene Caplan Andree Rasquin-Weber Am~s: Recent development ot the Pediatric Rome Criteria has standardized classification of pediatric functional gastrointestinal disorders (FGIDs) using a symptom-based approach. We tested the hypothesis that the majority of patients with childhood RAP could be classified into one or mot~ of the FGIDs defined by the Pediatric Rome Criteria Methods: Using a prmpective lmlgintdinal design, consecutive new patients referred for evaluation of RAP (n = 114) were studied at a tertiary care medical center Patmnts ranged in age from 4 to 17 years (M = i001, SD = 3.52) and 51.3% were male. Evahiation consisted of administration of a standardized parent-report questiom~aire that assesses symptoms of the pediatric Rome criteria (the Questionnaire on Pediatric Gastrointestinal Sympton~; QPGS), and a medical evahiation that included follow-up [br at least one year Physieians were blind to QPGS data. Medical records were revmwed to identify, patients whose medical evaluation yielded no evidence of organic etidogy for abdominal pain. Data from the QPGS were used to classity these patients (n = 107) into diagnostic groups defined by the Rome criteria. Resnhs: After a medical evaluation that yielded no evidence of organic disease, the majority' of cases (83%) met the Rome criteria {or a specific FGID. Specifically, 69% met criteria for a single
AGA
Abstracts
A-388
M1636
Comorbidity and Psychological Distress in Irritable Bowel Syndrome (1BS) Olatur S. Palsson, Rona L Levy, Michael Von Korff, Andrew Feld, Marsha J. Turner, William E. Whitehead We previously' (Gastro 2002,122(Suppl 1):A502) developed and validated the IBS-specific Recent Physical Symptoms Questionnaire (RPSQ) and Comorbid Medical Conditions Questionnaire (CMCQ) based on a systematic literature review We hypothesized that the excess comorhid medical cooditions and non-gastrointestinal symptoms seen in 1BS constitute somatization, that is, expresskm of psychological distress thmugb physieal symptoms (Gastro 2002;122(4):1140-56). Aims: (1) Test the hy'pothesis that comorbidity m IBS is related to anxiety and depression and (2) quantity' the impact of excess comorbidity on IBS symptom severity, disability, quality of fite and IBScelated health care utilization. Methods: The RPSQ and CMCQ were mchided in a marl survey completed by 1603 patients with functional bowel diagnoses in a large nortfiwestem US. health maintenance organization within 2 weeks of a clinic visit. The survey also included the IBS-QOL (Dig Dis Sci 1998;43:40011), the IBS Seventy Index (Aliment Pharmacol Tber 1997;11:395-402) the Brief Symptom Inventory' -18 (NCS Pearson, Inc.) attd questions about doctor's visits and disability days. Data from the 7g\5 IBS patients who met Rome II criteria were analyzed. Results: RPSQ # of non-gastrointestinal (non-GI) symptoms and CMCQ # of comorbid medical diagnoses were moderately intercorrelated (r= 49, p < 0001). Gender*adjusted BSI anxiety and depression scores were robustly correlated with gender-adjusted RPSQ (r = .50 and r = 4 0 , p<.0001) and CMCQ (r = 47 and r = .40, p < 0001) scores. In a multiple regression model, depression did not add to the contribution of anxiety to the variance m these comorbidity indices. Compared to uther IBS patients, high scorers (>1 standard deviation above the sample mean) on either comorbidity scale bad greater quality of li|e impairment, more than 3 times the number of disability days m the past year, and greater overall IBS symptom severity (p<.001 m all comparisons). High number of co-morbid medical diagnoses, but not nonspecific symptoms contributed to more frequent (p<.01) doctors' visits due to bowel symptoms in the past 6 montha Conclusions: Our results support the hypothesis that comorbidity in IBS is an expression of psychological distress. High number of co-morbid diagnoses and non*GI symptoms are related to a substantiaUy greater IBS morbidity, disability and worse quality ot lite. (Supported by RO1 DK31369, ROI HD36069 and a grant fi'om Novartis Pharmaceuticals Corp.)
M1639 Gender Differences in Plasma 5-Hydroxytryptamine (5-HT) Concentration in Diarrhoea Predominant Irritable Bowel Syndrome (d-IBS): Influence of the Menstrual Cycle Wendy Atkinson, Lesley A Houghton, Peter J. Whorwell, Paul Whitaker 1BS is more common in females than males (1) and a number of studies have suggested gender differences in both symptomatology and pathophysiology (2). However, these can also change with the menstrual cycle, as seen for example in female patients with d-IBS, who have higher post-prandial platelet depleted plasma (PDP) 5-HT concentrations during the hiteal compared with the menstrual phase of the menstrual cycle (3). The aim of this study was to compare PDP 5-HT concentrations in male patients with d-IBS (Rome II) with that seen in female d-IBS patients (Rome II) who were either in the hiteaI or menstrual phase of their menstrual cycle. Methods: PDP 5-HT concentration was assessed tbr 2 hours under fasting conditions and for 4 hours after a standard carbohydrate meal (457keal) in 11 male patients (aged 20-48 yrs), 12 female patients (aged 22-45 yrs) during menses and 39 female patients (aged 19-52 yrs) during the lnteal phase of the menstrual cycle. 5-HT concentration was measured by reverse-phase high performance liquid chromatography with fluorimetric detection. In addition, symptomatology was assessed throughout the study. Results: Male patients had higher PDP 5-HT concentrations under both fasting (35.3nmol/ l (mean)) and fed (64.0nmoH) conditions compared with female patients at menses (fasting: 26.8nmol/1, ratio male:female (95%Cl), 1.32 (0.62, 0.93), p=0.010; fed: 39.2nmogl, ratio male:female, 1.63 (0.34, lAD; p=0.101)). However, these differences were reduced when female patients were studied m the luteal phase of the cycle (fasting: 29.1nmolA, ratio male:female, 1.21 (0.66, 1.03), p=0.088; fed: 53.7nmol/[, ratio male:temale, 1.19 (0.56, 1.26), p=0.390). These results were not related to differences m s)~nptomatology under either tasting (males, 1.41(0.38, 321); female hiteal, 2.18 (1.42, 3.18); female menses, 2.58(1.18, 4.90)) or fed (4.71(2.12, 9.45); 5.14(3.35, 7.66); 5.29(3.21, 8.40)) conditions. Conclusions: Gender differences in PDP 5-HT concentration in patients with d-IBS are influenced by the phase of the menstrual cycle that the female patients are studied. Caution needs be applied when interpreting gender differences in IBS. (1)Drossman et al Dig Dis Sci 1993; 38: t569-80, (2)Chang et al Gastroenterol 2002; 123: 1686-1701, (3) Atkinson et al Gastroenterol 2002; 122 (No 4): M1489.
\ M1637
Excess Surgery in Irritable Bowel Syndrome (IBS) Andrew D Feld, Michael Von Korff, Rona L. Levy, Olatur S. Palsson, Marsha J Turner, William E, Whitehead Ptvvlous studies suggest that IBS patients receive excess numbers of hysterectomies (int J Clin Pract 2000;54:647-50), cholecystectomies (BrJ Surg 2000;87:1658-63), and appendectomies (S Air Med J 1986;70:91) Aim: To compare the incidence of selected surgical procedures in a large group of IBS patients and age-matched controls, bletbe, ds: Using the computerized inibrmation system of a large health maintenance organization, 3153 patients who received a diagnosis of IBS at one or more clinic visits during 1994 or 1995 (index visit) and 3153 age"and sex matched controls were identified (75% female, average age 52.7 years). These groups were cmnpared by Chi square for the frequenQ" of 8 selected surgical procedures occumng within a 4-year period linked to the index visit, plus the fi'equency of receiving at least one of these 8 operations in the same 4-years. Results: Significantly more ~IBS patients had at least one surgical procedure: females 9.9% vs. 5.6%, p
M1640 Diagnosis of Pelvic Floor Dyssynergia according to the Type of Attempted Defecation during Anorectal Manometry Js Lee, Ka Kwon, Hh Im, Kr Hwang, Sh Lee, Gy Jang, Sh Kim, Jy Jang, ls Jung, Bm 1(o, SI Hong, Cb Ryu, Jo Kim, Jy Cho, Ms Lee, Cs Shim, Bs Kim Aim:To compare th%chmcal and physiologic characteristics of each types of attempted defecation during ARM. Methods and Materials: We evaluated retrospectively data from 184 patients with functional constipation (mean age -+ SD, 47 -+ 15 yr; M:F = 51:133). Manometric pattern of attempted defecation was classified as five types. Type 0, adequate rectal pushing tbrce with adequate relaxation of AS (->20%); type 1, adequate rectal pushing force (->50 mmHg) with paradoxical increase m AS pressure; type 2, inadequate rectal pushing force with possible paradoxical increase in AS pressure; type 3, adequate rectal pushing force with absent or incomplete relaxation of AS (< 20%); type 4, inadequate rectal pushing force but adequate relaxation of AS. We compare the prevalence of PFD, clinical and physiologic data among the these types. Results: Number of patients classified as type 0, 1, 2, 3, 4 were 28 (15%), 88 (47.8%), 51 (27.7%), 1 (0.5%)and 16 (8.7%), respectively. Patients with PDF by Rome II were 50 out of 184 patients; 49 from type 1 (55.7%) and one from type 3 (100%). However, 17 out of 51 patients (33%) from type 2 and 5 out of 16 patients (31%) from type 4, showed puborectalis muscle indentation or incomplete relaxation of AS on defecogram, and evidence of incomplete evacuation from defecography, balIoon expulsion test, EMG, and transit study. They did not show"any evidence of neurulogie or skeletal muscle disorders despite of inadequate pushing force. Age of type 1 was older than type 2 (50.2_+ 13.7 vs. 43.1-+155, p<0.05), but sex ratio and clinical syp~ptoms failed to show significant difference among the types. Defecation index(D1) shows significant dilterences among the types except ty~pe 0 or I vs. tyTue 4 (median 0.88, 0.54, 0.25, and 0.67 in type 0, 1, 2, and 4 respectively, p<0.05) The differences of posterior anorectal angle (ARAstrammg-ARArestmg) did not show slgnifieant difterences (median 21.1 ~ 6.2 ~ 5.0~ 26.0~ 7.6~ in type 0, 1, 2, 3 and 4 respectively'). Conclusions: Many patients with type 1 and 3 of the attempted defecation dunng ARM in constipation patients, suggest PFD by Rome ll. Although the patients with type 2 and 4 did not fit with PFD by Rome II criteria because of inadequate pushing force, more than 30% of these patients strongly suggest PFD. Especially the patients with type 2 showed low DI and failure to widen the anorectal angle on straining, suggesting PFD. These finding suggests adequate rectal pushing force (rectal pressure > 50 mmHg) should not be an absolute criteria in the diagnosis of PFD.
M1638
Subtypes of Recurrent Abdominal Pain based on the Rome Criteria for Functional Gastrointestinal Disorders Lymr S. Walker, Tricia Lipam, John W. Greene, Karen Caines, John Stutts, D. Brent Polk, Arlene Caplan Andree Rasquin-Weber Am~s: Recent development ot the Pediatric Rome Criteria has standardized classification of pediatric functional gastrointestinal disorders (FGIDs) using a symptom-based approach. We tested the hypothesis that the majority of patients with childhood RAP could be classified into one or mot~ of the FGIDs defined by the Pediatric Rome Criteria Methods: Using a prmpective lmlgintdinal design, consecutive new patients referred for evaluation of RAP (n = 114) were studied at a tertiary care medical center Patmnts ranged in age from 4 to 17 years (M = i001, SD = 3.52) and 51.3% were male. Evahiation consisted of administration of a standardized parent-report questiom~aire that assesses symptoms of the pediatric Rome criteria (the Questionnaire on Pediatric Gastrointestinal Sympton~; QPGS), and a medical evahiation that included follow-up [br at least one year Physieians were blind to QPGS data. Medical records were revmwed to identify, patients whose medical evaluation yielded no evidence of organic etidogy for abdominal pain. Data from the QPGS were used to classity these patients (n = 107) into diagnostic groups defined by the Rome criteria. Resnhs: After a medical evaluation that yielded no evidence of organic disease, the majority' of cases (83%) met the Rome criteria {or a specific FGID. Specifically, 69% met criteria for a single
AGA
Abstracts
A-388