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Is irritable bowel syndrome more than just a gastroenterologist’s problem?
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2001 by Am. Coll. of Gastroenterology Published by Elsevier Science Inc.
Vol. 96, No. 4, 2001 ISSN 0002-9270/01/$20.00
EDITORIALS Is Irritable Bowel Syndrome More Than Just a Gastroenterologist’s Problem? The nature of irritable bowel syndrome (IBS) remains perplexing. The criteria that have been developed for its diagnosis are reasonably sensitive, but not very specific (1). A firm diagnosis often requires tests that prove the absence of structural or other disorders, as well as sufficient time to confirm the nonprogressive nature of the illness. In addition, there are multiple comorbidities reported, including those for psychiatric disorders (2, 3) and other functional syndromes (4), such as functional dyspepsia (5) and fibromyalgia (6). These comorbid conditions have been reported to occur in IBS patients with a high frequency. Psychiatric disorders are associated with IBS in over half of the cases, in settings ranging from secondary and tertiary care (7) to general practice (8). This high level of comorbidity raises an interesting question: how high would the prevalence rates have to rise before one questions the independent status of IBS? The large and careful study reported by Talley et al. in this issue (9) approaches in logical fashion the question of a link between psychiatric disorders and IBS. Although it does not provide definitive answers to the questions posed above, it provides a standard of study design for all subsequent studies attempting to discover if IBS (or some subset of it) is an isolated GI disorder or part of a more inclusive syndrome. The study by Talley et al. followed a general population birth cohort of 1037 subjects (equally male and female) until their mid-20s, obtaining validated IBS questionnaires at age 26 and validated psychiatric diagnostic histories at ages 18 and 21. The prevalence of IBS and psychiatric disorders was similar to those found in other populations, yet no association was found between psychiatric diagnoses and IBS. The conclusion of the authors was that these disorders were not related. This conclusion is similar to that from an earlier study by the same group, in which the Minnesota Multiphasic Personality Index was found to correctly classify somatoform disorder but not irritable bowel (10). How can the recent data, properly obtained in a cohort study, be reconciled with the previous publications and suggestions of association with psychiatric illness?
THE FEATURES OF IBS IDENTIFY ONLY PART OF A LARGER SYNDROME The criteria for diagnosis of IBS have been well agreed on by panels of experts (1), yet they are neither precise nor validated. The prevalence of IBS varies substantially (from
8 –13% to 20 – 41%) depending on the precise cluster of symptoms used (11, 12). Part of the problem is that the symptoms of IBS are not very specific for functional GI disorders. Perhaps a larger problem, however, is that a large number of functional syndromes may result from medical specialization but be related, at least in part (4). These syndromes include IBS, functional dyspepsia, premenstrual syndrome, chronic pelvic pain, fibromyalgia, noncardiac chest pain, tension headache, hyperventilation syndrome, low back pain, temporomandibular joint dysfunction, globus syndrome, and multiple chemical sensitivity. Using the same Diagnostic Interview Schedule (DIS) employed by Talley et al., models hypothesizing more latent variables fit the approximated diagnoses of IBS and fibromyalgia as separate entities (13). Other studies using data based on the same DIS, however, suggested a diagnostic overlap between panic disorder and IBS (14, 15). If these disorders are related in some way, then the symptoms of IBS may be neither dominant nor expressed at all times during the patient’s lifetime.
THE PSYCHIATRIC DIAGNOSIS REALLY ASSOCIATED WITH IBS IS NOT ANY OF THOSE SEARCHED FOR (ANXIETY, MOOD DISORDER, EATING DISORDER, OR SUBSTANCE ABUSE) The diagnoses most often associated with IBS have included the primary affective disorders, depression and anxiety (2), although somatization disorder has also been reported (16). The DSM-IV criteria for somatization disorder (300.81) are instructive to review here. Criteria for this disorder include four pain symptoms, two GI symptoms, one sexual symptom, and one pseudoneurological symptom, with no known medical cause (17). Patients with IBS and comorbid functional pain syndromes often fulfill these criteria. DSM-IV points out that somatization disorder is often difficult to distinguish from anxiety disorders, depression, and personality disorders (especially histrionic, borderline, and antisocial). It has not been possible to distinguish between the DSM-IV “pure” pain syndromes and syndromes that include pain among multiple somatoform complaints (18). It has been suggested that there is a gradation of somatization, rather than the extremes of normal and somatization disorder, and that the diagnostic criteria should reflect this gradation (19, 20). Using abridged somatization criteria, one fifth of primary care patients were identified and strongly associated with psychopathology and physical disability (21). The presence of sexual abuse (22, 23) and nonalimentary symptoms in patients with IBS (24) has been reported. Despite, or because of, this symptom abundance, symptoms of somatization disorder can be lost with time,
944
Editorials
probably representing inconsistent recall (25). Interestingly, the same inconstancy of symptoms has been reported in IBS patients (26, 27). Yet somatizers attribute their somatic symptoms to environmental and somatic causes (28). These features make somatization disorder difficult to diagnose, and could make it more so among a sample population from which the data have been gathered only by two questionnaires 3 years apart. In fact, the DIS employed in the study by Talley et al. is known to miss many of the cases of somatization disorder, because the patients usually do not provide enough information in a single interview to allow the diagnosis (29, 30).
PEAK PREVALENCE OF LIFETIME IBS AND PSYCHIATRIC DIAGNOSES DID NOT OCCUR DURING THE STUDY PERIOD IN THIS YOUNG POPULATION The majority of IBS patients consult a physician for the first time between the ages of 30 and 50 (26, 31). On the other hand, most patients with somatization disorder have their initial symptoms by age 25. Thus, it is possible that the study by Talley et al., which sampled subjects only until age 26, found a discrepancy between psychiatric disorders and IBS because of this difference in peak of onset of each illness.
ONLY THE MORE SEVERELY ILL SUBSET OF IBS PATIENTS IS ASSOCIATED WITH PSYCHIATRIC DISORDERS Some studies have suggested that most IBS patients do not seek medical care, and those who do have more psychological problems (32). An epidemiological study by Talley et al. (33) found that psychological factors did not predict health care–seeking behavior. About half of patients with chronic abdominal complaints and/or IBS consulted their general practitioner (8, 34), and those with more severe symptoms sought medical care. A recent study has confirmed that patients with severe functional bowel diseases have more depression and psychological distress (35). Thus, it is possible that the current population sampled by Talley et al. did not include enough patients with IBS who had sought care from a physician. If such patients could have been identified, they might have had increased psychiatric diagnoses. In summary, in this well-conducted study Talley et al. have provided provocative, albeit negative, data regarding the possible association of IBS with other disorders. For the reasons outlined above, it seems premature to consider the issue settled. Further studies will be needed before it will be known if the interpretation of this study is correct, rather than the other literature suggesting an association of IBS
AJG – Vol. 96, No. 4, 2001
with psychiatric disorders. The truth will probably lie somewhere in the middle. David H. Alpers, M.D. Gastroenterology Division Washington University School of Medicine St. Louis, Missouri
REFERENCES 1. Rome II. The functional bowel disorders, 2nd ed. McLean, VA: Degnon Associates, 2000. 2. Fullwood A, Drossman DA. The relationship of psychiatric illness with gastrointestinal disease. Annu Rev Med 1995;46: 483–96. 3. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999;130:910 –21. 4. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: One or many? Lancet 1999;354:936 –9. 5. Caballero-Plasencia AM, Sofos-Kontoyannis S, ValenzuelaBarranco M, et al. Irritable bowel syndrome in patients with dyspepsia: A community-based study in southern Europe. Eur J Gastroenterol Hepatol 1999;11:517–22. 6. Sperber AD, Atzmon Y, Neumann L, et al. Fibromyalgia in the irritable bowel syndrome: Studies of prevalence and clinical implications. Am J Gastroenterol 1999;94:3541– 6. 7. Young SJ, Alpers DH, Norland CC, Woodruff RA Jr. Psychiatric illness and the irritable bowel syndrome. Practical implications for the primary physician. Gastroenterology 1976;70: 162– 6. 8. Osterberg E, Blomquist L, Krakau I, et al. A population study on irritable bowel syndrome and mental health. Scand J Gastroenterol 2000;35:264 – 8. 9. Talley NJ, Howell S, Poulton R. The irritable bowel syndrome and psychiatric disorders in the community: Is there a link? Am J Gastroenterol 2001;96:1071– 8. 10. Talley NJ, Phillips SF, Bruce B, et al. Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome. Gastroenterology 1990;99:327–33. 11. Saito YA, Locke GR, Talley NJ, et al. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000;95:2816 –24. 12. North CS, Alpers DH. Irritable bowel syndrome in a psychiatric patient population. Compr Psychiatry 2000;41:116 –22. 13. Robbins JM, Kirmayer LJ, Hemami S. Latent variable models of functional somatic distress. J Nerv Ment Dis 1997;185: 606 –15. 14. Lydiard RB, Greewald S, Weissman MM, et al. Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area project. Am J Psychiatry 1994; 151:64 –70. 15. Maunder RG. Panic disorder associated with gastrointestinal disease: Review and hypotheses. J Psychosom Res 1998;44: 91–105. 16. Clouse RE, Alpers DH. The relationship of psychiatric disorder to gastrointestinal illness. Annu Rev Med 1986;37:283–95. 17. Diagnostic and statistical manual of mental disorders, DSMIV. Washington, DC: American Psychiatric Association, 2000. 18. Hiller W, Heuser J, Fichter MM. The DSM-IV nosology of chronic pain: A comparison of pain disorder and multiple somatization disorder. Eur J Pain 2000;4:45–55. 19. Katon W, Lin E, Von Korff M, et al. Somatization. A spectrum of severity. Am J Psychiatry 1991;148:34 – 40.
AJG – April, 2001
20. Kellner R. Psychosomatic syndromes, somatization and somatoform disorders. Psychother Psychosom 1994;61:4 –24. 21. Escobar JI, Waitzkin H, Silver RC, et al. Abridged somatization: A study in primary care. Psychosom Med 1998; 60:466 –72. 22. Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization: Characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406. 23. Drossman DA, Talley NJ, Leserman J, et al. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med 1995;123:782–94. 24. Nyhlin H, Ford MJ, Eastwood J, et al. Non-alimentary aspects of the irritable bowel syndrome. J Psychosom Res 1993;37: 155– 62. 25. Simon GE, Gureje O. Stability of somatization disorder and somatization symptoms among primary care patients. Arch Gen Psychiatry 1999;56:90 –5. 26. Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: A five-year prospective study. Lancet 1987; 1:963–5. 27. Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med 1994;236: 23–30. 28. Garcia-Campayo J, Sanz-Carrillo C. A review of the differences between somatizing and psychologizing patients in primary care. Int J Psychiatry Med 1999;29:337– 45. 29. Cloninger C. Somatoform and dissociative disorders. In: Winokur G, Clayton P, eds. The medical basis of psychiatry, 2nd ed. Philadelphia: Saunders, 1994. 30. Martin RL. Problems in the diagnosis of somatization disorder: Effects on research and clinical practice. Psychiatr Ann 1988;18:357– 62. 31. Ruigomez A, Wallender MA, Johansson S, Garcia-Rodriguez LA. One-year follow-up of newly diagnosed irritable bowel patients. Aliment Pharmacol Ther 1999;13:1097–102. 32. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:701– 8. 33. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: A population based study. Gut 1997;41:394 – 8. 34. Janssen HA, Borghouts JA, Muris JW, et al. Health status and management of chronic non-specific abdominal complaints in general practice. Br J Gen Pract 2000;50:375–9. 35. Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000;95:974 – 80. Reprint requests and correspondence: David H. Alpers, M.D., Washington University School of Medicine, Gastroenterology Division, Box 8124, 660 South Euclid Avenue, St. Louis, MO 63110. Received Dec. 8, 2000; accepted Dec. 29, 2000.
“I Think You Have Pancreatic Cancer but I Can’t Prove It Yet” What a devastating thing to tell a patient! However diplomatically we try to say it (or sometimes avoid saying it) it leaves both the patient and endoscopist feeling terrible and in limbo. Many of us can find ourselves in this dilemma after
Editorials
945
endoscopically stenting a biliary stricture for a patient with painless jaundice. We figure that if we could just give them a definitive diagnosis, these patients could at least reach closure with this phase of their illness. We’d like to recommend and use an easy, quick, painless, and inexpensive method for making a diagnosis that’s 100% accurate. We’d like to, but we can’t. In this issue Kaufman et al. (1) describe their experience with the Simpson atherectomy catheter biopsy method for detecting pancreaticobiliary malignancies. For the select group of patients that they studied in a retrospective manner this technique was an effective method for dealing with the dilemma above. They report the sensitivity for the atherectomy catheter when used for endoluminal biliary biopsy to be 97%. The positive predictive and negative predictive values were 100% and 93%, respectively. It should be pointed out that this method of obtaining tissue required percutaneous access to the biliary tract. The catheter is relatively bulky and somewhat difficult to maneuver around acute angles. Therefore, it should not be used without first considering the other gadgets and gizmos that we have in our “tool box” as well as the unique circumstances that accompany each of our patients. Sometimes it’s good to focus on a particular aspect of a problem being studied, such as getting a correct tissue diagnosis. But, as any pyromaniac can demonstrate, sometimes if you focus too much (such as with a magnifying glass on a dried leaf) you can “get burned”! Most patients have significant clinical, psychological, and financial issues that accompany the problem we focused on above. In addition to a tissue diagnosis, the presence and extent of metastasis will play a pivotal role in determining further management. In these situations other modalities such as endoscopic ultrasonography and/or CT-guided tissue sampling have the potential for providing accurate staging information as well as a tissue diagnosis. The accuracy of these methods for making a tissue diagnosis can also be as high as 96% in select groups of patients (2– 4). Also, some patients are averse to procedures where surgery or long sharp needles are described as being “advanced” into their bodies. Many of these patients favor endoscopic management strategies where they are not left with scars or tubing dangling from their sides. This preference by the patient might be a conscious or unconscious effort to maintain a state of denial where no tubing or scar is left to remind them of their illness. For these reasons and others, the initial diagnostic evaluation in these patients often leads to an endoscopic evaluation rather than a percutaneous or surgical procedure. In some of these patients a tissue diagnosis can be made via brushings or bile cytology during an initial therapeutic endoscopy. Although the yield from these techniques is not high in many centers (44 –56% in some studies) (5, 6), a positive result can spare the individual patient more costly and time-consuming subsequent methods of making a tissue diagnosis. Furthermore,
Vol. 96, No. 4, 2001 ISSN 0002-9270/01/$20.00
EDITORIALS Is Irritable Bowel Syndrome More Than Just a Gastroenterologist’s Problem? The nature of irritable bowel syndrome (IBS) remains perplexing. The criteria that have been developed for its diagnosis are reasonably sensitive, but not very specific (1). A firm diagnosis often requires tests that prove the absence of structural or other disorders, as well as sufficient time to confirm the nonprogressive nature of the illness. In addition, there are multiple comorbidities reported, including those for psychiatric disorders (2, 3) and other functional syndromes (4), such as functional dyspepsia (5) and fibromyalgia (6). These comorbid conditions have been reported to occur in IBS patients with a high frequency. Psychiatric disorders are associated with IBS in over half of the cases, in settings ranging from secondary and tertiary care (7) to general practice (8). This high level of comorbidity raises an interesting question: how high would the prevalence rates have to rise before one questions the independent status of IBS? The large and careful study reported by Talley et al. in this issue (9) approaches in logical fashion the question of a link between psychiatric disorders and IBS. Although it does not provide definitive answers to the questions posed above, it provides a standard of study design for all subsequent studies attempting to discover if IBS (or some subset of it) is an isolated GI disorder or part of a more inclusive syndrome. The study by Talley et al. followed a general population birth cohort of 1037 subjects (equally male and female) until their mid-20s, obtaining validated IBS questionnaires at age 26 and validated psychiatric diagnostic histories at ages 18 and 21. The prevalence of IBS and psychiatric disorders was similar to those found in other populations, yet no association was found between psychiatric diagnoses and IBS. The conclusion of the authors was that these disorders were not related. This conclusion is similar to that from an earlier study by the same group, in which the Minnesota Multiphasic Personality Index was found to correctly classify somatoform disorder but not irritable bowel (10). How can the recent data, properly obtained in a cohort study, be reconciled with the previous publications and suggestions of association with psychiatric illness?
THE FEATURES OF IBS IDENTIFY ONLY PART OF A LARGER SYNDROME The criteria for diagnosis of IBS have been well agreed on by panels of experts (1), yet they are neither precise nor validated. The prevalence of IBS varies substantially (from
8 –13% to 20 – 41%) depending on the precise cluster of symptoms used (11, 12). Part of the problem is that the symptoms of IBS are not very specific for functional GI disorders. Perhaps a larger problem, however, is that a large number of functional syndromes may result from medical specialization but be related, at least in part (4). These syndromes include IBS, functional dyspepsia, premenstrual syndrome, chronic pelvic pain, fibromyalgia, noncardiac chest pain, tension headache, hyperventilation syndrome, low back pain, temporomandibular joint dysfunction, globus syndrome, and multiple chemical sensitivity. Using the same Diagnostic Interview Schedule (DIS) employed by Talley et al., models hypothesizing more latent variables fit the approximated diagnoses of IBS and fibromyalgia as separate entities (13). Other studies using data based on the same DIS, however, suggested a diagnostic overlap between panic disorder and IBS (14, 15). If these disorders are related in some way, then the symptoms of IBS may be neither dominant nor expressed at all times during the patient’s lifetime.
THE PSYCHIATRIC DIAGNOSIS REALLY ASSOCIATED WITH IBS IS NOT ANY OF THOSE SEARCHED FOR (ANXIETY, MOOD DISORDER, EATING DISORDER, OR SUBSTANCE ABUSE) The diagnoses most often associated with IBS have included the primary affective disorders, depression and anxiety (2), although somatization disorder has also been reported (16). The DSM-IV criteria for somatization disorder (300.81) are instructive to review here. Criteria for this disorder include four pain symptoms, two GI symptoms, one sexual symptom, and one pseudoneurological symptom, with no known medical cause (17). Patients with IBS and comorbid functional pain syndromes often fulfill these criteria. DSM-IV points out that somatization disorder is often difficult to distinguish from anxiety disorders, depression, and personality disorders (especially histrionic, borderline, and antisocial). It has not been possible to distinguish between the DSM-IV “pure” pain syndromes and syndromes that include pain among multiple somatoform complaints (18). It has been suggested that there is a gradation of somatization, rather than the extremes of normal and somatization disorder, and that the diagnostic criteria should reflect this gradation (19, 20). Using abridged somatization criteria, one fifth of primary care patients were identified and strongly associated with psychopathology and physical disability (21). The presence of sexual abuse (22, 23) and nonalimentary symptoms in patients with IBS (24) has been reported. Despite, or because of, this symptom abundance, symptoms of somatization disorder can be lost with time,
944
Editorials
probably representing inconsistent recall (25). Interestingly, the same inconstancy of symptoms has been reported in IBS patients (26, 27). Yet somatizers attribute their somatic symptoms to environmental and somatic causes (28). These features make somatization disorder difficult to diagnose, and could make it more so among a sample population from which the data have been gathered only by two questionnaires 3 years apart. In fact, the DIS employed in the study by Talley et al. is known to miss many of the cases of somatization disorder, because the patients usually do not provide enough information in a single interview to allow the diagnosis (29, 30).
PEAK PREVALENCE OF LIFETIME IBS AND PSYCHIATRIC DIAGNOSES DID NOT OCCUR DURING THE STUDY PERIOD IN THIS YOUNG POPULATION The majority of IBS patients consult a physician for the first time between the ages of 30 and 50 (26, 31). On the other hand, most patients with somatization disorder have their initial symptoms by age 25. Thus, it is possible that the study by Talley et al., which sampled subjects only until age 26, found a discrepancy between psychiatric disorders and IBS because of this difference in peak of onset of each illness.
ONLY THE MORE SEVERELY ILL SUBSET OF IBS PATIENTS IS ASSOCIATED WITH PSYCHIATRIC DISORDERS Some studies have suggested that most IBS patients do not seek medical care, and those who do have more psychological problems (32). An epidemiological study by Talley et al. (33) found that psychological factors did not predict health care–seeking behavior. About half of patients with chronic abdominal complaints and/or IBS consulted their general practitioner (8, 34), and those with more severe symptoms sought medical care. A recent study has confirmed that patients with severe functional bowel diseases have more depression and psychological distress (35). Thus, it is possible that the current population sampled by Talley et al. did not include enough patients with IBS who had sought care from a physician. If such patients could have been identified, they might have had increased psychiatric diagnoses. In summary, in this well-conducted study Talley et al. have provided provocative, albeit negative, data regarding the possible association of IBS with other disorders. For the reasons outlined above, it seems premature to consider the issue settled. Further studies will be needed before it will be known if the interpretation of this study is correct, rather than the other literature suggesting an association of IBS
AJG – Vol. 96, No. 4, 2001
with psychiatric disorders. The truth will probably lie somewhere in the middle. David H. Alpers, M.D. Gastroenterology Division Washington University School of Medicine St. Louis, Missouri
REFERENCES 1. Rome II. The functional bowel disorders, 2nd ed. McLean, VA: Degnon Associates, 2000. 2. Fullwood A, Drossman DA. The relationship of psychiatric illness with gastrointestinal disease. Annu Rev Med 1995;46: 483–96. 3. Barsky AJ, Borus JF. Functional somatic syndromes. Ann Intern Med 1999;130:910 –21. 4. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: One or many? Lancet 1999;354:936 –9. 5. Caballero-Plasencia AM, Sofos-Kontoyannis S, ValenzuelaBarranco M, et al. Irritable bowel syndrome in patients with dyspepsia: A community-based study in southern Europe. Eur J Gastroenterol Hepatol 1999;11:517–22. 6. Sperber AD, Atzmon Y, Neumann L, et al. Fibromyalgia in the irritable bowel syndrome: Studies of prevalence and clinical implications. Am J Gastroenterol 1999;94:3541– 6. 7. Young SJ, Alpers DH, Norland CC, Woodruff RA Jr. Psychiatric illness and the irritable bowel syndrome. Practical implications for the primary physician. Gastroenterology 1976;70: 162– 6. 8. Osterberg E, Blomquist L, Krakau I, et al. A population study on irritable bowel syndrome and mental health. Scand J Gastroenterol 2000;35:264 – 8. 9. Talley NJ, Howell S, Poulton R. The irritable bowel syndrome and psychiatric disorders in the community: Is there a link? Am J Gastroenterol 2001;96:1071– 8. 10. Talley NJ, Phillips SF, Bruce B, et al. Relation among personality and symptoms in nonulcer dyspepsia and the irritable bowel syndrome. Gastroenterology 1990;99:327–33. 11. Saito YA, Locke GR, Talley NJ, et al. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol 2000;95:2816 –24. 12. North CS, Alpers DH. Irritable bowel syndrome in a psychiatric patient population. Compr Psychiatry 2000;41:116 –22. 13. Robbins JM, Kirmayer LJ, Hemami S. Latent variable models of functional somatic distress. J Nerv Ment Dis 1997;185: 606 –15. 14. Lydiard RB, Greewald S, Weissman MM, et al. Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area project. Am J Psychiatry 1994; 151:64 –70. 15. Maunder RG. Panic disorder associated with gastrointestinal disease: Review and hypotheses. J Psychosom Res 1998;44: 91–105. 16. Clouse RE, Alpers DH. The relationship of psychiatric disorder to gastrointestinal illness. Annu Rev Med 1986;37:283–95. 17. Diagnostic and statistical manual of mental disorders, DSMIV. Washington, DC: American Psychiatric Association, 2000. 18. Hiller W, Heuser J, Fichter MM. The DSM-IV nosology of chronic pain: A comparison of pain disorder and multiple somatization disorder. Eur J Pain 2000;4:45–55. 19. Katon W, Lin E, Von Korff M, et al. Somatization. A spectrum of severity. Am J Psychiatry 1991;148:34 – 40.
AJG – April, 2001
20. Kellner R. Psychosomatic syndromes, somatization and somatoform disorders. Psychother Psychosom 1994;61:4 –24. 21. Escobar JI, Waitzkin H, Silver RC, et al. Abridged somatization: A study in primary care. Psychosom Med 1998; 60:466 –72. 22. Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization: Characteristics of patients presenting with irritable bowel syndrome and nonepileptic attack disorder. Psychol Med 1999;29:399 – 406. 23. Drossman DA, Talley NJ, Leserman J, et al. Sexual and physical abuse and gastrointestinal illness. Review and recommendations. Ann Intern Med 1995;123:782–94. 24. Nyhlin H, Ford MJ, Eastwood J, et al. Non-alimentary aspects of the irritable bowel syndrome. J Psychosom Res 1993;37: 155– 62. 25. Simon GE, Gureje O. Stability of somatization disorder and somatization symptoms among primary care patients. Arch Gen Psychiatry 1999;56:90 –5. 26. Harvey RF, Mauad EC, Brown AM. Prognosis in the irritable bowel syndrome: A five-year prospective study. Lancet 1987; 1:963–5. 27. Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med 1994;236: 23–30. 28. Garcia-Campayo J, Sanz-Carrillo C. A review of the differences between somatizing and psychologizing patients in primary care. Int J Psychiatry Med 1999;29:337– 45. 29. Cloninger C. Somatoform and dissociative disorders. In: Winokur G, Clayton P, eds. The medical basis of psychiatry, 2nd ed. Philadelphia: Saunders, 1994. 30. Martin RL. Problems in the diagnosis of somatization disorder: Effects on research and clinical practice. Psychiatr Ann 1988;18:357– 62. 31. Ruigomez A, Wallender MA, Johansson S, Garcia-Rodriguez LA. One-year follow-up of newly diagnosed irritable bowel patients. Aliment Pharmacol Ther 1999;13:1097–102. 32. Drossman DA, McKee DC, Sandler RS, et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterology 1988;95:701– 8. 33. Talley NJ, Boyce PM, Jones M. Predictors of health care seeking for irritable bowel syndrome: A population based study. Gut 1997;41:394 – 8. 34. Janssen HA, Borghouts JA, Muris JW, et al. Health status and management of chronic non-specific abdominal complaints in general practice. Br J Gen Pract 2000;50:375–9. 35. Drossman DA, Whitehead WE, Toner BB, et al. What determines severity among patients with painful functional bowel disorders? Am J Gastroenterol 2000;95:974 – 80. Reprint requests and correspondence: David H. Alpers, M.D., Washington University School of Medicine, Gastroenterology Division, Box 8124, 660 South Euclid Avenue, St. Louis, MO 63110. Received Dec. 8, 2000; accepted Dec. 29, 2000.
“I Think You Have Pancreatic Cancer but I Can’t Prove It Yet” What a devastating thing to tell a patient! However diplomatically we try to say it (or sometimes avoid saying it) it leaves both the patient and endoscopist feeling terrible and in limbo. Many of us can find ourselves in this dilemma after
Editorials
945
endoscopically stenting a biliary stricture for a patient with painless jaundice. We figure that if we could just give them a definitive diagnosis, these patients could at least reach closure with this phase of their illness. We’d like to recommend and use an easy, quick, painless, and inexpensive method for making a diagnosis that’s 100% accurate. We’d like to, but we can’t. In this issue Kaufman et al. (1) describe their experience with the Simpson atherectomy catheter biopsy method for detecting pancreaticobiliary malignancies. For the select group of patients that they studied in a retrospective manner this technique was an effective method for dealing with the dilemma above. They report the sensitivity for the atherectomy catheter when used for endoluminal biliary biopsy to be 97%. The positive predictive and negative predictive values were 100% and 93%, respectively. It should be pointed out that this method of obtaining tissue required percutaneous access to the biliary tract. The catheter is relatively bulky and somewhat difficult to maneuver around acute angles. Therefore, it should not be used without first considering the other gadgets and gizmos that we have in our “tool box” as well as the unique circumstances that accompany each of our patients. Sometimes it’s good to focus on a particular aspect of a problem being studied, such as getting a correct tissue diagnosis. But, as any pyromaniac can demonstrate, sometimes if you focus too much (such as with a magnifying glass on a dried leaf) you can “get burned”! Most patients have significant clinical, psychological, and financial issues that accompany the problem we focused on above. In addition to a tissue diagnosis, the presence and extent of metastasis will play a pivotal role in determining further management. In these situations other modalities such as endoscopic ultrasonography and/or CT-guided tissue sampling have the potential for providing accurate staging information as well as a tissue diagnosis. The accuracy of these methods for making a tissue diagnosis can also be as high as 96% in select groups of patients (2– 4). Also, some patients are averse to procedures where surgery or long sharp needles are described as being “advanced” into their bodies. Many of these patients favor endoscopic management strategies where they are not left with scars or tubing dangling from their sides. This preference by the patient might be a conscious or unconscious effort to maintain a state of denial where no tubing or scar is left to remind them of their illness. For these reasons and others, the initial diagnostic evaluation in these patients often leads to an endoscopic evaluation rather than a percutaneous or surgical procedure. In some of these patients a tissue diagnosis can be made via brushings or bile cytology during an initial therapeutic endoscopy. Although the yield from these techniques is not high in many centers (44 –56% in some studies) (5, 6), a positive result can spare the individual patient more costly and time-consuming subsequent methods of making a tissue diagnosis. Furthermore,