- Email: [email protected]
S1306 Physiological Characteristics of Traditional Chinese Medicine (TCM) Based Irritable Bowel Syndrome (IBS) Sub-Groups
between ROM CT and WMC SLBTT [r=0.704]. There were moderate correlations of CTT and SLBTT with stool consistency (respectively r = -0.399 and r = -0.427, both p<.0001), not with daily stool frequency (r = -0.015, and r = -0.023, both p>0.77). There were no significant adverse events. Conclusion: The 87% overall agreement (positive and negative) validates WMC relative to ROM in differentiating slow versus normal CT in a multicenter clinical study of constipation.
S1307
BACKGROUND: A single previous paper on this topic found a direct effect of CBT on an IBS global symptom score that did not operate via patients' emotional state. This was quite controversial since under the biopsychosocial model of the relationship between bowel symptoms and mood, the expectation was that CBT's effect would be mediated by mood. Our data include more sensitive bowel symptom scales and measurements at additional time points AIMS: To determine the pathway of action of CBT on symptoms of irritable bowel syndrome METHODS: We evaluated direct pathways between CBT and change in IBS symptoms and indirect pathways that operate via mood state using structural equation modelling of the data set of a large number (n=105) of Rome I diagnosed people with IBS randomised to individual CBT (n=34), relaxation therapy (n=36) and usual medical care (n=35). The primary outcome was defined as change in IBS symptom score in terms of the distress, frequency, and impairment because of symptoms in the prior week according to the Bowel Symptom Severity Scale (BSSS). RESULTS: Direct pathways between CBT and changes in bowel symptom scores were not identified in our data. We do however find indirect pathways between CBT and bowel symptoms that operate via mood, most clearly through anxiety but to a lesser extent depression (Figure 1). Statistically significant pathways were identified that lead from CBT to changes during the first period in anxiety (B=1.74, p=0.02) thence to change in distress (B=0.64, p<0.01) and impairment (B=0.43, p=0.01). Change in frequency (period 1) was associated subsequent change in period 2 in depression (B=0.16, p<0.01). Change in distress (period 1) was associated with subsequent change in period 2 in anxiety (B=-0.23, p<0.01) and depression (B=-0.17, p=0.01). Change in frequency (B=0.44, p=0.01) and distress (B=0.35, p=0.03) in period 2 were associated with concurrent change in anxiety CONCLUSIONS: That CBT would directly affect bowel symptoms is counterintuitive and was not confirmed in our study. The present study suggests however that CBT may operate via changes in mood state, consistent with the biopsychosocial model. This finding suggests that CBT may have a useful role in the management of IBS.
S1305 How Useful is Colonic Manometry in the Evaluation of Sensorimotor Dysfunction in Slow Transit Constipation (STC)? Satish S. Rao, Siddharth Singh, Deborah Dickinson Background: Limited studies have described normal or decreased colonic motility in STC, but the characteristics of sensory and motor dysfunction in the colon and anorectum and their clinical significance has not been examined. Aims: To investigate the prevalence, clinical features and colonic and anorectal sensorimotor dysfunction in pathophysiological subsets of patients with STC, refractory to treatment. Methods: Consecutive patients with STC (>20% sitzmarker), underwent 24-hr ambulatory colonic manometry, colonic sensation/ tone study (barostat) and anorectal manometry. We evaluated clinical features, manometric characteristics, colonic sensation and anorectal sensorimotor function. Patients were classified as normal motility or colonic neuropathy or myopathy based on the absence or attenuated response of 2 out of 3 features: HAPCs, gastrocolonic response, waking response. Coexisting dyssynergic defecation (DD) or IBS was also evaluated. Data was compared with 25 healthy controls for colonic and 45 controls for ARM. Results: 65 patients (56 females) with severe STC (duration=17 yrs, mean retention=66% of markers) were evaluated. Predominant symptoms were <3 BMs/wk (92%), hard stools (97%), straining (87%), incomplete evacuation (95%) and laxative dependence (87%). Of these, 28% had colonic neuropathy, 31% colonic myopathy and 41% normal colonic manometry. 60% had colonic hyposensitivity and 9% had colonic hypersensitivity. 77% had associated DD, with persistent symptoms in ~60% despite correction of dyssynergia suggesting severe STC. Rectal hyposensitivity was found in 51% and rectal hypersensitivity in 31%. Patients with colonic neuropathy were more likely to have severe DD. There was no correlation between pathophysiological subsets of STC and either demographic, clinical features, or colonic/ anorectal sensory impairment. Conclusions: Colonic manometry revealed significant colonic motor (60%) and sensory dysfunction (70%) in STC patients that were independent of each other. About 40% had normal colonic function despite severe symptoms. Many patients had coexisting features of DD (77%) and/or IBS (18%). Colonic manometry with sensation/tone assessment characterizes underlying pathophysiology and could guide therapy.
S1308 Beliefs About GI Medications and Adherence to Pharmacotherapy in Functional GI Disorder (FGID) Outpatients Benjamin Cassell, C. Prakash Gyawali, Patrick J. Lustman, Billy D. Nix, Gregory S. Sayuk
*- p <0.05 for neuropathy vs. normal; #- p<0.05 for myopathy vs. normal; +- p<0.05 for neuropathy vs myopathy
Background: Pharmacotherapy is a preferred treatment approach in FGID, but little is known about patient attitudes toward medication regimens. Understanding patient concerns and adherence to pharmacotherapy is particularly important for off-label medication use (e.g., antidepressants, ADs) in FGID. Methods: Consecutive outpatients with established FGID (using Rome III Research Diagnostic Questionnaire) in a tertiary GI setting completed the Beliefs About Medications Questionnaire (BMQ). This validated instrument assesses patient attitudes toward medications on two subscales, the Concern subscale (measures worry of long-term effects and dependence on medications) and the Necessity subscale (measures dependence on, and perceived protective effects of medications), using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Non-FGID GI diagnoses, contemporaneous GI medications and doses were recorded from chart review. Adherence to GI-specific medication regimens were determined using 10-cm visual analog scale (VAS) ratings. Results: 275 subjects (mean age 49.9 ±15.6 yrs, range 18-96 yr, 220 female) with FGID were identified over a 20-month interval; 211 (76.7%) satisfied ROME criteria for >1 FGID and 156 (56.7%) for >2 FGID. IBS and functional dyspepsia were the most frequently diagnosed FGIDs (65.8% and 53.5%, respectively). Medication regimens most commonly used included PPIs (n=100, 36.4%), TCAs (n=79, 28.7%), anxiolytics (n=53, 19.3%), anticholinergics (n= 46, 16.7%), and SSRIs (n=41, 14.9%). Mean BMQ Concern and Necessity scores were 12.4 ±6.7 and 16.9 ±9.0, respectively, with no significant differences between IBS and non-IBS FGIDs, or between those with 1 and >1 FGID. Good adherence (>80%) to prescribed medications was reported by 70.3% of subjects. Medication adherence correlated positively with perceived medication Necessity (r=0.27, p<0.001), and negatively with concerns about medication Harm (r=-0.21, p=0.001) and Overuse (r=-0.13, p=0.045). Subjects prescribed ADs for their FGID (n=142, 51.6%) expressed a greater medication Necessity (18.5 ±7.8 vs. 15.3 ±9.9, p<0.001) and acknowledged a greater Concern about their medications (14.0 ±5.9 vs. 10.8 ±7.0, p=0.02) on the BMQ. Still, subjects using ADs reported higher medication adherence compared to non-AD regimens (p=0.07). Discussion: FGID subjects report medication need and concern scores comparable to those reported with chronic illnesses (e.g., asthma, heart disease) in the literature. Concerns of medication harm and overuse affect adherence to pharmacotherapy, and preemptively addressing these concerns may further improve patient acceptance and compliance to FGID treatment regimens.
S1306 Physiological Characteristics of Traditional Chinese Medicine (TCM) Based Irritable Bowel Syndrome (IBS) Sub-Groups Aditi A. Joshi, Steven Tan, Suzanne R. Smith, Deborah Ackerman, Kirsten Tillisch, Ka Kit Hui, David Shapiro, Bruce D. Naliboff Abstract: It is well known that patients with IBS have a high rate of co-morbid extra-intestinal symptoms.Traditional Chinese Medicine (TCM) views all illnesses as arising from global patterns of dysregulation and TCM predicts that despite similar symptoms, subgroups of IBS patients vary in important characteristics such as pain sensitivity and stress responses and these differences reflect different IBS pathophysiology and require different treatment. AIMS: To determine stress reactivity and pain sensitivity of IBS subgroups classified into TCM categories of Excess (Liver Qi stagnation), Deficiency (Spleen Qi deficiency) and Overlap (mixed symptoms). METHODS: 63 ROME III+ female IBS patients (Mean age= 36.38; SD +/- 13.0) were independently evaluated by two TCM practitioners and also filled out a TCM symptom questionnaire. Sensitivity to pressure pain at three body sites and autonomic responses to a psychological stressor were evaluated in a laboratory session. RESULTS: TCM practitioners agreed on 82.6% of diagnoses (excess=29, overlap=23, discrepancy=11 (not included in further analysis)) although there were not differences in IBS symptom severity by TCM subgroup. Older Excess subjects showed significantly less sensitivity to pressure pain compared to those with overlap (emeans: Excess =9.97+SE 1.08; Overlap = 10.33+ SE 1.06., p<.03). Similarly subjects with greater deficiency symptoms by questionnaire tended to have non-significantly higher pain sensitivity. 3) No significant differences were found in autonomic reactivity to the psychological stressor between the two groups based on TCM diagnosis. However, high deficiency scorers on the symptom questionnaire had a significantly greater increase in Diastolic BP during the stress tasks - Pre-Speech (p= .005); Speech (p= 0.01); Math (p=0.03 but not in the initial or end baseline (p< .4). Similar findings were present for heart rate but no differences were found for a purely sympathetic measure, skin conductance. CONCLUSION: TCM based subgroups of IBS patients show differences in non-GI characteristics with greater pain sensitivity and cardiovascular stress responses in subjects showing increased deficiency symptoms. TCM subgroups may therefore reflect differences in underlying physiological responses relevant for IBS development and/or treatment. Funding- NCCAM R21AT003221.
S-225
AGA Abstracts
AGA Abstracts
Cognitive Behaviour Therapy's Role in the Treatment of Irritable Bowel Syndrome: Direct Effect on Symptoms or Operates via Mood ? Michael Jones, Natasha A. Koloski, Nick Talley
S1307
BACKGROUND: A single previous paper on this topic found a direct effect of CBT on an IBS global symptom score that did not operate via patients' emotional state. This was quite controversial since under the biopsychosocial model of the relationship between bowel symptoms and mood, the expectation was that CBT's effect would be mediated by mood. Our data include more sensitive bowel symptom scales and measurements at additional time points AIMS: To determine the pathway of action of CBT on symptoms of irritable bowel syndrome METHODS: We evaluated direct pathways between CBT and change in IBS symptoms and indirect pathways that operate via mood state using structural equation modelling of the data set of a large number (n=105) of Rome I diagnosed people with IBS randomised to individual CBT (n=34), relaxation therapy (n=36) and usual medical care (n=35). The primary outcome was defined as change in IBS symptom score in terms of the distress, frequency, and impairment because of symptoms in the prior week according to the Bowel Symptom Severity Scale (BSSS). RESULTS: Direct pathways between CBT and changes in bowel symptom scores were not identified in our data. We do however find indirect pathways between CBT and bowel symptoms that operate via mood, most clearly through anxiety but to a lesser extent depression (Figure 1). Statistically significant pathways were identified that lead from CBT to changes during the first period in anxiety (B=1.74, p=0.02) thence to change in distress (B=0.64, p<0.01) and impairment (B=0.43, p=0.01). Change in frequency (period 1) was associated subsequent change in period 2 in depression (B=0.16, p<0.01). Change in distress (period 1) was associated with subsequent change in period 2 in anxiety (B=-0.23, p<0.01) and depression (B=-0.17, p=0.01). Change in frequency (B=0.44, p=0.01) and distress (B=0.35, p=0.03) in period 2 were associated with concurrent change in anxiety CONCLUSIONS: That CBT would directly affect bowel symptoms is counterintuitive and was not confirmed in our study. The present study suggests however that CBT may operate via changes in mood state, consistent with the biopsychosocial model. This finding suggests that CBT may have a useful role in the management of IBS.
S1305 How Useful is Colonic Manometry in the Evaluation of Sensorimotor Dysfunction in Slow Transit Constipation (STC)? Satish S. Rao, Siddharth Singh, Deborah Dickinson Background: Limited studies have described normal or decreased colonic motility in STC, but the characteristics of sensory and motor dysfunction in the colon and anorectum and their clinical significance has not been examined. Aims: To investigate the prevalence, clinical features and colonic and anorectal sensorimotor dysfunction in pathophysiological subsets of patients with STC, refractory to treatment. Methods: Consecutive patients with STC (>20% sitzmarker), underwent 24-hr ambulatory colonic manometry, colonic sensation/ tone study (barostat) and anorectal manometry. We evaluated clinical features, manometric characteristics, colonic sensation and anorectal sensorimotor function. Patients were classified as normal motility or colonic neuropathy or myopathy based on the absence or attenuated response of 2 out of 3 features: HAPCs, gastrocolonic response, waking response. Coexisting dyssynergic defecation (DD) or IBS was also evaluated. Data was compared with 25 healthy controls for colonic and 45 controls for ARM. Results: 65 patients (56 females) with severe STC (duration=17 yrs, mean retention=66% of markers) were evaluated. Predominant symptoms were <3 BMs/wk (92%), hard stools (97%), straining (87%), incomplete evacuation (95%) and laxative dependence (87%). Of these, 28% had colonic neuropathy, 31% colonic myopathy and 41% normal colonic manometry. 60% had colonic hyposensitivity and 9% had colonic hypersensitivity. 77% had associated DD, with persistent symptoms in ~60% despite correction of dyssynergia suggesting severe STC. Rectal hyposensitivity was found in 51% and rectal hypersensitivity in 31%. Patients with colonic neuropathy were more likely to have severe DD. There was no correlation between pathophysiological subsets of STC and either demographic, clinical features, or colonic/ anorectal sensory impairment. Conclusions: Colonic manometry revealed significant colonic motor (60%) and sensory dysfunction (70%) in STC patients that were independent of each other. About 40% had normal colonic function despite severe symptoms. Many patients had coexisting features of DD (77%) and/or IBS (18%). Colonic manometry with sensation/tone assessment characterizes underlying pathophysiology and could guide therapy.
S1308 Beliefs About GI Medications and Adherence to Pharmacotherapy in Functional GI Disorder (FGID) Outpatients Benjamin Cassell, C. Prakash Gyawali, Patrick J. Lustman, Billy D. Nix, Gregory S. Sayuk
*- p <0.05 for neuropathy vs. normal; #- p<0.05 for myopathy vs. normal; +- p<0.05 for neuropathy vs myopathy
Background: Pharmacotherapy is a preferred treatment approach in FGID, but little is known about patient attitudes toward medication regimens. Understanding patient concerns and adherence to pharmacotherapy is particularly important for off-label medication use (e.g., antidepressants, ADs) in FGID. Methods: Consecutive outpatients with established FGID (using Rome III Research Diagnostic Questionnaire) in a tertiary GI setting completed the Beliefs About Medications Questionnaire (BMQ). This validated instrument assesses patient attitudes toward medications on two subscales, the Concern subscale (measures worry of long-term effects and dependence on medications) and the Necessity subscale (measures dependence on, and perceived protective effects of medications), using a 5-point Likert scale (1=strongly disagree, 5=strongly agree). Non-FGID GI diagnoses, contemporaneous GI medications and doses were recorded from chart review. Adherence to GI-specific medication regimens were determined using 10-cm visual analog scale (VAS) ratings. Results: 275 subjects (mean age 49.9 ±15.6 yrs, range 18-96 yr, 220 female) with FGID were identified over a 20-month interval; 211 (76.7%) satisfied ROME criteria for >1 FGID and 156 (56.7%) for >2 FGID. IBS and functional dyspepsia were the most frequently diagnosed FGIDs (65.8% and 53.5%, respectively). Medication regimens most commonly used included PPIs (n=100, 36.4%), TCAs (n=79, 28.7%), anxiolytics (n=53, 19.3%), anticholinergics (n= 46, 16.7%), and SSRIs (n=41, 14.9%). Mean BMQ Concern and Necessity scores were 12.4 ±6.7 and 16.9 ±9.0, respectively, with no significant differences between IBS and non-IBS FGIDs, or between those with 1 and >1 FGID. Good adherence (>80%) to prescribed medications was reported by 70.3% of subjects. Medication adherence correlated positively with perceived medication Necessity (r=0.27, p<0.001), and negatively with concerns about medication Harm (r=-0.21, p=0.001) and Overuse (r=-0.13, p=0.045). Subjects prescribed ADs for their FGID (n=142, 51.6%) expressed a greater medication Necessity (18.5 ±7.8 vs. 15.3 ±9.9, p<0.001) and acknowledged a greater Concern about their medications (14.0 ±5.9 vs. 10.8 ±7.0, p=0.02) on the BMQ. Still, subjects using ADs reported higher medication adherence compared to non-AD regimens (p=0.07). Discussion: FGID subjects report medication need and concern scores comparable to those reported with chronic illnesses (e.g., asthma, heart disease) in the literature. Concerns of medication harm and overuse affect adherence to pharmacotherapy, and preemptively addressing these concerns may further improve patient acceptance and compliance to FGID treatment regimens.
S1306 Physiological Characteristics of Traditional Chinese Medicine (TCM) Based Irritable Bowel Syndrome (IBS) Sub-Groups Aditi A. Joshi, Steven Tan, Suzanne R. Smith, Deborah Ackerman, Kirsten Tillisch, Ka Kit Hui, David Shapiro, Bruce D. Naliboff Abstract: It is well known that patients with IBS have a high rate of co-morbid extra-intestinal symptoms.Traditional Chinese Medicine (TCM) views all illnesses as arising from global patterns of dysregulation and TCM predicts that despite similar symptoms, subgroups of IBS patients vary in important characteristics such as pain sensitivity and stress responses and these differences reflect different IBS pathophysiology and require different treatment. AIMS: To determine stress reactivity and pain sensitivity of IBS subgroups classified into TCM categories of Excess (Liver Qi stagnation), Deficiency (Spleen Qi deficiency) and Overlap (mixed symptoms). METHODS: 63 ROME III+ female IBS patients (Mean age= 36.38; SD +/- 13.0) were independently evaluated by two TCM practitioners and also filled out a TCM symptom questionnaire. Sensitivity to pressure pain at three body sites and autonomic responses to a psychological stressor were evaluated in a laboratory session. RESULTS: TCM practitioners agreed on 82.6% of diagnoses (excess=29, overlap=23, discrepancy=11 (not included in further analysis)) although there were not differences in IBS symptom severity by TCM subgroup. Older Excess subjects showed significantly less sensitivity to pressure pain compared to those with overlap (emeans: Excess =9.97+SE 1.08; Overlap = 10.33+ SE 1.06., p<.03). Similarly subjects with greater deficiency symptoms by questionnaire tended to have non-significantly higher pain sensitivity. 3) No significant differences were found in autonomic reactivity to the psychological stressor between the two groups based on TCM diagnosis. However, high deficiency scorers on the symptom questionnaire had a significantly greater increase in Diastolic BP during the stress tasks - Pre-Speech (p= .005); Speech (p= 0.01); Math (p=0.03 but not in the initial or end baseline (p< .4). Similar findings were present for heart rate but no differences were found for a purely sympathetic measure, skin conductance. CONCLUSION: TCM based subgroups of IBS patients show differences in non-GI characteristics with greater pain sensitivity and cardiovascular stress responses in subjects showing increased deficiency symptoms. TCM subgroups may therefore reflect differences in underlying physiological responses relevant for IBS development and/or treatment. Funding- NCCAM R21AT003221.
S-225
AGA Abstracts
AGA Abstracts
Cognitive Behaviour Therapy's Role in the Treatment of Irritable Bowel Syndrome: Direct Effect on Symptoms or Operates via Mood ? Michael Jones, Natasha A. Koloski, Nick Talley