Advances in Functional Bowel Disorders

Brooks D Cash, MD, FACP

Disclosures

October 31, 2003

Editorial Collaboration

Medscape &

Baltimore, Wednesday, October 15, 2003 -- Irritable bowel syndrome (IBS) is one of the most common conditions encountered in general medical practice.[1,2] IBS has the potential for protean manifestations but is generally characterized by abdominal pain, bloating, and disturbed defecation. Because it is a very common condition, it represents a leading cause of gastroenterology and primary-care consultations. Additionally, patients with IBS are more likely to exhibit healthcare-seeking behaviors than patients without IBS. The prevalence of IBS is estimated to range between 14% and 24% in women and 5% and 19% in men in the United States and the United Kingdom.[3] The impact of IBS is not restricted to individual patient discomfort. It has been estimated that the total direct cost associated with this functional bowel disorder includes $10 billion in direct medical costs and $20 billion in indirect costs, such as absenteeism and lost work productivity.[4,5,6]

This report highlights various aspects regarding the care of patients with IBS, as discussed on Wednesday during sessions presented at the annual meeting of the American College of Gastroenterology.

Patterns of Care

It has been estimated that IBS is responsible for 2.4-3.5 million physician visits per year and represents 12% of primary-care and 28% of gastroenterological referrals.[7]

To assess the differences in management between primary-care practitioners and specialists, Whitehead and colleagues[8] compared the 2 practice settings within a large health maintenance organization specifically examining IBS treatment, explanation of symptoms, and patient satisfaction. Overall care was strikingly similar among gastroenterologists and primary-care practitioners. Prescribing habits were equal between the 2 groups with the exception of laxatives, which were more likely to be prescribed by primary-care practitioners. Advice regarding diet, exercise, and coping behaviors demonstrated similar patterns among the 2 groups, as did referral patterns to dietary specialists and mental health professionals (< 10% in both settings). Primary-care practitioners were more likely to explain IBS to patients, but this did not appear to affect patient satisfaction scores, which were similar among the 2 settings.

The results of this study suggest that additional education for both specialists and primary-care practitioners regarding effective IBS therapy and communication techniques may be needed. It also raises some questions with respect to what features of IBS care (effective therapy, reassurance, education) are most important for patient satisfaction.

Therapeutic Options in IBS Measuring Treatment Effects in IBS Trials

There is no single therapeutic approach to IBS. Most patients (ie, those with mild symptoms and minimal impairment) with IBS can be managed at a primary-care level. Fewer than 25% of patients with IBS have more severe symptoms with significant lifestyle impairment requiring management by a gastroenterologist, and 5% of patients with IBS have such severe and incapacitating symptoms that they require referral to a center with multispecialty capability.[9] Goals of therapy should focus on symptom management rather than cure.

It would seem intuitive that investigators performing therapeutic trials for IBS would measure changes in individual IBS symptoms, such as abdominal pain, bloating, and bowel habit satisfaction in order to determine therapeutic efficacy. Reliance on changes in individual symptoms, however, may not be as sensitive an endpoint as global IBS symptom relief, likely due to the nonspecific, variable, and subjective complaints that are common with IBS.

Dunger-Baldauf and colleagues[10] presented data from a large Nordic trial assessing tegaserod for treatment of IBS symptoms in 647 patients (83% women) with nondiarrhea-predominant disease. These investigators examined the primary outcome variable -- global IBS symptom relief -- relative to changes in the individual symptoms of IBS. They demonstrated that global relief is responsive to changes in the individual symptoms of IBS and is therefore appropriate as a primary outcome of IBS therapy trials. This is an important concept because trials that show improvement in individual IBS symptoms may not translate into overall improvement of the patient with IBS. Clinicians examining IBS therapy trials should look for this outcome.

Psychologic Aspects of IBS

Among therapies for IBS, only alosetron and tegaserod have been shown to be effective agents for global symptom relief in rigorous clinical trials. Several groups have found that psychosocial stress alters both gastrointestinal motor activity and sensation and can exacerbate gastrointestinal symptoms in patients with functional disorders.[11,12]

A symposium on functional bowel disorders conducted during these meeting proceedings addressed the integration of psychologic care in patients with IBS. Dr. William Orr[13] presented a review of the various rating scales that are commonly used to measure psychologic symptoms and level of impairment in clinical trials. Dr. Orr stressed that any scales used in clinical or research practice should be both valid (ie, measure what they are designed to measure) and reliable (ie, produce similar results with repeated testing). He recommended 3 important scales to assess psychologic traits or impairment in patients with IBS: (1) the Beck Depression Inventory, which evaluates the cognitive/affective and somatic aspects of depression; (2) the SF-36, which is a generic quality-of-life measurement instrument that has been used for many medical conditions; and (3) the Pittsburgh Sleep Quality Index (PSQI), which reflects sleeping habits over the previous month and can distinguish between patients with and without primary insomnia.

Dr. Lawrence Brandt[14] then described key features of interview techniques designed to identify a history of abuse. He cited historically greater rates of gastrointestinal disorders (1.5-3 times) in patients with a history of abuse and the sobering statistic that physicians are only aware of their patients' abuse history 5% to 17% of the time. A high level of suspicion, based on typical comorbid conditions and behavioral traits, should alert the physician to the possibility of unresolved emotional effects of previous or concurrent abuse. Dr. Brandt presented the following integral aspects for obtaining an abuse history: (1) establish a good rapport, be sensitive and compassionate; (2) establish a safe interview setting, free of interruptions; (3) use open-ended questions; (4) validate patient answers; (5) observe nonverbal cues of the patient and be aware of your own nonverbal communication; (6) assess the comfort/discomfort level of the patient; (7) remain nonjudgmental; (8) exhibit empathy; (9) allow the patient to retain some control of the interview and examination; (10) allow enough time for the interview; and (11) be prepared to refer the patient for appropriate psychologic care.

Dr. Michael Crowell[15] presented a multidimensional approach to functional bowel disease and medications. Dr. Crowell reinforced the concept of IBS as a biopsychosocial condition. The origins of IBS can best be described as a complex interplay of disturbances involving gastrointestinal motility, visceral sensation, and central pain processing. Psychologic and emotional disturbances can affect all of these aspects. He emphasized the role of serotonin and its effects on gastrointestinal motility and sensation, as well as its role in the multiple comorbid conditions that can accompany IBS. Multiple other neurotransmitters may also be important in the origin of IBS and psychologic symptoms. Additional therapeutic investigations using a multidimensional approach (medical therapy plus psychologic therapy) need to be performed to validate this concept.

And finally, Dr. Kevin Olden[16] concluded the symposium by reviewing current issues surrounding psychologic care for patients with functional gastrointestinal disorders. According to Dr. Olden, 90% of psychologic disturbances in patients with IBS will fall into 3 broad categories: (1) major depression; (2) anxiety disorders (panic disorder, generalized anxiety, obsessive-compulsive disorder, and posttraumatic stress disorder); and (3) somatoform disorders (somatization, pain disorder, conversion disorder, and hypochondriasis). He stressed the importance of recognizing these conditions and referral to mental health specialists focusing on the burden of the illness, rather than on the illness itself. It is especially important to find skilled and interested mental health colleagues and to try to coordinate subsequent care with these specialists.

Hypnosis for IBS

Palsson and colleagues[17] previously reported positive results associated with the use of hypnosis in patients with IBS. It was found that hypnosis (45 minutes every other week for 12 weeks as well as self-hypnosis techniques) improved both IBS symptoms (pain, bloating, and disturbed defecation) and psychologic parameters (somatization and anxiety scores). However, the real-world effectiveness of hypnotherapy presupposes motivated patients and ready access to an appropriately trained therapist.

During this year's meeting of the American College of Gastroenterology, Palsson and colleagues[18] expanded on their previous work by reporting the results of a 3-month home hypnosis program for patients with IBS. The study authors compared the improvement (in multiple symptom parameters) of 19 patients with IBS treated with self-hypnosis (conducted via audio compact disc instruction) with 57 age-, sex-, and symptom severity-matched controls treated with standard medical therapy. Fifty-three percent of the hypnosis patients had improvement in overall IBS symptoms compared with 26% of the controls (10 of 19 vs 15 of 57; P < .05). Quality of life was also significantly improved among patients who underwent hypnosis, and these treatment differences were shown to persist at 6 months. These investigators also found that patients exhibiting greater degrees of anxiety were less likely to respond to hypnotherapy, suggesting that other methods of therapy may be more useful in this subset of patients with IBS.

Summary

IBS is a common and important gastroenterologic disorder. Although most patients with IBS will never seek medical care for their symptoms, physician familiarity with IBS symptoms and the comorbid conditions associated with IBS represent an integral aspect of optimizing care for these patients. A history of abuse, especially in women, is common in patients with IBS and may play an important role in symptom origin and patient coping behaviors. Identification of abuse or psychologic disturbance in patients with IBS can be accomplished in routine practice, and appropriate referral to mental health specialists should be a standard aspect of care for IBS patients with identified psychologic comorbidity. Last, alternative psychologic therapies such as hypnosis may be both effective and practical for certain subsets of patients with IBS, although additional investigation is warranted.

The opinions and assertions contained herein are the sole views of the author and should not be construed as official or as representing the views of the US Navy or Department of Defense.

References
  1. Longstreth GF, Wolde-Tsadik G. Irritable bowel-type symptoms in HMO examinees: prevalence, demographics and clinical correlates. Dig Dis Sci. 1993;38:1581-1589.

  2. Mitchell CM, Drossman DA. Survey of the AGA membership relating to patients with functional gastrointestinal disorders. Gastroenterology. 1987;92:1282-1284.

  3. Drossman DA, Whitehead WE, Camilleri M. Irritable bowel syndrome: a technical review for practice guideline development. Gastroenterology. 1997;112:2120-2137.

  4. MartinR, Barron JJ, Zacker C. Irritable bowel syndrome: toward a cost-effective management approach. Am J Manag Care. 2001;7(8 suppl):S268-S275.

  5. American Gastroenterological Association. The Burden of Gastrointestinal Diseases. Bethesda, MD: American Gastroenterological Association; 2001:1-86.

  6. Camilleri M, Williams DE. Economic burden of irritable bowel syndrome. Lancet. 1992;340:1447-1452.

  7. Sandler RS. Epidemiology of irritable bowel syndrome in the United States. Gastroenterology. 1990;99:409-415.

  8. Whitehead WE, Palsson OS, Levy R, et al. What constitutes standard medical care for irritable bowel syndrome (IBS) in US primary care and gastroenterology clinics? Am J Gastroenterol 2003;98:S272. [Abstract #819]

  9. Drossman DA, Thompson WG. The irritable bowel syndrome: review and a graduated, multicomponent treatment approach. Ann Intern Med. 1992;116:1009-1016.

  10. Dunger-Baldauf C, Nyhlin H, Ruegg P, et al. Subject's global assessment of satisfactory relief as a measure to assess treatment effect in clinical trials in irritable bowel syndrome (IBS). Am J Gastroenterol. 2003;98:S269.[Abstract #809]

  11. Dickhaus B, Mayer EA, Firooz N, et al. Irritable bowel syndrome patients show enhanced modulation of visceral perception by auditory stress. Am J Gastroenterol. 2003;98:135-143.

  12. Drossman D, Ringel Y, Voight BA, et al. Alterations of brain activity associated with resolution of emotional distress and pain in a case of severe irritable bowel syndrome. Gastroenterology. 2002;124:754-761.

  13. Orr W. Screening for depression and anxiety -- rating the rating scales. In: ACG Simultaneous Symposia A -- The functional bowel disease: Helping the patient without ruining your day. Program and abstracts of the Annual Meeting of the American College of Gastroenterology; October 10-15, 2003; Baltimore, Maryland.

  14. Brandt LJ. Taking a three minute abuse history. In: ACG Simultaneous Symposia A -- The functional bowel disease: Helping the patient without ruining your day. Program and abstracts of the Annual Meeting of the American College of Gastroenterology; October 10-15, 2003; Baltimore, Maryland.

  15. Crowell M. A multidimensional approach to functional bowel disease and medication. In: ACG Simultaneous Symposia A -- The functional bowel disease: Helping the patient without ruining your day. Program and abstracts of the Annual Meeting of the American College of Gastroenterology; October 10-15, 2003; Baltimore, Maryland.

  16. Olden K. How do I get a psychiatrist to work with my patient? In: ACG Simultaneous Symposia A -- The functional bowel disease: Helping the patient without ruining your day. Program and abstracts of the Annual Meeting of the American College of Gastroenterology; October 10-15, 2003; Baltimore, Maryland.

  17. Palsson OS, Turner MJ, Johnson DA, et al. Hypnosis treatment for severe irritable bowel syndrome: Investigation of mechanism and effects on symptoms. Dig Dis Sci. 2002;47:2605-2614.

  18. Palsson OS, Whitehead WE, Turner MJ. Hypnosis home treatment for irritable bowel syndrome (IBS): exploratory study. Am J Gastroenterol. 2003;98:S274. [Abstract #822]

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