Perceptions of illness stigma in patients with inflammatory bowel disease and irritable bowel syndrome.

PURPOSE: To compare the experiences of perceived stigma (PS) in both patients with irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) and examine its relationship to patient-reported outcomes in both patient populations. METHODS: IBD and IBS patients were recruited from an outpatient gastroenterology clinic and online via support message boards and classifieds. Participants completed a series of questionnaires to measure the perception of illness stigma, psychological functioning, and clinical and demographic data. RESULTS: Two hundred and sixty-nine IBS and 227 IBD patients participated. IBS patients were more likely to report high levels of perceived stigma across a wider range of sources, with the largest difference being for health care providers. Twenty-seven percent of IBS patients reported moderate to high levels of perceived stigma, compared with 8% of IBD. While perception of stigma was correlated with poorer patient-reported outcomes in both patient groups, correlations were larger for IBD compared with IBS. CONCLUSIONS: This study demonstrates that both IBD and IBS patients perceive stigma about their illness. As demonstrated by increased depression and anxiety, decreased self-esteem and self-efficacy, and lower quality of life in both patient groups, PS was shown to have a negative impact on clinical outcomes.

Prolonged recording of duodenal acid exposure in patients with functional dyspepsia and controls using a radiotelemetry pH monitoring system.

INTRODUCTION: Increased duodenal acid exposure (DAE) is associated with ulcer and dyspeptic symptoms but our understanding is limited by cumbersome recording methods. We have recently shown that prolonged radiotelemetry pH monitoring (RpHM) in the duodenum is feasible. This study compared DAE in controls and patients with functional dyspepsia (FD) using RpHM. METHODS: FD and controls underwent 48-hour recording of DAE using endoclip-secured RpHM capsules in the distal duodenal bulb. Subjects were nil per os except for meals eaten twice daily. FD completed a 14-item symptom checklist. Sleep periods were determined from diaries. Meal periods were defined as the 3-hour period after meal initiation. RESULTS: Thirty-four FD and 25 controls were studied. Prolonged recordings were obtained in 32/34 FD and 17/25 controls. Reasons for incomplete recordings were capsule dislodgement (7), procedural complication (1), and suspected gastric prolapse of capsule (2). Within groups, pH values for recording periods did not differ. Between groups, FD had significantly lower mean pH values [median (25th to 75th percentile)] during meals [5.11 (4.44 to 5.59) vs. 5.63 (5.17 to 6.10); P=0.003] and upright periods [4.69 (3.92 to 5.64) vs. 5.35 (4.55 to 6.31); P=0.01] but not during sleep. Duodenal pH values did not correlate with symptoms except for complaints of inability to finish a meal with meal (r=-0.341; P=0.05) and sleep (r=-0.383; P=0.03) pH. CONCLUSIONS: RpHM allows for prolonged recording of DAE. FD have l greater DAE than controls during daytime and meal periods. DAE and symptoms are poorly associated. The association of DAE with inability to finish a meal is consistent with prior studies demonstrating impaired proximal stomach function after duodenal acidification.

Psychometric development and validation of the chronic constipation treatment satisfaction questionnaire (CTSAT-Q).

OBJECTIVES: To develop and validate the constipation treatment satisfaction questionnaire (CTSAT-Q) for use in patients with chronic constipation and irritable bowel syndrome with constipation (IBS-c). METHODS: Questionnaire development included item representation from the reviewed literature, focus groups, and pretesting. Dimensions related to treatment satisfaction were identified with exploratory factor analysis, verified with confirmatory factor analysis (CFA), and tested with structural equation modeling. RESULTS: A total of 31,988 email invitations were disseminated to obtain 311 qualified respondents with diagnoses for chronic constipation and IBS-c using ROME II criteria, which required that two of the following symptoms: fewer than 3 bowel movements per week, hard or lumpy stools, straining with defecation, and a sensation of incomplete evacuation, a sensation of anorectal obstruction, and the use of manual maneuvers to assist defecation be present 25% of the time during the last year. Approximately 84% of the sample was female. Item-to-total correlations were 0.66 for activities, ranged from 0.60 to 0.67 for expectations, from 0.59 to 0.69 for value, from 0.56 to 0.60 for effectiveness, and 0.68 to 0.79 for treatment satisfaction. All standardized parameter estimates from CFA were significant (P < 0.01). The chi-square was 46.98, df = 41, P = 0.241, comparative fit index = 0.996, Tucker-Lewis Index = 0.994, root mean square error of approximation = 0.022, indicating an excellent fit between the sample data and proposed model. Treatment satisfaction was a strong and significant predictor of effectiveness, activities, and value (P < 0.001). CONCLUSIONS: The CTSAT-Q was demonstrated to be reliable and valid, and appears to assess treatment satisfaction for patients with chronic constipation and patients with IBS-c.

Development and initial validation of a measure of perceived stigma in irritable bowel syndrome.

Irritable bowel syndrome (IBS) is a poorly understood digestive disorder prone to stigmatization. We developed a measure of condition-specific perceived stigma to better understand the role of stigma in this common disorder. Questionnaire items were established through structured patient interviews. A 10-item measure assessing relevant stigma variables across social domains was then administered to 148 patients with IBS. Test-retest reliability was assessed by having a subset of 26 patients re-complete the measure after 2 weeks. Twenty-eight out of 49 (57%) interview subjects with some degree of perceived stigma related to their IBS. A 10-item measure was developed with the following areas of perceived stigmatization: limited disclosure of IBS; belief that public knowledge about IBS was low; feeling that IBS was not taken seriously; people implying that IBS symptoms are self-inflicted; role limitations because of IBS; and others having the belief that IBS is 'all in their head'. Respondents rated the 10 items on the new measure with respect to perceived stigma in the social domains of healthcare providers; spouses/significant others; family members; friends; boss/supervisor; and coworkers/classmates. Stigma scores were significantly correlated with scores from the modified HIV stigma instrument (r = 0.56; p < 0.0001). Cronbach's alpha was estimated at 0.91. Mean inter-item correlation was 0.50 and ranged from 0.29 to 0.71. Guttman's split-half reliability coefficient was estimated at 0.89. Test-retest reliability was high (r = 0.91; p < 0.0001). Patients with IBS reported the greatest degrees of perceived stigma related to coworkers, employers, and friends. Stigma dimensions which received the highest scores focused upon limited knowledge of IBS by others along with a lack of interest or understanding of others towards the condition. The IBS perceived stigma scale is a reliable, valid measure of perceived stigma related to IBS.

Lactulose breath testing does not discriminate patients with irritable bowel syndrome from healthy controls.

INTRODUCTION: Recent reports suggest that abnormalities of lactulose breath testing (LBT) are common in patients with irritable bowel syndrome (IBS), although the criteria for abnormal studies are poorly validated, and controlled comparisons are limited. The goal of this study was to determine the prevalence of abnormal LBT using the previously published criteria in both IBS patients and healthy controls, as well as to determine the prevalence and symptom association with methane (CH(4)) and hydrogen (H(2)) productions during LBT. METHODS: Consecutive LBT from patients meeting Rome II criteria for IBS and healthy control subjects were examined. Patients listed their most bothersome digestive symptom at the start of the test. LBT was performed using 10 g of lactulose mixed in 240 mL of water, and breath samples collected every 20 min for a 180-min period. Both breath H(2) and CH(4) were measured. LBT was considered positive if it met any of the previously published criteria: (a) breath H(2) of > 20 parts per million (ppm), (b) increase in breath H(2) in < 90 min, (c) dual H(2) peaks (12-ppm increase over baseline with a decrease of > or = 5 ppm before 2nd peak), and (d) breath CH(4) of > 1 ppm. RESULTS: In total, 224 patients with IBS and 40 controls were studied. Twenty percent of IBS patients were CH(4)(+) compared with 15% of controls. CH(4)(+) IBS patients were significantly more likely than CH(4)(-) IBS patients to have constipation, and significantly less likely to have diarrhea; however, the association did not hold for symptoms of bloating or pain. Patients and controls did not differ significantly with respect to the frequency of a positive study defined by increase in breath H(2) in < 90 min (121 per 180 vs 26 per 40, P = 0.79), increase in breath H(2) of > 20 ppm (92 per 180 vs 24 per 40, P= 0.31), or dual peaks (25 per 180 vs 9 per 40, P = 0.17). CONCLUSIONS: The majority of patients with IBS and healthy subjects meet criteria for an "abnormal" LBT using previously published test criteria, and groups are not discriminated using this diagnostic method. Similarly, while CH(4) production was associated with constipation among IBS patients, the prevalence of CH(4)-positive subjects did not significantly differ between IBS patients and controls. The utility of LBT, in its current form as a diagnostic tool in IBS requires critical reappraisal.

Small intestinal motility.

PURPOSE OF REVIEW: To review recently published studies presenting novel and relevant information on small intestinal motility. RECENT FINDINGS: The reviewed studies covered a variety of topics with several themes emerging. Our understanding of the influence of systemic disorders, intestinal and extraintestinal infections and enteric bacteria on digestive motor function continues to involve. Elegant and important new studies have been published that better define the physiology of intestinal gas handling along with the genesis of symptoms commonly attributed to excessive intestinal gas. While interest in small intestinal bacterial overgrowth in irritable bowel syndrome continues, the utility and specificity of lactulose hydrogen breath testing is yet again questioned and further data are needed before the practice of routinely prescribing antibiotics to patients with irritable bowel syndrome can be endorsed. SUMMARY: Small intestinal motility remains an understudied area. Recent publications provide additional new information related to physiology and pathophysiology of small bowel motility. These findings should be of interest to clinician and investigator alike.

Multicenter study of gastroenterologists' ability to identify anxiety and depression in a new patient encounter and its impact on diagnosis.

AIM: Although gastroenterologists are frequently exposed to psychopathology few data exist regarding their ability to accurately assess anxiety and depression or the impact of their perceptions of anxiety and depression on diagnostic decisions. The aims of this study were to determine gastroenterologists' ability to correctly identify anxiety and depression in patients with gastrointestinal symptoms and to determine whether gastroenterologist perceptions of anxiety and depression affected postvisit diagnosis. METHODS: One hundred fifty-nine consecutive patients making their initial visit to 3 university outpatient clinics were evaluated by 38 gastroenterologists and completed Hospital Anxiety and Depression Scale. Gastroenterologists rated their perceptions of patient anxiety and depression on 100-mm visual analog scales and indicated whether they thought the patient was clinically anxious or depressed. On the basis of the gastroenterologists' postvisit diagnosis, patients were entered into functional gastrointestinal disorder (FGID; n=28), symptom-based (SB) diagnosis (n=45), or organic disease (OD; n=86) groups. RESULTS: Anxiety and depression were present in 40% and 20% of patients, respectively. Gastroenterologists' categorization of patients as having clinically significant anxiety and depression were poor with positive predictive values of 0.52 and 0.26, respectively. Patients perceived as anxious by their gastroenterologist were more than twice as likely to receive a FGID diagnosis. CONCLUSIONS: Anxiety and depression were prevalent in the study population yet gastroenterologists did not accurately detect these conditions. However, gastroenterologists were more than twice as likely to diagnose patients whom they perceived as anxious as having an FGID, highlighting a need for improved psychosocial assessment in clinical practice and education to diminish misattributions regarding FGID.

The Irritable Bowel Syndrome Outcome Study (IBSOS): rationale and design of a randomized, placebo-controlled trial with 12 month follow up of self- versus clinician-administered CBT for moderate to severe irritable bowel syndrome.

Irritable bowel syndrome is a common, oftentimes disabling, gastrointestinal disorder whose full range of symptoms has no satisfactory medical or dietary treatment. One of the few empirically validated treatments includes a specific psychological therapy called cognitive behavior therapy which, if available, is typically administered over several months by trained practitioners in tertiary care settings. There is an urgent need to develop more efficient versions of CBT that require minimal professional assistance but retain the efficacy profile of clinic based CBT. The Irritable Bowel Syndrome Outcome Study (IBSOS) is a multicenter, placebo-controlled randomized trial to evaluate whether a self-administered version of CBT is, at least as efficacious as standard CBT and more efficacious than an attention control in reducing core GI symptoms of IBS and its burden (e.g. distress, quality of life impairment, etc.) in moderately to severely affected IBS patients. Additional goals are to assess, at quarterly intervals, the durability of treatment response over a 12 month period; to identify clinically useful patient characteristics associated with outcome as a way of gaining an understanding of subgroups of participants for whom CBT is most beneficial; to identify theory-based change mechanisms (active ingredients) that explain how and why CBT works; and evaluate the economic costs and benefits of CBT. Between August 2010 when IBSOS began recruiting subjects and February 2012, the IBSOS randomized 171 of 480 patients. Findings have the potential to improve the health of IBS patients, reduce its social and economic costs, conserve scarce health care resources, and inform evidence-based practice guidelines.

Quality of life in patients with inflammatory bowel disease and irritable bowel syndrome differs between subjects recruited from clinic or the internet.

INTRODUCTION: The Internet is used increasingly to recruit patients for studies of gastroenterological disorders. The Internet allows access to potentially large study populations but no data exist comparing Internet-based populations with patients recruited from a clinical setting. We conducted an assessment of the quality of life (QOL) in patients with active inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) recruited from a gastroenterology clinic and the Internet. METHODS: Patients were recruited from a university gastroenterology clinic and several condition-specific support group web sites. The diagnosis of IBD and IBS was confirmed for clinic patients while Internet respondents were self-identified. Subjects completed both general (SF-36) and condition specific (IBS-QOL) measures. RESULTS: Subjects with IBD included 47 recruited from clinic and 96 recruited from the Internet. The IBS group included 147 patients recruited from clinic and 84 recruited from the Internet. Both IBS and IBD clinic and Internet IBD groups did not differ by. IBD Internet respondents were more likely to be women (clinic: 28F/19M, online: 80F/16M, P= 0.002) while IBS Internet respondents were more likely to be male (123F/24M) than IBS clinic patients (62F/22M) (P= 0.09). Compared with patients seen in clinic, both IBS and IBD Internet respondents had significantly poorer QOL as measured by both SF-36 and IBS-QOL. The greatest decrements in QOL occurred on SF-36 scales for physical and emotional roles and social functioning. On the IBS-QOL, the greatest decrement was seen on scales for dysphoria and life interference. Significant differences were maintained after controlling for gender. CONCLUSIONS: For both IBS and IBD, Internet-respondents had significantly poorer QOL than subjects recruited from clinic. These data demonstrate that subjects recruited from the Internet may represent a clinically distinct population and data obtained from online surveys may not generalize to broader clinical populations. Further study is needed to determine whether these differences reflect psychosocial characteristics of Internet responders or simply self-report behaviors in a relatively anonymous environment.

Small intestinal motility.

PURPOSE OF REVIEW: The aim of this article is to review recently published studies presenting novel and relevant information on small intestinal motility. RECENT FINDINGS: The reviewed studies covered a variety of topics with several themes emerging. The presentation and causes of chronic intestinal dysmotility continue to expand. Evidence continues to accrue that at least a subset of patients with severe colonic inertia may have a more diffuse motility disorder highlighting the need for careful assessment prior to embarking on surgery for refractory constipation. While interest in bacterial overgrowth in irritable bowel syndrome continues, the utility and specificity of lactulose hydrogen breath testing is yet again being called into question. Methane appears to slow intestinal transit and constipation appears more common among methane-positive patients. The association is presently only correlative and further study is needed. SUMMARY: Small intestinal motility remains an understudied area. Recent publications provide additional new information related to physiology and pathophysiology of small bowel motility. These findings should be of interest to clinician and investigator alike.

New directions in the assessment of gastric function: clinical applications of physiologic measurements.

A variety of methods exist to assess gastric motor and sensory function. Specific techniques allow for the measurement of emptying, contractility, accommodation and sensation. Several of these techniques are suitable for in-office use rather than in a hospital or gastroenterology laboratory. While gastric function tests continue to proliferate and become more clinically accessible, their relevance to specific digestive symptoms or syndromes remains poorly studied. Additionally, the ability of gastric function testing to guide therapy or predict responses to interventions also remains poorly studied. Gastric function testing should be employed cautiously in clinical practice with an awareness that test results represent observations rather than diagnosis.

The Optical Dilator: a clear, over-the-scope bougie with sequential dilating segments.

PURPOSE: The safety and efficacy of esophageal dilation is enhanced when direct visualization is possible, tactile sensation and feedback from resistance is maintained, and multiple dilations with a single passage of the dilating device is an option. The InScope Optical Dilator (InScope, a Division of Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) is a flexible, transparent bougie fitted over a standard endoscope, with 3 dilating segments allowing sequential dilation under direct visualization. We report our experience with this device in treating benign esophageal strictures. METHODS: Patients with solid food dysphagia due to peptic strictures or Schatzki's ring were studied by using a 27F or 29F endoscope. Based on stricture appearance and estimated luminal diameter, 1 of 3 dilator sizes was chosen: IN0216 (14-, 15-, and 16-mm dilating segments), IN0218 (16-, 17-, and 18-mm dilating segments), or IN0220 (18-, 19-, and 20-mm dilating segments). RESULTS: Twenty-six patients were dilated and included 17 peptic strictures and 9 Schatzki's rings. Before dilation, most patients reported difficulties with solids at every meal. Median improvement 3 weeks after dilation was rated by patients as "substantial relief." Patients rated the dilation experience as largely "not at all unpleasant" immediately after endoscopy and had no recollection at 3 weeks' follow-up. There were no complications. Endoscopists rated dilator use as typical of experience with other bougies, and visualization was rated as high. CONCLUSION: The Optical Dilator maintains the value of tactile sensation and the convenience of 3 dilating sizes for each passage of the instrument with the added benefit of direct visualization.