Attention Deficit Hyperactivity Disorder and Functional Defecation Disorders in Children.

OBJECTIVES: The aim of the study was to assess the prevalence of attention deficit hyperactivity disorder (ADHD) in children presenting with functional defecation disorders (FDDs) and to assess the prevalence of FDDs in children with ADHD. METHODS: A cross-sectional cohort study was carried out between September 2014 and May 2016. Group 1: Parents of children with FDDs according to the Rome III criteria completed the Child Behavior Checklist and the VvGK (Dutch questionnaire based on the American Disruptive Behavior Disorder rating scale). Patients with ADHD subarea scores ≥70 on the Child Behavior Checklist and/or ≥16 on the VvGK were referred for further psychiatric evaluation. Group 2: Parents of children treated for ADHD at a specialized ADHD outpatient clinic completed a standardized questionnaire regarding their child's defecation pattern. RESULTS: In group 1 (282 children with FDDs), 10.3% (7.1%-13.5% bias-corrected and accelerate confidence interval) were diagnosed with ADHD. Group 2 consisted of 198 children with ADHD, 22.7% (17.6-28.8 bias-corrected and accelerate confidence interval) fulfilled the Rome III criteria for an FDD. Children with both an FDD and ADHD reported urinary incontinence significantly more often compared to children with an FDD or ADHD alone: 57.1% in FDD + ADHD versus 22.8% in FDD alone (P < 0.001) and 31.1% in ADHD + FDD versus 7.8% in ADHD alone (P < 0.001). CONCLUSIONS: Approximately 10.3% of children with FDDs had ADHD and 22.7% of children with a known diagnosis of ADHD fulfilled the Rome III criteria for an FDD. This observation suggests that screening for behavioral disorders and FDDs should be incorporated into the diagnostic workup of these groups of children.

Prevalence of functional bowel disorders and faecal incontinence: an Australian primary care survey.

AIM: Interest in functional bowel disorders (FBDs) and faecal incontinence (FI) has increased amongst coloproctologists. The study aimed to assess the prevalence of FBDs and FI (including its severity) among Australian primary healthcare seekers using objective criteria. METHOD: A cross-sectional survey was conducted in a primary care setting in Sydney, Australia. A self-administered questionnaire was used to collect demographic information and diagnose FBDs (irritable bowel syndrome, constipation, functional bloating and functional diarrhoea) based on Rome III criteria. The severity of FI was determined using the Vaizey incontinence score. Associations with medical/surgical history and healthcare utilization were assessed. RESULTS: Of 596 subjects approached, 396 (66.4%) agreed to participate. Overall, 33% had FBD and/or FI. Irritable bowel syndrome was present in 11.1% and these participants were more likely to report anxiety/depression (P < 0.01) and to have had a previous colonoscopy (P < 0.001) or cholecystectomy (P = 0.02). Functional constipation was present in 8.1%, and functional bloating and functional diarrhoea were diagnosed in 6.1%, and 1.5%, respectively. FI was present in 12.1% with the majority (52%) reporting moderate/severe incontinence (Vaizey score > 8). Participants with FI were more likely to have irritable bowel syndrome, urinary incontinence and previous anal surgery (P < 0.01). CONCLUSION: FBDs and FI are prevalent conditions amongst primary healthcare seekers and the needs of those affected appear to be complex given their coexisting symptoms and conditions. Currently, the majority do not reach colorectal services, although increased awareness by primary care providers could lead to sufferers being referred for specialist management.

Prevalence and risk factors for abdominal bloating and visible distention: a population-based study.

BACKGROUND: Abdominal bloating and visible distention are common yet poorly understood symptoms. Epidemiological data distinguishing visible distention from bloating are not available. We aimed to evaluate the prevalence and potential risk factors for abdominal bloating and visible distention separately in a representative US population, and their association with other functional gastrointestinal disorders (FGIDs). METHODS: The validated Talley Bowel Disease Questionnaire was mailed to a cohort selected at random from the population of Olmsted County, Minnesota. The complete medical records of responders were abstracted; 2259 subjects (53% females; mean age 62 years) provided bloating and distention data. RESULTS: The age and sex-adjusted (US White 2000) overall prevalence per 100 for bloating was 19.0 [95% confidence interval (CI), 16.9 to 21.2] vs 8.9 (95% CI, 7.2 to 10.6) for visible distention. Significantly increased odds for bloating alone and separately for distention (vs neither) were detected in females, and in those with higher overall Somatic Symptom Checklist (SSC) scores and higher scores of each individual SSC item. Further, females [odds ratio (OR), 1.5; 95% CI, 1.0 to 2.1], higher SSC score (OR, 1.4; 95% CI, 1.1 to 1.8), constipation-predominant irritable bowel syndrome (OR, 2.3; 95% CI, 1.3 to 4.1), dyspepsia (OR, 1.9; 95% CI, 1.1 to 3.2), and gastro-intestinal symptom complex overlap (OR, 1.7; 95% CI, 1.1 to 2.7) significantly increased odds for distention over bloating alone. CONCLUSIONS: Bloating and distention are common and have similar risk factors; somatisation probably plays a role.

Abdominal bloating in employed adults: prevalence, risk factors, and association with other bowel disorders.

UNLABELLED: BACKGROUND Bloating is common, but its significance as a marker of underlying disease has not been defined. AND AIMS: We report on risk factors for bloating, its relationship to physical activity and quality of life (QOL), and its predictive value for functional bowel disorders. METHODS: This is a cross-sectional population-based study of 1,069 employees of the Veterans Affairs Black Hills Health Care System. The validated Bowel Disease Questionnaire was used to identify subjects with abdominal bloating and other bowel disorders. The association of bloating with QOL was assessed using the SF36 (Short-Form 36) questionnaire. Physical activity was assessed using the modified Baecke questionnaire. RESULTS: The response rate was 72% (723 of 1,069). Bloating was reported by 21% of all subjects (95% confidence interval [CI] 17.7-23.7), 64% with irritable bowel syndrome (IBS), 35% with non-IBS constipation, 23% with non-IBS diarrhea, and 42% with dyspepsia. Functional bloating (i.e., bloating in the absence of other bowel disorders) was reported by 7% of subjects (95% CI 5.2-9.0). Of those with bloating, 28% had IBS, 25% non-IBS constipation, 8% non-IBS diarrhea, and 30% dyspepsia. The positive and negative predictive values of bloating in the diagnosis of functional bowel disorder were 66% and 87%, respectively. The only risk factors were smoking and high-dose aspirin. Bloating was not associated with physical activity. QOL on all subscales of SF36 was lower in subjects with bloating than those without bloating. CONCLUSIONS: Bloating is a common symptom in otherwise healthy adults, and is often associated with but not predictive of functional bowel disorders. Smoking and high-dose aspirin are associated with bloating while physical activity is not.

Applying case definition criteria to irritable bowel syndrome.

OBJECTIVE: The quality of documentation of signs and symptoms and validation of the diagnosis of irritable bowel syndrome (IBS) according to case definition criteria of Manning, Rome I and Rome II in an office setting has not been previously described. We sought to identify and validate cases of IBS based on the Manning, Rome I and Rome II diagnostic criteria in a rural practice setting. SETTING: Marshfield Epidemiologic Study Area (MESA) Central consisting of 14 ZIP codes in central Wisconsin, USA. METHODS: A retrospective cohort study involved 890 patients with the diagnostic codes 564.1 for irritable bowel syndrome and 306.4 spastic colon-psychogenic who had presented to the practice from 1993-2003. Duration, frequency, concordance and intensity of symptoms based on case definitions of IBS were abstracted from the medical records. RESULTS: During the study period, 890 incident cases of IBS were identified. Only 404 met one or more of the three diagnostic criteria, 340 (84%) met only the Manning criteria, 35 (10%) met only Manning and Rome I criteria, 4 (1%) met both Manning and Rome II criteria, and 25 (6%) met Manning and Rome I and Rome II criteria. Age adjusted incidence rates per 100,000 person-years for validated IBS cases during the observational period were 87 to 170 by Manning (lower confidence interval [CI]: 57-127, upper CI: 116-213), 8 to 34 (lower CI: 0-14, upper CI: 16-53) for Rome I and 3 to 16 (lower CI: 0-3, upper CI: 8-28) for Rome II. Comparison of Rome I and Rome II showed moderate concordance (kappa statistic = 0.51; 95% CI: 0.39-0.64). CONCLUSIONS: Only a small percentage of IBS cases with assigned diagnostic codes met case definition criteria for IBS. There were low concordance rates among the three diagnostic criteria applied.

Epidemiology of slow and fast colonic transit using a scale of stool form in a community.

BACKGROUND: Measurement of gastrointestinal transit is commonly performed in the clinic, but data on transit in the community are lacking. AIM: To estimate the prevalence of slow and fast colonic transit using stool form, and potential risk factors. METHODS: A validated self-reported gastrointestinal symptom questionnaire was mailed to 4196 randomly selected members of the community (response rate 54%). One question asked the subject to self-report their stool form using the Bristol Stool Scale. RESULTS: Overall, 18%, 9% and 73% met stool form criteria for slow, fast or normal colonic transit, respectively. Increased odds for slow transit were observed with a higher Somatic Symptom Checklist score (OR = 1.6; 1.3-2.0), while a decreased odds for slow transit was observed in males relative to females (OR = 0.6; 0.5-0.8). An increased odds for fast transit was observed with higher Somatic Symptom Checklist score (OR = 2.3; 1.7-2.9) and a history of cholecystectomy (OR = 1.8; 1.2-2.8). Increasing body mass index (per 5 units) was associated with decreased odds for slow (OR = 0.85; 0.78-0.93), and an increased odds for fast (OR = 1.1; 1.04-1.24) colonic transit. CONCLUSION: Based on stool form assessment, nearly one in five community members may have slow colonic transit and one in 12 have accelerated colonic transit.

Irritable bowel syndrome and the Rome III criteria: for better or for worse?

The paper by Sperber et al. in this issue is an early evaluation of the Rome III criteria against the Rome II criteria for irritable bowel syndrome that throws up several important observations. A three to four-fold increase was observed in irritable bowel syndrome prevalence with the Rome III criteria. Individuals with the Rome II criteria had more doctor visits, perception of stress and a negative global feeling. There could be a shift of individuals between irritable bowel syndrome and other functional bowel disorder diagnostic groups such as functional constipation and functional bloating. In this review, it is suggested that rigid application of the symptom frequency and duration requirements of the older Rome criteria could have introduced a selection bias for patients with greater psychological disturbance, and that this could have impacted negatively on our perception and management of irritable bowel syndrome. The findings of Sperber et al. suggest that the new Rome III criteria may enable us to pay more attention to the average irritable bowel syndrome patient we see in our clinics as opposed to the chronically severe patient. It is proposed that improved management of our average patient may translate into better outcomes in terms of reduction in specialist referral, unnecessary surgery and potentially harmful alternative treatments.

A comparative reappraisal of the Rome II and Rome III diagnostic criteria: are we getting closer to the 'true' prevalence of irritable bowel syndrome?

OBJECTIVES: Revisions of the diagnostic criteria for irritable bowel syndrome have led to varying prevalence estimates. The Rome III criteria require a lower symptom frequency than Rome II (at least 10% of the time for Rome III, compared with at least 25% of the time for Rome II). In an epidemiological survey of a representative sample of Israeli adults using Rome II, we reported the prevalence for irritable bowel syndrome as 2.9%. The official Rome II integrative questionnaire, used for that study, enables a close approximation of Rome III rates, facilitating a retrospective comparison of these criteria. METHODS: A representative sample of 1000 adults was interviewed with a validated Hebrew version of the official Rome II integrative questionnaire. The data were re-evaluated retrospectively to compare the Rome II results with a close approximation of the new Rome III criteria. RESULTS: The prevalence rates for irritable bowel syndrome were 2.9 and 11.4%, respectively, for Rome II and Rome III. The corresponding consultation rates were 57.1 and 41.7%, indicating that the more strict Rome II criteria may select out a group of patients with more severe disease or greater psychosocial problems. Women made up 71.4% of irritable bowel syndrome by Rome II and 62.5% by Rome III. CONCLUSIONS: In the present retrospective study, the prevalence rate for irritable bowel syndrome in our population is significantly higher by Rome III compared with Rome II. Rome III may more closely reflect the socioeconomic burden of irritable bowel syndrome compared with the overly strict Rome II. Prospective comparative studies should be conducted to confirm these results.

[An epidemiologic study of functional bowel disorders in adolescents in China].

OBJECTIVE: To explore the most common bowel frequency and the prevalence rates of functional bowel disorders among adolescents in China. METHODS: A questionnaire survey was conducted among 51,956 students from high and primary schools in 6 Chinese cities distributed in the whole China collected by stratified, randomized, cluster sampling to study the epidemiology of functional bowel disorders. RESULTS: (1) 88.05% +/- 0.28% of the students had bowel frequency between 1 - 2 times/day and 1 time/two days. Girl students were found to have a lower bowel frequency than boy students (P < 0.01). (2) The prevalence rates of irritable bowel syndrome, chronic constipation, and chronic diarrhea were 20.19% (10 490), 25.92% (13 467), and 8.77% (4557) respectively. CONCLUSION: (1) The normal bowel frequency among adolescents in China may be defined as bowel movements between 1 - 2 times per day and 1 time per two days. (2) Irritable bowel syndrome, chronic constipation and chronic diarrhea are common disorders among the adolescents in China.

[Chronic heart failure: structural and microbiological changes in the colon].

AIM: To study microbiocenosis of the parietal layer of the colon and feces, concentrations of endotoxin and proinflammatory cytokines in patients with chronic heart failure (CHF) of different functional classes vs. healthy subjects of the same age. MATERIAL AND METHODS: The trial includes 37 patients with ischemic CHF and 13 healthy volunteers. The examination comprised 6-min walking test, echocardiographic evaluation of the left ventricular ejection fraction, clinical state by a special scale, assay for C-reactive protein, endotoxin, fecal seeding, colonoscopy with biopsy and seeding. RESULTS: Gram-negative flora in the colon and parietal layer occurred in high concentrations correlating with severity of CHF. The examinees with CHF of functional class III-IV had elevated levels of circulating endotoxin and serum C-reactive protein.

A unifying hypothesis for the functional gastrointestinal disorders: really multiple diseases or one irritable gut?

The functional gastrointestinal disorders are defined by the Rome criteria as a heterogeneous group of symptom-based conditions that have no structural or biochemical explanation. However, this definition now seems outdated, because structural and molecular abnormalities have begun to be recognized in subsets of patients with the irritable bowel syndrome (IBS), the prototypic functional bowel disease. A complex classification system based arbitrarily on symptom criteria does not fit in with a number of emerging facts. For example, the symptom overlap of IBS with gastroesophageal reflux disease is not due to chance, and the emergence of post-infectious IBS, dyspepsia, or both after Salmonella gastroenteritis fits better with a 1-disease model. A new paradigm seems to be needed. All of these disorders may arise after infection or gut inflammation, but the phenotype depends on localized neuromuscular dysfunction in the predisposed human host (the "irritable gut").

Functional bowel disorders in rotating shift nurses may be related to sleep disturbances.

OBJECTIVES: To compare the frequency and severity of bowel disturbances between rotating shift and regular day nurses and to determine whether functional bowel disorders (FBD) were related to sleep disturbances. METHODS: Sixty regular day and 58 rotating shift nurses answered three standardized questionnaires: the Gastrointestinal Symptom Questionnaire; the Hospital Anxiety and Depression Scale; and the Irritable Bowel Syndrome Symptoms Evaluation Questionnaire, which included the Sleep Questionnaire, on the frequency and severity of gastrointestinal symptoms, sleep disturbances and psychological distress. Responses to these questions were numerically rated and the sums of individual symptom scores under the respective categories were computed and analysed using statistical tests, as appropriate. RESULTS: Although 22 out of 58 rotating shift nurses (38%) had FBD, only 12 out of 60 regular day nurses (20%) had it (P=0.04). The mean FBD symptom score (P<0.002), sleep disturbance score (P<0.0001) and anxiety score (P<0.002) were all significantly higher among the rotating shift nurses. FBD symptom scores were positively correlated with the sleep disturbance (P=0.0001), anxiety (P=0.0001), depression (P=0.0001), well-being (P=0.0001), fatigue (P=0.0001), and somatic pain scores (P=0.0001). Sleep disturbance (P=0.04), decreased well-being (P=0.04), anxiety (P=0.02), and somatic pain (P=0.03) were independent predictors of FBD symptoms. CONCLUSION: FBD were more common and severe among rotating shift nurses. The FBD symptom score was positively and independently correlated with the sleep disturbance score, suggesting that poor sleep might be associated with increased FBD symptoms in rotating shift nurses.

Functional bowel and anorectal disorders in patients with pelvic organ prolapse and incontinence.

OBJECTIVE: The purpose of this study was 1) to determine the prevalence of functional bowel and anorectal disorders as defined by the Rome II criteria in patients with advanced pelvic organ prolapse (POP) and urinary incontinence (UI), and (2) to determine if the extent of prolapse on gynecologic examination is related to the subtypes of constipation or any functional anorectal pain disorder. STUDY DESIGN: Three hundred and two consecutive female subjects presenting to a tertiary urogynecology clinic were enrolled. Demographic, general medical, and physical examination information, including POPQ measurements and a standardized sacral neurologic evaluation, were collected. The prevalence of functional disorders of the bowel, rectum, and anus as defined by the Rome II criteria were collected using the Rome II Modular questionnaire. Relationships of functional disorders to various components of the vaginal examination were reviewed. RESULTS: Thirty-six percent (108/302) met the criteria for constipation, including the following subtypes: 19% outlet constipation, 5% functional constipation, 5% constipation predominant irritable bowel syndrome (IBS), and 7% IBS-outlet. Nineteen percent (56/302) of subjects had IBS or 1 of its subtypes. Functional diarrhea was seen in 6% (17/302), fecal incontinence in 19% (58/302), and anorectal pain disorders in 25% (77/302). After controlling for age, parity, diabetes, constipating medications, and previous pelvic surgery, there were no differences in the prevalence of constipation or any of its subtypes between patients with UI and those with stage 3 or 4 POP. Fecal incontinence was independently associated with UI (adjusted odds ratio [OR] 6.3; 95% CI 2.6-19.1), but not advanced POP. Neither overall stage of POP nor stage of posterior vaginal prolapse was significantly associated with any of the functional bowel disorders, including constipation and its subtypes. Perineal body measurement was significantly longer in patients with outlet type constipation (mean 3.5 +/- 0.6 cm vs 3.1 +/- 0.9 cm, P < .01) and in those with proctalgia fugax (mean 3.4 +/- 1.0 vs 3.1 +/- 0.8, P < .05). CONCLUSION: There is a high prevalence of constipation and anorectal pain disorders in women with urinary incontinence and pelvic organ prolapse. However, patients with stage 3 or 4 pelvic organ prolapse have similar rates of constipation compared with those with urinary incontinence. Constipation and its subtypes are not related to the stage of pelvic organ prolapse. It appears that either constipation is not a significant contributor to prolapse, or constipation contributes equally to the development of both urinary incontinence and pelvic organ prolapse.

Family study of affective spectrum disorder.

BACKGROUND: Affective spectrum disorder (ASD) represents a group of psychiatric and medical conditions, each known to respond to several chemical families of antidepressant medications and hence possibly linked by common heritable abnormalities. Forms of ASD include major depressive disorder (MDD), attention-deficit/hyperactivity disorder, bulimia nervosa, cataplexy, dysthymic disorder, fibromyalgia, generalized anxiety disorder, irritable bowel syndrome, migraine, obsessive-compulsive disorder, panic disorder, posttraumatic stress disorder, premenstrual dysphoric disorder, and social phobia. Two predictions of the ASD hypothesis were tested: that ASD, taken as a single entity, would aggregate in families and that MDD would coaggregate with other forms of ASD in families. METHODS: Probands with and without MDD, together with their first-degree relatives, were interviewed using the Structured Clinical Interview for DSM-IV and a supplemental interview for other forms of ASD. The familial aggregation and coaggregation of disorders were analyzed using proband predictive logistic regression models, including a novel bivariate model for the presence or absence of each of 2 disorders in a relative as predicted by the presence or absence of each of 2 disorders in the associated proband. RESULTS: In the 178 interviewed relatives of 64 probands with MDD and 152 relatives of 58 probands without MDD, the estimated odds ratio (95% confidence interval) for the familial aggregation of ASD as a whole was 2.5 (1.4-4.3; P =.001) and for the familial coaggregation of MDD with at least one other form of ASD was 1.9 (1.1-3.2; P =.02). CONCLUSIONS: Affective spectrum disorder aggregates strongly in families, and MDD displays a significant familial coaggregation with other forms of ASD, taken collectively. These results suggest that forms of ASD may share heritable pathophysiologic features.

Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area project.

OBJECTIVE: Clinical experience and recent reports suggest that there is a high prevalence of gastrointestinal symptoms in patients with panic disorder and that there is a high prevalence of panic disorder in patients with irritable bowel syndrome, a functional gastrointestinal disorder. To assess gastrointestinal symptoms in a nonpatient, community-based sample, the authors surveyed the prevalence of gastrointestinal symptoms in individuals with panic disorder and other or no psychiatric disorders obtained in a national community survey. METHOD: Subjects were 13,537 respondents at four sites of the National Institute of Mental Health (NIMH) Epidemiological Catchment Area project. DSM-III diagnoses were determined by using the NIMH Diagnostic Interview Schedule (DIS). Gastrointestinal symptoms were assessed from the somatization disorder section of the DIS. RESULTS: Individuals with panic disorder had a significantly higher rate of endorsing gastrointestinal symptoms, including those typically associated with irritable bowel syndrome, than those with other or no psychiatric diagnosis. CONCLUSIONS: Findings suggest a diagnostic overlap between panic disorder and irritable bowel syndrome, with similar demographic and clinical characteristics of patients. Limitations of the study are discussed in terms of medical assessment and self-report inventories. Practical and theoretical implications are discussed.

Histories of sexual victimization in patients with irritable bowel syndrome or inflammatory bowel disease.

OBJECTIVE: Two reports have suggested a possible association between a history of sexual trauma and irritable bowel syndrome, but several factors in their study designs limited their generalizability. The authors used a more rigorous methodology to confirm this association. METHOD: They administered structured psychiatric and sexual trauma interviews to 28 patients with irritable bowel syndrome and 19 patients with inflammatory bowel disease and compared prevalence rates of sexual victimization in the two groups. RESULTS: Compared with patients diagnosed as having inflammatory bowel disease, patients with irritable bowel syndrome had a significantly higher rate of severe lifetime sexual trauma (32% versus 0%), severe childhood sexual abuse (11% versus 0%), and any lifetime sexual victimization (54% versus 5%). The nine patients who had experienced severe lifetime victimization had significantly higher odds ratios for lifetime depression, panic disorder, phobia, somatization disorder, alcohol abuse, functional dyspareunia, and inhibited sexual desire than the 38 patients who had experienced less severe sexual trauma or no trauma. A logistic regression analysis showed that gender, the number of medically unexplained physical symptoms, and self-reported anxiety and hostility accounted for all of the variance in the victimized group. CONCLUSIONS: These preliminary results suggest that sexual victimization may be an important factor in the development of irritable bowel syndrome in some patients. Future studies attempting to categorize subgroups of patients with irritable bowel syndrome should inquire into past histories of sexual victimization.

PIP: This study confirms the previously studied findings by using a more rigorous methodology concerning the association of sexual victimization history and irritable bowel syndrome or inflammatory bowel disease. Structured psychiatric and sexual trauma interviews were given to 28 patients with irritable bowel syndrome and 19 inflammatory bowel disease, and the prevalence rates of sexual victimization in the 2 groups were compared. A logistic regression analysis was performed to summarize the differences between patients who had severe trauma and those who had none, and to account for intercorrelations among the study variables. Results showed that patients with irritable bowel syndrome were more likely to have a history of previous sexual victimization. The odd ratios for current and lifetime psychiatric disorders in the 9 patients who had experienced severe forms of victimization showed that they were at significantly greater risk for affective, anxiety, and somatoform disorders as well as substance abuse and sexual dysfunction. It was also demonstrated that the best predictors of having experienced severe forms of victimization were gender, the number of medically unexplained physical symptoms, and self-reported anxiety and hostility. This study suggests that irritable bowel syndrome may be part of a chronic adjustment to previous sexual victimization in some patients.

Familial association in adults with functional gastrointestinal disorders.

OBJECTIVE: To evaluate the association between functional gastrointestinal (GI) symptoms and a family history of abdominal pain or bowel problems. SUBJECTS AND METHODS: A valid self-report questionnaire that records GI symptoms and spouse's and first-degree relatives' history of abdominal pain or bowel troubles and includes the psychosomatic symptom checklist (a measure of somatization) was mailed to an age- and sex-stratified random sample of Olmsted County, Minnesota, residents aged 30 to 64 years. A logistic regression model that adjusted for age, sex, and somatic symptom score was used to estimate the odds ratio (OR) and 95% confidence interval (CI) of a positive family history for each functional GI disorder. RESULTS: Six hundred forty-three (72%) of 892 eligible subjects returned the survey. Reporting a first-degree relative with abdominal pain or bowel problems was significantly associated with reporting of irritable bowel syndrome (OR, 2.3; 95% CI, 1.3-3.9) and dyspepsia (OR, 1.8; 95% CI, 1.05-3.0) but not constipation, diarrhea, or gastroesophageal reflux. The reporting of a spouse with abdominal pain or bowel problems was not associated with any of these disorders. CONCLUSIONS: A history of abdominal pain or bowel troubles in first-degree relatives was significantly associated with irritable bowel syndrome and dyspepsia. Whether the familial associations represent similar exposures in a shared environment, heightened familial awareness of GI symptoms (reporting bias), or genetic factors remains to be determined.

Review article: irritable bowel syndrome.

Irritable bowel syndrome is a disease that can be diagnosed positively on the basis of an established series of criteria and limited exclusion of organic disease. It is the most common disease diagnosed by gastroenterologists and affects about 20% of all people at any one time. Symptoms fluctuate, and the overall prevalence rate is relatively constant in Western communities. Ten per cent of patients present to their physicians; the illness has a large economic impact on health-care utilization and absenteeism. Irritable bowel syndrome is a biopsychosocial disorder in which three major mechanisms interact: psychosocial factors; altered motility; and/or sensory function of the intestine. Management of patients is based on positive diagnosis of the symptom complex, limited exclusion of underlying organic disease and institution of a therapeutic trial. If patient symptoms are intractable, further investigations are needed to exclude significant motility or other disorders. Symptomatic treatment includes fibre for constipation, loperamide for diarrhoea and low-dose antidepressants or infrequent use of antispasmodics for pain; novel pharmacological agents, psychotherapy and hypnotherapy are being evaluated.

Clinical economics review: irritable bowel syndrome.

The ubiquitous nature of irritable bowel syndrome (IBS), coupled with a lack of good treatment options, has created the impression that the condition must represent a large drain on health-care resources. The literature certainly appears to support this view but is largely based on patients seen in referral centres (10-15%) and it may not be appropriate to extrapolate these data to the IBS population as a whole (85-90%). In addition to reviewing such literature that exists on the economics of IBS, this paper contains some new data, which suggest that the direct costs of the condition, certainly in the UK, may not be quite as high as has previously been assumed. This may be partly due to factors such as the low cost of the drugs used to treat the condition and the tendency for many patients to stop consulting because of disenchantment with the inadequacies of current therapy. Conversely, the indirect and intangible costs of the disorder appear to be much greater, but these burdens obviously do not have such an impact on those responsible for purchasing and providing health care for IBS sufferers. Paradoxically, if a new, effective therapy for IBS were forthcoming, the situation could change dramatically, especially if it involved a new drug. Any such agent would inevitably be more expensive than anything available today, leading to a potentially dramatic escalation in the direct costs of this disorder.