What determines severity among patients with painful functional bowel disorders? (original) (raw)

Functional bowel disorders and functional abdominal pain

Gut, 1999

The Rome diagnostic criteria for the functional bowel disorders and functional abdominal pain are used widely in research and practice. A committee consensus approach, including criticism from multinational expert reviewers, was used to revise the diagnostic criteria and update diagnosis and treatment recommendations, based on research results. The terminology was clarified and the diagnostic criteria and management recommendations were revised. A functional bowel disorder (FBD) is diagnosed by characteristic symptoms for at least 12 weeks during the preceding 12 months in the absence of a structural or biochemical explanation. The irritable bowel syndrome, functional abdominal bloating, functional constipation, and functional diarrhea are distinguished by symptom-based diagnostic criteria. Unspecified FBD lacks criteria for the other FBDs. Diagnostic testing is individualized, depending on patient age, primary symptom characteristics, and other clinical and laboratory features. Functional abdominal pain (FAP) is defined as either the FAP syndrome, which requires at least six months of pain with poor relation to gut function and loss of daily activities, or unspecified FAP, which lacks criteria for the FAP syndrome. An organic cause for the pain must be excluded, but aspects of the patient's pain behavior are of primary importance. Treatment of the FBDs relies upon confident diagnosis, explanation, and reassurance. Diet alteration, drug treatment, and psychotherapy may be beneficial, depending on the symptoms and psychological features.

Symptoms and Visceral Perception in Patients With Pain-Predominant Irritable Bowel Syndrome

American Journal of Gastroenterology, 1999

OBJECTIVE: Abdominal pain is thought to be a hallmark of the irritable bowel syndrome (IBS), although currently used symptom criteria do not differentiate between abdominal pain and discomfort. By focusing on viscerosensory symptoms, we sought to determine: 1) which type of symptoms are most commonly reported by IBS patients, and 2) whether patients who report pain as their most bothersome symptom differ in clinical, psychological, and physiological characteristics. METHODS: A total of 443 consecutive new patient referrals to a tertiary referral center for functional gastrointestinal disorders who met symptom criteria for IBS were given validated, psychometric, health status, and bowel symptom questionnaires containing specific questions regarding the patients' predominant viscerosensory gastrointestinal symptom. Of these patients, 155 (35%) also met criteria for functional dyspepsia. A representative subset of the total IBS patient population (n ϭ 58) underwent evaluation of perceptual responses to controlled rectal distension before and after a noxious sigmoid conditioning stimulus. RESULTS: Viscerosensory symptoms clustered into four groups: 1) abdominal pain, 2) bloating-type discomfort, 3) sensation of incomplete rectal evacuation, and 4) extraabdominal (chest pain or pressure and nausea). A total of 66% of patients reported gas as one of their viscerosensory symptoms, whereas 60% reported abdominal pain as one of their symptoms. Only 29% rated abdominal pain as their most bothersome symptom, whereas bloating-type symptoms were listed by 60% as most bothersome. Although pain predominance did not correlate with the severity of gastrointestinal or psychological symptoms, there was a significant correlation with the development of rectal hypersensitivity in response to the sigmoid conditioning stimulus. CONCLUSIONS: In a tertiary referral population of IBS patients: 1) abdominal pain is reported by only one third of patients as their most bothersome viscerosensory symptoms; and 2) pain-predominance correlates with development of rectal hypersensitivity after a noxious sigmoid stimulus.

Functional bowel disorders

Digestive Diseases and Sciences, 1995

In a multicenter study of patients with painful functional bowel disorders (FBD), we compared the demographic, health status, and diagnostic features of patients with FBD and developed a functional bowel disorder severity index (FBDSI) for research and clinical care. Two hundred seventy patients with FBD in the United States, England, and Canada were surveyed on symptoms and health status, and their physicians made a diagnosis and rated illness severity as mild, moderate, or severe. Comparisons of 22 demographic and clinical variables were made by study site in addition to physicians' severity ratings. To develop the FBDSI, multiple regression analysis used the demographic and clinical variables to predict the physician's rating of severity. We found that most health status measures of patients with FBD across study sites are comparable and the derived and validated FBDSI scoring system uses three easy to obtain variables: FBDSI = [current pain by visual analog scale (0-100)] + [diagnosis of chronic functional abdominal pain (0 if absent and 106 if present)] + [number of physicians visits over previous six months × 11]. The FBDSI can be used to select patients for research protocols and/or follow their clinical outcome or response to treatments over time.

Pain Management in Functional Gastrointestinal Disorders

Canadian Journal of Gastroenterology

Pain is a common feature in functional gastrointestinal disorders (FGID). An abnormally low visceral sensory threshold, as well as a number of central, spinal and peripheral pain-modulating abnormalities, have been proposed for this syndrome. Clinical aspects of pain associated with irritable esophagus, functional dyspepsia, biliary dysmotility, inflammatory bowel syndrome and proctalgia fugax are reviewed. Because of its unclear pathophysiology, pain expression is the main target for the successful assessment and management of symptomatic FGID. The sensory, cognitive and affective components of pain intensity expression need to be addressed in the context of a good physician-patient rapport. A multidisciplinary team approach is ideal for the smaller subset of patients with severe and disabling symptoms. Although pharmacotherapy may target specific functional disorders, the role of behavioural techniques and psychotherapy appears much more important for pain management in FGID. Func...

Pain Hypersensitivity in Patients with Functional Gastrointestinal Disorders: A Gastrointestinal-Specific Defect or a General Systemic Condition

Digestive Diseases and Sciences, 2001

Visceral hypersensitivity was shown in patients with functional gastrointestinal disorders (FGID). The mechanisms underlying this sensory dysfunction remain undetermined. The initial hypothesis of a generalized reduction in pain tolerance was rejected by further studies that suggested a normal tolerance to somatic stimuli and led to the generally accepted assumption that pain intolerance is specific and exclusive for visceral stimuli in these patients. We wanted to revisit this theory by examining whether patients with FGID reported perception and tolerance to somatic pain differently from normal subjects and whether the response to somatic pain stimulus was correlated to gastrointestinal symptoms or psychological status or distress. Thirty-three patients with FGID (Rome II criteria)(F/M: 26/7; mean age 48 ± 9.9) and 33 normal controls (F/M: 24/9; mean age 44.1 ± 6.8) were asked to immerse their nondominant hand into 4°C water for as long as possible (maximum 120 sec). Time before appearance of: (1) discomfort, (2) pain, and (3) withdrawing of the hand were noted. The intensity of pain was rated on a visual analog scale from 0 to 100. Self-report questionnaires were used to assess the severity of gastrointestinal symptoms (St-Luc GI index) and the psychological distress (SCL-90) in the patient group. Data are expressed in seconds as mean ± sem. Discomfort sensory thresholds were similar in controls and FGID patients (28 ± 3 and 24 ± 2, respectively; NS) whereas pain and withdrawing were significantly lower in FGID (41 ± 3 and 76 ± 6 sec) than in controls (62 ± 6 and 102 ± 4; P ). Pain intensity was similar in both groups (64 ± 4 vs 67 ± 3; NS). Female patients showed lower sensory thresholds than male patients and control females (pain thresholds: 39.8 ± 3.4 vs 67.8 ± 16.7 and vs 56.8 ± 8.7; P ). Sensory thresholds were not different in subgroups of patients with FGID (irritable bowel syndrome and functional dyspepsia). No correlation was shown between sensory thresholds and gastrointestinal index or SCL 90-test. In conclusion, FGID patients showed a threshold to painful somatic stimulus that was lower than in normal subjects. These findings suggest that patients with FGID may have hyperalgesia and low pain tolerance that is not limited to the viscera, but that is part of a systemic general condition.

Symptom Profiles in Patients with Irritable Bowel Syndrome or Functional Abdominal Pain Compared to Healthy Controls

Journal of Pediatric Gastroenterology and Nutrition, 2015

Objectives: Patient-reported outcome (PRO) measures of gastrointestinal symptoms are recommended to determine treatment effects for irritable bowel syndrome (IBS) and functional abdominal pain (FAP). Study objectives were to compare the symptom profiles of pediatric patients with IBS or FAP with healthy controls and with each other using the PedsQL Gastrointestinal Symptoms and Gastrointestinal Worry Scales, and to establish clinical interpretability of PRO scale scores through identification of minimal important difference (MID) scores. Methods: Gastrointestinal Symptoms and Worry Scales were completed in a 9-site study by 154 pediatric patients and 161 parents (162 families; IBS n ¼ 46, FAP n ¼ 119). Gastrointestinal Symptoms Scales measuring stomach pain, stomach discomfort when eating, food and drink limits, trouble swallowing, heartburn and reflux, nausea and vomiting, gas and bloating, constipation, blood in poop, and diarrhea were administered along with Gastrointestinal Worry Scales. A matched sample of 447 families with healthy children completed the scales. Results: Gastrointestinal Symptoms and Worry Scales distinguished between patients with IBS or FAP compared with healthy controls (P < 0.001), with larger effect sizes (>1.50) for symptoms indicative of IBS or FAP, demonstrating a broad multidimensional gastrointestinal symptom profile and clinical interpretability with MID scores for individual PRO scales. Patients with IBS manifested more symptoms of constipation, gas and bloating, and diarrhea than patients with FAP. Conclusions: Patients with IBS or FAP manifested a broad gastrointestinal symptom profile compared with healthy controls with large differences, indicating the critical need for more effective interventions to bring patient functioning within the range of healthy functioning.

Increased pain sensitivity among adults reporting irritable bowel syndrome symptoms in a large population-based study

PAIN, 2013

The aim of this study was to examine whether irritable bowel syndrome (IBS) is associated with increased somatic pain sensitivity in a large population-based sample and to test whether this association was independent of sex, age, comorbid chronic pain, and psychological distress. Pain sensitivity tests included assessment of heat-pain threshold (N = 4054) and pressure-pain threshold (N = 4689) and of cold-pressor pain intensity and tolerance (N = 10,487). Cox regression and analysis of variance (ANOVA) were used to assess the relationship between IBS and pain sensitivity in stepwise multivariate models. The prevalence of IBS symptoms meeting the ROME II criteria was 5.3%. Compared with control subjects, IBS cases had reduced cold-pressor tolerance (hazard ratio = 1.4, P < .01), increased cold-pressor pain intensity ratings (z-score = +0.20, P < 0.01), and lower heat-pain thresholds (z-score =-0.20, P < 0.01), after adjusting for sex and age. These results were only slightly attenuated and remained significant when controlling for comorbid chronic pain and psychological distress. Results for pressure-pain threshold were not significant. Heat-and cold-pressor pain sensitivity was greatest for the IBS reporting severe chronic abdominal pain, indicating that hyperalgesia in IBS is related to degree of clinical pain rather than to the diagnosis per se. Because all pain tests were all carried out on the upper extremities, our findings indicate the presence of widespread hyperalgesia in IBS, which may be a contributing factor to the high rate of comorbid pain seen in this patient group.

Patient-Reported Outcomes for Irritable Bowel Syndrome Are Associated With Patients' Severity Ratings of Gastrointestinal Symptoms and Psychological Factors

Clinical Gastroenterology and Hepatology, 2011

PROs) are used to gauge the benefit of treatments for functional gastrointestinal disorders, including irritable bowel syndrome (IBS). Commonly used end points derived from scales of symptom severity differ in their structure, format, and the extent to which they are based on established psychometric fundamentals. We evaluated the overlap between 2 measures of IBS symptom severity, documented their association with different symptoms (pain, bloating, altered defecation), and identified psychological factors that might bias PRO ratings, by affecting how patients interpret IBS symptom severity.