Enteroscopy versus Video Capsule Endoscopy for Automatic Diagnosis of Small Bowel Disorders-A Comparative Analysis of Artificial Intelligence Applications.

BACKGROUND: Small bowel disorders present a diagnostic challenge due to the limited accessibility of the small intestine. Accurate diagnosis is made with the aid of specific procedures, like capsule endoscopy or double-ballon enteroscopy, but they are not usually solicited and not widely accessible. This study aims to assess and compare the diagnostic effectiveness of enteroscopy and video capsule endoscopy (VCE) when combined with artificial intelligence (AI) algorithms for the automatic detection of small bowel diseases. MATERIALS AND METHODS: We performed an extensive literature search for relevant studies about AI applications capable of identifying small bowel disorders using enteroscopy and VCE, published between 2012 and 2023, employing PubMed, Cochrane Library, Google Scholar, Embase, Scopus, and ClinicalTrials.gov databases. RESULTS: Our investigation discovered a total of 27 publications, out of which 21 studies assessed the application of VCE, while the remaining 6 articles analyzed the enteroscopy procedure. The included studies portrayed that both investigations, enhanced by AI, exhibited a high level of diagnostic accuracy. Enteroscopy demonstrated superior diagnostic capability, providing precise identification of small bowel pathologies with the added advantage of enabling immediate therapeutic intervention. The choice between these modalities should be guided by clinical context, patient preference, and resource availability. Studies with larger sample sizes and prospective designs are warranted to validate these results and optimize the integration of AI in small bowel diagnostics. CONCLUSIONS: The current analysis demonstrates that both enteroscopy and VCE with AI augmentation exhibit comparable diagnostic performance for the automatic detection of small bowel disorders.

Herbal Remedies for Constipation-Predominant Irritable Bowel Syndrome: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Constipation-predominant irritable bowel syndrome (IBS-C) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits. Conventional treatments for IBS-C often provide limited efficiency, leading to an increasing interest in exploring herbal remedies. This systematic review aims to evaluate the efficacy and safety of herbal remedies in the management of IBS-C. MATERIALS AND METHODS: A comprehensive search of PubMed, MEDLINE, Embase, Scopus, and the Cochrane Library was conducted to identify relevant studies published up to July 2023 and data extraction was performed independently by two reviewers. RESULTS: Overall, the included studies demonstrated some evidence of the beneficial effects of herbal remedies on IBS-C symptoms, including improvements in bowel frequency, stool consistency, abdominal pain, and quality of life. However, the heterogeneity of the interventions and outcome measures limited the ability to perform a meta-analysis. CONCLUSION: This systematic review suggests that herbal remedies may have potential benefits in the management of IBS-C. However, the quality of evidence is limited, and further well-designed, large-scale RCTs are needed to establish the efficacy and safety of specific herbal remedies for IBS-C. Clinicians should exercise caution when recommending herbal remedies and consider individual patient characteristics and preferences.

The Effect of Polyphenols, Minerals, Fibers, and Fruits on Irritable Bowel Syndrome: A Systematic Review.

BACKGROUND: Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder characterized by abdominal pain, bloating, and changes in bowel habits. Various dietary factors have been implicated in the pathogenesis and management of IBS symptoms. This systematic review aims to evaluate the effects of polyphenols, minerals, fibers, and fruits on the symptoms and overall well-being of individuals with IBS. MATERIALS AND METHODS: A comprehensive literature search was conducted in several electronic databases, including PubMed, Scopus, and Web of Science. Studies published up until July 2023 were included. RESULTS: The selected studies varied in terms of study design, participant characteristics, intervention duration, and outcome measures. Overall, the findings suggest that dietary interventions involving polyphenols, minerals, fibers, and fruits can have a positive impact on IBS symptoms. Dietary fiber supplementation, particularly soluble fiber, has been associated with reduced bloating and enhanced stool consistency. CONCLUSIONS: This systematic review provides evidence supporting the beneficial effects of polyphenols, minerals, fibers, and fruits in IBS patients. These dietary components hold promise as complementary approaches for managing IBS symptoms. However, due to the heterogeneity of the included studies and the limited number of high-quality randomized controlled trials, further well-designed trials are warranted to establish the optimal dosages, duration, and long-term effects of these interventions. Understanding the role of specific dietary components in IBS management may pave the way for personalized dietary recommendations and improve the quality of life for individuals suffering from this complex disorder.

Overlap syndrome of autoimmune hepatitis and primary biliary cholangitis complicated with atypical hepatocellular carcinoma: a case report.

BACKGROUND: Hepatocellular carcinoma (HCC) is a primary tumor of the liver. The majority of HCCs are associated most frequently with chronic B or C viral hepatitis, alcohol intake or aflatoxin exposure. Cirrhosis is a strong risk factor associated with HCC. The causes of liver cirrhosis are chronic viral hepatitis, alcohol intake, metabolic diseases (NAFLD), hemocromathosis, alfa 1 antitrypsisn deficiency. All aetiologic forms of cirrhosis are at risk to be complicated by HCC development, but the risk is higher for patients diagnosed with chronic viral hepatitis. Comparing to the above-mentioned causes, PBC and AIH are less associated with the risk of HCC development. A 71-year old Caucasian female previously diagnosed with overlap syndrome (AIH type 1 and PBC-ANA, SMA and AMA antibodies positive), liver cirrhosis, a nodule in the VI/VIIth hepatic segment, systemic sclerosis sine scleroderma, Hashimoto's thyroiditis, antiphospholipid syndrome, gastric antral vascular ectasia (GAVE) (with 2 previous sessions of argon plasma coagulation), cholecystectomy, arterial hypertension and nephro-angiosclerosis presented to the 2nd Department of Internal Medicine in Cluj-Napoca for a follow-up. The patient was following treatment with UDCA (Ursodeoxycholic acid), azathioprine, Plaquenil, calcium channel blockers, angiotensin-converting-enzyme inhibitor, calcium and vitamin D supplementation. The abdominal ultrasound showed a subcapsular hypoechoic nodule with a diameter of 29 mm (at the moment of the diagnosis the diameter was 9/10 mm) in the VI/VIIth hepatic segment. The contrast-enhanced ultrasound (CEUS) characterised the nodule as specific for hepatocellular carcinoma (LI-RADS 5). On MRI with gadoxetate disodium the nodule was hypovascular, non-specific, being classified as LI-RADS 3. An atypical resection of the VIIth hepatic segment was performed and the histohistological examination and imunohistochemistry (Hep Par-a positive, Glypican3 positive, CD34 positive) revealed a moderately differentiated hepatocellular carcinoma (G2), pT2 N0 M0 L0 V1 R0. CONCLUSION: Autoimmune hepatitis, PBC and the overlap syndrome are less associated with the development of liver cirrhosis and HCC than other chronic liver diseases, especially if other risk factors are not associated. This case highlights the importance of a proper surveillance of cirrhotic patients every 6 months including abdominal ultrasound and AFP levels is crucial for an early diagnosis of a HCC.

Adiponectin Levels in Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis.

INTRODUCTION: Adipose tissue plays an important role in the pathogenesis of inflammatory conditions. The role of adipokines in inflammatory bowel disease (IBD) has been evaluated in the current literature with conflicting results. The aim of this study was to evaluate adiponectin levels in IBD patients, including Crohn's disease (CD) and ulcerative colitis (UC), compared to controls, as well as further subgroup analyses. Hence, assessing the potential role of adiponectin as a surrogate marker. METHODS: We performed a systematic electronic search on PubMed, Embase, Scopus, and Cochrane Library, including observational or interventional studies evaluating serum or plasma adiponectin levels in IBD patients in humans. The primary summary outcome was the mean difference (MD) in serum or plasma adiponectin levels between IBD patients versus controls. Subgroup analyses were conducted involving adiponectin levels in CD and UC compared to controls, as well as CD compared to UC. RESULTS: A total of 20 studies were included in our qualitative synthesis and 14 studies in our quantitative synthesis, with a total population sample of 2,085 subjects. No significant MD in serum adiponectin levels was observed between IBD patients versus controls {-1.331 (95% confidence interval [CI]: -3.135-0.472)}, UC patients versus controls (-0.213 [95% CI: -1.898-1.472]), and CD patients versus controls (-0.851 [95% CI: -2.263-0.561]). Nevertheless, a significant MD was found between UC patients versus CD patients (0.859 [95% CI: 0.097-1.622]). CONCLUSIONS: Serum adiponectin levels were not able to differentiate between IBD, UC, and CD patients compared to controls. However, significantly higher serum adiponectin levels were observed in UC compared to CD patients.

Update on the Role of Rifaximin in Digestive Diseases.

Various environmental factors affecting the human microbiota may lead to gut microbial imbalance and to the development of pathologies. Alterations of gut microbiota have been firmly implicated in digestive diseases such as hepatic encephalopathy, irritable bowel syndrome and diverticular disease. However, while these three conditions may all be related to dysfunction of the gut-liver-brain axis, the precise pathophysiology appears to differ somewhat for each. Herein, current knowledge on the pathophysiology of hepatic encephalopathy, irritable bowel syndrome, and diverticular disease are reviewed, with a special focus on the gut microbiota modulation associated with these disorders during therapy with rifaximin. In general, the evidence for the efficacy of rifaximin in hepatic encephalopathy appears to be well consolidated, although it is less supported for irritable bowel syndrome and diverticular disease. We reviewed current clinical practice for the management of these clinical conditions and underlined the desirability of more real-world studies to fully understand the potential of rifaximin in these clinical situations and obtain even more precise indications for the use of the drug.

Automatic Diagnosis of High-Resolution Esophageal Manometry Using Artificial Intelligence.

BACKGROUND AND AIMS: High-resolution esophageal manometry (HREM) is the gold standard procedure used for the diagnosis of esophageal motility disorders (EMD). Artificial intelligence (AI) might provide an efficient solution for the automatic diagnosis of EMD by improving the subjective interpretation of HREM images. The aim of our study was to develop an AI-based system, using neural networks, for the automatic diagnosis of HREM images, based on one wet swallow raw image. METHODS: In the first phase of the study, the manometry recordings of our patients were retrospectively analyzed by three experienced gastroenterologists, to verify and confirm the correct diagnosis. In the second phase of the study raw images were used to train an artificial neural network. We selected only those tracings with ten test swallows that were available for analysis, including a total of 1570 images. We had 10 diagnosis categories, as follows: normal, type I achalasia, type II achalasia, type III achalasia, esophago-gastric junction outflow obstruction, jackhammer oesophagus, absent contractility, distal esophageal spasm, ineffective esophageal motility, and fragmented peristalsis, based on Chicago classification v3.0 for EMDs. RESULTS: The raw images were cropped, binarized, and automatically divided in 3 parts: training, testing, validation. We used Inception V3 CNN model, pre-trained on ImageNet. We developed a custom classification layer, that allowed the CNN to classify each wet swallow image from the HREM system into one of the diagnosis categories mentioned above. Our algorithm was highly accurate, with an overall precision of more than 93%. CONCLUSION: Our neural network approach using HREM images resulted in a high accuracy automatic diagnosis of EMDs.

Automated Chicago Classification for Esophageal Motility Disorder Diagnosis Using Machine Learning.

The goal of this paper is to provide a Machine Learning-based solution that can be utilized to automate the Chicago Classification algorithm, the state-of-the-art scheme for esophageal motility disease identification. First, the photos were preprocessed by locating the area of interest-the precise instant of swallowing. After resizing and rescaling the photos, they were utilized as input for the Deep Learning models. The InceptionV3 Deep Learning model was used to identify the precise class of the IRP. We used the DenseNet201 CNN architecture to classify the images into 5 different classes of swallowing disorders. Finally, we combined the results of the two trained ML models to automate the Chicago Classification algorithm. With this solution we obtained a top-1 accuracy and f1-score of 86% with no human intervention, automating the whole flow, from image preprocessing until Chicago classification and diagnosis.

Exclusion Diets in Functional Dyspepsia.

Functional dyspepsia represents one of the most common and prevalent disorders of the brain-gut interaction, with a large number of widespread risk factors being identified. With an intricate pathogenesis and symptomatology, it heavily impacts the quality of life and, due to the limited efficacy of traditional pharmacological agents, patients are likely to seek other medical and non-medical solutions to their problem. Over the last few years, significant research in this domain has emphasized the importance of various psychological therapies and nutritional recommendations. Nevertheless, a correlation has been established between functional dyspepsia and food intolerances, with more and more patients adopting different kinds of exclusion diets, leading to weight loss, restrictive eating behaviour and an imbalanced nutritional state, further negatively impacting their quality of life. Thus, in this systematic review, we aimed at analysing the impact and efficiency of certain exclusion diets undertook by patients, more precisely, the gluten-free diet and the low-FODMAP diet.

Supragastric belching: Pathogenesis, diagnostic issues and treatment.

Belching is defined as an audible escape of air from the esophagus or the stomach into the pharynx. It becomes pathologic if it is excessive and becomes bothersome. According to Rome IV diagnostic criteria, there is a belching disorder when one experiences bothersome belching (severe enough to impact on usual activities) more than 3 days a week. Esophageal impedance can differentiate between gastric and supragastric belching. The aim of this review was to provide data on pathogenesis and diagnosis of supragastric belching and study its relationship with gastroesophageal reflux disease and psychological factors. Treatment options for supragastric belching are also presented.

Romanian Guidelines for the Diagnosis and Treatment of GERD-induced Respiratory Manifestations.

BACKGROUND AND AIMS: Gastroesophageal reflux disease (GERD) is a common condition present in daily practice with a wide range of clinical phenotypes. In this line, respiratory conditions may be associated with GERD. The Romanian Societies of Gastroenterology and Neurogastroenterology, in association with the Romanian Society of Pneumology, aimed to create a guideline regarding the epidemiology, diagnosis and treatment of respiratory conditions associated with GERD. METHODS: Delphi methodology was used and eleven common working groups of experts were created. The experts reviewed the literature according to GRADE criteria and formulated 34 statements and recommendations. Consensus (>80% agreement) was reached for some of the statements after all participants voted. RESULTS: All the statements and the literature review are presented in the paper, together with their correspondent grade of evidence and the voting results. Based on >80% voting agreement, a number of 22 recommendations were postulated regarding the diagnosis and treatment of GERD-induced respiratory symptoms. The experts considered that GERD may cause bronchial asthma and chronic cough in an important number of patients through micro-aspiration and vagal-mediated tracheobronchial reflex. GERD should be suspected in patients with asthma with suboptimal controlled or after exclusion of other causes, also in nocturnal refractory cough which needs gastroenterological investigations to confirm the diagnosis. Therapeutic test with double dose proton pump inhibitors (PPI) for 3 months is also useful. GERD induced respiratory conditions are difficult to treat; however,proton pump inhibitors and laparoscopic Nissen fundoplication are endorsed for therapy. CONCLUSIONS: This guideline could be useful for the multidisciplinary management of GERD with respiratory symptoms in current practice.

Helicobacter pylori infection and positive Rome IV criteria for functional dyspepsia in Romanian medical students.

Recent data suggest that the prevalence of Helicobacter pylori (HP) infection in Romania has been declining in the last 30 years. However, there are no studies regarding HP prevalence among medical students. The objectives of this study were to estimate the prevalence of HP infection and assess the prevalence of dyspepsia in medical students and the relationship between dyspepsia and infection. We included 150 students from the Iuliu Hatieganu University of Medicine and Pharmacy of Cluj-Napoca, Romania (102 females and 48 males, mean age 21 years). Each student completed a lifestyle questionnaire, personal history, family history as well as the Rome IV questionnaire for functional dyspepsia. The status of HP infection was determined using the C13-urea respiratory test. The prevalence of HP infection was 25.33%, and 18% met the Rome IV criteria for functional dyspepsia. 37% of students with functional dyspepsia had a positive HP test. Of all students, 8% had a history of HP infection. Those with a history of HP infection had a 4.45% (95% CI 1.6 - 12.37) higher risk of having positive Rome IV criteria for functional dyspepsia than those with no previous history of infection (p=0.008). Thus, the present study adds to the body of evidence regarding HP prevalence among medical students, 25.33% being positive. We found no statistically significant correlation between HP infection and functional dyspepsia. Those with a history of HP infection had a higher risk of functional dyspepsia.

Eosinophilic esophagitis and esophageal motility changes.

Eosinophilic esophagitis is a chronic condition that can affect any age, with an increasing prevalence in the last years. Esophageal symptoms are accompanied by normal endoscopic findings or changes suggestive for the disease, like rings, furrows, exudates, or strictures. The definitive diagnosis is based on esophageal biopsies, with identification of at least 15 eosinophils/high power field. In about 1/3 of patients esophageal motility abnormalities are observed. Ineffective esophageal motility is the most frequent. In some cases, major motility disorders, such as achalasia can be observed. The treatment depends on the patients' preferences and on symptoms severity, and usually a step-up approach is used. A diet change can be helpful in more than half of patients, some respond to proton pump inhibitors. In non-responders, short courses of topical corticosteroids are recommended. Endoscopic procedures might be helpful in patients with obstructive motility changes, non-responding to medical therapy. This review discusses the motility changes observed in patients with eosinophilic esophagitis.

Dietary interventions and irritable bowel syndrome - what really works?

PURPOSE OF REVIEW: The review examines the latest research on the use of dietary interventions in the management of irritable bowel syndrome (IBS) in order to understand what is the evidence supporting the efficacy of a dietary approach in this disorder. RECENT FINDINGS: A general dietary advice should be offered to all IBS patients. Psyllium supplementation is recommended in IBS with both constipation and diarrhea predominance. There is increasing evidence showing the beneficial effects of a low fermentable oligo-, di-, monosaccharides, and polyols (FODMAP) diet (LFD) on IBS symptoms. FODMAPs that are well tolerated should be reintroduced in daily diet, to increase acceptability of the diet, and limit potentially harmful effects. The benefits observed with the gluten-free diet seem determined by the reduction of FODMAPs rather than gluten. Modulation of gut microbiota using probiotics shows promising results, but there are unanswered questions regarding the optimal strains, dose and duration of treatment. Additional evidence is also needed for the role of prebiotics and synbiotics in IBS. SUMMARY: Food is both trigger of IBS symptoms and therapeutic tool. Recent studies demonstrated the beneficial effects of LFD on symptom control, as well as the role of probiotics, which seem to contribute to gut health and function.

Integrated Relaxation Pressure Classification and Probe Positioning Failure Detection in High-Resolution Esophageal Manometry Using Machine Learning.

High-resolution esophageal manometry is used for the study of esophageal motility disorders, with the help of catheters with up to 36 sensors. Color pressure topography plots are generated and analyzed and using the Chicago algorithm a final diagnosis is established. One of the main parameters in this algorithm is integrated relaxation pressure (IRP). The procedure is time consuming. Our aim was to firstly develop a machine learning based solution to detect probe positioning failure and to create a classifier to automatically determine whether the IRP is in the normal range or higher than the cut-off, based solely on the raw images. The first step was the preprocessing of the images, by finding the region of interest-the exact moment of swallowing. Afterwards, the images were resized and rescaled, so they could be used as input for deep learning models. We used the InceptionV3 deep learning model to classify the images as correct or failure in catheter positioning and to determine the exact class of the IRP. The accuracy of the trained convolutional neural networks was above 90% for both problems. This work is just the first step in fully automating the Chicago Classification, reducing human intervention.

Clinical and Manometric Characteristics of Patients with Achalasia: One Disease with Three Presentations or Three Diseases with One Presentation?

BACKGROUND AND AIMS: The three manometric patterns of achalasia are considered by some authors as different stages in the evolution of the same disorder. The aims of our study were to characterize patients with achalasia, in order to find key differences supporting the idea of progression from one type to the other, and to assess the clinical evolution in time. METHODS: From 280 high resolution esophageal manometry recordings we selected unique patients with achalasia. A standardized questionnaire used prior to each manometry recorded their symptoms. Manometric parameters (resting lower esophageal sphincter (LES) pressure, 4s-integrated relaxation pressure (IRP), length of the esophagus, etc.) were recorded. Patients were contacted to establish the clinical evolution. RESULTS: We identified 108 new achalasia cases (mean age 48.2±16.2 years, 52.8% type I, 42.6% type II), 52 (48.1%) women. Dysphagia (98.1%), cough (64.8%), belching (60.2%) and reflux symptoms (53.7%) were frequently reported. Patients with type I achalasia reported more often that dysphagia worsened, compared to type II patients (χ2=7.3, p =0.007). Age, duration of dysphagia, body mass index (p=0.067) and esophageal length were similar in type I and type II achalasia. Resting LES pressure (64.7±22.6 mmHg vs. 54.3±21.6 mmHg, p=0.019) and 4s-IRP (45.3±17.6 mmHg vs. 38.4±15.5 mmHg, p=0.036) were higher in type II compared to type I achalasia. Overweight patients had a lower LES resting pressure and 4s-IRP compared to lean subjects. After a mean follow-up of 36.8±13.4 months, 49 (45.3%) patients responded to our follow-up, and 77.5% had an Eckardt score ≤ 3. CONCLUSIONS: Type I achalasia was the most common in our group. Type I patients had lower BMI but similar duration of dysphagia and mean age compared to type II. Type III is seldom and present in older patients. These findings suggest low probability of progression from type III and II to type I achalasia. Patients with type II achalasia had higher resting LES pressure and 4s-IRP than type I achalasia patients.

POEM: Five Years of Experience in a Single East European Center.

BACKGROUND AND AIMS: Achalasia is an esophageal motility disorder with many available therapies. Peroral endoscopic myotomy (POEM) is a therapeutic alternative to surgical myotomy, harboring significant potential short term advantages. Our aim was to analyze a single-series POEM's learning curve, safety and efficiency over short, medium and long-terms in an East European Center. METHODS: This observational, prospective study was carried out in the Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Romania. Patients with symptomatic achalasia (Eckardt score>3) and pre-op evaluations consistent with the diagnosis of achalasia were included. All POEMs were performed by a highly skilled endoscopist. All patients were allowed to eat 48 hours after POEM. An esophagography was performed in all patients to exclude any leakage. The patients were asked to return for follow-up at established intervals: 1 month, 6 months, 12 months, and annually thereafter. RESULTS: 136 patients were included with an average duration of symptomatology of 36.75 months. The procedure was technically successful in all patients, while a clinical success rate was achieved in 87.5% (n=119) of patients after one POEM session. The success rate was 92.64% after 6 months, 91.17% after one year, 88.9% after 2 years, and 87.5% after 3 years or more; 12.5% of patients required additional treatment. Eighteen patients (13.23%) presented major early complications. Gastroesophageal reflux disease was encountered in 16 patients immediately after POEM and in 22 patients at subsequent follow-ups. CONCLUSION: POEM is a safe and effective minimally invasive therapeutic option which can substitute surgical myotomy, having a high success rate and a low rate of adverse events in short, medium and long-term.

Eosinophilic Esophagitis: Diagnosis and Current Management.

Eosinophilic esophagitis (EoE) is an eosinophil-rich, Th2 antigen-mediated disease of increasing worldwide prevalence. Originally considered common in children and young adults, it can be seen at any age, with the highest prevalence between 30 and 40 years. Symptoms reflect esophageal dysfunction, and typical endoscopic pictures consist of rings, furrows, exudates and edema. Progressive disease leads to pathologic tissue remodeling, with ensuing esophageal rigidity and loss of luminal diameter caused by strictures. The definitive diagnosis is histological (at least 15 eosinophils/HPF, high power field), upper gastrointestinal endoscopy with multiple esophageal biopsies being mandatory. Current therapeutic options include dietary and pharmacologic treatments. Despite being successful in a high proportion of patients, elemental diet has multiple disadvantages. Therefore, a step-up approach (using a two-, four- and six food elimination diets) is preferred, being globally effective in up to 79% of cases and avoiding unnecessary restrictions. Drug therapy relies on proton pump inhibitors and topical corticosteroids. Esophageal dilation may be required to increase luminal patency, leading to immediate symptomatic improvement in 95% of EoE patients, who have strictures or narrow caliber esophagus. The chronic nature of the disease necessitates long-term therapy. In this review, current diagnostic and treatment options are discussed and a treatment algorithm is proposed.

Anger Mediates the Relationship between Pain and Depression in Irritable Bowel Syndrome.

BACKGROUND AND AIMS: Anger has been linked to irritable bowel syndrome (IBS), but the mechanism underlying this relationship is still unknown. This cross-sectional study explores the possibility that anger mediates the relationship between pain severity and depression in IBS patients. METHODS: The sample included 70 consecutively evaluated patients who met Rome III criteria for IBS diagnosis and 55 healthy controls. All participants completed measures of depression, pain, state and trait anger, and anger expression style. RESULTS: Using a mediational model involving a series of linear regressions we found that trait anger and anger expression index partially mediated the association between depression and abdominal pain severity. The IBS patients with significant pain reported higher depressive symptoms; these results could be partially explained by their tendency to experience angry feelings generated by pain. CONCLUSIONS: The relation between pain and depression is not a direct and linear one, but works partly through patients' tendency to become angry and through anger expression style regarding their pain.