Characterization of IBS-like symptoms in patients with ulcerative colitis in clinical remission.

BACKGROUND: Gastrointestinal symptoms compatible with Irritable Bowel Syndrome (IBS) are common in patients with inflammatory bowel disease. It has been suggested that these symptoms are a reflection of occult inflammation rather than coexisting IBS. The aim of this study was to characterize IBS-like symptoms in patients with Ulcerative Colitis (UC) in clinical remission by assessing inflammatory markers, psychological symptoms, and quality of life. METHODS: Ninety-four patients with new onset of UC were followed prospectively during 3 years with yearly follow-up visits. The patients completed self-administrated questionnaires. Fecal calprotectin was used as an inflammatory biomarker. Remission was defined as a total Mayo-score ≤2 and an endoscopic subscore ≤1, with no relapse during the 3-month period prior to visit. KEY RESULTS: The prevalence of patients that fulfilled Rome II criteria for IBS among UC patients in remission was 11% at visit 1, 23% at visit 2, and 17% at visit 3. When comparing UC patients in remission with and without IBS-like symptom, patients with IBS-like symptoms had more severe gastrointestinal symptoms, tendencies toward more severe psychological symptoms and reduced levels of quality of life, but the calprotectin levels did not differ between the two groups. CONCLUSIONS & INFERENCES: IBS-like symptoms are common in patients with UC in clinical remission and these fluctuate over time. The symptoms are associated with poor psychological well-being and reduced quality of life, and do not seem to be a reflection of low-grade inflammatory activity.

Predictors of subjective fatigue in chronic gastrointestinal disease.

BACKGROUND: Fatigue is a common, but poorly understood symptom in patients with chronic gastrointestinal (GI) diseases. AIM: To evaluate factors of importance for fatigue in patients with chronic GI diseases, and to compare it with fatigue in the general population. METHODS: In all, 399 patients attending a GI out-patient clinic completed questionnaires assessing fatigue, sleep disturbances, psychological general well-being and GI symptom severity. The patients were divided into two diagnostic groups: functional GI disorders (n = 112) and organic GI diseases (n = 287). The severity of fatigue was also evaluated in an age- and gender-matched group of 399 individuals from the general population. RESULTS: Both patient groups had more severe fatigue than controls and patients with functional GI disorders were more fatigued than patients with an organic GI disease. Fatigue was associated with psychological general well-being, GI symptom severity, gender, employment status and sleep disturbances. In a linear regression analysis, psychological general well-being (vitality, general health, self-control), sleep disturbances and employment status were independently associated with the severity of fatigue (adjusted R(2) = 55%). CONCLUSIONS: Fatigue is a troublesome symptom in a subgroup of patients with chronic GI diseases. These patients have a high symptom burden as regards both GI and psychological symptoms, as well as sleep disturbances.

Patients' subjective symptoms, quality of life and intake of food during the recovery period 3 and 12 months after upper gastrointestinal surgery.

Few studies describe patients' quality of life and their experienced symptoms during the recovery period after having undergone upper gastrointestinal surgery at 3 and 12 months. The aims of this study were to explore patients' quality of life and symptoms preoperatively and at 3 and 12 months following upper gastrointestinal surgery and to describe and compare patients' experiences of appetite, food intake, weight changes, tiredness and sleeping patterns. A descriptive and comparative quantitative design was used. Three instruments were used: the Gastrointestinal Symptom Rating Scale, the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire and the Eating Dysfunction Scale. A questionnaire was used to investigate symptoms such as mood, appetite, sleep, activities and well-being. Twenty-four patients were included in the study. The major results were that anxiety levels and global health status decreased and that patients felt more disappointed after 12 months compared with after 3 months. Four patients at 3 months after surgery and eight patients at 12 months regained their weight compared with the situation before surgery. The contribution of nursing care activities focusing on the importance of food intake and the patients' current and historical medical records in relation to their health status should continue to be examined and researched over a longer period of time.

Impact of sex and psychological factors on the water loading test in functional dyspepsia.

BACKGROUND: The pathogenesis of upper abdominal symptoms in patients with functional dyspepsia (FD) is still unclear. The water loading test (WLT) is a new method for evaluation of gastric function. Our aim was to determine the impact of sex, age and psychological factors on the results of WLT in FD patients, FD-subgroups and healthy controls (HCs), and to evaluate the safety of the test. METHODS: Fifty-six HCs and 35 consecutive patients with FD drank mineral water (100 ml/min) until intolerable. Serum samples for sodium, potassium and creatinine was taken before and after drinking. Water quantity was registered and symptoms were assessed after maximal water intake and 30 min later using a VAS scale. Participants also completed questionnaires measuring psychological general well-being (PGWB) and gastrointestinal symptoms (GSRS and Mearin score). RESULTS: Healthy men drank more than healthy women, 2350 +/- 105 ml versus 1860 +/- 100 ml (P < 0.01), and the same gender difference was noted in FD patients, 1770 +/- 115 ml versus 1180 +/- 110 ml (P < 0.01). Maximal water intake was significantly higher in HC than in FD patients, both in males (P < 0.001) and females (P < 0.0001). Age had no impact on drinking capacity. FD patients had more symptoms 30 min after maximal water intake than HCs. Serum sodium decreased from 141 +/- 0.3 mmol/l to 138 +/- 0.5 mmol/l. Two of the assessed psychological factors, general health and depressed mood, correlated with water intake in FD patients (Rho = 0.47, P < 0.01 respectively Rho = 0.41, P < 0.05). CONCLUSION: WLT is a useful, simple and safe test for evaluating symptoms in FD patients. Sex, but not age affects the results of the WLT. Furthermore, psychological factors must also be taken into consideration when interpreting the WLT.

Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic.

The relationship between tinnitus and psychiatric disorders has long been recognised. We have addressed this question by investigating the prevalence of psychiatric diagnosis in a consecutive series of tinnitus patients (n=82) without severe socially disabling hearing loss referred to an audiological clinic. The psychiatric evaluation was based on a standardised diagnostic interview (SCID-P) in accordance with the Diagnostic and Statistical Manual of mental disorders (DSM-III-R) and on the Hospital Anxiety and Depression Scale (HAD Scale). An experienced psychiatrist performed the interview 24 months after the patient's first visit to the clinic. Lifetime depressive and anxiety disorders were recorded in 62 per cent and 45 per cent of the cases respectively, but only 34 per cent had had contact with any healthcare institution for emotional disturbances. Only 7 per cent reported that they had tinnitus prior to their depressive and/or anxiety disorders. We conclude that it is of great importance to identify these emotional disturbances in patients suffering from tinnitus.

Quality of life in patients with irritable bowel syndrome seen in referral centers versus primary care: the impact of gender and predominant bowel pattern.

BACKGROUND: Quality of life (QOL) is reduced in patients with irritable bowel syndrome (IBS) and little is known about differences in QOL in relation to referral status, gender and predominant bowel pattern in IBS patients. This study aimed to explore these relationships. METHODS: 343 patients with IBS according to the Rome I criteria (251 females, 92 males) completed five different self-administered questionnaires to evaluate QOL. There were 119 patients with diarrhea-predominant IBS (IBS-D), 93 with constipation-predominant IBS (IBS-C) and 131 with alternating constipation and diarrhea (IBS-A). The study group comprised 209 hospital outpatients and 134 primary care patients. The questionnaires were mailed to the patients with an overall response rate of 88%. RESULTS: QOL was reduced in hospital outpatients compared to primary care patients, but only in females. IBS subgroup (IBS-D), physical fatigue and general health independently predicted referral to a gastroenterologist. Females had lower QOL than males. No differences, except in severity of diarrhea and constipation, were observed between IBS subgroups. Perceived fatigue was related to well-being, psychological and gastrointestinal symptoms. Independent predictors for fatigue were depression, trait anxiety, general health and vitality, along with eating dysfunction and female sex. CONCLUSION: IBS female patients seen in referral centers versus primary care is a highly selected group with reduced QOL. QOL in IBS is affected by gender, but not by subgroup. Our findings have implications for the generalizability of results in IBS trials. Fatigue is a common symptom in IBS that correlates to general well-being and psychological and subjective gastrointestinal symptoms.

Food-related gastrointestinal symptoms in the irritable bowel syndrome.

BACKGROUND/AIMS: Postprandial symptoms are common in patients with irritable bowel syndrome (IBS). However, existing studies have come to different conclusions about the role of food in the pathophysiology of IBS. We explored the prevalence of subjective food-related gastrointestinal (GI) symptoms and its relationship to clinical characteristics and psychological factors in IBS. METHODS: 330 patients with IBS and 80 healthy volunteers completed a food questionnaire developed for this study. The subjects graded their subjective symptoms after 35 different foods and a food score was obtained by adding the item scores. The relationship between subjective food-related GI symptoms and referral status, IBS subgroup (predominant bowel pattern), sex, anxiety, depression and body mass index (BMI) was estimated. RESULTS: In 209 (63%) of the patients the GI symptoms were related to meals. Gas problems and abdominal pain were the most frequently reported symptoms. Foods rich in carbohydrates, as well as fatty food, coffee, alcohol and hot spices were most frequently reported to cause symptoms. The food score was higher in patients than in controls (p < 0.0001). In the IBS group higher scores were observed in patients with anxiety (p = 0.005), and females (p < 0.001), but the results were unrelated to IBS subgroup, referral status or BMI. The BMI did not differ between groups. CONCLUSION: A majority of IBS patients consider their symptoms to be related to meals. Especially foods rich in carbohydrates and fat cause problems. Nevertheless, the majority of IBS patients are normal or overweight. Female sex and anxiety predict a high degree of food-related symptoms in IBS.

Symptom control may improve food intake, body composition, and aspects of quality of life after gastrectomy in cancer patients.

That severe malnutrition affects body function and psychological well-being is well documented. We addressed the question of whether quality of life relates to changes in variables such as food intake, body composition, and gastrointestinal symptomatology after gastrectomy for gastric cancer. Thirty-two patients undergoing gastric resection had their dietary intake, body composition, and specific and general aspects of quality of life determined preoperatively, at 12 months and, in the 15 surviving patients, several years after the operation. The patients lost 10% of their preoperative weight (mainly body fat) during the first year. Food intake did not correlate to changes in body composition or quality of life. Gastrointestinal symptoms adversely related to changes in lean body mass, meal size, and general aspects of quality of life for a long time after the operation. Gastrointestinal symptom control seems important to minimize impairment in quality of life, body composition, and eating after gastrectomy.

Abnormal propagation pattern of duodenal pressure waves in the irritable bowel syndrome (IBS) [correction of (IBD)].

The propagation pattern of individual pressure waves in the gastroduodenal area in IBS is unexplored. We performed antroduodenojejunal manometry on 26 patients with IBS--13 with diarrhea predominant IBS (IBS-D) and 13 with constipation predominant IBS (IBS-C)--and 32 healthy controls. Neuropathic-like motor abnormalities were found in 38% of the patients with conventional manometric evaluation. With high-resolution analysis additional abnormalities were observed in the majority of the patients, with increased frequency of retrograde pressure waves postprandially in both IBS subgroups and in phase II in IBS-D. A correlation between subjective gastrointestinal symptoms and the frequency of retrograde pressure waves in phase II in IBS-D was demonstrated. Motility indices and the number of long clusters were also higher in patients compared to controls. To conclude, an abnormal propagation pattern of individual duodenal pressure waves in IBS patients was demonstrated and found to be related to symptom severity in diarrhea-predominant IBS. High-resolution analysis adds information to standard manometry.

Psychosocial aspects of the functional gastrointestinal disorders.

The functional gastrointestinal disorders (FGID) are the most frequent conditions seen in gastroenterology practice and comprise a major portion of primary care. Psychosocial factors are important in these disorders with regard to: (1) their effects on gut physiology; (2) their modulation of the symptom experience; (3) their influence on illness behavior; (4) their impact on outcome; and (5) the choice of the therapeutic approach. This paper provides a review and consensus of the existing literature by gastroenterologists, psychiatrists, psychologists, physiologists, and health services investigators. Evidence is provided to support the biopsychosocial model as a basis for understanding and treating these disorders, and epidemiological and clinical information on the relations of psychosocial factors to gut physiology, symptom presentation, health behavior, and outcome is offered. Features of motility, personality, abuse history, health concerns, and treatment-seeking differ between patients with FGID and healthy controls, but they are not specific to FGID. They occur in other patients with chronic medical conditions and/or psychiatric disorders. Review of treatment trials indicates clear support for psychotherapeutic treatments, especially in the long term, as well as some evidence for the benefit of antidepressants in FGID, even in the absence of improvements in mood.

Long term consequences of gastrectomy for patient's quality of life: the impact of reconstructive techniques.

OBJECTIVE: During recent years considerable interest has been focused on quality of life as an additional therapeutic outcome measure in the surgical treatment of gastric carcinoma. However, the long term consequences of gastrectomy and the impact on quality of life of different reconstructive techniques are still a matter of controversy. To broaden the criteria for choice of treatment, we conducted a prospective randomized clinical trial to determine the impact of various gastrectomy procedures on quality of life during a 5-yr follow-up period. METHODS: Consecutive patients (n = 64) eligible for curative gastric cancer surgery were randomized to have either total (n = 31) or subtotal (n = 13) gastrectomy or a jejunal S-shaped pouch (n = 20) as a gastric substitute after total gastrectomy. Assessments of quality of life were made on seven occasions during a 5-yr period: within 1 wk before surgery, 3 and 12 months after the surgical intervention, and then once/yr. All patients were interviewed by one of two psychiatrists, who rated their symptoms and introduced standardized self-report questionnaires covering both general and specific aspects of life. The raters were blinded for the patients' group affiliations. RESULTS: Survival rates were similar in all treatment groups. Patients who had a total gastrectomy continued to suffer from alimentary symptoms, especially indigestion and diarrhea, during the entire follow-up period. However, patients who underwent subtotal gastrectomy had a significantly better outcome already during the first postoperative yr. Patients given a gastric substitute after gastrectomy improved with the passage of time and had an even better outcome in the long run. CONCLUSIONS: To optimize the rehabilitation after gastrectomy, patients' quality of life must be taken into consideration. When subtotal gastrectomy is clinically feasible, this procedure has advantages in the early postoperative period. However, a pouch reconstruction after total gastrectomy should be considered in patients having a favorable tumor status suggesting a fair chance of long term survival.

Quality of life after gastrectomy for gastric carcinoma: controlled study of reconstructive procedures.

The choice of reconstruction after gastrectomy and the significance of remaining reservoir function is a matter of controversy. To broaden the criteria for choice of treatment, we conducted a prospective randomized clinical trial to determine the impact of various gastrectomy procedures on quality of life. Consecutive patients (n = 64) eligible for curative gastric cancer surgery were randomized to have either a total (n = 31) or subtotal (n = 13) gastrectomy or a jejunal S-shaped pouch (n = 20) implanted as a gastric substitute. The quality-of-life evaluation was based on a battery of questionnaires covering both general and specific aspects of life. The patients were rated by one of two psychiatrists who were blinded to the patients' group affiliation. Assessments were made on three occasions: during the week prior to surgery and 3 and 12 months after the surgical intervention. The postoperative complication and mortality rates were similar in all treatment groups, with few serious complications recorded. Irrespective of type of treatment, the patients suffered from alimentary symptoms and functional limitations in everyday life, whereas their mental well-being improved after surgery. Patients who underwent subtotal gastrectomy had the best outcome, especially with respect to complaints of diarrhea. Patients given a gastric substitute after gastrectomy showed no difference from those who had only a total gastrectomy. We conclude that despite significant unfavorable consequences that follow gastrectomy, patients recover with an improved mental status. A pouch reconstruction after total gastrectomy does not improve quality of life, but a subtotal gastrectomy has advantages that must be considered when the procedure is clinically feasible.

Quality of life in gastric cancer prior to gastrectomy.

A growing number of surgical trials include quality of life variables in the overall assessment of outcomes. This is believed to broaden the criteria for choice of treatment and the evaluation of treatment regimens. The present study is a baseline evaluation of the health-related quality of life in patients with gastric cancer facing surgery. The quality of life in these patients was related to that of other patient groups referred for surgical interventions and general population groups. Our study included 103 consecutive patients with carcinoma of the stomach considered amenable to a curative major surgical procedure. The quality of life evaluation was based on a battery of questionnaires, covering general body symptoms, mood level and functional limitations. Patients with gastric cancer reported more neurasthenic complaints such as reduced sexual interest, insomnia and poor appetite as well as a lower mood level than the general population. The gastric cancer group also showed a markedly lower mood level in comparison with a group of cancer survivors 2-3 years after diagnosis and patients with intermittent claudication. The mental well-being of gastric cancer patients matched that of cancer survivors with one or more recurrences. Overall, 25% of the gastric cancer patients reported functional limitations regarded as clinically significant. Patients with intermittent claudication reported more and patients with small cell lung cancer markedly more limitations. We conclude that although patients with gastric cancer showed a low level of limitations on average, problems in the areas of sleep/rest, home management and, especially, eating were frequently reported.

Well-being and gastrointestinal symptoms among patients referred to endoscopy owing to suspected duodenal ulcer.

BACKGROUND: Few studies have evaluated quality of of life (QoL) in patients with upper gastrointestinal diseases, and there is a lack of validated measures for use in gastroenterology. METHODS: The applicability and relevance of self-administered questionnaires such as the Psychological General Well-Being (PGWB) index and the Gastrointestinal Symptoms referred to endoscopy because of suspected duodenal ulcer were evaluated. RESULTS: In total, 1526 patients with suspected duodenal ulcer were screened for inclusion in a clinical study. On the basis of medical history and endoscopy, 1424 patients who completed the questionnaire before endoscopy were classified in five diagnostic groups: oesophagitis, gastric ulcer, duodenal ulcer, negative endoscopy, and gastritis duodenitis. Irrespective of diagnosis, all patient groups reported a considerable decrease in their general well-being (mean score, 85, compared with 105 in healthy populations) with no significant differences between the groups. The results of the GSRS, however, showed statistically significant differences between the groups in dimensions depicting Abdominal pain, Reflux, Indigestion, and Diarrhoea Syndrome. CONCLUSIONS: The results of the study showed that, irrespective of endoscopic findings, patients complaining of upper gastrointestinal symptoms have a low degree of general well-being. The symptoms profiles in the different diagnostic groups vary considerably.

Quality of life in patients with upper gastrointestinal symptoms. An improved evaluation of treatment regimens?

There is growing interest in measuring quality of life (QoL) in medicine. Together with objective variables such as healing rate, as recorded with endoscopy, this is believed to give a better basis for evaluation of treatment regimens in patients with upper gastrointestinal diseases. A strategy for the assessment of QoL in patients with upper gastrointestinal symptoms is presented here. The QoL evaluation was based on a battery of questionnaires, covering both general and specific aspects of life. General well-being was evaluated with the Psychological General Well-being Index (PGWB), and subjective symptoms with two specific questionnaires, the Gastrointestinal Symptom Rating Scale (GSRS) and the Ulcus Esophagitis Subjective Symptoms Scale (UESS). This new strategy was applied clinically in a study including 146 outpatients with suspected peptic ulcer. Initially, the patients reported a low degree of general well-being as evaluated with the PGWB, but the values returned to those found in normal populations within 4 weeks. Evaluation of the GSRS and UESS with regard to internal consistency, construct validity, and the ability to detect changes showed them to be satisfactory. The psychometric documentation of the measures indicates that they may give reliable and clinically valid information when used for evaluation of medical treatments in upper gastrointestinal disease. Further documentation of the methods is, however, needed to establish a generally acceptable QoL assessment in gastroenterology.

GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease.

An interview-based rating scale consisting of 15 items for assessment of gastrointestinal symptoms in irritable bowel syndrome and peptic ulcer disease has been developed. The interrater reliability was estimated by means of independent and simultaneous duplicate ratings by two raters in 20 cases and ranged from 0.86 to 1.00. The scale was easy to apply and proved to be useful in comparing the effectiveness of different modes of treatment in two clinical trials.

An ultrastructural study of the synaptology of gamma-motoneurones during the postnatal development in the cat.

The postnatal development of cat triceps surae gamma-motoneurones, retrogradely labelled with horseradish peroxidase (HRP), was studied light and electron microscopically. The mean diameter of the cell bodies of the gamma-motoneurones increased by about 25% from birth to the adult stage, which was much less than the increase in cell body diameter of alpha-motoneurones (about 45%). Throughout development the only bouton types apposing the gamma-motoneurones were the F- and S-types, with flattened and spherical synaptic vesicles, respectively. Thus, the C-, M- and T-types of boutons seen on a alpha-motoneurones. The number of boutons on the gamma-motoneurone cell bodies seemed to decrease postnatally. This decrease was only moderate for S-type boutons but substantial for F-type boutons. In contrast, the number of boutons on the proximal dendrites appeared to increase and this was most evident for S-type boutons. The mentioned postnatal changes in synaptology were more differentiated with regard to bouton type and part of the neurones under study than what could be inferred from earlier studies on the postnatal development of alpha-motoneurones. These changes also occurred later than in alpha-motoneurones. The relative dominance of F-type boutons with probable inhibitory actions on the immature gamma-motoneurone may explain the previously demonstrated poor encoding of muscle length by muscle spindles during the first postnatal weeks in the kitten.