Self-Perceived Stress Is Associated With Chest Pain and Personality in Patients With Refractory Functional Gastrointestinal Disorders.

ABSTRACT: Stressful events are frequently associated with functional gastrointestinal disorders (FGID). This study aims to determine if the severity of self-perceived stress is associated with specific FGID and personality characteristics in 822 patients with FGID who have filled a Rome III questionnaire, Minnesota Multiphasic Personality Inventory 2 (MMPI-2), and a 10-point Likert scale for self-perceived stress. According to stress severity, the patients were divided into three groups: low (<4; n = 183), moderate (4-6; n = 283), and severe stress (>6; n = 356). Female sex was more frequent in the severe stress group than in the low stress group (p = 0.001). Stress severity was strongly correlated with the two MMPI-2 posttraumatic stress scales. Clinically, chest pain was more frequently reported by severe stress patients than moderate stress patients. MMPI-2 clinical scales vary significantly according to the severity of stress, and "mild stress" patients have increased hysteria and depression scales and showed a higher frequency of irritable bowel syndrome-diarrhea. This study shows that severe stress severity is associated with a higher frequency of noncardiac chest pain and correlated with most personality items.

Functional gastrointestinal disorders as predictors of suicidal ideation. An observational study.

BACKGROUND/OBJECTIVES: Suicidal ideation (SI), a symptom of depression, is known to be associated with irritable bowel syndrome (IBS) but is not known to be associated with other functional gastrointestinal disorders (FGIDs). However, the source of this association is discussed. It could be related to a possible abnormal biochemical pathway implicating neurotransmitters common to both disorders like serotonin or pain and an ill-being associated with a chronic disorder of unknown etiology. The present study aims to search for the FGIDs associated with suicidal ideation. DESIGN: Observational study. METHODS: A total of 1469 patients with FGIDs (71% of women) were included in the present study. They filled the Rome III questionnaire, Beck depression inventory, and state and trait anxiety questionnaires. Data were analyzed using analysis of variance with Bonferroni correction and logistic regression analysis. RESULTS: Suicidal ideation was reported by 15% of patients, associated with increased scales of depression (P < 0.001), state (P = 0.006), and trait anxiety (P = 0.021). Clinically, these patients reported a higher prevalence of IBS-diarrhea subtype (P = 0.045), fecal incontinence (P = 0.020), soiling (P = 0.016), and difficult defecation (P = 0.005), and higher perceived severity for constipation, diarrhea, bloating, and abdominal pain (P < 0.001 for all scales). CONCLUSIONS: This study shows that only functional bowel and functional anorectal disorders are associated with suicidal ideation. This result must be taken into account in the management of these patients.

Personality of patients with fecal incontinence.

BACKGROUND/AIMS: Although idiopathic fecal incontinence (FI) patients have some psychological characteristics, the personality of FI patients was not described. The present study aims to describe the clinical and personality characteristics of FI patients. PATIENTS AND METHODS: This retrospective observational study included 996 outpatients, 72 with fecal incontinence. They filled out the Rome III diagnostic questionnaire, the personality inventory MMPI-2, the questionnaires for urological and sexual disorders, and Likert scales for bowel disorders perceived symptom severity. The main outcome measures were the presence in FI patients of functional gastrointestinal disorders, the self-reported symptom severity, and the personality profile. RESULTS: Patients were mainly females (72%). FI patients were characterized by higher age (P = 0.015), and by a higher prevalence of functional diarrhea (P = 0.001), urological (P = 0.001), and sexual disorders (P = 0.005). These patients also report higher diarrhea severity (P < 0.001) and lower abdominal pain severity (P = 0.009). The personality of FI patients is distinguished by a higher score for psychopathic deviate (P = 0.006), social responsibility (P = 0.003), Mac Andrew revised scale (P = 0.005), and antisocial practice (P = 0.007), and a lower score for type A behavior (P = 0.005). CONCLUSION: FI patients are characterized not only by older age, and a high prevalence of diarrhea but also by a specific personality profile characterized by an unfavorable comparison with others.

Psychological profiles of irritable bowel syndrome patients with different phenotypes.

BACKGROUND/AIMS: Abnormal psychological profiles are frequently found in patients with functional gastrointestinal disorders (FGIDs). The present study aimed to evaluate the psychological profiles of FGID patients with irritable bowel syndrome (IBS), and IBS phenotypes. METHODS: In 608 FGID patients, including 235 with IBS, have filled a Rome III questionnaire and the French version of the Minnesota Multiphasic Personality Inventory 2. Data analysis was performed using univariate analysis and multivariate logistic regression. RESULTS: This study shows that IBS patients have abnormal psychological profiles with more significant symptom exaggeration and decreased test defensiveness than non-IBS patients. They have a significantly higher score for all clinical scales. Logistic regression analysis showed in IBS patients a decrease of body mass index (P= 0.002), and test defensiveness score K (P= 0.001) and an increase of Hypochondriasis (P< 0.001) and Masculinity-Femininity scale (P= 0.018). By comparison with non-IBS patients, IBS-constipation, IBS-diarrhea, and mixed IBS patients have increased Hypochondriasis value and Depression score, mixed IBS patients have higher Psychasthenia score and higher Hypomania score. No item was significantly different in the IBS-unspecified group. CONCLUSIONS: This study shows that IBS patients have different psychological profiles than other FGID patients and that psychological characteristics are associated with IBS phenotypes except for patients with unsubtyped IBS.

Clinical, Physiological, and Psychological Correlates of the Improvement of Defecation during Menses in Women with Functional Gastrointestinal Disorders.

BACKGROUND/AIMS: Little is known about the improvement in defecation frequently reported by women around menses. We aimed to describe clinical, physiological, and psychological correlates of this improvement in those with functional bowel disorders. PATIENTS AND METHODS: We recruited 478 consecutive premenopausal adult females with no indication of gynecologic or psychiatric disease, who were attending an outpatient functional bowel disorders clinic. Patients completed a Rome III questionnaire, psychological evaluation stool form, and a 10-point Likert scale for constipation, diarrhea, bloating, and abdominal pain. These patients underwent physiological tests, anorectal manometry, and colonic transit time and were classified according to the presence or the absence of improvement in defecation during menses. The reverse selection procedure was used for model selection during multivariate logistic regression where statistically significant variables (p < 0.01) remained in the adjusted model. RESULTS: Ninety-seven patients (20%) reported easier defecation during menstruation. These patients were younger (p < 0.001) but had similar body mass indices and psychological profiles as the other patients. Clinically, they only reported more frequent irritable bowel syndrome (IBS) with constipation (p = 0.007), with harder stools (p = 0.005) and delayed left colon transit time (p = 0.002). No anorectal manometric parameter was different between the 2 groups. CONCLUSION: Improvement of constipation during menses is mainly associated with younger age and constipation-IBS phenotype and not with functional constipation.

Data Mining Approach for the Characterization of Functional Bowel Disorders According to Symptom Intensity Provides a Small Number of Homogenous Groups.

BACKGROUND/AIMS: The aim of the present study is to evaluate if the intensity of the cardinal symptoms of functional bowel disorders could be used to identify homogenous groups of patients defined by the Rome criteria. METHOD: In this observational study, 1,729 consecutive outpatients (73% females) filled out the Rome III questionnaire and 10-point Likert scales for constipation, diarrhea, bloating (BL)/distension, abdominal pain (AP) during the week before the medical consultation. A Gaussian mixture model was used for clustering the patients according to the intensity of symptoms without a priori information, and a classification tree was constructed from this clustering. Data were analyzed using analysis of variance and logistic regression analysis. RESULTS: According to the intensity of symptoms, the patients are divided into 8 groups named according to their main symptomatology: "painful constipation" (PFC), "mild pain constipation" (MPC), "painful diarrhea" (PFD), "mild pain diarrhea" (MPD), "mixed transit" (MT), "BL," "AP," and "nonspecific" (NS). The study of the relationship between the Rome III classification and this new grouping shows that irritable bowel syndrome (IBS)-constipation is associated with PFC, IBS-diarrhea with PFD and MPD, SII-mixed with MT, SII-unspecified with BL, functional constipation with PFC and MPC, functional diarrhea with MPD and NS, BL with "BL" and NS, nonspecific functional bowel disorders (FBD) with NS, and functional AP with "BL" and AP (p < 0.01 for all associations). CONCLUSION: A symptom intensity-based classification of FBD patients could simplify clinical phenotype, give homogeneous groups of patients, and could eventually be used by nongastroenterologists and in clinical research.

Clinical and psychological correlates of soiling in adult patients with functional gastrointestinal disorders.

BACKGROUND/AIMS: Fecal soiling (FS) is the staining of underwear without loss of significant amounts of fecal material. It is frequently associated with defecation disorders in children. The aim of this study was to search for psychological and clinical correlates of adult patients with soiling. Clinically, the complaint of staining is confused with that of fecal incontinence (FI) in the mind of both patients and attending physicians. DESIGN: Observational study PATIENTS AND METHOD: We included 1454 consecutive outpatients (71% females). They filled out the Rome III questionnaire for functional gastrointestinal disorders (FGIDs); Beck depression inventory, and state and trait anxiety questionnaires; and Likert scales for constipation, diarrhea, bloating, and abdominal pain. Data were analyzed using ANOVA and logistic regression analysis. RESULTS: Soiling was found in 123 patients (8.5%). They reported similar frequencies of esophageal, gastroduodenal, and abdominal pain as patients without soiling. In contrast, patients with soiling reported higher prevalence of IBS, such as IBS-Diarrhea, Mixed-IBS, functional diarrhea, functional constipation, and levator ani syndrome, and higher Likert scale for diarrhea, bloating, abdominal pain, and softer stools. The multivariable logistic regression analysis shows that patients with soiling have increased odds to report IBS (P = 0.019; OR = 1.958; 95% CI = [1.118-3.431]), functional diarrhea (P = 0.040; OR = 1.901; 95% CI = [1.028-3.513]), and high Diarrhea Likert scale (P < 0.001; OR = 1.215; 95% CI = [1.130-1.306]). No association was found with psychological evaluation. CONCLUSION: In FGID patients, soiling is not associated with psychological disorders and is mainly associated with IBS and functional diarrhea.

Painful or Mild-Pain Constipation? A Clinically Useful Alternative to Classification as Irritable Bowel Syndrome with Constipation Versus Functional Constipation.

PURPOSE: Abdominal pain is not used to characterize constipated patients. This study aimed to compare clinical, psychological, and physiological features in patients with IBS-constipation (IBS-C) with those in patients with functional constipation (FC) according to the intensity of abdominal pain. METHODS: All patients filled a standard Rome III questionnaire. In addition, they indicated the intensity of constipation, diarrhea, bloating, and abdominal pain on a 10-point Likert scale, and their stool form with the Bristol Stool Form Scale. Anxiety and depression were assessed with the Beck Depression Inventory and the State-Trait Anxiety Inventory. Physiological evaluation included anorectal manometry and total and segmental colonic transit time. MAIN RESULTS: A total of 546 consecutive patients, 245 with IBS-C and 301 with FC, were included. Painful constipation (PFC) was found by cluster analysis and subsequently defined as having a value over four on the Likert scale for abdominal pain. PFC was found in 67% of IBS-C patients and in 22% of FC patients. PFC patients have digestive disorders with greater frequency and report higher levels of constipation and bloating, despite similar stool form. They have higher scores of depression, state and trait anxiety, and shorter terminal transit time than mild-pain constipated patients. Compared to IBS-C patients, PFC patients report higher levels of abdominal pain (P < 0.001). Psychological and physiological parameters were similar in PFC and IBS-C patients. CONCLUSION: Painful constipation and mild-pain constipation could be an alternative way to identify constipated patients than using the diagnosis of IBS-C and FC for clinical evaluation and drug studies.

Neurostimulation for fecal incontinence after correction of repair of imperforate anus.

We are reporting the case of a 32-year-old female who had suffered from fecal incontinence (FI). She was born with an imperforate anus and a recto-vaginal fistula; she underwent repair at 6 mo of age. At 29 years of age, she was still fecally incontinent despite extensive pelvic floor reeducation. A magnetic resonance imaging and an anal electromyography were performed. Because her symptoms were considered to be probably due to extra-sphincteric implantation of the neo-anus, a redo was performed of the recto-neo-anal intra-sphincteric anastomosis. A neurostimulator device was subsequently implanted for persistent incontinence. Solid and liquid FI resolved, and her quality of life improved markedly. Combining surgery to correct the position of the neo-anus within the anal sphincter complex and neurostimulation could thus become a new approach in cases of refractory FI for patients with imperforate anus as a newborn. Follow-up into adulthood after pediatric imperforate anus surgery should be recommended for adult patients with persistent FI.

Clinical, psychological, and physiological correlates of patients who defecate after meal.

BACKGROUND AND AIMS: Food is the most important synchronizer of gastrointestinal motility and secretion. Many patients with functional bowel or anorectal disorders complain of fecal urge and stool output after eating. PATIENTS AND METHODS: In this prospective observational study, 408 consecutive outpatients with functional bowel and/or anorectal disorders (74% female, 50.2±15.6 years, 24.8±5.0 kg/m²) filled Rome III questionnaires. Depression and anxiety scores, a physiological evaluation (total and segmental colonic transit time, colonic transit response to eating using a standard 1000 kcal test meal, and anorectal manometry), were measured. Univariate analysis and multivariate logistic regression were carried out according to the presence or not of stool output after eating. RESULTS: Defecation after eating was found in 21% of patients. These patients were not different according to the demographic characteristics of sex ratio (P=0.702), age (P=0.830), and BMI (P=0.314). In contrast, they had lower state anxiety (P=0.032), but similar scores of depression (P=0.240) and trait anxiety (P=0.933). They had similar manometric characteristics (anal pressure and rectal sensitivity), but a greater response to eating in all segments of the colon. There was an increase in the frequency of functional diarrhea (odds ratio=2.576, 95% confidence interval=1.312-5.056; P=0.006) and levator ani syndrome (odds ratio=2.331, 95% confidence interval=1.099-4.944; P=0.017), but no other functional bowel disorder including irritable bowel syndrome and its subtypes was found. CONCLUSION: Stool output after eating is associated with clinical disorders but not physiological parameters. This symptom is not associated with irritable bowel syndrome, but a higher frequency of functional diarrhea.

Difficult defecation in constipated patients and its relationship to colonic disorders.

BACKGROUND: The importance in constipated subjects of having difficult defecation is poorly known. According to the Rome III criteria, constipated patients are classified as having either irritable bowel syndrome with constipation or functional constipation, depending on the presence and characteristics of abdominal pain. But, the Rome III criteria also identify another group of patients, labeled as suffering from functional anorectal disorders. Within this group, two complaints are akin to being constipated, but not labeled so: having dyssynergic defecation or inadequate defecation. OBJECTIVE: The aim of this study was to search for an association between difficult defecation and colonic transit abnormalities in constipated patients and, thus, shed some light on the definition of constipation according to the Rome III criteria. PATIENTS: Four hundred four consecutive patients (81% female), aged 44.9 ± 16.6 years, with a BMI of 25.5 ± 6.4 kg/m(2) (mean ± SD), suffering from chronic constipation were included in the present study. After filling out a standard Rome III questionnaire, patients were classified as suffering from an irritable bowel syndrome with constipation or functional constipation. In addition, they were classified as complaining of difficult defecation or not. Patients completed the Bristol Stool Form Scale as well as visual analogue scales for constipation, bloating, and abdominal pain. The colonic transit time was measured using radiopaque markers and analyzed according to three sites: the right colon, the left colon, and the rectosigmoid area. RESULTS: Difficult defecation is more frequent in patients with irritable bowel syndrome with constipation (84%) than in patients with functional constipation (68%). It is associated with an increase in constipation and abdominal pain scores on Likert scales, and a longer oroanal transit time, due to a delay in the left part of the colon. CONCLUSIONS: This study demonstrates that difficult defecation is part of a more generalized colorectal dysfunction in both irritable bowel syndrome and in functional constipation patients with an overlap of symptomatology. It also demonstrates the relative inadequacy of the Rome III criteria to describe the relationship between constipation and difficult defecation.

How many segments are necessary to characterize delayed colonic transit time?

BACKGROUND AND AIMS: Measuring colonic transit time with radiopaque markers is simple, inexpensive, and very useful in constipated patients. Yet, the algorithm used to identify colonic segments is subjective, rather than founded on prior experimentation. The aim of the present study is to describe a rational way to determine the colonic partition in the measurement of colonic transit time. METHODS: Colonic transit time was measured in seven segments: ascending colon, hepatic flexure, right and left transverse colon, splenic flexure, descending colon, and rectosigmoid in 852 patients with functional bowel and anorectal disorders. An unsupervised algorithm for modeling Gaussian mixtures served to estimate the number of subgroups from this oversegmented colonic transit time. After that, we performed a k-means clustering that separated the observations into homogenous groups of patients according to their oversegmented colonic transit time. RESULTS: The Gaussian mixture followed by the k-means clustering defined 4 populations of patients: "normal and fast transit" (n = 548) and three groups of patients with delayed colonic transit time "right delay" (n = 82) in which transit is delayed in the right part of the colon, "left delay" (n = 87) with transit delayed in the left part of colon and "outlet constipation" (n = 135) for patients with transit delayed in the terminal intestine. Only 3.7 % of patients were "erroneously" classified in the 4 groups recognized by clustering. CONCLUSIONS: This unsupervised analysis of segmental colonic transit time shows that the classical division of the colon and the rectum into three segments is sufficient to characterize delayed segmental colonic transit time.

Are floating stools associated with specific functional bowel disorders?

BACKGROUND: Functional bowel disorders are recognized as being common, but remain very difficult to diagnose accurately and to differentiate from one another, despite their significant impact on the quality of life of patients.The aim of this study was to evaluate whether the clinical sign of 'floating stools' is associated with psychological disorders, colonic transit time, or other specific bowel disorders as defined by the Rome III diagnostic criteria. MATERIALS AND METHODS: A total of 1252 consecutive patients, referred for and found to have functional gastrointestinal disorders, filled in a standard clinical questionnaire on the basis of the Rome III diagnostic criteria and were asked to provide information on the presence of floating stools. Overall, 344 of these scored positive for functional bowel disorders and underwent psychometric testing and colonic transit time studies. RESULTS: Floating stools were reported by 26% of functional bowel disorder patients and 3% of the other functional gastrointestinal disorder patients (P<0.001). The basic demographic characteristics, psychometric evaluation scores, Bristol stool form scales, and total and segmental colonic transit times were not statistically different according to the presence or not of floating stools in these patients. Logistic regression showed that mixed irritable bowel syndrome was the only functional gastrointestinal disorder associated independently with floating stools (P=0.003). CONCLUSION: Floating stools are a characteristic of patients with mixed irritable bowel syndrome.

Patients with irritable bowel syndrome and constipation are more depressed than patients with functional constipation.

BACKGROUND: Psychosocial factors, such as depression, have been shown to be associated with gastrointestinal disorders like constipation. METHODS: We retrospectively compared the depression and anxiety profiles of patients with irritable bowel syndrome with constipation versus those of patients with functional constipation using validated questionnaires. Subjects rated the intensity of digestive symptoms experienced during the previous month using visual analogue scales. Colonic transit time measurements and anorectal manometry were performed. RESULTS: Of the 128 consecutive, constipated patients included (84% females, mean age 49.7 ± 15.5 years) 66 suffered from irritable bowel syndrome with constipation and 62 from functional constipation. Demographic and physiological traits were similar in the two groups. Patients suffering from irritable bowel syndrome with constipation reported higher depression scores (18.8 ± 1.4 vs 12.7 ± 1.3, P=0.002) and higher symptom intensity scores for constipation (6.2 ± 0.3 vs 4.3 ± 0.4, P<0.001), bloating (6.7 ± 0.3 vs 3.3 ± 0.4, P<0.001) and abdominal pain (6.0 ± 0.3 vs 2.7 ± 0.4, P<0.001) than patients with functional constipation. Multiple linear regression showed positive correlations between symptom intensity and depression and anxiety scores for functionally constipated patients only. CONCLUSIONS: Our results support the integration of a psychosocial component to the traditional treatment of constipated patients; however, further research exploring causality between psychosocial factors and specific gastrointestinal disorders would contribute to developing a tailored therapeutic approach.

Long-term durability of sacral nerve stimulation therapy for chronic fecal incontinence.

BACKGROUND: Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence. OBJECTIVES: The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed. DESIGN: Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation. PATIENTS: Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected. INTERVENTIONS: Patients with ≥ 50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy. MAIN OUTCOME MEASURES: Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥ 50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected. RESULTS: A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥ 50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant. CONCLUSIONS: The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.

Anxiety and depression as markers of multiplicity of sites of functional gastrointestinal disorders: a gender issue?

BACKGROUND: Anxiety and depression are frequently present in patients with different types of functional gastrointestinal disorders (FGID), and seem to play a major part in both the perception of symptoms and the outcome of treatment. AIMS: The aim of the present study was therefore to evaluate levels of anxiety and depression in adult patients according to the extent and the type of FGID. METHODS: Three hundred and eighty-five consecutive patients (72% female) were evaluated. Each patient filled a standard clinical questionnaire based on diagnostic questions for uro-genital complaints and for FGID according to the Rome III criteria. In addition, they indicated on a 10-cm visual analog scale (VAS) the intensity of constipation, diarrhea, bloating, and abdominal pain, and stool description using the Bristol Stool Form Scale. Anxiety and depression were evaluated using Beck Depression Inventory and Anxiety State and Trait Anxiety Inventory. RESULTS: In FGID patients, levels of depression, state and trait anxiety are higher in patients with several sites of complaint. Females are more depressed than males, regardless of the level of FGID. Females tend to react emotionally to stress with a lot of anxiety ("state" anxiety), as well as in the long run ("trait" anxiety). VAS parameters for constipation, bloating and abdominal pain were related to psychological scores in contrast to VAS diarrhea and stool form. In males, the extent of sites of FGID was strongly related to trait anxiety. In females, it was strongly related to depression. CONCLUSION: Different types of FGID are associated with depression and anxiety according to the number of sites of complaints linked to gender and psychological parameters, as well as the magnitude of complaint expressed by the VAS.

Comparing pain modulation and autonomic responses in fibromyalgia and irritable bowel syndrome patients.

OBJECTIVES: Past studies confirm that patients with fibromyalgia (FM) and irritable bowel syndrome (IBS) show similar pain processing dysfunctions, such as reduced pain inhibition and aberrant autonomic nervous system (ANS) responses. However, patients with FM and IBS have rarely been investigated in the same study. The aim of the present study, therefore, was to compare descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls (HC). METHODS: Female patients with FM (n=10), IBS (n=13), and HCs (n=10) were exposed to multiple cold water (12°C) immersions to study pain sensitivity and descending pain inhibition. Heart rate variability was also assessed during immersions. RESULTS: Pain intensity scores were highest in FM, intermediate in IBS, and smallest in HCs. In contrast, pain inhibition was absent in FM, intermediate in IBS, and strongest in HCs. Importantly, controlling for differences in pain inhibition abolished group differences in pain sensitivity. Heart rate variability analyses confirmed that, in response to mild levels of pain, patients with FM showed greater sympathetic activity whereas HCs showed greater parasympathetic activity. Patients with IBS showed intermediate ANS responses. DISCUSSION: Our results confirm the presence of graded levels of somatic hyperalgesia across patients with IBS and FM. A similar pattern of result was observed for pain inhibitory dysfunctions. These pain processing changes were accompanied by abnormal autonomic responses, which maintained patients (principally patients with FM) in a state of sympathetic hyperactivity. Results suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.

Quality of life is markedly improved in patients with fecal incontinence after sacral nerve stimulation.

OBJECTIVE: The aim of the present analysis was to report on the relationship between long-term improvement in quality of life (QOL) and fecal incontinence (FI) severity and long-term reduction in FI episodes after sacral nerve stimulation (SNS) or sacral neuromodulation. METHODS: Patients who met inclusion/exclusion criteria, and initially had more than 2 FI episodes per week, were offered SNS therapy. Patients with 50% or higher reduction in FI during a 2-week test period were implanted with a neurostimulator (InterStim; Medtronic, Minneapolis, Minn). Assessments were completed by patients at baseline and at 3, 6, and 12 months after implant, and annually thereafter. The present report includes data from the 4-year postimplant follow-up. RESULTS: A total of 133 patients underwent test stimulation with a 90% success rate, and as a result, 120 (110 females) with a mean age of 60.5 years and a mean duration of FI of 6.8 years received long-term implantation. Of them, 78 patients completed all or part of the 4-year follow-up assessment. Fecal incontinence episodes decreased from a mean of 9.4 per week at baseline to 1.9 per week at 48 months (P < 0.001). The 4-year analyses showed that SNS had a positive and sustained impact on all 4 scales of the Fecal Incontinence Quality of Life questionnaire (P < 0.001), Fecal Incontinence Severity Index scores improved from a mean of 39.9 to 28 (P < 0.001), and self-rated bowel health scores improved from a mean of 3.5 to 6.9 (P < 0.001). CONCLUSIONS: Sacral nerve stimulation not only restores or improves continence in treated patients with chronic FI but also improves their quality of life and symptom severity.