The relationship of current psychiatric disorder to functional disability and distress in patients with inflammatory bowel disease.

Although prior theories about psychiatric disorders causing inflammatory bowel disease (IBD) have largely been discredited, these same disorders have at times been associated with functional gastrointestinal symptoms such as those found in irritable bowel syndrome. Since functional gastrointestinal symptoms can also occur in patients with organic pathology, we hypothesized that a current psychiatric disorder might amplify or produce additional gastrointestinal symptoms in patients with organic gastrointestinal diseases such as IBD, leading to additive functional disability and decreased quality of life. This pilot study evaluated a sequential sample of 40 IBD patients using the NIMH Diagnostic Interview Schedule, structured interviews for functional gastrointestinal symptoms, and prior episodes of emotional, physical, and sexual abuse as well as self-report measures of personality and disability. We compared IBD patients with and without a current psychiatric disorder while controlling for disease severity. Eight patients with major depression were treated with antidepressants. Patients with a current psychiatric disorder had significantly higher 1) mean number of lifetime psychiatric diagnoses, 2) prevalence rates of prior sexual and physical victimization, and, 3) mean numbers of both gastrointestinal and other medically unexplained symptoms despite no differences in severity of IBD. Significant and trend level differences were apparent on several measures of functional disability. A regression analysis showed that number of psychiatric diagnoses, number of functional gastrointestinal symptoms, and dissociation scale scores significantly discriminated the groups. Treatment of current major depression decreased functional disability despite no objective changes in gastrointestinal disease severity. It was concluded that the presence of a current psychiatric disorder appears to alter the perception of disease severity in patients with IBD. Nonrecognition of the psychiatric disorder may lead to unnecessary and aggressive interventions for IBD patients such as medication changes, invasive testing, or surgery. The presence of a current psychiatric illness also appears to be associated with increased functional disability. Psychiatric evaluation and treatment, therefore, have an important role in the ongoing management of IBD patients with distressing gastrointestinal symptoms not directly attributable to their IBD.

Chronic pelvic pain and gynecological symptoms in women with irritable bowel syndrome.

Chronic pelvic pain and irritable bowel syndrome are common disorders, yet very little is known about their comorbidity. As part of an epidemiological study of patients with irritable bowel syndrome or irritable bowel disease we inquired about a history of chronic pelvic pain and related gynecological problems, and hypothesized that distress associated with either of these conditions was additive in women with both syndromes. A medically trained interviewer evaluated a sequential sample of 60 women with irritable bowel syndrome and 26 women with inflammatory bowel disease in an urban gastroenterology clinic using the National Institute of Mental Health Diagnostic Interview Schedule, the Briere Child Maltreatment Interview (emotional, physical and sexual abuse), and a structured interview to elicit a lifetime history of chronic pelvic pain that was distinct from the history of bowel distress. Chronic pelvic pain was reported in 21 (35.0%) of the irritable bowel syndrome patients vs. 4 (13.8%) of the inflammatory bowel disease group (p < 0.05). Compared to women with irritable bowel syndrome alone, those with both irritable bowel syndrome and chronic pelvic pain were significantly more likely to have a lifetime history of dysthymic disorder, current and lifetime panic disorder, somatization disorder, childhood sexual abuse and hysterectomy. Logistic regression showed that mean number of somatization symptoms was the best predictor of a history of both irritable bowel syndrome and chronic pelvic pain compared either to inflammatory bowel disease or irritable bowel syndrome alone. Many women with irritable bowel syndrome may have a history of chronic pelvic pain as well. The high rates of psychopathology associated with irritable bowel syndrome and chronic pelvic pain independently are even higher in women with both syndromes, and women who present with either irritable bowel syndrome or chronic pelvic pain should probably be evaluated for both disorders.

Psychiatric diagnoses, sexual and physical victimization, and disability in patients with irritable bowel syndrome or inflammatory bowel disease.

We compared 71 patients with irritable bowel syndrome (IBS) and 40 patients with inflammatory bowel disease (IBD) using structured interviews for psychiatric, gastrointestinal and sexual/physical victimization histories, as well as self-reported measures of personality, functional disability and dissociation. IBS patients had significantly higher lifetime prevalence rates of major depression, current panic disorder, and childhood sexual abuse. Despite the absence of organic pathology, IBS patients had significantly higher numbers of medically unexplained physical symptoms and disability ratings equal to, or greater than, those of patients with severe organic gastrointestinal disease.

Medical and psychiatric symptoms in female gastroenterology clinic patients with histories of sexual victimization.

Several recent retrospective reports have associated prior sexual victimization and long-term medical sequelae such as increased medical clinic utilization and reports of physical symptoms. However, methodological constraints have limited the generalizability of these findings. Our study was designed using structured interviews with a sequential sample of 89 female gastroenterology clinic patients, who were classified by severity of sexual trauma and studied for differences in lifetime psychiatric diagnoses, physical abuse, and medically unexplained symptom patterns. Compared with the 46 women who had experienced less severe or no prior sexual trauma, the 43 patients with severe victimization had significantly higher life-time and current rates of several selected psychiatric disorders as well as significantly higher mean numbers of lifetime psychiatric disorders, medically unexplained physical and anxiety symptoms, greater harm avoidance and dissociation scores, and increased functional disability. A logistic regression showed that the main predictors of a history of severe sexual abuse were the number of medically unexplained symptoms, adult physical abuse, and lifetime dysthymic disorder. We concluded that women with prior severe sexual trauma episodes may express medically unexplained physical symptoms as part of the long-term adaptation to their victimization.

Iatrogenic achalasia. A case series.

Between 1984 and 1992, 14 cases of "secondary" achalasia were diagnosed at our institution, five due to malignancy and nine as a result of esophageal or paraesophageal surgery. Preoperative manometry had excluded preexistent achalasia in eight of nine of the latter patients. Dysphagia developed immediately postoperatively in all. Esophagram and subsequent manometry were consistent with achalasia. All failed conventional dilation sessions and eight of nine underwent pneumatic dilation: Five were cured by this alone, two required surgery (one for iatrogenic perforation), and one was lost to follow-up. This achalasia-like picture appears to be the result of a tight antireflux repair that impairs the ability of the lower esophageal sphincter to completely relax, creating a functional obstruction with proximal dilation and stasis. Such secondary achalasia appears to be a distinct clinical entity and was more common than that associated with neoplasia in our institution. Therapeutically, pneumatic dilation was required and probably causes partial disruption of a tight surgical repair.

Gastroesophageal reflux disease.

Gastroesophageal reflux disease, usually manifested by frequent heartburn, occurs in approximately 10% of our adult population. The presence of a hiatal hernia is usually associated with, but does not necessarily cause, LES dysfunction, allowing acid reflux to produce esophageal and aerodigestive symptoms. The mucosa can be extensively damaged and, ultimately, a columnar lining, termed Barrett's esophagus, a premalignant condition, can develop. Treatment with H2-antagonists has been nirvana to some patients, but has proved only partially helpful to others. Adjunctive agents may increase relief and may help heal erosive esophagitis in some patients, but side effects and cost limit their use. Maintenance therapy with full doses is required, as the relapse rate for this chronic condition is high. Omeprazole temporarily heals almost everyone with otherwise resistant GERD, but it is currently used only on a short-term basis unless surgery, eminently successful in well-selected patients, is contraindicated.

An experience with polyethylene balloons for pneumatic dilation in achalasia.

The Rigiflex achalasia dilator system was used to treat consecutively 24 patients with achalasia. The 30-mm balloon achieved a 70% satisfactory result, and the 35-mm balloon, 93%, including two patients who did not achieve a good response to the smaller balloon. No complications occurred. Dilation pressure, which averaged only 7 +/- 2 (SD) lb/inch2 (psi), was determined by insufflating 1-2 psi more than needed for complete gastroesophageal waist expansion at fluoroscopy. The mean lower esophageal sphincter pressure (LESP) of 39 +/- 11 (SD) mm decreased by 68% with the 35-mm balloon and 60% with the 30-mm. Solid food emptying by radionuclide scintiscan, which pretreatment averaged 62 +/- 36% (mean +/- SD) retention at 20 min, was highly variable both before and in response to dilation. A decrease in scintigraphy of less than 25% retention was present in two of three unsatisfactory treatment responses. A decrease of LESP of greater than 50% and scintigraphy greater than 25% corresponded well with a satisfactory response from the dilation. The excellent results obtained with this system, as well as the distinct advantages of durability, presence of three reliable sizes, and ease of use, make this an attractive alternative to other dilating systems in the treatment of achalasia.

Methotrexate induces clinical and histologic remission in patients with refractory inflammatory bowel disease.

STUDY OBJECTIVE: To determine whether methotrexate has anti-inflammatory activity in refractory inflammatory bowel disease. DESIGN: Nonrandomized, open-label, preliminary trial of methotrexate along with standard medications for 12 weeks. SETTING: Referral-based gastroenterology practice. PATIENTS: Twenty-one patients with refractory inflammatory bowel disease (14, Crohn disease; 7, chronic ulcerative colitis); 17 taking variable doses of corticosteroids and 14 on sulfasalazine or metronidazole. Of the 21 patients, 10 had previously failed azathioprine or 6-mercaptopurine trials. INTERVENTIONS: Sulfasalazine and metronidazole were continued and prednisone dose was tapered according to clinical response. Methotrexate was given as a 25-mg intramuscular injection weekly for 12 weeks, then switched to a tapering oral dose if a clinical and objective improvement was noted. MEASUREMENTS AND MAIN RESULTS: Sixteen of twenty-one patients (11 of 14 patients with Crohn disease, 5 of 7 patients with chronic ulcerative colitis) had an objective response as measured by disease activity indices (modified Crohn's Disease Activity Index, 13.3 to 5.4 [P = 0.0001], Ulcerative Colitis Activity Index, 13.3 to 6.3 [P = 0.007]). Prednisone dosage decreased from 21.4 mg +/- 5.6 (SEM) to 5.5 mg +/- 2.0; P = 0.006 and 38.6 mg +/- 6.35 to 12.9 mg +/- 3.4; P = 0.01, respectively. Five patients with Crohn colitis had colonoscopic healing and 4 had normal histology at 12 weeks. In contrast, none of the 7 patients with ulcerative colitis had normal flexible sigmoidoscopies, despite histologic improvement in 5. Side effects included mild rises in transaminase levels in 2 patients, transient leukopenia in 1, self-limited diarrhea and nausea in 2 patients, and 1 case each of brittle nails and atypical pneumonitis. CONCLUSIONS: Although this pilot study is encouraging, further work is needed before methotrexate can be recommended for inflammatory bowel disease.

Barrett esophagus in sexagenarian identical twins.

Identical twins presented as sexagenarians with heartburn, regurgitation, and dysphagia; each had a Barrett esophagus remarkably similar to the other. This instance suggests a hereditary influence upon the development of mucosal dysplasia in some patients with this condition.

Irreversible esophageal motor dysfunction in postvagotomy dysphagia.

Postvagotomy dysphagia is typically a temporary phenomenon but a small subgroup of patients appear to develop irreversible motility disorders of the esophagus. Two patients are reported with persistent symptomatic esophageal dysfunction demonstrated by modern hydraulic infusion technics. Both initially lost weight rapidly and then stabilized. The distal esophagus of both was greatly dilated but in one patient, lower esophageal sphincter pressure was normal. Aperistalsis with diminished motor activity was present throughout the body of the esophagus. Dysphagia and objective esophageal abnormalities were refractory to dilations with simple mercury bougies in one patient whose condition was improved by treatment with pneumatic dilation. The cause of this unusual complication is unknown but may involve a nonneoplastic form of secondary achalasia.

Pneumatic dilation under general anesthesia after unsuccessful cardiomyotomy for achalasia.

A 12-year-old girl with achalasia was treated successfully under general anesthesia with pneumatic dilation after she had experienced two unsuccessful surgical procedures. The Mosher dilator was passed into the stomach by threading it over a guide wire. Our experience suggests that pneumatic dilation can be performed in children or adults after surgical failure and that general anesthesia may be employed.