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Stress and the gastrointestinal tract new
      #164743 - 03/28/05 01:27 PM
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Journal of Gastroenterology and Hepatology
Volume 20 Issue 3 Page 332 - March 2005
doi:10.1111/j.1440-1746.2004.03508.x


REVIEW
Stress and the gastrointestinal tract

VIKRAM BHATIA* AND RAKESH K TANDON*

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the braingut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray.

It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamuspituitaryadrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response.

Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus.

Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4+ lymphocytes.

The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

Stress and the gastrointestinal tract.
Journal of Gastroenterology and Hepatology 20 (3), 332-339.
doi: 10.1111/
j.1440-1746.2004.03508.x


http://www.blackwell-synergy.com/links/doi/10.1111/j.1440-1746.2004.03508.x/abs/




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Irritable bowel syndrome in developing countries new
      #164746 - 03/28/05 01:29 PM
HeatherAdministrator

Reged: 12/09/02
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Neurogastroenterology and Motility
doi:10.1111/j.1365-2982.2005.00627.x


Irritable bowel syndrome in developing countries: a disorder of civilization or colonization?

k.-a. gwee


While irritable bowel syndrome (IBS) is common in the West, early studies suggest that the prevalence is low in developing countries. However, recent studies point to increasing prevalence in newly developed Asian economies. The presentation appears to differ from the West, with a lack of female predominance, a greater frequency of upper abdominal pain and defecatory symptoms perceived as being less bothersome. This difference, together with the preoccupation with organic disease, could explain why we may be missing IBS in Asia and also why excess surgery has been observed in some Asian countries.

While a recent study from China, consistent with western studies, support an important role for infection and inflammation, early studies from India reporting no association between amoebic infection and IBS appear to dispute this observation. To reconcile these seemingly contradictory observations, an hygiene hypothesis model is proposed.

Exposure to a variety of microorganisms early in life could result in the colonization of the intestine with microflora that can respond more efficiently to an episode of gastroenteritis. Together with the changes with evolution of Asian economies such as westernization of the diet and increased psychosocial stress, it is proposed that loss of this internal protective effect, could give rise to a more uniform worldwide prevalence of IBS.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2005.00627.x/abs/

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New Recommendations for Treating Children With Chronic Abdominal Pain new
      #164767 - 03/28/05 01:59 PM
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New Recommendations for Treating Children With Chronic Abdominal Pain

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

March 4, 2005 — A subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics (AAP) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have generated a clinical report to provide guidance to clinicians treating children with this condition. The clinical report and an accompanying technical report are published in the March issue of Pediatrics.

"Children and adolescents with chronic abdominal pain pose unique challenges to their caregivers," write Richard B. Colletti, MD, and colleagues from the Subcommittee on Chronic Abdominal Pain. "Affected children and their families experience distress and anxiety that can interfere with their ability to perform regular daily activities. Although chronic abdominal pain in children is usually attributable to a functional disorder rather than organic disease, numerous misconceptions, insufficient knowledge among health care professionals, and inadequate application of knowledge may contribute to a lack of effective management."

Recommendations in the clinical report are based on the evidence reviewed in the technical report and on consensus opinion of the subcommittee members. However, the subcommittee acknowledges that the recommendations do not indicate an exclusive course of treatment or serve as a standard of medical care and that variations based on individual circumstances may be appropriate.

Although the classic definition of chronic abdominal pain used during the last four decades has used the criterion of at least three pain episodes for at least three months interfering with function, the authors suggest that in clinical practice, pain that exceeds one or two months in duration can be considered chronic.

Specific recommendations are as follows:

The term "recurrent abdominal pain" should no longer be used. Functional abdominal pain, the most common cause of chronic abdominal pain, is a specific diagnosis distinct from anatomic, infectious, inflammatory, or metabolic causes of abdominal pain. Specific categories may include functional dyspepsia, irritable bowel syndrome, abdominal migraine, or functional abdominal pain syndrome.


Without needing additional diagnostic testing, the primary care clinician can generally diagnose functional abdominal pain correctly in children four to 18 years of age with chronic abdominal pain, provided there are no alarm symptoms or signs, the physical examination is normal, and stools are negative for occult blood.


Alarm symptoms prompting additional diagnostic testing may include involuntary weight loss, linear growth deceleration, gastrointestinal tract blood loss, significant vomiting, chronic severe diarrhea, persistent right-upper or right-lower quadrant pain, unexplained fever, family history of inflammatory bowel disease, or abnormal or unexplained physical findings. Alarm signs may include localized right-upper or right-lower quadrant tenderness, localized fullness or mass effect, hepatomegaly, splenomegaly, costovertebral angle tenderness, spine tenderness, and perianal abnormalities.


If pain significantly decreases quality of life, testing may also be indicated to reassure the patient, parent, and physician of the absence of organic disease.


Psychological factors should be addressed in diagnostic evaluation and management, even though they may not help distinguish between organic and functional pain.


Family education is an important part of management of functional abdominal pain, using simple language to explain that the pain is real, but that there is most likely no underlying serious or chronic disease.


Reasonable treatment goals should be established, aimed at return to normal function and to school rather than the complete disappearance of pain.


Medications for functional abdominal pain "are best prescribed judiciously as part of a multifaceted, individualized approach to relieve symptoms and disability." Time-limited use of medications, such as acid-reduction therapy, antispasmodic agents, smooth muscle relaxants, low doses of psychotropic agents, or nonstimulating laxatives or antidiarrheals may be appropriate to decrease symptom frequency or severity.


Additional research is needed to advance still limited knowledge on chronic abdominal pain in children. The authors recommend detailed description of symptoms, eligibility criteria, work-up, and findings; use of validated outcome measures; evaluation of potential differences in course and treatment in subgroups of patients with different symptom phenotypes; research in diverse populations; and validation of the Rome II criteria in a range of clinical settings and populations.
"In view of the paucity of published literature on therapeutic approaches to this condition, there is an urgent need for trials of all currently used interventions in children with functional abdominal pain," the authors conclude.

The current authors also support the statements of the Functional Bowel Disorders Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition meeting that "there is a need to develop drugs to modulate abnormalities in sensorimotor function of the enteric nervous system in functional disorders to relieve specific symptoms and to assess the proper role of these drugs in the treatment of children and adolescents," and that "the role of antidepressants (tricyclics, selective serotonin reuptake inhibitors) in the treatment of functional gastrointestinal disorders associated with abdominal pain needs to be assessed."

Pediatrics. 2005;115:812-815, e370-e381

http://www.medscape.com/viewarticle/500799

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IBS is a risk factor for GERD new
      #168750 - 04/10/05 06:25 PM
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Alimentary Pharmacology & Therapeutics
Volume 21 Issue 7 Page 821 - April 2005
doi:10.1111/j.1365-2036.2005.02426.x


Risk factors for gastro-oesophageal reflux disease symptoms: a community study
I. Mohammed*, P. Nightingale & N. J. Trudgill*
Summary

Aim: To examine the prevalence of gastro-oesophageal reflux disease symptoms and potential risk factors among community subjects.

Methods: A questionnaire was sent to 4000 subjects, stratified by age, gender and ethnicity to be representative of the local population. Gastro-oesophageal reflux disease symptoms were defined as at least weekly heartburn or acid regurgitation.

Results: 2231 responded (59%), 691 refused to participate and seven were incomplete. 1533 (41%) were evaluable (637 male, mean age 51 years, range: 2080). The prevalence of gastro-oesophageal reflux disease symptoms was 21%. Smoking, excess alcohol, irritable bowel syndrome, increasing body mass index, a family history of upper gastrointestinal disease, increasing Townsend deprivation index, anticholinergic drugs (all P < 0.0001), weight gain, antidepressant drugs, inhaled bronchodilators, no educational attainment (all P < 0.01), south Asian origin (P = 0.02) and manual work (P < 0.05) were associated with gastro-oesophageal reflux disease symptoms. Multivariate logistic regression revealed increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin (all P < 0.0001), smoking, excess alcohol, no educational attainment and anticholinergic drugs (all P < 0.01) were independently associated with gastro-oesophageal reflux disease symptoms.

Conclusions: Frequent gastro-oesophageal reflux disease symptoms affect 21% of the population. Increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin, smoking, excess alcohol, social deprivation and anticholinergic drugs are independently associated with gastro-oesophageal reflux disease symptoms.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1192685&specid=13&ok=yes

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Towards a better understanding of abdominal bloating and distension in functional GI disorders new
      #173166 - 04/24/05 03:40 PM
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Neurogastroenterology and Motility
OnlineEarly
doi:10.1111/j.1365-2982.2005.00666.x


REVIEW
Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders

l. a. houghton & p. j. whorwell
Abstract Abdominal bloating is an extremely common symptom affecting up to 96% of patients with functional gastrointestinal disorders and even 30% of the general population. To date bloating has often been viewed as being synonymous with an actual increase in abdominal girth, but recent evidence suggests that this is not necessarily the case. This review examines the relationship between the symptom of bloating and the physical sign of abdominal distension, as well as examining the epidemiology, pathophysiology and treatment options available for this debilitating aspect of the functional gastrointestinal disorders. Pathophysiological mechanisms explored include psychological factors, intestinal gas accumulation, fluid retention, food intolerance and malabsorption of sugars, weakness of abdominal musculature, and altered sensorimotor function. Treatment options are currently rather limited but include dietary changes, pharmacological approaches, probiotics and hypnotherapy.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2005.00666.x/abs/

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What Does the Future Hold for Irritable Bowel Syndrome new
      #177493 - 05/08/05 06:02 PM
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What Does the Future Hold for Irritable Bowel Syndrome and the Functional Gastrointestinal Disorders?

Journal of Clinical Gastroenterology. The Spectrum of Functional Gastrointestinal Disorders (FGID). 39(4) Supplement 3:S251-S256, May/June 2005.

Drossman, Douglas A MD

Abstract:
Our understanding of irritable bowel syndrome and the functional GI disorders has grown considerably over the last 15 years. In part this relates changes in their classification and definition from being due solely to motility disturbances, to being symptom based (eg, Rome criteria). This opened the door to the study of many other factors that contribute to the clinical expression of these disorders, including visceral hypersensitivity, sensitization, altered mucosal immunity, and dysfunction in brain-gut regulatory processes. New knowledge has been gained in areas of genetics, central nervous system and enteric nervous system neurotransmitters of motility, sensitivity and secretion, the effect of altered mucosal inflammation on cytokine and paracrine activation, and neural sensitization, postinfectious disorders, the influence of psychologic stress on gut functioning via alterations in regulatory pathways (eg, hypothalamic-pituitary adrenal axis, or pain regulatory system like the cingulate cortex), improved accuracy of diagnosis using Rome II criteria plus "red flags" the institution of behavioral treatments, and the use of new pharmacologic treatments both at the gut and brain level.

Future research will improve upon this new knowledge via basic and translational studies of neuropeptide signaling with new neurotransmitters, new knowledge on the mechanisms for central nervous system-enteric nervous system communication and dysfunction, and more advanced clinical research on education, communication skills and their effects on outcome, genetics, pharmacogenetics and genetic epidemiology, better understanding as to how certain psychosocial domains (eg, catastrophizing, abuse) affect symptom behavior and outcome, newer pharmacologic treatments, and the use of combined pharmacologic and behavioral treatment packages. I am pleased to have the opportunity to provide a personal perspective on what the future will be for irritable bowel syndrome and the other functional GI disorders. Having been involved in this field for almost 30 years, I have been fortunate to witness tremendous changes. The focus of this presentation is to address the advances that have recently occurred that set the stage for proposing future research to help move the field along and ultimately to help our patients.

(C) 2005 Lippincott Williams & Wilkins, Inc.



--------------------------------------------------------------------------------
Copyright © 2005, Lippincott Williams & Wilkins. All rights reserved.
Published by Lippincott Williams & Wilkins.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1212785&specid=13&ok=yes

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Nerves, Reflexes, and the Enteric Nervous System: Pathogenesis of the Irritable Bowel Syndrome new
      #177494 - 05/08/05 06:06 PM
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Nerves, Reflexes, and the Enteric Nervous System: Pathogenesis of the Irritable Bowel Syndrome.

Journal of Clinical Gastroenterology. The Spectrum of Functional Gastrointestinal Disorders (FGID). 39(4) Supplement 3:S184-S193, May/June 2005.

Gershon, Michael D MD

Abstract:
The bowel exhibits reflexes in the absence of CNS input. To do so, epithelial sensory transducers, such as enterochromaffin (EC) cells, activate the mucosal processes of intrinsic (IPANs) and extrinsic primary afferent (sensory) neurons. EC cells secrete serotonin (5-HT) in response to mucosal stimuli. Submucosal IPANs, which secrete acetylcholine and calcitonin gene-related peptide, initiate peristaltic and secretory reflexes and are activated via "5-HT1P" receptors.

Release of neurotransmitters is enhanced by 5-HT4 receptors, which are presynaptic and strengthen neurotransmission in prokinetic pathways. 5-HT3 receptors mediate signaling to the CNS and thus ameliorate cancer chemotherapy-associated nausea and the visceral hypersensitivity of diarrhea-predominant irritable bowel syndrome (IBS-D); however, because 5-HT3 receptors also mediate fast ENS neurotransmission and activate myenteric IPANs, they may be constipating.

5-HT4 agonists are prokinetic and relieve discomfort and constipation in IBS-C and chronic constipation. 5-HT4 agonists do not initiate peristaltic and secretory reflexes but strengthen pathways that are naturally activated. Serotonergic signaling in the mucosa and the ENS is terminated by a transmembrane 5-HT transporter, SERT. Mucosal SERT and tryptophan hydroxylase-1 expression are decreased in experimental inflammation, IBS-C, IBS-D, and ulcerative colitis. Potentiation of 5-HT due to the SERT decrease could account for the discomfort and diarrhea of IBS-D, while receptor desensitization may cause constipation. Similar symptoms are seen in transgenic mice that lack SERT. The loss of mucosal SERT may thus contribute to IBS pathogenesis.

(C) 2005 Lippincott Williams & Wilkins, Inc.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1212776&specid=13&ok=yes

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Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS new
      #177495 - 05/08/05 06:11 PM
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Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS


Bonnie B. Dean, PhD; Daniel Aguilar, MPH; Victoria Barghout, MSPH; Kristijan H. Kahler, SM; Feride Frech, MPH; David Groves, PhD; and Joshua J. Ofman, MD


Irritable bowel syndrome (IBS) is a long-term and episodic medical disorder shown to have an impact on work productivity and health-related quality of life (QOL). The objective of this study was to assess the impact of IBS on work productivity and on health-related QOL in an employed population in the United States and to quantify the cost of these factors to the employer. A 2-phase survey was sent to the workforce of a large US bank to assess the presence of IBS among employees and to measure their work productivity (absenteeism [time lost from work] and presenteeism [reduced productivity at work]) and health-related QOL. Forty-one percent of the 1776 employees responding to both phases of the survey met the Rome II criteria for IBS. Employees with IBS reported a 15% greater loss in work productivity because of gastrointestinal symptoms than employees without IBS and had significantly lower Medical Outcomes Study Short Form 36 (SF-36) scores than those without IBS. IBS was associated with a 21% reduction in work productivity, equivalent to working less than 4 days in a 5-day workweek. Employees with IBS also had significantly lower scores on all domains of the SF-36, indicating poorer functional outcomes. Reduced work productivity and diminished QOL of these magnitudes may have substantial financial impact on employers.

(Am J Manag Care. 2005;11:S17-S26)





Patients with irritable bowel syndrome (IBS) report symptoms that may wax and wane in type and severity over time1,2 and that can have a negative impact on health-related quality of life (QOL).3-6 IBS affects adults of all ages, primarily those of working age (30-50 years old).2 In the United States, an estimated 10% to 20% of adults are believed to have symptoms consistent with this disorder.3

Although estimates of the direct costs associated with IBS are staggering and can vary greatly,7 the impact of IBS on absenteeism (hours absent from work), presenteeism (reduced productivity while at work), and health-related QOL is of increasing concern to employers in the United States, who rely heavily on a healthy workforce and who contract with health plans and other payers to cover the healthcare costs of their employees. For these reasons, employers often implement wellness and disease management programs to optimize workforce health.

Leong and colleagues8 studied healthcare insurance data of the employees of a self-insured Fortune 100 company and determined that direct and indirect costs for patients with IBS were substantially greater than those for a matched non-IBS control group. In 1998, the direct and indirect medical costs to the employer for 1 employee with IBS were $3997 and $2367, respectively, which were $1651 and $468 greater than the direct and indirect medical costs for 1 employee without IBS. The indirect cost for patients with IBS is likely to have been underestimated, however, because this estimate included absenteeism but not presenteeism.

Hahn and colleagues9 measured the impact of IBS on absenteeism. Although the actual number of hours employees were absent from work because of IBS was not substantial, the number of missed workdays increased significantly as the severity of illness increased. In a separate study of IBS patients, Hahn and colleagues10 found that Medical Outcomes Study Short Form 36 (SF-36) scores of respondents from the United States and the United Kingdom were significantly lower, meaning that they were worse than the respective population norms. Moreover, 30% of US respondents missed at least 1 full day of work in the 4 weeks preceding the survey, and 46% reported "cutting back" on some workdays because of IBS.

Although several studies have reported reduced health-related QOL in IBS populations, 3-6 limited research has been conducted to assess health-related QOL or absenteeism in an employed population with IBS, and even less research has been conducted to quantify the economic impact of these factors on the employer. Additionally, these studies have largely ignored the specific impact of IBS-associated gastrointestinal (GI) symptoms on presenteeism.

Our objective was to assess the impact of IBS on work productivity (presenteeism and absenteeism) and on health-related QOL in a US employed population and to quantify the cost of these factors to the employer.

Methods

Participants were employees of Comerica Incorporated, a nationwide bank with major branches in multiple states (Michigan, California, Texas, and Florida). From April 2002 to August 2002, all employees of Comerica (N = 11 806) were invited to participate in a 2-phase survey regarding GI health and related symptoms.

All Comerica employees were mailed a survey designed to (1) identify those with IBS (including subgroup classification for constipation [IBS-C] or diarrhea [IBS-D]) using the Rome II criteria11-13; (2) measure the frequency, severity, and bothersomeness of IBS symptoms; and (3) capture information on sociodemographics, long-term health conditions (including physician-diagnosed IBS), and job characteristics. A postcard was included in the initial mailing to request signed consent for participation in the followup survey. Employees who completed initial surveys and consent forms received a second survey measuring work productivity loss because of IBS and assessing QOL (Figure 1). The Cedars-Sinai Health System Institutional Review Board approved this study.



Names of initial survey participants were entered in a raffle for 1 of 9 gift checks valued between $100 and $500. Second-phase survey participants received a gift check for $25. All participants received educational material regarding IBS at the conclusion of the study.

Rome II Criteria. Employees were administered the Rome II diagnostic criteria questionnaire11-13 to assess the presence of IBS. According to the Rome II criteria, IBS is defined by the presence of abdominal discomfort or pain for at least 12 weeks, which need not be consecutive, during the preceding 12 months, and the discomfort or pain should have 2 of the following 3 features: it should be relieved with defecation; its onset should be associated with a change in the frequency of the stool; its onset should be associated with a change in the form (appearance) of the stool.13 Supportive symptoms can be used to classify IBS patients into symptom subgroups: IBS-C, characterized by less than 3 stools per week, hard/lumpy stools, straining, and feeling of incomplete bowel evacuation; IBS-D, characterized by more than 3 stools per week, loose or watery stools, and urgency; and mixed-pattern subtypes (alternating IBS).13,14

Assessment of Work Productivity. Work productivity was measured using the Work Productivity and Activity Impairment (WPAI) questionnaire,15 which was developed and validated as a general health measure that can be easily modified for specific health conditions. Adapted versions of the WPAI16 have been developed for use in patients with conditions such as allergy,16,17 long-term hand dermatitis,18 and gastroesophageal reflux disease (GERD).19,20 We adapted the WPAI to estimate the impact of GI symptoms consistent with IBS, including abdominal pain or discomfort, bloating, and constipation or diarrhea, on work productivity.16 Areas assessed included level of impairment during work and other daily activities and hours absent from work because of IBS symptoms during the previous 7 days. A scale from 0 to 10 was used to assess the degree to which GI symptoms consistent with IBS negatively affected a patient's productivity while working and to assess how they affected daily activity. Measures of productivity and absenteeism were combined in the work productivity score (WPS), which quantifies reduced work productivity (absenteeism and presenteeism) attributed to GI symptoms consistent with IBS as a percentage of potential total work productivity during a full-time workweek. The WPS was calculated as follows:



WPAI measures are interpreted as a percentage reduction in productivity (or a percentage of productivity lost) and are adjusted for part-time status. For example, a WPS of 5% indicates that a full-time employee is working at only 95% of full work potential (eg, 40 hours) because of reductions associated with absenteeism and presenteeism. A WPS of 5% for an employee working 40 hours per week would imply a reduction of 2 hours of potential work productivity lost.

Medical Outcomes Study Short Form. QOL was assessed using the SF-36 questionnaire, a generic instrument designed to measure overall health status.21,22 The WPS = [(hours absent from work + percentage of reduced productivity at work × hours actually worked)/(hours missed because of ill health + hours worked)] × 100. SF-36, which has previously been validated for use in the measurement of health-related QOL among IBS patients,23 assesses health status across 8 subscales, including physical functioning, physical role limitations, emotional role limitations, social functioning, bodily pain, general mental health, vitality, and general health perceptions. Additionally, subscale scores can be collapsed into 2 summary scores, the mental component summary (MCS) and the physical component summary (PCS).24 Scores for each subscale and summary score range from 0 (poor health) to 100 (optimal health).

Statistical Analysis. Employees meeting the Rome II criteria for IBS were compared with those not meeting the criteria with respect to a variety of variables, including demographic and work-related measures, presence of comorbid conditions, and history of hysterectomy or surgeries of the GI tract. Chi-square tests were used for categorical variables and t tests for continuous variables. Two-sided P values were calculated, and statistical significance was set at the &#954;= 0.05 level.

The kappa coefficient was calculated to assess the agreement between respondents meeting the Rome II criteria (based on the questionnaire) and respondents indicating a diagnosis of IBS by a physician or another medical professional (formal diagnosis). The kappa statistic describes the degree of agreement between 2 variables. Kappa values range between -1.0 (perfect disagreement) and +1.0 (perfect agreement), with zero indicating agreement that is completely accounted for by chance. Values of 0.0 to 0.2 indicate slight agreement, 0.2 to 0.4 fair agreement, 0.4 to 0.6 moderate agreement, 0.6 to 0.8 substantial agreement, and 0.8 to 1.0 near-perfect agreement.

Employees with and without IBS (as determined by their having met the Rome II criteria) were compared with respect to mean percentage reductions across WPAI measures of productivity, and a similar comparison was made between IBS-C and IBS-D subgroups. A nonparametric method, bootstrapping, was used to estimate the 95% confidence interval (CI) for differences in productivity impairments. Bootstrapping is a statistical approach for estimating CIs from data simulations when distributions deviate considerably from the assumptions of parametric statistics. Mean percentage reductions in WPAI measures of productivity were converted to lost work productivity based on total number of hours absent from work (absenteeism) and total number of hours at reduced productivity while at work (presenteeism) based on a 40-hour workweek (using the WPS formula presented in this article). These hours were also quantified based on the mean salary and mean wages of employees in the sample. The mean cost in dollars of reduced work productivity (absenteeism and presenteeism) per year (assuming full-time employment of 2080 hours of potential work time annually per employee) because of GI symptoms consistent with IBS was calculated as the difference in cost of reduced work productivity between employees with and without IBS. The cost per employee was extrapolated to a company with 10 000 employees assuming IBS prevalence estimates ranging from 10% to 20%.

Health-related QOL scores were calculated for the MCS and PCS and for each of the 8 SF-36 subscales. Mean differences in scores between IBS and non-IBS groups and between IBS-C and IBS-D subgroups were calculated with 95% CI.

Results

Survey participation is outlined in Figure 1. The initial survey was sent to all 11 806 Comerica employees and was returned by 2615 (22.2%) employees. Compared with the general Comerica employee population, respondents were similar in age, sex, and work status (full-time vs part-time). Completed surveys along with consent forms were submitted by 2276 (87.0%) employees, who then received the phase 2 survey; that survey was completed by 1776 (78.0%) of the initial respondents. The 1776 phase 2 respondents were similar to the 500 phase 2 nonrespondents in age, sex, education, compensation type (salary vs hourly wage), and work status (full-time vs part-time) (P >.05 for each). However, those who completed the survey were more likely to be white (P = .0002).

Patient Characteristics. Among the 1776 phase 2 respondents, 720 (40.5%) employees met Rome II criteria for IBS. Of these, 191 (27%) and 255 (35%) met Rome II IBS subtype criteria for IBS-C and IBS-D, respectively; the remaining 38% reported mixed-pattern bowel habit. Employees with IBS were similar to those without IBS (n = 1056) in age, compensation type (salary vs hourly wage), and work status (full-time vs part-time) (P >.05 for each) (Table 1). Employees with IBS were more likely to be women (P <.0001) (man/woman ratio, 1:5.1), were less likely to have a graduate degree (P = .03), and differed slightly with regard to race and ethnicity (P = .04). Employees with IBS were also more likely to have allergies, anxiety, depression, GERD, stomach ulcers, gallstones, and incontinence than employees without IBS (P <.001 for each).



Symptoms of abdominal pain or discomfort, diarrhea, constipation, gas, and bloating were each significantly more frequent and severe among employees with IBS than among those without IBS (P <.05). In addition, the IBS group reported greater levels of distress (moderate to extreme) because of each of the above symptoms than the group without IBS (P <.05). The greatest differences in reported frequency of symptoms between employees with and without IBS were for abdominal pain or discomfort and bloating, whereas the greatest reported differences in distress were attributed to the symptoms of constipation, diarrhea, and bloating. Exploratory and excisional surgeries associated with abdominal pain or symptoms were significantly more common among employees with IBS (Table 2), as were other types of surgery, such as appendectomy, cholecystectomy, and hysterectomy (P <.05). Small bowel resection and obstruction were more common among employees with IBS (P = .06).



Agreement Between Rome II Criteria and Professional Diagnosis of IBS. Data from the initial survey responders (n = 2615) were used to assess agreement between employees meeting Rome II symptom criteria (n = 1042) and those reporting a previous diagnosis of IBS determined by a physician or another medical professional (n = 269) (Figure 2). Agreement between a diagnosis of IBS by a physician or a medical professional and a diagnosis of IBS using the Rome II criteria was low (&#954;= 0.22), indicating that most patients whose IBS was diagnosed using the Rome II criteria had not been previously diagnosed by a physician or a medical professional. Among employees reporting a previous diagnosis of IBS by a physician or another medical professional, 86% (n = 230) met Rome II criteria; in comparison, of the 2346 employees who did not report a diagnosis of IBS by a physician or a medical professional, 35% (n = 812) met Rome II criteria. Thus, the Rome II captured most of the IBS diagnoses previously made by a physician or another medical professional, and it was also able to capture a significant number of IBS cases that had not yet been formally diagnosed. Of the total number of respondents who met Rome II criteria during the initial survey (n = 1042), 22% (n = 230) also reported IBS previously diagnosed by a physician or another medical professional, whereas only 2% (n = 39) of employees not meeting the Rome II criteria for IBS (n = 1573) reported a physician or a medical professional diagnosis of IBS. Thus, the proportion of diagnoses by a physician or a medical professional that were not identified using the Rome II criteria was small.



Impact of IBS on Work Productivity. Figure 3 provides measures of work productivity (absenteeism and presenteeism) and activity impairment for employees with and without IBS. Among employees with IBS, productivity at work (presenteeism) was reduced by more than 21% because of GI symptoms consistent with IBS; this figure was 15% (95% CI, 13.4-16.6) higher than that reported among employees without IBS. The percentages of work time missed (absenteeism) were 1.7% and 0.4% (mean percentage difference, 1.3; 95% CI, 0.7-1.9) among those with and without IBS, respectively.



The largest contributor to total productivity loss, WPS, was reduced productivity at work (presenteeism) (15%; 95% CI, 13-17). In comparison, absenteeism contributed only slightly to the total WPS (1.3%; 95% CI, 0.7-1.9). GI symptoms consistent with IBS were associated with a 21.1% reduction in total WPS among employees with IBS compared with a 6.1% reduction among those without IBS. Reductions in total WPS among employees with IBS-C and IBS-D were comparable at 18.2% and 20.8%, respectively. Based on the average hourly wage of each employee, reduction in total WPS resulted in average losses of $10 884 and $3147 for employees with and without IBS, respectively. Thus, the value of work productivity loss per individual because of IBS-attributable GI symptoms was $7737 (95% CI, $7332-$8143) per year.

Employees with IBS reported a mean reduction of nearly 27% in regular daily activities (ie, work around the house, shopping, childcare, exercising, studying) because of GI symptoms consistent with IBS. This accounted for the largest difference between IBS and non-IBS employees, as shown by a 19% (95% CI, 16.9-20.7) mean difference in daily activity impairment.

Impact of Work Productivity Reduction on the Employer. The incremental work productivity loss associated with IBS represents an additional 39 days of reduced productivity at work and an additional 3.4 days of absence per year for each employee with IBS. Assuming participants are representative of the Comerica employee population (10 000 employees) and assuming a 10% prevalence of IBS, the employer loses a total of $7 737 600 per year. If the prevalence of IBS is 20%, the resultant work productivity loss increases to $15 475 200 per year. Among salaried employees with IBS (n = 481), mean work productivity losses attributable to GI symptoms consistent with IBS ranged from 19% to 21%, regardless of salary range ($15 000-$35 000, $35 000-$55 000, $55 000-$80 000, and >$80 000). In contrast, hourly employees with IBS earning &#8804;$15 per hour (n = 155) experienced a 44% greater work productivity loss than those with IBS earning >$15 per hour (n = 100) (26% vs 18% work productivity loss for &#8804;$15 per hour vs >$15 per hour, respectively).

Impact of IBS on Health-related QOL. Scores for all SF-36 subscales were significantly lower for employees with IBS than for those without IBS (P <.05) (Figure 4). The most significant difference was in physical role limitations, with a mean difference of 24.6 (95% CI, 21.4-27.7) points between employees with and employees without IBS. Compared with subjects with IBS-D, those with IBS-C scored lower on the MCS and reported greater impairment on 6 of 8 SF-36 domains (although only emotional role functioning was statistically significant).



MCS and PCS scores were lower among employees with IBS than among those with- out IBS, with mean differences of 5.9 (95% CI, 5.0-6.9) and 5.4 (95% CI, 4.7-6.0), respectively.

Discussion

IBS is a long-term and episodic disorder, with GI symptoms (abdominal pain or discomfort and bloating associated with altered bowel function) that can wax and wane and that affect many persons during their most productive years of adulthood. This study is one of the first evaluations performed in a US employed population that measure the impact of IBS on work productivity and on health-related QOL. We found that IBS is significantly associated with reduced work productivity and that it significantly impacts health-related QOL, suggesting that management strategies targeting improvements in symptoms consistent with IBS and health-related QOL should be expected to have a positive impact on work productivity.

Reduced productivity while at work (presenteeism) because of GI symptoms consistent with IBS was a major contributor to total reduced work productivity. Employees with IBS experienced an additional 15% reduction in work productivity beyond that reported among controls. For an employee who works 40 hours per week, this 15% difference amounts to another 6 hours of work productivity lost per week. Although reduced work productivity resulting from GI symptoms amounts to approximately 15.8 days per year for employees without IBS, it accounts for more than 54.8 days per year for employees with IBS.

The largest component of total productivity reduction in employees with IBS was impairment while working. Absenteeism because of GI symptoms consistent with IBS contributed less to reductions in work productivity in this population. Absenteeism was low among all participants—1.7% and 0.4% among those with and without IBS, respectively (Figure 3), corresponding to approximately 3 hours per month of absence among employees with IBS and less than 1 hour per month of absence for non-IBS employees. Although studies have reported higher average absenteeism rates of 1 to 2 days per month, they have assessed absenteeism from all causes, not just GI symptoms.9,25

The impact of IBS on absenteeism and presenteeism observed in this study may impose a substantial financial burden on employers. It is possible that this study has underestimated the work productivity loss—a previous study using objective measures of productivity among employees from a large US credit card company found that mean total time lost per month from presenteeism, absenteeism, and disability for employees with digestive disorders was equivalent to more than twice the hours per month of work productivity loss measured in the present study.26 Few data are available to compare subjective (self-report) and objective measures of productivity, but the validation studies of the Work Limitations Questionnaire and the WPAI suggest that estimates based on self-reported data are valid.15,27

Our findings on overall work impairment in employees with IBS (21%) are comparable with those previously reported for other GI disorders, such as GERD (16%-35%).19,20 Overall work impairment was also comparable with that for other health conditions, including chronic hand dermatitis (17%)18 and allergic rhinitis (23%-42%),28 in studies that used the WPAI.

Employees with IBS had SF-36 scores within the range of scores reported for other long-term health conditions, such as back pain, ulcer, osteoarthritis, and congestive heart failure,29 and were comparable with previous measurements of health-related QOL in IBS populations.3-5

There are limitations to this observational study. As with all surveys, there is a risk for selection bias, particularly given the 22% response rate. Although low, this response rate is consistent with rates seen in other employer-based studies (20%-50%).30-34 The study cover letter sent to employees indicated that the study dealt with GI symptoms, a disclosure required by the employer and the institutional review board. It is possible that employees with symptoms were more likely to participate, leading to an overrepresentation of IBS patients in the study population. The similarity between employees with and without IBS along demographic and workrelated variables suggests that study results were unlikely to have been biased by differences in these variables. The banking industry employs a disproportionate number of women, but the ratio of women to men with IBS in our study was approximately 1.5:1—similar to proportions observed in other epidemiologic studies of IBS.25,35,36 Additionally, treatment for IBS symptoms may influence the degree of reduced work productivity. However, we were unable to explore the percentages of reduced work productivity among IBS patients being treated compared with those who had not sought care, because we did not question employees regarding their current treatments.

Our results indicate that IBS significantly affects work productivity. Further studies are required to better assess this impact in more defined populations of IBS, such as those seeking or receiving medical care, and in other employed populations. In addition, there is a need to better understand the determinants of work productivity losses in IBS and the relationship between direct medical costs and indirect costs (absenteeism and presenteeism). Finally, from an employer's perspective, additional efforts are needed to ensure that patients are identified and offered appropriate treatment because unique therapeutic agents can decrease symptom severity and frequency while improving employee health-related QOL and work productivity. Such efforts could pay dividends in the form of improved productivity and reduced absenteeism.




References


1. Kay L, Jorgensen T, Jensen KH. The epidemiology of irritable bowel syndrome in a random population: prevalence, incidence, natural history and risk factors. J Intern Med. 1994;236:23-30.

2. Talley NJ, Weaver AL, Zinsmeister AR, Melton LJ 3rd. Onset and disappearance of gastrointestinal symptoms and functional gastrointestinal disorders. Am J Epidemiol. 1992;136:165-177.

3. Creed F, Ratcliffe J, Fernandez L, et al. Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome. Ann Intern Med. 2001;134:860-868.

4. Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119:654-660.

5. Whitehead WE, Burnett CK, Cook EW 3rd, Taub E. Impact of irritable bowel syndrome on quality of life. Dig Dis Sci. 1996;41:2248-2253.

6. Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.

7. Talley NJ, Gabriel SE, Harmsen WS, Zinsmeister AR, Evans RW. Medical costs in community subjects with irritable bowel syndrome. Gastroenterology. 1995;109:1736-1741.

8. Leong SA, Barghout V, Birnbaum HG, et al. The economic consequences of irritable bowel syndrome: a US employer perspective. Arch Intern Med. 2003;163:929-935.

9. Hahn BA, Kirchdoerfer LJ, Fullerton S, Mayer E. Patient-perceived severity of irritable bowel syndrome in relation to symptoms, health resource utilization and quality of life. Aliment Pharmacol Ther. 1997;11:553-559.

10. Hahn BA, Yan S, Strassels S. Impact of irritable bowel syndrome on quality of life and resource use in the United States and United Kingdom. Digestion. 1999;60:77-81.

11. Drossman DA. The functional gastrointestinal disorders and the Rome II process. Gut. 1999;45(suppl 2):II1-II5.

12. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999;45(suppl 2):II43-II47.

13. Thompson WG, Longstreth GF, Drossman DA, Heaton K, Irvine EJ, Muller-Lissner S. Rome II: The Functional Gastrointestinal Disorders. 2nd ed. McLean, Va: Degnon Associates; 2000.

14. Brandt LJ, Bjorkman D, Fennerty MB, et al. Systematic review on the management of irritable bowel syndrome in North America. Am J Gastroenterol. 2002;97(suppl):S7-S26.

15. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993;4:353-365.

16. Reilly MC, Bracco A, Ricci JF, Santoro J, Stevens T. The validity and accuracy of the Work Productivity and Activity Impairment questionnaire—irritable bowel syndrome version (WPAI:IBS). Aliment Pharmacol Ther. 2004;20:459-467.

17. Murray JJ, Nathan RA, Bronsky EA, Olufade AO, Chapman D, Kramer B. Comprehensive evaluation of cetirizine in the management of seasonal allergic rhinitis: impact on symptoms, quality of life, productivity, and activity impairment. Allergy Asthma Proc. 2002;23:391-398.

18. Reilly MC, Lavin PT, Kahler KH, Pariser DM. Validation of the Dermatology Life Quality Index and the Work Productivity and Activity Impairment-Chronic Hand Dermatitis questionnaire in chronic hand dermatitis. J Am Acad Dermatol. 2003;48:128-130.

19. Wahlqvist P. Symptoms of gastroesophageal reflux disease, perceived productivity, and health-related quality of life. Am J Gastroenterol. 2001;96(suppl):S57-S61.

20. Wahlqvist P, Carlsson J, Stalhammar NO, Wiklund I. Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastroesophageal reflux disease (WPAI-GERD): results from a cross-sectional study. Value Health. 2002;5:106-113.

21. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-263.

22. Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30:473-483.

23. Bensoussan A, Chang SW, Menzies RG, Talley NJ. Application of the general health status questionnaire SF36 to patients with gastrointestinal dysfunction: initial validation and validation as a measure of change. Aust N Z J Public Health. 2001;25:71-77.

24. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33(suppl):AS264-AS279.

25. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569-1580.

26. Burton WN, Conti DJ, Chen CY, Schultz AB, Edington DW. The role of health risk factors and disease on worker productivity. J Occup Environ Med. 1999;41:863-877.

27. Lerner D, Amick BC 3rd, Rogers WH, Malspeis S, Bungay K, Cynn D. The Work Limitations Questionnaire. Med Care. 2001;39:72-85.

28. Meltzer EO, Casale TB, Nathan RA, Thompson AK. Once-daily fexofenadine HCl improves quality of life and reduces work and activity impairment in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 1999;83:311-317.

29. Ware JE Jr, Kosinski M. SF-36 Physical & Mental Health Summary Scales: A Manual for Users of Version 1. 2nd ed. Lincoln, RI: QualityMetric Incorporated;2001.

30. Chang LA. Job satisfaction, dissatisfaction of Texas newspaper reporters. Dissertation Abstracts International Section A: Humanities & Social Sciences. 1999;59:3260.

31. Miller-Burke JA. The impact of traumatic events and organizational response. Dissertation Abstracts International Section B: The Sciences & Engineering. 1998;58:5177.

32. Productivity and quality in the USA today. Management Services. 1990;34:27-31.

33. Seiler RE, Sapp RW. Just how satisfied are accountants with their jobs? Management Accounting. 1979;60:18-21.

34. Industrial engineers describe productivity improvement efforts, identify obstacles to their success. Industrial Engineering. 1983;15:84-88.

35. Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991;101:927-934.

36. Saito YA, Locke GR, Talley NJ, Zinsmeister AR, Fett SL, Melton LJ 3rd. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol. 2000;95:2816-2824.

Copyright© 2003-2005 Medical World Communications, Inc.


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Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation
      #177496 - 05/08/05 06:16 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7795
Loc: Seattle, WA

From Medscape General Medicine™

MedGenMed Gastroenterology

Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation

Posted 4/28/2005
Brian E. Lacy, MD, PhD; Stephen A. Brunton, MD


Abstract and Introduction
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and imposes a heavy economic burden on patients and society. Most patients with chronic constipation are evaluated and treated in the primary care setting. Primary care clinicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral. There are numerous steps that primary care clinicians can take to address these issues and maximize the benefits of the referral process, including understanding key elements of an effective diagnostic work-up, familiarizing themselves with the utility of various diagnostic tests of colonic and anorectal function, implementing strategies/instruments to optimally communicate what they are striving to achieve through the referral process (eg, via a referral form), and developing a network of long-term working relationships with local gastroenterologists.

Introduction
Constipation is a highly prevalent disorder that affects approximately 12% to 19% of North Americans -- estimates vary widely depending on study design and methodology.[1-6] For many persons, constipation is a chronic problem, lasting from several months to several years.[2] The multiple symptoms of chronic constipation encompass much more than reduced stool frequency; many patients report straining, feelings of incomplete evacuation, abdominal pain/discomfort, bloating, hard and/or small stools, or a need for digital manipulation to enable defecation.[5,7-12] For research purposes (eg, enrolling patients into clinical trials), the Rome II diagnostic criteria for constipation are generally used ( Table 1 ).[2,13]

Chronic constipation leads to decreased quality of life. The general well-being of patients with this disorder is lower than that of comparable normal populations,[14,15] and symptom severity has a negative correlation with perceived quality of life (ie, the more severe the symptoms, the lower the quality of life).[14]

The economic impact of constipation is substantial both for patients and society as a whole. Between 1979 and 1981, constipation resulted in 13.7 million days per year of restricted activity; in 1975, 3.43 million days per year of bed disability[16] occurred; and annually in the United States, over-the-counter (OTC) laxative sales total more than $800 million.[1] Although they account for only approximately one third of those with chronic constipation, adults with chronic constipation who seek medical care consume significant and costly healthcare resources. For instance, total healthcare costs for patients with constipation enrolled in the California Medicaid program (n = 105,130) for a 15-month period amounted to $18,891,007.[17]

Most patients with chronic constipation are evaluated and treated in the primary care setting. In 2000, constipation was 13th on the list of leading physician diagnoses for gastrointestinal (GI) disorders in outpatient clinic visits in the United States. Furthermore, constipation was ranked as the sixth leading GI symptom that prompts outpatient visits.[16] One study estimated ambulatory healthcare use related to constipation in the United States by assessing data from the 2001 National Ambulatory Medical Care Survey and the 2001 National Hospital Ambulatory Medical Care Survey. Study findings showed that more than 5.7 million visits related to constipation were made in the outpatient setting in 2001. Of these, constipation was the primary reason for a visit or was the primary diagnosis in 44%, 51%, and 56% of visits to physician offices, hospital outpatient clinics, and emergency rooms, respectively.[18]

Primary care clinicians are often frustrated when faced with patients who do not respond to empiric treatment measures. When, how, and to whom to refer such patients is often unclear, and expectations of the referral process -- to gain a better understanding of the underlying cause of the constipation and guidance on management strategies -- are often not met (see Sidebar). Furthermore, primary care physicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral.

This article discusses common communication barriers between primary care clinicians and gastroenterologists in the care of patients with chronic constipation, and suggests strategies and tools that can be used to facilitate effective communication and optimize patient care. Suggestions for conducting a thorough prereferral work-up for patients with constipation are also presented, and the usefulness of various diagnostic tests that are commonly employed is discussed.[19]

Section 1 of 6 Next Page and Footnotes: Considerations Regarding the Referral Process

Please click here to continue reading this full article:

http://www.medscape.com/viewarticle/501075?src=mp


Brian E. Lacy, MD, PhD , Associate Professor of Medicine; Director, GI Motility Laboratory, Division of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Stephen A. Brunton, MD , Director of Faculty Development, Cabarrus Family Medicine Residency, Charlotte, North Carolina


Disclosure: Brian E. Lacy, MD, PhD, has received investigator-initiated grant support in the past from Novartis Pharmaceuticals for both basic and clinical research. He currently has funding for investigator-initiated research from AstraZeneca. He was a member of an advisory board for Novartis Pharmaceuticals during calendar year 2004, and is on the speaker's bureau for both AstraZeneca and Novartis.

Disclosure: Stephen A. Brunton, MD, has served as a consultant for GlaxoSmithKline, Novartis, Santarus, and Wyeth.


Medscape General Medicine. 2005; 7 (2): ©2005 Medscape



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Nongastrointestinal symptoms of irritable bowel syndrome
      #180703 - 05/22/05 07:14 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7795
Loc: Seattle, WA

Nongastrointestinal symptoms of irritable bowel syndrome: An office-based clinical survey

Noel B. Hershfield

Irritable bowel syndrome (IBS) is the most prevalent gastrointestinal problem faced by practicing gastroenterologists. For many years, nongastrointestinal symptoms have been documented in IBS patients, but the medical literature does not emphasize them.

The present study explored how IBS and inflammatory bowel disease patients differ in their reporting of nongastrointestinal symptoms. Information from 200 consecutive patients with IBS and a similar number of patients with Crohn's disease (in a single gastroenterology practice) was obtained at the initial visit using a simple questionnaire.

Comparison of the data revealed that IBS patients describe certain nongastrointestinal symptoms far more frequently than do those with inflammatory bowel disease. It is recommended that these symptoms be considered along with the generally accepted criteria for making a positive diagnosis of IBS.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1206844&specid=13&ok=yes

Dr. Hershfield is currently conducting a groundbreaking clinical trial of the dietary guidelines original to the book Eating for IBS. You can participate in his study, and help change the way all physicians treat their IBS patients!


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