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Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life new
      #112099 - 10/11/04 03:25 PM
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Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life.
Journal of Clinical Gastroenterology. 38(9):782-789, October 2004.
Gralnek, Ian M MD, MSHS *+++[S]++; Hays, Ron D PhD [//][P]; Kilbourne, Amy M PhD, MPH #**; Chang, Lin MD +++++; Mayer, Emeran A MD +++++
Abstract:
Goals: To compare the impact of irritable bowel syndrome (IBS) on health related quality of life (HRQOI) for non-white and white IBS patients.

Background: There are no reported data evaluating the HRQOL of non-white persons with IBS.

Study: SF-36 scores are compared between non-white IBS patients (n = 166), white IBS patients (n = 707), the general US population, and patients with selected chronic diseases.

Results: Of the n = 166 non-white IBS patients included for analysis, 66 (40%) described themselves as African-American, 56 (34%) as Hispanic, 25 (15%) as Asian-American, 2 (1%) as Native American and the remaining 17 (10%) as "other." Compared with white IBS patients, non-white IBS patients reported similar decrements in their HRQOL after controlling for age, gender, income and education level. On all 8 SF-36 scales, non-white IBS patients had significantly worse HRQOL compared with the general US population, (P < 0.001). Compared with GERD patients, non-white IBS patients scored significantly lower on all SF-36 scales (P < 0.001) except physical functioning. Similarly, non-white IBS patients had significantly worse HRQOL on selected SF-36 scales compared with diabetes mellitus and ESRD patients. Non-white IBS patients had significantly better emotional well-being than depressed patients, (P < 0.001).

Conclusions: Non-white IBS patients experience impairment in vitality, role limitations-physical, and bodily pain. Yet overall, non-white IBS patients report similar HRQOL to white IBS patients. These data provide the first detailed evaluation of the impact of IBS on HRQOL in non-white IBS patients.

(C) 2004 Lippincott Williams & Wilkins, Inc.


http://www.mdlinx.com/GILinx/thearts.cfm?artid=1066771&specid=13&ok=yes

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Clinical Update on the Treatment of Constipation in Adults new
      #112101 - 10/11/04 03:34 PM
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Clinical Update on the Treatment of Constipation in Adults

Rosemary R. Berardi , PharmD, FCCP, FASHP

Behavioral Objectives
After participating in this activity, participants should be better able to:

Define constipation (from clinical research, physician, and patient perspectives), and discuss the impact of poorly controlled constipation on patients and society.
List examples of primary and secondary causes of constipation, and distinguish between the acute, temporary forms and the ongoing, chronic forms of constipation.
Differentiate the efficacy and tolerability profiles and discuss the role of traditional pharmacologic agents used to treat constipation.
Explain the current hypothesis regarding the pathophysiology of chronic constipation, discuss the role of serotonin in normalizing gastrointestinal function, and summarize the role of new and emerging agents in the treatment of patients with chronic constipation.
Identify ways in which pharmacists can assist self-treating patients who report constipation, and describe clinical situations that require referral to a health care practitioner.
Constipation often is regarded simply as a minor annoyance, but, in actuality, the disorder places a substantial burden on patients and society. In some cases, constipation is a temporary problem that can be self-treated. In other instances, however, it is a complex problem that requires the attention of a health care practitioner. Patients and health care practitioners often define constipation differently. Pharmacists are in an ideal position to help bridge this communication gap. This article will (1) provide an overview of the burden that constipation places on society; (2) differentiate key aspects of treatment options; and (3) assist pharmacists in determining when referral or further evaluation is necessary.

To read this entire article, check here....

https://secure.pharmacytimes.com/lessons/200410-01.asp

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Relationship Between Colon Ischemia, Irritable Bowel Syndrome new
      #112114 - 10/11/04 04:15 PM
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From Medscape Gastroenterology

Irritable Bowel Syndrome Expert Column

On the Relationship Between Colon Ischemia, Irritable Bowel Syndrome, and Serotonergic Therapy of Irritable Bowel Syndrome

Posted 09/24/2004

Lawrence J. Brandt, MD

Introduction and Context

The Problem

Colon ischemia and irritable bowel syndrome (IBS) are 2 common gastroenterologic disorders that, until recently, were thought to occur independently in very different populations. We know now, however, that there is a complex association between the 2: (1) colon ischemia appears to be more common in the IBS patient than was recognized previously; and (2) there is concern that the newly developed serotonin receptor agonists or antagonists may increase the risk of colon ischemia, and serotonergic signaling may be abnormal in patients with colitis. This review highlights some of the relationships between colon ischemia, IBS, and therapy for IBS.

IBS -- Pathophysiology and Clinical Presentation
IBS is a disorder that is diagnosed by various symptom-based criteria, such as the Manning, Rome, and Rome II criteria. IBS lacks any biologic, physiologic, structural, or serologic marker, and so diagnosis is symptom-based. Symptoms typically include abdominal discomfort or pain, bloating, diarrhea, fecal urgency, and constipation. Symptoms may change with time, and patients who have diarrhea or constipation as a major part of their illness may evolve to the opposite bowel habit or develop a pattern in which they alternate between the 2. IBS must never be considered as the explanation for rectal bleeding, bloody diarrhea, weight loss, fever, constitutional symptoms, or anemia, and in the presence of these "alarm" symptoms or signs, organic disease must be excluded using conventional stool tests, endoscopic, and radiologic examinations. For the IBS patient without alarm symptoms, the routine use of these tests is not recommended, although for patients with IBS and diarrhea, serologic testing for celiac sprue may be appropriate and cost-effective.[1,2] Of course, screening tests for colon cancer are recommended for all patients 50 years of age or older, including those with IBS.

Colon Ischemia -- Pathophysiology and Clinical Presentation
Colon ischemia generally presents in individuals older than 55 years, a population considerably older than that typically affected by IBS. The known causes of colon ischemia are many, but in the usual case, no definitive cause is found; most episodes of colon ischemia are thought to be caused by brief periods of localized nonocclusive ischemia. The acute onset of mild, lower abdominal pain accompanied or followed by diarrhea, rectal bleeding, or bloody diarrhea is typical. Most patients with colon ischemia have spontaneous resolution of symptoms within several days. Computed tomography of the abdomen usually shows segmental thickening of the colon, although this is not a specific finding. Colonoscopy, if performed within the first 24-48 hours, usually will show submucosal hemorrhage or edema in a segmental pattern (ischemic colopathy). If the examination is repeated within a few days after the onset of symptoms, it will show the disease process to have evolved into a segmental (ischemic) colitis pattern with ulceration and even pseudopolyp formation, an appearance that may mimic inflammatory bowel disease or infectious colitis; biopsy usually is nonspecific, with only infarction and ghost cells pathognomonic of ischemic injury. In general, mesenteric angiography is not used to evaluate patients suspected of having colon ischemia, because by the time of presentation, colonic blood flow usually has normalized.

It is important for primary care practitioners to be aware of colon ischemia because it is a common cause of bloody diarrhea in the elderly and can be seen in patients of all ages, especially those who have a coagulation disorder, systemic illness associated with vasculitis, or those with IBS. Moreover, colon ischemia can mimic or be mimicked by infectious colitis or inflammatory bowel disease. Most patients who develop colon ischemia do well with conservative management. For the patient who continues to have symptoms for more than 2 weeks, referral to a gastroenterologist is recommended because it is likely that these individuals will have a complicated course.




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Section 1 of 6 Next Page: Issues in Epidemiology

Read this entire article here http://www.medscape.com/viewarticle/488174?src=mp


Lawrence J. Brandt, MD, Chief of Gastroenterology, Montefiore Medical Center, Bronx, New York; Professor of Medicine and Surgery, Albert Einstein College of Medicine, Bronx, New York


Disclosure: Lawrence J. Brandt, MD, has served as an advisor or consultant for Novartis, GlaxoSmithKline, Solvay, and TAP. He has also disclosed he is on the speakers bureau for AstraZeneca.

Medscape Gastroenterology 6(2), 2004. 2004 Medscape






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Stress Therapy Can Help Irritable Bowel new
      #115470 - 10/24/04 07:38 PM
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Stress Therapy Can Help Irritable Bowel

Don't Just Put Up With Symptoms; Treatments Can Improve Life Quality

By Jeanie Lerche Davis

Reviewed By Brunilda Nazario, MD
on Monday, September 13, 2004

Sept. 13, 2004 -- Tense, tired, depressed: For people with irritable bowel syndrome (IBS), dealing with their disease takes a mental and physical toll. Emotional state and energy level -- not just bowel problems -- need a doctor's attention, a new study shows.

Many doctors do a poor job of addressing their patients' fears and concerns and understanding how quality of life is affected, writes lead researcher Brennan M.R. Spiegel, MD, MSHS, a gastroenterologist with The David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Healthcare System.

His paper appears in the latest Archives of Internal Medicine.

"There's a disconnect between how patients and doctors view the disease," Spiegel tells WebMD. "Doctors are trained to think about bowel movements -- their frequency, their color, texture. But this study shows that our patients feel we are underestimating the severity of the effect on their quality of life."

It's very clear that IBS can reduce quality of life, he adds. "It causes what we refer to as 'vital exhaustion' -- loss of vitality, sleep disorders, sexual dysfunction, feeling tired all the time, dispirited, low energy -- all the things that interfere with quality of life."

Picture of Health

Spiegel has developed a quality-of-life survey that busy doctors can use. He used the survey on 770 patients with irritable bowel syndrome. Each completed the questions: Do you feel low in energy? Nervous? Hopeless? Tense? Tire easily? Have sleep difficulties? Not interested in sex? Feel there is something seriously wrong with your body? They also answered questions related to their bowel problems.

Physical health-related quality of life is related to the severity of bowel problems, frequency, and pain, he explains. But mental health-related quality of life is related to sexuality, mood, and anxiety.

His study showed that how patients felt physically and mentally affected their quality of life. Patients who got tired easily had a 9% lower physical health-related quality-of-life score, compared with those who didn't tire easily. Patients whose symptoms flared up for a day had a 4% lower physical health-related quality-of-life score. If they had both problems, they lost 13% in quality-of-life scores.

Mental health had a similar impact; patients who felt tense had a 14% lower mental health-related quality of life. When their IBS symptoms interfered with their sexual function, they had a 4% lower mental health-related quality of life. For those who had both problems, their mental health-related quality of life was 17% lower.

"We have to spend some time talking about these emotional issues," Spiegel tells WebMD. "Sometimes, all that's necessary is letting a patient know it's not cancer, that it will not cause cancer. That in itself can help relieve the depression and anxiety."

Stress Therapy, Medications Help

Many people put up with symptoms of IBS without getting treatment. "Yet the quality-of-life impact of IBS has been shown to be comparable to congestive heart disease and may be as great as diabetes," says William E. Whitehead, PhD, director of the Center for Functional GI and Motility Disorders Center at the University of North Carolina School of Medicine.

"The anxiety and stress can impact how well a patient interacts with friends and family," he tells WebMD. "Also, work absenteeism is three times higher for irritable bowel patients, compared to rest of the population."

There are a range of effective treatments for irritable bowel, says Whitehead. "Treatments range from low doses of antidepressants, hypnosis, [stress] therapy to dietary changes, medicines for constipation and diarrhea, a whole spectrum of treatments."

It's true that "with IBS one symptom can make other symptoms seem worse," says Ryan Madanick, MD, a gastrointestinal specialist at the University of Miami School of Medicine. "It's like when you're under stress, you tend to respond more negatively to stimuli that don't normally cause you problems, they irritate you. With IBS, it seems to be the same thing going on in the intestine.

"Antidepressants and anti-anxiety medications probably help the most, because unfortunately stress-related disorders and IBS go hand in hand," Madanick tells WebMD. "If you can decrease the stress, you're breaking the cycle and improving overall quality of life."

Also, make regularly scheduled visits for irritable bowel problems, not visits on an emergency basis, he advises.


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SOURCES: Spiegel, B. Archives of Internal Medicine, Sept. 15, 2004; vol 164: pp 1773-1780. Brennan M.R. Spiegel, MD, MSHS, gastroenterologist, The David Geffen School of Medicine, UCLA, and the VA Greater Los Angeles Healthcare System. William E. Whitehead, PhD, director, Center for Functional GI and Motility Disorders, University of North Carolina School of Medicine. Ryan Madanick, MD, gastrointestinal specialist, University of Miami School of Medicine.


http://content.health.msn.com/content/article/94/102633.htm?pagenumber=2

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Obesity is Associated With Increased Risk of Gastrointestinal Symptoms new
      #115473 - 10/24/04 07:42 PM
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From The American Journal of Gastroenterology

Obesity is Associated With Increased Risk of Gastrointestinal Symptoms: A Population-Based Study

Posted 09/23/2004

Silvia Delgado-Aros, M.D., Ph.D.; G. Richard Locke, III, M.D.; Michael Camilleri, M.D.; Nicholas J. Talley, M.D., Ph.D.; Sara Fett, B.S.; Alan R. Zinsmeister, Ph.D.; L. Joseph Melton, III, M.D

Abstract and Introduction
Abstract
Objectives: Perception of sensations arising from the gastrointestinal tract may be diminished in obese subjects and thus facilitate overeating. Alternatively, excess food intake may cause gastrointestinal (GI) symptoms in obese patients. We evaluated the relationship between body mass index (BMI) and specific GI symptoms in the community.
Methods: Residents of Olmsted County, MN were selected at random to receive by mail one of two validated questionnaires. The association of reported GI symptoms with BMI (kg/m2) was assessed using a logistic regression analysis adjusting for age, gender, psychosomatic symptom score, and alcohol and tobacco use.
Results: Response rate was 74% (1,963 of 2,660). The prevalence of obesity (BMI >/= 30 kg/m2) was 23%. There was a positive relationship between BMI and frequent vomiting (p = 0.02), upper abdominal pain (p = 0.03), bloating (p = 0.002), and diarrhea (p = 0.01). The prevalence of frequent lower abdominal pain, nausea, and constipation was increased among obese (BMI >/= 30 kg/m2) compared to normal weight participants, however, no significant association was found between BMI and these symptoms.
Conclusions: In the community, increasing BMI is associated with increased upper GI symptoms, bloating, and diarrhea. Clarification of the cause-and-effect relationships and the mechanisms of these associations require further investigation.

Introduction
Obesity has reached epidemic proportions. Data from the National Center for Health Statistics show that 64.5% of the U.S. population of age 20 or above is overweight (body mass index, BMI >/= 25 kg/m2), and 31% is clinically obese (BMI >/= 30 kg/m2).[1] Obesity has a substantial impact on morbidity[2-8] and on the quality of life of these individuals, who have a poorer general health perception and daily functioning.[9,10] Obesity induces an enormous psychological burden.[11,12]

There are many factors involved in the development of obesity including environmental, psychological, and social factors as well as physiological mechanisms. Most of these mechanisms and their interactions are not fully understood.[13-16]

Dysregulation of the mechanisms that control food intake and energy expenditure is a key to the development of obesity. The gastrointestinal (GI) tract is a source of satiation factors, which contribute to meal termination, and hence determine meal size.[17-20] A decreased satiation response to food intake may play a role in the development of obesity.[21,22]

In contrast to the observation of decreased satiation in obese individuals, an increased prevalence of different GI symptoms has been reported in obese patients seeking treatment in a tertiary care center compared to community controls.[23] However, obese patients seeking treatment may not be representative of obese individuals in the community.

We have previously reported that BMI is an independent risk factor for the presence of self-reported heartburn and regurgitation in a community-based population in the United States.[24] Although BMI was not found to be associated with irritable bowel syndrome (IBS) in another study,[25] the relationship between BMI and other GI symptoms has not previously been explored in the community.

If perception of satiation signals arising in the gut is reduced in obesity, one could entertain the hypothesis that perception of other sensations originated from the GI tract would be similarly reduced in obese individuals. An exception to this hypothesis would be the association between obesity and GERD symptoms, for which a mechanistic role (i.e., hiatal hernia) is assumed to be the cause of the symptoms. An alternative hypotheses is that excess food intake could lead to responses that increase GI symptoms.

In this study, we aimed to evaluate the relationship between BMI and specific GI symptoms, other than heartburn and regurgitation, in a community-based population.




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Section 1 of 4 Next Page: Methods


Silvia Delgado-Aros, M.D., Ph.D., G. Richard Locke, III, M.D., Michael Camilleri, M.D., Nicholas J. Talley, M.D., Ph.D., Sara Fett, B.S., Alan R. Zinsmeister, Ph.D., and L. Joseph Melton, III, M.D, Clinical Enteric Neuroscience Translational & Epidemiological Research (C.E.N.T.E.R.) Program; and Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota



Am J Gastroenterol 99(9):1801-1806, 2004. 2004 Blackwell Publishing

To continue reading this article click here http://www.medscape.com/viewarticle/489428_2


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Obese Women Face Higher Risk of Colorectal Cancer new
      #120111 - 11/08/04 04:48 PM
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Source: American College of Gastroenterology (ACG) Released: Tue 26-Oct-2004, 10:00 ET


Obese Women Face Higher Risk of Colorectal Cancer

New study findings show a high body mass index (BMI) among women is a more significant risk factor for colorectal neoplasia than for men.



Newswise New study findings show a high body mass index (BMI) among women is a more significant risk factor for colorectal neoplasia than for men. According to data released today at the 69th Annual Scientific Meeting of the American College of Gastroenterology, researchers from Stony Brook University found a positive correlation between increased body mass index (BMI) and the risk of colorectal neoplasia among asymptomatic women who underwent colonoscopies.

The researchers examined a population of 2300 patients, including 1250 men and 1050 women. Overall, their findings reveal that increasing BMI is associated with higher risk of significant colorectal neoplasia. This effect was shown to be statistically significant in women but not men.

The researchers divided the women into several groups based on BMI and evaluated whether their screening tests detected large polyps or multiple polyps, high grade dysplasia (a precancerous change in the colon) or cancer. Women who had a BMI of 40 (considered obese) or more were 5.2 times as likely to have significant colonic neoplasia detected during colonoscopy as women with a BMI of 25 or less (considered healthy weight) while controlling for smoking, age, alcohol use and family history of colorectal cancer.

Explaining the disparity in the findings between men and women, Joseph C. Anderson, M.D., one of the Stony Brook investigators, said, "We use body mass index as a surrogate measure for body fat. It may be that for men and women with similar BMI, women have less muscle than men. This needs to be explored further." According to Dr. Anderson, the implications of this study are important for physicians counseling overweight and obese women about colorectal cancer screening in light of their increased risk.

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2004 Newswise. All Rights Reserved.

http://www.newswise.com/articles/view/507863/?sc=wire

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Symptom patterns in functional dyspepsia and irritable bowel syndrome new
      #125858 - 11/28/04 02:34 PM
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Gut 2004;53:1445-1451
2004 by BMJ Publishing Group Ltd & British Society of Gastroenterology

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IRRITABLE BOWEL SYNDROME

Symptom patterns in functional dyspepsia and irritable bowel syndrome: relationship to disturbances in gastric emptying and response to a nutrient challenge in consulters and non-consulters

S Haag1, N J Talley2 and G Holtmann1

1 Department of Internal Medicine, Division of Gastroenterology and Hepatology, University Hospital Essen, Hufelandstr 55, D-45122 Essen, Germany
2 Mayo Clinic, College of Medicine, Rochester, MN, USA

ABSTRACT
Background: Our aim was to assess the relationship between gastric motor and sensory function and symptom patterns in community subjects and patients with functional dyspepsia (FD) or irritable bowel syndrome (IBS).

Methods: We recruited 291 asymptomatic blood donors, 151 symptomatic blood donors (recurrent abdominal pain or discomfort), and 40 patients with FD or IBS. Abdominal symptoms were assessed using the bowel disease questionnaire (BDQ) and, in addition, the most bothersome symptom complex identified (dysmotility-type, ulcer-type dyspepsia, or IBS). Gastric emptying time (GET (t1/2, min)) was measured by 13C-octanoic breath test and a nutrient challenge performed. Twenty randomly selected asymptomatic blood donors, 48 symptomatic blood donors (30 FD, 18 IBS), and 40 patients (23 FD, 17 IBS) had additional function testing.

Results: GET (t1/2) was significantly (p<0.05) longer in blood donors with FD symptoms (99 (6) min) and FD patients (110 (12) min) compared with asymptomatic controls (76.7 (7) min), but was not significant in IBS blood donors or patients. Overall, 25 of 48 blood donors with symptoms and 18 of 40 patients had slow gastric emptying. GET was most delayed in subjects with predominantly dysmotility-type symptoms (167 (36) min v controls; p<0.01). Symptom intensities after a nutrient challenge were significantly higher in FD patients and symptomatic blood donors compared with asymptomatic controls; 14 of 48 blood donors with symptoms and 16 of 40 patients had a symptom response to the nutrient challenge exceeding the response (mean (2SD)) of healthy asymptomatic controls.

Conclusion: Gastric emptying and the global symptom response to a standardised nutrient challenge are abnormal in population based (non-health care seeking) subjects with dyspepsia.

http://gut.bmjjournals.com/cgi/content/abstract/53/10/1445

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Advances in the Treatment of Chronic Constipation new
      #125864 - 11/28/04 02:55 PM
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From Medscape Gastroenterology

Expert Interview

Advances in the Treatment of Chronic Constipation: An Expert Interview With Lawrence R. Schiller, MD

11/10/2004

Editor's Note:
Chronic constipation is a common clinical problem. It generally refers to unsatisfactory defecation, as defined in terms of alterations in the frequency, size, consistency, and ease of passage of stool. Although reports of prevalence vary depending on whether estimates are derived from self-reports or are based on the Rome criteria, chronic constipation accounts for approximately 2.5 million physician visits each year in the United States. Medscape spoke with Lawrence R. Schiller, MD, Program Director, Gastroenterology Fellowship, Baylor University Medical Center, Dallas, Texas, to discuss the clinical impact of this problem upon the patient and the healthcare industry alike, and the current challenges facing the physician treating the patient with chronic constipation.

Medscape: Although physicians generally relate constipation with decreased stool frequency, patients often apply this term to a number of defecatory complaints. How would you clinically define chronic constipation and how does the multiple-symptom nature of this disorder affect the healthcare industry?

Dr. Schiller: The definitions that really matter are the ones that individual patients have for this group of defecation problems. Physicians must take the time to understand what the patient means by the complaint of "constipation." The main features that patients describe in their definitions include altered consistency ("hard" or "lumpy" stools), small stool size (diameter or volume), and infrequency of defecation. It is important to realize that these changes are relative to the patients' usual habits, and are not necessarily those cited in published criteria. In addition, a variety of coexisting symptoms, such as bloating, abdominal distension, and discomfort or pain, influence patients when they report the symptom of "constipation" to their physicians.

The diverse nature of patients' definitions makes the study of constipation and its treatment difficult. To introduce some uniformity to the definition of constipation for research purposes, the Rome II committee has set forth criteria for a diagnosis of chronic functional constipation. These criteria include a chronicity definition (at least 3 months' duration) and 2 or more specific alterations in defecation occurring at least 25% of the time (fewer than 3 bowel movements per week, hard or lumpy stools, straining with evacuation, a sensation of incomplete evacuation, a sense of anorectal obstruction, and the use of manual maneuvers to assist defecation). In addition, criteria for irritable bowel syndrome are not present. Operationally, this means that abdominal pain is not a prominent symptom. It is important to realize that patients who complain of chronic constipation may or may not meet these criteria. To the extent that they do, they will behave like other patients who meet criteria and have been studied in research projects. Patients who do not meet these specific criteria may still respond to treatments for constipation, but with less certainty.

The impact of constipation on the healthcare system is substantial. Patients presenting with chronic constipation require at least some evaluation. The variety of presenting symptoms may cause excessive evaluation if the physician does not recognize the connected nature of these complaints.

Medscape: What can you tell us about patients' overall satisfaction with the traditionally available treatment options (bulking agents, laxatives) for chronic constipation?

Dr. Schiller: Last spring a consumer panel of more than 37,000 Americans selected to be representative of the US population was queried about chronic constipation.[1] Over 24,000 individuals consented to be questioned and 4680 (19%) had 2 or more Rome II symptoms of chronic constipation. A total of 1147 respondents had sought medical attention for constipation in the previous year and of these, 557 were not diagnosed as having irritable bowel syndrome with constipation or some other gastrointestinal disease-causing constipation. Only 4% of these patients had never been treated with over-the-counter or prescription drugs; 80% had tried over-the-counter remedies and 35% had tried prescription drugs.

Only half of the respondents were satisfied with their current treatments. Lack of efficacy was the reason for dissatisfaction cited by 82% of those unhappy with their therapy. Major problems with efficacy included both the agents not working well enough as well as inconsistency of results. Sixteen percent of respondents cited side effects as the reason that they were dissatisfied with the results of treatment.

When asked about the effect of specific products on quality of life, 64% of individuals were dissatisfied with fiber, 68% were dissatisfied with over-the-counter laxatives, and 44% were dissatisfied with prescription laxatives. Thus, from the patients' viewpoints, there was plenty of room for improvement in the treatment of constipation.

Medscape: A study presented during the 69th Annual Meeting of the American College of Gastroenterology assessed the primary care physician's perception of the clinical impact of chronic constipation as a medical condition and looked at its effect on patients' lives as well as physicians' impressions of the current therapeutic armamentarium. What can you tell us about this study, and what were the key findings with respect to the physicians' vs patients' perceptions regarding the clinical impact and unmet medical needs in this setting?

Dr. Schiller: In April 2004, approximately 8000 primary care physicians listed in an American Medical Association database were contacted about participating in a survey about constipation; 461 were screened for eligibility. The main eligibility criteria were being board-certified or board-eligible in family practice or internal medicine, having been in practice for 2-40 years, spending 75% or more of the time in clinical practice, and treating 5 or more patients with constipation each week. Three hundred and eleven eligible physicians then completed a 37-question survey administered by trained interviewers.[2]

Physicians reported that their typical patients had symptoms for 2-3 years, but 17% had typical patients with symptoms for 10 or more years. Two thirds of the physicians reported that their typical patients had 1-2 bowel movements per week.

The vast majority of physicians felt that constipation was at least somewhat severe as a medical condition (83%), was at least somewhat bothersome (98%), and had at least some impact on their patients' quality of life (95%). Physicians reported that abdominal discomfort or pain, straining, bloating, and hard stools were at least as important as infrequency of defecation as causes of severity, "bothersomeness," and decreased quality of life. Gas, the sensation of incomplete evacuation, rectal pain, and urgency were also cited as problematic for patients with constipation.

Surveyed physicians believed that worsening symptoms, frustration with symptom control, and frustration with current treatment were the main reasons that patients consulted with them for constipation. Most of these physicians were dissatisfied with the ability of fiber products (58%) and over-the-counter laxatives (63%) to improve quality of life in these patients. Even existing prescription laxatives were unsatisfactory in the opinion of 42% of the physicians surveyed; 90% wished that there were better treatment options for these patients.

Thus, while most physicians view constipation as an important medical problem for their patients, they are dissatisfied with the available treatments and wish that they had better therapeutic options for these patients.

Medscape: Results of a survey conducted to examine the prevalence of constipation, the symptoms that patients include in their description of constipation, and patients' satisfaction with the current treatment options were also presented during this year's meeting. What can you tell us about this study and what were the key findings?

Dr. Schiller: The prevalence of chronic constipation has been estimated to be as high as 28% of the adult population in the United States, based on a number of surveys over the years, as recently reviewed by Higgins and Johanson.[3] To reexamine the prevalence of this condition using modern definitions of constipation and its symptoms, we took advantage of an existing large panel of consumers selected to be representative of the US population who regularly participate in Internet-based surveys.[1] Of the 37,000 individuals in this panel, 24,090 consented to be questioned about their bowel habits. A total of 4680 of these individuals (19%) met Rome II criteria for functional constipation: experiencing 2 or more symptoms (fewer than 3 bowel movements per week, hard or lumpy stools, straining with evacuation, a sensation of incomplete evacuation, a sense of anorectal obstruction, and the use of manual maneuvers to assist defecation) more than 25% of the time for at least 3 months. This estimate of prevalence is very much in keeping with older estimates in the literature.

We next looked at the 1147 of these individuals who sought attention from a physician for constipation during the last year. About half of these subjects were diagnosed as having some gastrointestinal disease or irritable bowel syndrome that was causing their constipation, leaving a pool of 557 participants with "functional constipation" who were queried in more detail about their symptoms.

The percentages of men and women in this select group were nearly identical to those in the pool of 24,090 who consented to enter the study (56% women and 44% men), indicating that the prevalence of constipation was roughly equal between the sexes. There was an enhancement in the proportion of older individuals in the select constipation group (27% vs 17% >/= 65 years of age), suggesting that constipation is more common in the elderly.

A majority of the respondents (72%) reported that they had constipation for 5 years or less, but 21% described symptoms that lasted 10 years or longer. Half of respondents reported having 2 or fewer bowel movements per week, but the other half had 3 or more bowel movements per week, a "normal" stool frequency. Straining during evacuation was the most common defining symptom (reported by 77%), followed by lumpy or hard stools (73%), sensation of incomplete evacuation (58%), fewer than 3 bowel movements per week (47%), and the sensation of blocked defecation (40%).

Constipation degraded quality of life, with 52% of respondents claiming that it had at least some impact on their lives; 12% of those employed or going to school missed time from work or class because of constipation symptoms.

Almost all of the respondents (96%) had tried some treatments for constipation, with 80% having tried over-the-counter remedies and 35% having used prescription drugs for constipation. Yet only 53% of individuals were completely satisfied with their treatment. Those respondents who were dissatisfied cited ineffectiveness and inconsistency of effect as the main reasons for their unhappiness; 16% cited side effects as the reason for their dissatisfaction. These results suggest that a substantial proportion of patients with constipation want and need better treatments.

Medscape: Were there any other data presented during the meeting that would help put this information into clinical context? Also, how do you view the path forward in terms of the treatment of chronic constipation?

Dr. Schiller: There were several other studies presented during this year's meeting of the American College of Gastroenterology that addressed chronic constipation.

An analogous population survey conducted in Canada[4] showed very similar findings as the US patient survey mentioned above, although the prevalence rates for lower gastrointestinal tract symptoms were somewhat lower than in the US study. Important to note is that a large proportion of Canadians with constipation were dissatisfied with their therapies.

A survey of constipated patients in Alabama addressed a problem not covered in our study (discussed above) -- the problem of medication-associated constipation.[5] Of 329 subjects with self-reported constipation, 195 (59%) were taking drugs associated with constipation, such as antidepressants, pain medications, and calcium-channel blockers. Clearly, clinicians must take a careful drug history when evaluating patients with constipation.

Another study looked at bloating and gaseousness in patients with functional constipation or irritable bowel syndrome with constipation.[6] Lower abdominal bloating was present in 90% of the patients in this study. Constipated patients with lower abdominal bloating were likely to have upper abdominal bloating as well. There were only modest associations with belching and flatulence in the constipated patients.

Several reports highlighted the impact of constipation on healthcare utilization. Using the California Medicaid database, healthcare expenses during the period around a first physician encounter for constipation were compiled.[7] Gastrointestinal-related procedures and laboratory tests accounted for most of the $18 million spent over 15 months on 76,854 individuals. Nearly 0.6% of these patients were hospitalized for constipation. This somewhat surprising statistic was confirmed in another study that documented over 38,000 admissions primarily for constipation, nationally.[8] Of course, most physician encounters with patients for constipation occur in the outpatient or emergency room setting; more than 5.7 million constipation-related visits occurred in outpatient venues in 2001 according to another study abstract.[9]

The impact of constipation on quality of life was addressed in a study involving patients with refractory constipation.[10] SF-36 questionnaires were administered to 31 patients with constipation who were referred to a pelvic floor laboratory and showed significantly lower quality-of-life scores than healthy controls. Work productivity and activity impairment was demonstrated in a subanalysis of our patient survey data.[11]

A systematic review of traditional therapy for chronic constipation pointed out the lack of evidence to support most currently used treatments.[12] The ineffectiveness of current treatments was examined in a study of 1660 HMO (health maintenance organization) patients, 334 of whom met Rome II criteria for functional constipation.[13] These patients had less improvement than patients with other functional bowel disorders when treated with therapies that included diet changes, exercise, reducing life-stress, laxatives, and antispasmodics.

It is fairly clear from these reports that clinicians need to do a better job in treating chronic constipation so that we can improve our patients' quality of life and reduce losses in productivity and healthcare-related expenses. Fortunately, new agents are being developed and introduced that make these goals feasible. For example, tegaserod has recently been approved by the US Food and Drug Administration for the treatment of chronic constipation in men and women. Studies have shown that this agent improves constipation symptoms in significantly more patients than placebo and is well tolerated by most patients with chronic constipation. Tegaserod works by stimulating peristalsis via its effects on 5-HT4 receptors in the enteric nervous system. Because slow transit is the mechanism underlying most cases of constipation, tegaserod provides targeted therapy. I expect that additional drugs that target other physiologic activities of the gut will eventually allow us to provide satisfactory results for more patients with chronic constipation.


References
Schiller LR, Dennis E, Toth G. An Internet-based survey of the prevalence and symptom spectrum of chronic constipation. Am J Gastroenterol. 2004;99:S234. [Abstract #723]
Schiller LR, Dennis E, Toth G. Primary care physicians consider constipation as a severe and bothersome medical condition that negatively impacts patients' lives. Am J Gastroenterol. 2004;99:S234. [Abstract #724]
Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004;99:750-759.
Hunt R, Dhaliwal S, Tougas G, et al. Lower GI symptoms: A Canadian prescriptive drug study assessing prevalence, impact, and satisfaction with treatments. Am J Gastroenterol. 2004;99:S227. [Abstract #703]
Rutland TJ, Adeniji OA, Di Palma JA. Prevalence of medication-associated constipation. Am J Gastroenterol. 2004;99:S103. [Abstract #320]
Williams M, Wessinger S, Soanier J, et al. Bloating and gaseousness in healthy subjects and patients with constipation. Am J Gastroenterol. 2004;99:S287. [Abstract #879]
Singh G, Kahler K, Bharathi V, et al. Adults with chronic constipation have significant health care resource utilization and costs of care. Am J Gastroenterol. 2004;99:S227. [Abstract #701]
Martin BC, Barghout V. National estimates of constipation-related hospitalizations in the United States. Am J Gastroenterol. 2004;99:S244. [Abstract #753]
Martin BC, Barghout V. National estimates of office and emergency room constipation-related visits in the United States. Am J Gastroenterol. 2004;99:S244. [Abstract #754]
Robson K, Barrett R, Liberman RF. Psychological profiles and quality of life in patients with refractory constipation. Am J Gastroenterol. 2004;99:S278. [Abstract #852]
Bracco A, Kahler K. Burden of chronic constipation must include estimates of work productivity and activity impairment in addition to traditional healthcare utilization. Am J Gastroenterol. 2004;99:S233. [Abstract #719]
Ramkumar DP, Rao SS. Systematic review: the efficacy and safety of traditional medical therapies for chronic constipation. Am J Gastroenterol. 2004;99:S278. [Abstract #853]
Palsson OF, Whitehead WE, Levy RL, et al. Constipation less effectively treated than other functional bowel problems in a health maintenance organization (HMO). Am J Gastroenterol. 2004;99:S287. [Abstract #878]



Disclosure: Lawrence R. Schiller, MD, has disclosed that he has received grants for clinical research from GlaxoSmithKline, Procter & Gamble, and Novartis, and has received grants for educational activities from AstraZeneca, Procter & Gamble, and TAP Pharmaceuticals. He has served as an advisor or consultant for Salix Pharmaceuticals, Novartis, McNeil, and Boehringer Ingelheim. He has also served on the Speaker's Bureau for AstraZeneca, Procter & Gamble, Novartis, and TAP Pharmaceuticals.

Medscape Gastroenterology 6(2), 2004. 2004 Medscape

http://www.medscape.com/viewarticle/492110?src=mp

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Complementary and alternative medicine in gastroenterology new
      #131895 - 12/20/04 01:16 PM
HeatherAdministrator

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

Clin Gastroenterol Hepatol. 2004 Nov;2(11):957-67.

Complementary and alternative medicine in gastroenterology: the good, the bad, and the ugly.

Koretz RL, Rotblatt M.

Department of Medicine, Olive View--UCLA Medical Center, Sylmar, California 91342, USA. rkoretz@ladhs.org

A large proportion of the American population avails itself of a variety of complementary and alternative medicine (CAM) interventions. Allopathic practitioners often dismiss CAM because of distrust or a belief that there is no sound scientific evidence that has established its utility. However, although not widely appreciated, there are thousands of randomized controlled trials (RCTs) that have addressed the efficacy of CAM. We reviewed the RCTs of herbal and other natural products, acupuncture, and homeopathy as examples of typical CAM modalities, focusing on conditions of interest to gastroenterologists. Peppermint (alone or in combination) has supportive evidence for use in patients with dyspepsia, irritable bowel syndrome, and as an intraluminal spasmolytic agent during barium enemas or endoscopy. Ginger appeared to be effective in relieving nausea and vomiting due to motion sickness or pregnancy. Probiotics were useful in childhood diarrhea or in diarrhea due to antibiotics; one particular formulation (VSL#3) prevented pouchitis. Acupuncture appeared to ameliorate postoperative nausea and vomiting and might be useful elsewhere. There is even a suggestion that homeopathy has efficacy in treatment of gastrointestinal problems or symptoms. The major problem in interpreting these CAM data is the generally low quality of the RCTs, although that quality might not be different compared to RCTs in the general medical literature. Gastroenterologists should become familiar with these techniques; it is likely that their patients already are.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15551247

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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Link Between Irritable Bowel Syndrome (IBS), Alcoholism and Mental Illness
      #131896 - 12/20/04 01:24 PM
HeatherAdministrator

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

Friday, November 05, 2004

Mayo Clinic Researchers Find Link Between Irritable Bowel Syndrome (IBS), Alcoholism and Mental Illness

ROCHESTER, Minn. -- Mayo Clinic researchers have found evidence to suggest a common genetic link between irritable bowel syndrome, alcoholism and mental illness. The results of this study are being presented on Monday at the 69th Annual Scientific Meeting of the American College of Gastroenterology (ACG) in Orlando, Fla.

In previous work, this research team found that IBS runs in families. Alcoholism and mental illness run in families as well. The team was interested in knowing if alcoholism and mental illness were more common in family members of people who have IBS. G. Richard Locke, M.D., senior author of the research and a Mayo Clinic gastroenterologist, says the findings point researchers closer to finding a specific therapy to help families who have these conditions. IBS is estimated to be present in 10 to 20 percent of the general population, according to the International Foundation for Functional Gastrointestinal Disorders. MayoClinic.com reports that IBS typically begins around age 20. Overall, two to three times as many women as men have the condition.

"This work confirms what doctors see every day in our patients," says Dr. Locke. "People who have IBS often have mental illness and alcoholism in their families."

Specifically, the Mayo Clinic researchers found that people who have IBS but who do not drink are more likely to have a family history of alcoholism or mental illness. "Our thinking is that there is a common gene that can manifest itself as IBS, alcoholism or mental illness in a family member, so a person who chooses not to drink is more likely to have IBS," says Dr. Locke.

Others who conducted research from Mayo Clinic in Rochester are: James Knight, Alan Zinsmeister, Ph.D., Cathy Schleck, and Nicholas Talley, M.D.

A gastrointestinal symptom survey was mailed to a group of Olmsted County (Minn.) residents who had been randomly selected and responded to a similar symptom survey in the past. Survey responses were used to identify people who have IBS (cases) and healthy controls for this study. The electronic medical record was reviewed to record the subjects' self-reported personal and family health histories. In the study, 2,457 people responded to the questionnaire. The researchers found IBS reported in 13 percent of the respondents. In the analysis, the cases had a mean age of 62 years and 70 percent were female in the IBS group, while the group it was compared with had a mean age of 61 years and 64 percent were female.

MayoClinic.com notes that IBS is characterized by abdominal pain or cramping and changes in bowel function, including bloating, gas, diarrhea and constipation -- problems most people don't like to discuss. Up to one in five American adults has irritable bowel syndrome. The disorder accounts for more than one of every 10 doctor visits. For most people, signs and symptoms of irritable bowel disease are mild. Only a small percentage of people who have IBS have severe signs and symptoms.

http://www.mayoclinic.org/news2004-rst/2502.html

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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!

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