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1.  Development, Translation and Validation of Enhanced Asian Rome III Questionnaires for Diagnosis of Functional Bowel Diseases in Major Asian Languages: A Rome Foundation-Asian Neurogastroenterology and Motility Association Working Team Report 
The development-processes by regional socio-cultural adaptation of an Enhanced Asian Rome III questionnaire (EAR3Q), a cultural adaptation of the Rome III diagnostic questionnaire (R3DQ), and its translation-validation in Asian languages are presented. As English is not the first language for most Asians, translation-validation of EAR3Q is essential. Hence, we aimed to culturally adapt the R3DQ to develop EAR3Q and linguistically validate it to show that the EAR3Q is able to allocate diagnosis according to Rome III criteria.
After EAR3Q was developed by Asian experts by consensus, it was translated into Chinese, Hindi-Telugu, Indonesian, Korean, and Thai, following Rome Foundation guidelines; these were then validated on native subjects (healthy [n = 60], and patients with irritable bowel syndrome [n = 59], functional dyspepsia [n = 53] and functional constipation [n = 61]) diagnosed by clinicians using Rome III criteria, negative alarm features and investigations.
Experts noted words for constipation, bloating, fullness and heartburn, posed difficulty. The English back-translated questionnaires demonstrated concordance with the original EAR3Q. Sensitivity and specificity of the questionnaires were high enough to diagnose respective functional gastrointestinal disorders (gold standard: clinical diagnoses) in most except Korean and Indonesian languages. Questionnaires often uncovered overlapping functional gastrointestinal disorders. Test-retest agreement (kappa) values of the translated questionnaires were high (0.700–1.000) except in Korean (0.300–0.500) and Indonesian (0.100–0.400) languages at the initial and 2-week follow-up visit.
Though Chinese, Hindi and Telugu translations were performed well, Korean and Indonesian versions were not. Questionnaires often uncovered overlapping FGIDs, which were quite common.
PMCID: PMC4288097  PMID: 25537673
Asia; Gastrointestinal diseases; Rome III criteria; Translations; Validation
2.  Central Processing of Noxious Somatic Stimuli in Patients With Irritable Bowel Syndrome Compared With Healthy Controls 
The Clinical journal of pain  2010;26(2):104-109.
To compare a central analgesic mechanism known as diffuse noxious inhibitory controls (DNIC) using somatic test stimuli and somatic conditioning stimuli, (CS) in irritable bowel syndrome (IBS) patients and healthy controls.
Participants were 48 premenopausal females (27 with IBS), mean age of 29 years. The phasic heat test stimulus (peak temperature, 50°C) was applied to the left palm. The DNIC effect, which measured reductions in average pain ratings (APR) during counter irritation (submersion of the participant’s right hand in painful 12°C circulating water) compared with baseline, was compared between groups. In addition, a second, counterbalanced, CS protocol (right hand submerged in nonpainful 32°C circulating water) was performed. Differences in APR between the 2 counter-irritation protocols were compared between groups to control for nonspecific effects known to influence DNIC. Psychologic measures and cardiovascular reactivity were also assessed.
IBS patients demonstrated smaller DNIC than controls (P=0.011, repeated measures analysis of variance), and greater state-anxiety, depression, catastrophizing, and anger-out expression (P<0.05). Group differences in DNIC were enhanced after controlling for nonspecific effects occurring during the nonpainful CS, and for psychologic measures (P=0.001, repeated measures analysis of covariance). There were no group differences in age, cardiovascular reactivity, APR, or pain ratings for the 12°C CS.
These data demonstrate deficient DNIC in IBS. This is the first study to adequately control for alternative explanations of pain reduction during counterirritation. Only by controlling for nonspecific effects can evidence of deficient DNIC be attributed to dysregulation in endogenous analgesic mechanisms.
PMCID: PMC4321817  PMID: 20090435
diffuse noxious inhibitory controls; DNIC; pain; irritable bowel syndrome
3.  Twelve Month Follow-up of Cognitive Behavioral Therapy for Children with Functional Abdominal Pain 
JAMA pediatrics  2013;167(2):178-184.
To determine whether a brief intervention for children with functional abdominal pain and their parents' responses to their child's pain resulted in improved coping 12 months later.
Prospective, randomized, longitudinal study.
Families were recruited during a 4-year period in Seattle, WA and Morristown, NJ.
200 children with persistent functional abdominal pain and their parents.
A 3-session social learning and cognitive behavioral therapy intervention or an education and support intervention.
Main outcome measures
Child symptoms and pain coping responses were monitored using standard instruments, as was parental response to child pain behavior. Data were collected at baseline and after treatment (1 week and 3, 6, and 12 months after treatment). This article reports the 12-month data.
Relative to children in the education and support group, children in the social learning and cognitive behavioral therapy group reported greater baseline to 12-month follow-up decreases in gastrointestinal symptom severity (estimated mean difference = -0.36, CI = -0.63, -0.01) and greater improvements in pain coping responses (estimated mean difference = 0.61, CI = 0.26, 1.02). Relative to parents in the education and support group, parents in the social learning and cognitive behavioral therapy group reported greater baseline to 12-month decreases in solicitous responses to their child's symptoms (estimated mean difference = -0.22, CI = -0.42, -0.03) and greater decreases in maladaptive beliefs regarding their child's pain (estimated mean difference = -0.36, CI = -0.59, -0.13).
Results suggest long-term efficacy of a brief intervention to reduce parental solicitousness and increasing coping skills. This strategy may be a viable alternative for children with functional abdominal pain.
Trial registration Identifier #NCT00494260
PMCID: PMC4167735  PMID: 23277304
4.  Risk Factors for Urinary, Fecal or Dual Incontinence in the Nurses’ Health Study 
Obstetrics and gynecology  2013;122(3):539-545.
To estimate the prevalence of urinary incontinence, fecal incontinence, and dual incontinence in a large cohort of older women and compare risk factors across the three conditions.
These cross-sectional analyses utilized data from the Nurses’ Health Study. The 2008 questionnaire, mailed to 96,480 surviving participants aged 62–87 years, included two separate items on prevalence of urinary and fecal incontinence. A response of leakage at least once per month defined incontinence for both urine and stool. Dual incontinence was defined by responses at this frequency for both conditions. Using a polytomous logistic regression model we assessed each risk factor for prevalence of urinary, fecal, and dual incontinence, respectively.
The survey was completed by 64,396 women. Thirty-eight percent had urinary incontinence alone, 4% had fecal incontinence alone, and 7% had dual incontinence. Age older than 80 years compared with age younger than 70 years was associated most strongly with dual incontinence (odds ratio [OR] 2.49, 95% confidence interval [CI] 2.28–2.73), followed by depression (OR 2.28, 95% CI 2.13–2.43), neurologic disease (OR 1.84, 95% CI 1.65–2.07), functional limitations (OR 1.86, 95% CI 1.71–2.02), multiparity (OR 1.66, 95% CI 1.41–1.94), and heavier fetal birth weight (OR 1.24, 95% CI 1.10–1.41). Obesity was associated only with urinary incontinence (OR 1.99, 95% CI 1.90–2.08) and type 2 diabetes was a stronger risk factor for fecal than urinary incontinence (OR 1.43, 95% CI 1.28–1.59). Black race was associated with a reduced risk of all types of incontinence, especially dual incontinence (OR 0.30, 95% CI 0.21–0.44).
In this large cohort, dual incontinence was primarily associated with advanced age, decompensating medical conditions, depression, and multiparity.
PMCID: PMC3952631  PMID: 23921863
5.  Psychological Treatments in Functional Gastrointestinal Disorders: A Primer for the Gastroenterologist 
The functional gastrointestinal disorders (FGIDs) often show inadequate response to usual medical care. Psychological treatments can help improve FGID patient outcomes, and such treatment should be considered for patients who have moderate or severe symptoms after 3 to 6 months of medical care, and those whose symptoms are clearly exacerbated by stress or emotional symptoms. Effective psychological treatments, based on multiple randomized controlled trials, include cognitive behavioral therapy (CBT) and hypnosis for irritable bowel syndrome and pediatric functional abdominal pain; CBT for functional chest pain; and biofeedback for dyssynergic constipation in adults. Successful referral by the gastroenterologist for psychological treatment is facilitated by educating the patient about the rationale for such treatment, reassurance about the diagnosis and continuation of medical care, firm doctor-patient therapeutic alliance, and identification of, and communication with, an appropriate psychological services provider.
PMCID: PMC3591464  PMID: 23103907
6.  Obstetric Sphincter Injury Interacts with Diarrhea and Urgency to Increase the Risk of Fecal Incontinence in Women with IBS 
To confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with IBS (irritable bowel syndrome), and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI.
The study is a supplement to a diary study of bowel symptoms in 164 female patients with IBS. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement (BM) for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire which included the Fecal Incontinence Severity Index (FISI).
Out of 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least one episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean FISI score was 13.9±9.7. Upon multivariable analysis, FI was significantly associated with parity (p=0.007), operative vaginal delivery (p=0.049), obstetrical sphincter lacerations (p=0.007), fecal urgency (p=0.005), diarrhea (p=0.008), and hysterectomy (p=0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (p=0.002) and diarrhea (p=0.004) were significant risk factors for FI.
Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI.
PMCID: PMC3920582  PMID: 23321658
fecal incontinence; obstetric anal sphincter injury; diarrhea; urgency
7.  Validation of Symptom-Based Diagnostic Criteria for Irritable Bowel Syndrome: A Critical Review 
The American journal of gastroenterology  2010;105(4):10.1038/ajg.2010.56.
Critically review the validity of symptom-based criteria (Manning, Rome I, Rome II, and Rome III) for irritable bowel syndrome (IBS).
Two kinds of validation are reported: (1) studies testing whether symptom criteria discriminate patients with structural disease at colonoscopy from patients without structural disease; and (2) studies testing whether symptom criteria discriminate patients presumed to have IBS by positive diagnosis from healthy subjects or patients with other functional and structural disorders.
The first study type addresses an important clinical management question but cannot provide meaningful information on sensitivity or positive predictive value because IBS is defined only by exclusion of structural disease. Specificity is modest (about 0.7), but can be improved to 0.9 by addition of red flag signs and symptoms. The second type of study judges validity by whether the symptom criteria consistently perform as predicted by theory. Here factor analysis confirms consistent clusters of symptoms corresponding to IBS; symptom-based criteria agree reasonably well (sensitivity 0.4–0.9) with clinical diagnoses made by experienced clinicians; patients with a clinical diagnosis of IBS who fulfill Rome II criteria have greater symptom severity and poorer quality of life than patients with a clinical diagnosis of IBS who do not fulfill Rome criteria; and (4) somatization does not explain endorsement of the symptom-based criteria for IBS. There are no consistent differences in sensitivity or specificity between Manning, Rome I, and Rome II.
Both study types support the validity of symptom-based IBS criteria. Tests of Rome III are needed.
PMCID: PMC3856202  PMID: 20179688
8.  Small Intestinal Bacterial Overgrowth in Irritable Bowel Syndrome: Association with Colon Motility, Bowel Symptoms, and Psychological Distress 
Small intestinal bacterial overgrowth (SIBO) has been implicated in the pathogenesis of irritable bowel syndrome (IBS), although with significant controversy.
To determine the prevalence of SIBO in IBS and its association with colonic motility, bowel symptoms and psychological distress.
Sucrose hydrogen and methane breath tests were performed in 158 IBS and 34 healthy controls (HC). Thresholds for pain and urgency were tested by barostat in the descending colon. The motility index (MI) was calculated as the average area under the curve for all phasic contractions. Questionnaires assessed psychological distress, IBS symptom severity (IBSSS), IBS Quality of Life (IBS-QOL) and self reported bowel symptoms.
52/158 (32.9%) IBS patients had abnormal breath tests compared with 6/34 (17.9%) HC (χ2=0.079). SIBO (SIBO+) and Non-SIBO (SIBO−) did not differ in the prevalence of IBS-subtypes, IBS-SS, IBS-QOL and psychological distress variables. IBS had a greater post-distension increase in MI than HC, but there was no difference between SIBO+ and SIBO−. Predominant methane producers had higher urge thresholds (28.4 vs. 18.3, p<0.05) and higher baseline MI (461 vs. 301.45, p<0.05) than SIBO− IBS, and they reported more “hard or lumpy stools” when compared to predominant hydrogen producers (p<0.05) and SIBO− IBS (p< 0.05).
SIBO is unlikely to contribute significantly in the pathogenesis of IBS. Methane production is associated with constipation.
PMCID: PMC3856223  PMID: 18482250
Small intestinal bacterial overgrowth; Irritable bowel syndrome; Breath test; Methane; Constipation; Visceral hypersensitivity; Psychological
9.  Development and Validation of New Disease-Specific Measures of Somatization and Comorbidity in IBS 
Journal of psychosomatic research  2012;73(5):10.1016/j.jpsychores.2012.08.007.
To create and validate empirically derived questionnaires that measure non-gastrointestinal symptoms and disorders that co-exist with irritable bowel syndrome (IBS).
A systematic review of the world literature identified all non-GI symptoms and diagnoses known to have excess frequency in IBS patients. This data was used to create the Recent Physical Symptoms Questionnaire (RPSQ), which measures somatization (the psychological tendency to report multiple physical symptoms), and the Comorbid Medical Conditions Questionnaire (CMCQ). The psychometric properties of these questionnaires were assessed in two studies: 109 IBS patients in Study I; 286 IBS patients and 67 healthy controls in Study II.
In Study I, the RPSQ and CMCQ showed high test-retest reliability (r=.88 and .95) and good internal consistency (Cronbach alphas: .86 and .70, respectively). In Study II, principal components analysis demonstrated that the RPSQ is a homogeneous somatization scale, but the CMCQ could be divided into 4 subscales: one for psychiatric disorders and 3 for different types of somatic disorders. Concurrent validity was shown by strong correlations of both the RPSQ and the CMCQ with the Cornell Medical Index (CMI) and the Brief Symptom Inventory-18 (BSI-18) somatization scales. Discriminant validity was modest: the BSI-18 anxiety and depression scales were less strongly correlated with the RPSQ than the BSI-18 somatization scale. The RPSQ and CMCQ scores of IBS patients were significantly higher than the scores of healthy controls (P<.001).
The RPSQ and CMCQ are highly reliable and valid measures of somatization and medical comorbidities in IBS.
PMCID: PMC3855416  PMID: 23062808
Irritable Bowel Syndrome; Comorbidity; Somatization; Validity
American journal of obstetrics and gynecology  2010;202(5):10.1016/j.ajog.2010.01.018.
To estimate the frequency of self-reported fecal incontinence (FI), identify what proportion of these patients have a diagnosis of FI in their medical record, and compare healthcare costs and utilization in patients with different severities of FI to those without FI.
Study Design
Patients in a healthcare maintenance organization were eligible and 1707 completed a survey. Patients with self-reported FI were assessed for a diagnosis of FI in their medical record for the last five years. Healthcare costs and utilization were obtained from claims data.
Fecal incontinence was reported by 36.2% of primary care patients, but only 2.7% of patients with FI had a medical diagnosis. FI adversely affected quality of life and severe FI was associated with 55% higher healthcare costs (including 77% higher gastrointestinal-related healthcare costs) compared to continent patients.
Increased screening of FI is needed.
PMCID: PMC3855440  PMID: 20223447
Fecal incontinence; screening; healthcare costs; healthcare utilization
11.  Neuromodulation for fecal incontinence: An effective surgical intervention 
Fecal incontinence is a disabling symptom with medical and social implications, including fear, embarrassment, isolation and even depression. Most patients live in seclusion and have to plan their life around the symptom, with secondary impairment of their quality of life. Conservative management and biofeedback therapy are reported to benefit a good percentage of those affected. However, surgery must be considered in the non-responder population. Recently, sacral nerve electrostimulation, lately named neuromodulation, has been reported to benefit patients with fecal incontinence in randomized controlled trials more than placebo stimulation and conservative management, by some unknown mechanism. Neuromodulation is a minimally invasive procedure with a low rate of adverse events and apparently favorable cost-efficacy profile. This review is intended to expand knowledge about this effective intervention among the non-surgically skilled community who deals with this disabled group of patients.
PMCID: PMC3819539  PMID: 24222947
Fecal incontinence; Neuromodulation; Sacral nerve stimulation; Biofeedback; Anal sphincter
12.  Which psychological factors exacerbate Irritable Bowel Syndrome? Development of a comprehensive model 
Journal of psychosomatic research  2013;74(6):486-492.
There is evidence that psychological factors affect the onset, severity and duration of Irritable Bowel Syndrome (IBS). However, it is not clear which psychological factors are the most important and how they interact. The aims of the current study are to identify the most important psychological factors predicting IBS symptom severity and to investigate how these psychological variables are related to each other.
Study participants were 286 IBS patients who completed a battery of psychological questionnaires including neuroticism, abuse history, life events, anxiety, somatization and catastrophizing. IBS severity measured by the IBS Severity Scale was the dependent variable. Path analysis was performed to determine the associations among the psychological variables, and IBS severity.
Although the hypothesized model showed adequate fit, post hoc model modifications were performed to increase prediction. The final model was significant (Chi2 = 2.2; p=0.82; RMSEA < .05) predicting 36% of variance in IBS severity. Catastrophizing (Standardized coefficient (β)=0.33; p <.001) and Somatization (β=0.20; p <.001) were the only two psychological variables directly associated with IBS severity. Anxiety had an indirect effect on IBS symptoms through catastrophizing (β=0.80; p <.001); as well as somatization (β=0.37; p <.001). Anxiety, in turn, was predicted by neuroticism (β=0.66; p<.001) and stressful life events (β=0.31; p<.001).
While cause-and-effect cannot be determined from these cross-sectional data, the outcomes suggest that the most fruitful approach to curb negative effects of psychological factors on IBS is to reduce catastrophizing and somatization.
PMCID: PMC3673027  PMID: 23731745
Irritable Bowel Syndrome; Psychological distress; Somatization; Catastrophizing; Life Events; Neuroticism
13.  Inability of the Rome III Criteria to Distinguish Functional Constipation from Constipation Subtype Irritable Bowel Syndrome 
Introduction and Aims
The Rome III classification system treats functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) as distinct disorders, but this distinction appears artificial, and the same drugs are used to treat both. This study’s hypothesis is that FC and IBS-C defined by Rome III are not distinct entities.
1,100 adults with a primary care visit for constipation and 1,700 age and gender matched controls from a health maintenance organization completed surveys 12 months apart; 66.2% returned the first questionnaire. Rome III criteria identified 231 with FC and 201 with IBS-C. The second survey was completed by 195 of the FC and 141 of the IBS-C cohorts. Both surveys assessed the severity of constipation and IBS, quality of life (QOL), and psychological distress.
(1) Overlap: If the Rome III requirement that patients meeting criteria for IBS cannot be diagnosed FC is suspended, 89.5% of IBS-C cases meet criteria for FC and 43.8% of FC patients fulfill criteria for IBS-C. (2) No qualitative differences between FC and IBS-C: 44.8% of FC patients report abdominal pain, and paradoxically IBS-C patients have more constipation symptoms than FC. (3) Switching between diagnoses: by 12 months, 1/3 of FC transition to IBS-C and 1/3 of IBS-C change to FC.
Patients identified by Rome III criteria for FC and IBS-C are not distinct groups. Revisions to the Rome III criteria, possibly including incorporation of physiological tests of transit and pelvic floor function, are needed.
PMCID: PMC3786710  PMID: 20502449
Constipation; Irritable bowel; Diagnostic criteria; Symptom-based diagnosis
14.  Likelihood of Nursing Home Referral for Fecally Incontinent Elderly Patients is Influenced by Physician Views on Nursing Home Care and Outpatient Management of Fecal Incontinence 
(1) Characterize physicians’ management practices for fecal incontinence (FI) among elderly patients, (2) describe physician perceptions of the quality of care for FI provided in nursing homes (NH), and (3) identify physician views and attributes associated with referral of elderly patients with FI to a NH.
United States.
Physician members of the American Geriatrics Society.
Questionnaire pertaining to physician views on (1) their own FI management practices, (2) management of FI in NHs, and (3) referral of an elderly patient with FI to a NH.
Of the respondents (N=606), 54.1% reported screening for FI and 59.3% thought FI could be managed conservatively on an outpatient basis. Only 32.9% believed NHs provide good care for FI, and 27.1% believed NH care conditions exacerbate FI. Responding to a hypothetical vignette, 10.6% would probably or definitely refer an older adult patient with only FI to a NH, and 17.2% were uncertain about whether or not to refer. Logistic regression analysis identified physician characteristics associated with decreased likelihood of NH referral as the belief that FI can be managed conservatively, the belief that NHs provide poor care for FI, longer practice experience, and practicing in an academic medical center.
Most geriatricians believe FI can be managed conservatively and that NH provide poor care for FI. These beliefs plus longer years of practice and practice in an academic setting decrease the likelihood of referral to NH for patients with FI.
PMCID: PMC3129470  PMID: 21450249
Fecal incontinence; nursing home admissions; physician perspectives
15.  Diagnosis and Treatment of Pelvic Floor Disorders: What’s New and What to Do 
Gastroenterology  2010;138(4):1231-1235.e4.
PMCID: PMC3924316  PMID: 20176023
16.  Therapeutic mechanisms of a mindfulness-based treatment for IBS: Effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations 
Journal of behavioral medicine  2011;35(6):591-602.
Irritable bowel syndrome (IBS) is a prevalent functional disorder characterized by abdominal pain and hypervigilance to gastrointestinal sensations. We hypothesized that mindfulness training (MT), which promotes nonreactive awareness of emotional and sensory experience, may target underlying mechanisms of IBS including affective pain processing and catastrophic appraisals of gastrointestinal sensations. Seventy five female IBS patients were randomly assigned to participate in either 8 weeks of MT or a social support group. A theoretically grounded, multivariate path model tested therapeutic mediators of the effect of MT on IBS severity and quality of life. Results suggest that MT exerts significant therapeutic effects on IBS symptoms by promoting nonreactivity to gut-focused anxiety and catastrophic appraisals of the significance of abdominal sensations coupled with a refocusing of attention onto interoceptive data with less emotional interference. Hence, MT appears to target and ameliorate the underlying pathogenic mechanisms of IBS.
PMCID: PMC3883954  PMID: 22161025
Mindfulness; irritable bowel syndrome; pain; therapeutic mechanisms; path analysis; interoception
17.  IBS Patients Show Frequent Fluctuations between Loose/Watery and Hard/Lumpy Stools: Implications for Treatment 
The American journal of gastroenterology  2011;107(2):10.1038/ajg.2011.358.
To determine how variable stool consistency is in patients with irritable bowel (IBS) and assess the relationship between stool consistency and gastrointestinal symptoms.
Individuals with a physician diagnosis of IBS were recruited by advertisement. Enrollment questionnaires included the Rome III Diagnostic Questionnaire and IBS Symptom Severity Scale. Then 185 patients meeting Rome criteria for IBS rated the consistency (using the Bristol Stool Scale) of each bowel movement (BM) for 90 days and whether the BM was accompanied by pain, urgency, or soiling. Each night they transferred BM ratings from a paper diary to an internet form and also reported the average daily intensity of abdominal pain, bloating, bowel habit dissatisfaction, and life interference of bowel symptoms. Only the longest sequence of consecutive days of diary data was used in analysis (average of 73 days).
Patients were 89% female with average age 36.6 years. 78% had both loose/watery and hard/lumpy stools; the average was 3 fluctuations between these extremes per month. The proportion of loose/watery stools correlated r=.78 between the first and second months and the proportion of hard/lumpy stools correlated r=.85 between months. Loose/watery stools were associated with more BM-related pain, urgency, and soiling than hard/lumpy or normal stools; however, IBS-C patients had significantly more BM-unrelated abdominal pain, bloating, dissatisfaction with bowel habits, and life interference than IBS-D. Questionnaires overestimated the frequency of abnormal stool consistency and gastrointestinal symptoms compared to diaries.
Stool consistency varies greatly within individuals. However, stool patterns are stable within an individual from month to month. The paradoxical findings of greater symptom severity after individual loose/watery BMs vs. greater overall symptom severity in IBS-C implies different physiological mechanisms for symptoms in constipation compared to diarrhea. Daily symptom monitoring is more sensitive and reliable than a questionnaire.
PMCID: PMC3855407  PMID: 22068664
18.  Contributions of pain sensitivity and colonic motility to IBS symptom severity and predominant bowel habits 
The American journal of gastroenterology  2008;103(10):10.1111/j.1572-0241.2008.02066.x.
Irritable bowel syndrome (IBS) patients show pain hypersensitivity and hypercontractility in response to colonic or rectal distention. Aims were to determine whether predominant bowel habits and IBS symptom severity are related to pain sensitivity, colon motility, or smooth muscle tone.
129 patients classified as IBS with diarrhea (IBS-D, n=44), IBS with constipation (IBS-C, n=29), mixed IBS (IBS-M, n=45) and unspecified IBS (IBS-U, n=11) based on stool consistency, and 30 healthy controls (HC) were studied. A manometric catheter containing a 600-ml capacity plastic bag was positioned in the descending colon. Pain threshold was assessed using a barostat. Motility was assessed for 10 min with the bag minimally inflated (individual operating pressure or IOP), 10 min at 20 mmHg above the IOP, and for 15-min recovery following bag inflation. Motility was also recorded for 30 min following an 810-kcal meal.
Compared to HC, IBS patients had lower pain thresholds (medians: 30 vs. 40 mmHg, p<0.01), but IBS subtypes were not different. IBS symptom severity was correlated with pain thresholds (rho=-0.36, p<0.001). During distention, the motility index (MI) was significantly higher in IBS compared to HC (909±73 vs. 563±78, p<0.01). Average barostat bag volume at baseline was higher (muscle tone lower) in HC compared to IBS-D and IBS-M but not compared to IBS-C. The baseline MI and bag volume differed between IBS-D and IBS-C and correlated with symptoms of abdominal distention and dissatisfaction with bowel movements. Pain thresholds and MI during distention were uncorrelated.
Pain sensitivity and colon motility are independent factors contributing to IBS symptoms. Treatment may need to address both and to be specific to predominant bowel habit.
PMCID: PMC3855425  PMID: 18684175
irritable bowel syndrome; visceral hypersensitivity; colonic motility; symptom severity; subtypes of bowel habit
19.  Randomized Controlled Trial Shows Biofeedback to be Superior to Alternative Treatments for Patients with Pelvic Floor Dyssynergia-type Constipation 
Diseases of the colon and rectum  2009;52(10):10.1007/DCR.0b013e3181b55455.
To determine whether biofeedback is more effective than diazepam or placebo in a randomized controlled trial for patients with pelvic floor dyssynergia-type constipation, and whether instrumented biofeedback is necessary for successful training.
One hundred seventeen patients participated in a 4-week run-in (education and medical management). The 84 who remained constipated were randomized to Biofeedback (n=30); Diazepam (n=30); or Placebo (n=24). All patients were trained to do pelvic floor muscle exercises to correct pelvic floor dyssynergia during 6 biweekly 1-hour sessions, but only Biofeedback patients received electromyography feedback. All other patients received pills 1-2 hours before attempting defecation. Diary data on cathartic use, straining, incomplete bowel movements, Bristol stool scores, and compliance with homework were reviewed biweekly.
Before treatment, the groups did not differ on demographic (average age 50, 85 percent females), physiologic or psychologic characteristics, severity of constipation, or expectation of benefit. Biofeedback was superior to diazepam by intention to treat analysis (70 percent vs. 23 percent reported adequate relief of constipation 3 months after treatment, χ2 = 13.1, p < 0.001), and also superior to placebo (38 percent successful, χ2 = 5.7, p = 0.017). Biofeedback patients had significantly more unassisted bowel movements at follow-up compared to Placebo (p = .005), with a trend favoring biofeedback over diazepam (p = .067). Biofeedback patients reduced pelvic floor electromyography during straining significantly more than diazepam patients (p < 0.001).
This investigation provides definitive support for the efficacy of biofeedback for pelvic floor dyssynergia and shows that instrumented biofeedback is essential to successful treatment.
PMCID: PMC3855426  PMID: 19966605
biofeedback; constipation; dyssynergia; dyssynergic defecation; electromyography
20.  Early life risk factors that contribute to irritable bowel syndrome in adults: a systematic review 
The American journal of gastroenterology  2008;103(3):10.1111/j.1572-0241.2007.01722.x.
IBS is a common disorder that occurs in adults. The natural history of symptoms and risk factors that contribute to IBS may begin in the childhood period. The aim of this systematic review of the published medical literature was to determine what early life factors have been demonstrated to contribute to the development of IBS in adolescents and adults.
A computer-assisted search of the PubMed database from 1966 to 2007 was performed. The selection criteria were: (1) studies conducted in adolescents or adults with IBS that (2) investigate pre-morbid factors occurring specifically during the childhood period and are (3) associated with the outcomes of symptoms, quality of life, health care utilization, and interferences with work or disability.
Twenty-five articles met inclusion criteria. The studies were categorized into articles examining the persistence of childhood gastrointestinal symptoms into adulthood, affluent childhood socioeconomic status and adult IBS, infantile and childhood trauma associated with the development of adult IBS, and social learning of illness behavior as predictors of adult IBS.
Pediatricians should be aware that potentially modifiable childhood factors such as early symptom management of recurrent functional abdominal pain with cognitive therapies and parent education about social learning may alter illness behavior and the manifestation of IBS. Research in examining the effect of affluent childhood socioeconomic status and early childhood trauma in the evolution of functional gastrointestinal disorders may help identify causative factors of IBS.
PMCID: PMC3856200  PMID: 18177446
abdominal pain; pediatrics; functional gastrointestinal disorders; irritable bowel syndrome
21.  Rome III survey of irritable bowel syndrome among ethnic Malays 
AIM: To survey irritable bowel syndrome (IBS) using Rome III criteria among Malays from the north-eastern region of Peninsular Malaysia.
METHODS: A previously validated Malay language Rome III IBS diagnostic questionnaire was used in the current study. A prospective sample of 232 Malay subjects (80% power) was initially screened. Using a stratified random sampling strategy, a total of 221 Malay subjects (112 subjects in a “full time job” and 109 subjects in “no full time job”) were recruited. Subjects were visitors (friends and relatives) within the hospital compound and were representative of the local community. Red flags and psychosocial alarm symptoms were also assessed in the current study using previously translated and validated questionnaires. Subjects with IBS were sub-typed into constipation-predominant, diarrhea-predominant, mixed type and un-subtyped. Univariable and multivariable analyses were used to test for association between socioeconomic factors and presence of red flags and psychosocial alarm features among the Malays with IBS.
RESULTS: IBS was present in 10.9% (24/221), red flags in 22.2% (49/221) and psychosocial alarm features in 9.0% (20/221). Red flags were more commonly reported in subjects with IBS (83.3%) than psychosocial alarm features (20.8%, P < 0.001). Subjects with IBS were older (mean age 41.4 years vs 36.9 years, P = 0.08), but no difference in gender was noted (P = 0.4). Using univariable analysis, IBS was significantly associated with a tertiary education, high individual income above RM1000, married status, ex-smoker and the presence of red flags (all P < 0.05). In multiple logistic regression analysis, only the presence of red flags was significantly associated with IBS (odds ratio: 0.02, 95%CI: 0.004-0.1, P < 0.001). The commonest IBS sub-type was mixed type (58.3%), followed by constipation-predominant (20.8%), diarrhea-predominant (16.7%) and un-subtyped (4.2%). Four of 13 Malay females (30.8%) with IBS also had menstrual pain. Most subjects with IBS had at least one red flag (70.8%), 12.5% had two red flags and 16.7% with no red flags. The commonest red flag was a bowel habit change in subjects > 50 years old and this was reported by 16.7% of subjects with IBS.
CONCLUSION: Using the Rome III criteria, IBS was common among ethnic Malays from the north-eastern region of Peninsular Malaysia.
PMCID: PMC3508643  PMID: 23197894
Irritable bowel syndrome; Malays; Prevalence; Rome III criteria; Malaysia
22.  Lubiprostone does not Influence Visceral Pain Thresholds in Patients with Irritable Bowel Syndrome 
In clinical trials, lubiprostone reduced the severity of abdominal pain.
The primary aim was to determine whether lubiprostone raises the threshold for abdominal pain induced by intraluminal balloon distention. A secondary aim was to determine whether changes in pain sensitivity influence clinical pain independently of changes in transit time.
Sixty-two patients with irritable bowel syndrome with constipation (IBS-C) participated in an 8-week crossover study. All subjects completed a 14-day baseline ending with a barostat test of pain and urge sensory thresholds. Half, randomly selected, then received 48 ug/day of lubiprostone for 14 days ending with a pain sensitivity test and a Sitzmark test of transit time. This was followed by a 14-day washout and then a crossover to 14 days of placebo with tests of pain sensitivity and transit time. The other half of the subjects received placebo before lubiprostone. All kept symptom diaries.
Stools were significantly softer when taking lubiprostone compared to placebo (Bristol Stool scores 4.20 vs. 3.44, p<0.001). However, thresholds for pain (17.36 vs. 17.83 mmHg, lubiprostone vs. placebo) and urgency to defecate (14.14 vs. 14.53 mmHg) were not affected by lubiprostone. Transit time was not significantly different between lubiprostone and placebo (51.27 vs. 51.81 hours), and neither pain sensitivity nor transit time was a significant predictor of clinical pain.
Lubiprostone has no effect on visceral sensory thresholds. The reductions in clinical pain that occur while taking lubiprostone appear to be secondary to changes in stool consistency.
PMCID: PMC3184461  PMID: 21914041
24.  Increased colonic pain sensitivity in irritable bowel syndrome is the result of an increased tendency to report pain rather than increased neurosensory sensitivity 
Gut  2007;56(9):1202-1209.
The aim was to determine whether lower visceral pain thresholds in irritable bowel syndrome (IBS) primarily reflect physiological or psychological factors.
Firstly, 121 IBS patients and 28 controls underwent balloon distensions in the descending colon using the ascending methods of limits (AML) to assess pain and urge thresholds. Secondly, sensory decision theory analysis was used to separate physiological from psychological components of perception: neurosensory sensitivity (p(A)) was measured by the ability to discriminate between 30 mm Hg vs 34 mm Hg distensions; psychological influences were measured by the report criterion—that is, the overall tendency to report pain, indexed by the median intensity rating for all distensions, independent of intensity. Psychological symptoms were assessed using the Brief Symptom Inventory (BSI).
IBS patients had lower AML pain thresholds (median: 28 mm Hg vs 40 mm Hg; p<0.001), but similar neurosensory sensitivity (median p(A): 0.5 vs 0.5; p = 0.69; 42.6% vs 42.9% were able to discriminate between the stimuli better than chance) and a greater tendency to report pain (median report criterion: 4.0 (“mild” pain) vs 5.2 (“weak” pain); p = 0.003). AML pain thresholds were not correlated with neurosensory sensitivity (r = −0.13; p = 0.14), but were strongly correlated with report criterion (r = 0.67; p<0.0001). Report criterion was inversely correlated with BSI somatisation (r = −0.26; p = 0.001) and BSI global score (r = −0.18; p = 0.035). Similar results were seen for the non‐painful sensation of urgency.
Increased colonic sensitivity in IBS is strongly influenced by a psychological tendency to report pain and urge rather than increased neurosensory sensitivity.
PMCID: PMC1954968  PMID: 17483191
hypersensitivity; hypervigilance; perceptual response bias; irritable bowel syndrome
25.  Association of Low Dietary Intake of Fiber and Liquids with Constipation: Evidence from the National Health and Nutrition Examination Survey (NHANES) 
Epidemiological studies support an association of self-defined constipation with fiber and physical activity, but not liquid intake. The aims of this study were to assess the prevalence and associations of dietary fiber and liquid intake to constipation.
Analyses were based on data from 10,914 adults (≥20 years) from the 2005-2008 cycles of the National Health and Nutrition Examination Surveys (NHANES). Constipation was defined as hard or lumpy stools (Bristol Stool Scale types 1 or 2) as the “usual or most common stool type.” Dietary fiber and liquid intake from total moisture content were obtained from dietary recall. Co-variables included: age, race, education, poverty income ratio, body mass index, self-reported general health status, chronic illnesses, and physical activity. Prevalence estimates and prevalence odds ratios (POR) were analyzed in adjusted multivariable models using appropriate sampling weights.
Overall, 9,373 (85.9%) adults (4,787 women and 4,586 men) had complete stool consistency and dietary data. Constipation rates were 10.2% (95% CI: 9.6,10.9) for women and 4.0 (95% CI: 3.2,5.0) for men (p<.001). After multivariable adjustment, low liquid consumption remained a predictor of constipation among women (POR: 1.3, 95% CI: 1.0,1.6) and men (POR: 2.4, 95% CI: 1.5,3.9); however, dietary fiber was not a predictor. Among women, African-American race/ethnicity (POR: 1.4, 95% CI: 1.0,1.9), being obese (POR: 0.7, 95% CI: 0.5,0.9), and having a higher education level (POR: 0.8, 95% CI: 0.7,0.9) were significantly associated with constipation.
The findings support clinical recommendations to treat constipation with increased liquid, but not fiber or exercise.
PMCID: PMC3786707  PMID: 23567352
constipation; functional bowel disorders; epidemiology

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