Irritable Bowel Syndrome Subtypes: Clinical And Psychological Features, Body Mass Index And Comorbidities

Irritable bowel syndrome (IBS) is classified into subtypes according to bowel habit. Objective: To investigate whether there are differences in clinical features, comorbidities, anxiety, depression and body mass index (BMI) among IBS subtypes. Methods: The study group included 113 consecutive patients (mean age: 48 11 years; females: 94) with the diagnosis of IBS. All of them answered a structured questionnaire for demographic and clinical data and underwent upper endoscopy. Anxiety and depression were assessed by the Hospital Anxiety and Depression scale (HAD). Results: The distribution of subtypes was: IBS-diarrhea (IBS-D), 46%; IBS-constipation (IBS-C), 32%, and mixed IBS (IBS-M), 22%. IBS overlap with gastroesophageal reflux disease (GERD), functional dyspepsia, chronic headache and fibromyalgia occurred in 65.5%, 48.7%, 40.7% and 22.1% of patients, respectively. Anxiety and/or depression were found in 81.5%. Comparisons among subgroups showed that bloating was significantly associated with IBS-M compared to IBS-D (odds ratio-OR-5.6). Straining was more likely to be reported by IBS-M (OR 15.3) and IBS-C (OR 12.0) compared to IBS-D patients, while urgency was associated with both IBS-M (OR 19.7) and IBS-D (OR 14.2) compared to IBS-C. In addition, IBS-M patients were more likely to present GERD than IBS-D (OR 6.7) and higher scores for anxiety than IBS-C patients (OR 1.2). BMI values did not differ between IBS-D and IBS-C. Conclusion: IBS-M is characterized by symptoms frequently reported by both IBS-C (straining) and IBS-D (urgency), higher levels of anxiety, and high prevalence of comorbidities. These features should be considered in the clinical management of this subgroup.1082596

Anti-Integrins, Anti-Interleukin 12/23p40, and JAK Inhibitors for the Inflammatory Bowel Disease Treatment

Inflammatory bowel diseases (IBD) present a broad inflammatory cascade that is sometimes difficult to control. Patients with ulcerative colitis (UC) and Crohn’s disease (CD) are exposed to intense and harmful effects that compromise their quality of life. There is a constant need for new classes of drugs that act on different fronts of inflammation control. Initially, biologics revolutionized inflammatory bowel disease treatment. Anti-tumor necrosis factor (anti-TNF) agents and infliximab, followed by adalimumab and certolizumab pegol, have been proven to induce clinical and endoscopic remission. However, some patients are primary nonresponders, and a significant proportion of initial responders lose response throughout the treatment. The emergence of new therapies, such as anti-integrins, anti-interleukins, and inhibitors of Janus kinase (JAK), can become an alternative option for patients with previous therapeutic failures, besides offering greater safety than other biological therapies up to now. Among anti-integrins, vedolizumab is the drug with proven efficacy in both induction and maintenance of remission and has local and selective action in the intestine. Ustekinumab represents the group of anti-interleukins, acting to control interleukin-12 (IL12) and interleukin-23 (IL23). JAK inhibitors (tofacitinib) act on intracellular inflammatory mediators and have the advantage of being orally administered

Dyspeptic symptoms in patients with type 1 diabetes: endoscopic findings, helicobacter pylori infection, and associations with metabolic control, mood disorders and nutritional factors

To evaluate, in a group of patients with long-standing type 1 diabetes (DM1), an association of dyspepsia symptoms with: changes in the gastroduodenal mucosa, infection by Helicobacter pylori, glycemic control, and psychological and nutritional factors. Subjects and methods: A total of 32 patient with DM1 were studied (age: 38 +/- 9 years; females: 25; diabetes duration: 22 +/- 5 years). All patients answered a standardized questionnaire for the evaluation of gastrointestinal symptoms and underwent upper gastrointestinal endoscopy, with gastric biopsies for the evaluation of Helicobacter pylori infection. The presence of anxiety and depression was evaluated by the HAD scale. Nutritional parameters were BMI, arm and waist circumference, skinfold measurement, and body fat percentage. Results: Upper endoscopy detected lesions in the gastric mucosa in 34.4% of the patients, with similar frequency in those with (n = 21) and without dyspepsia (n = 11). The patients with dyspepsia complaints showed greater frequency of depression (60% vs. 0%; p = 0.001), higher values for HbA1c (9.6 +/- 1.7 vs. 8.2 +/- 1.3%; p = 0.01) and lower values for BMI (24.3 +/- 4.1 vs. 27.2 +/- 2.6 kg/m(2); p = 0.02), body fat percentage (26.6 +/- 6.2 vs. 30.8 +/- 7.7%; p = 0.04), and waist circumference (78.7 +/- 8 vs. 85.8 +/- 8.1 cm; p = 0.02). No association was found between the symptoms and the presence of Helicobacter pylori. Dyspepsia symptoms in patients with long-standing DM1 were associated with glycemic control and depression, and they seem to negatively influence the nutritional status of these patients59212913

Investigation of autonomic function and orocrecal transit time in patients with non-alcoholic cirrrhosis : association of autonomic dysfunction with severity of cirrhosis and the occurrence of new onset encephalopathy

Orientador: Maria Aparecida MesquitaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias MedicasResumo: A disfunção autonômica (DA) parece ser freqüente na cirrose hepática (CH) de etiologia alcoólica, enquanto que os dados referentes à prevalência e repercussões clínicas desta complicação na cirrose de etiologia não alcoólica são controversos. Existem evidências na literatura de que o método da análise da variabilidade da freqüência cardíaca (VFC) em 24 horas é mais sensível que a pesquisa dos reflexos cardiovasculares para a avaliação da função autonômica. Esta técnica foi pouco utilizada na investigação de pacientes com CH. Estudos prévios em cirróticos demonstraram a presença de alterações da motilidade intestinal que predisporiam à ocorrência de supercrescimento bacteriano. Os mecanismos responsáveis por estas alterações não foram ainda esclarecidos. Considerando que o sistema nervoso autônomo (SNA) participa do controle da motilidade intestinal, parece provável que a DA esteja associada com as alterações da motilidade intestinal na CH. Os objetivos deste estudo foram investigar a presença de alterações do SNA parassimpático e simpático em pacientes com CH de etiologia não alcoólica, utilizando os métodos dos testes de reflexos cardiovasculares e da análise da VFC em 24 horas, e avaliar a associação das alterações autonômicas encontradas com a gravidade da disfunção hepática, com alterações do trânsito intestinal, e com o aparecimento de complicações da CH. Foram estudados trinta e quatro pacientes com diagnóstico de CH de etiologia não alcoólica, divididos em Child-Pugh A (13) e Child-Pugh B/C (21). A atividade autonômica foi avaliada através dos testes de reflexos cardiovasculares e da análise da VFC em 24 horas. O estudo do tempo de trânsito orocecal (TTOC) foi realizado pelo teste do H2 no ar expirado, após ingestão de lactulose. De acordo com os testes de reflexos cardiovasculares, a presença de disfunção parassimpática foi encontrada em 4 pacientes Child A (30,8%) e em 6 pacientes Child B/C (28,4%; p>0,05). A análise da VFC em 24 horas mostrou que os parâmetros relacionados com a atividade parassimpática (LF, lnLF, pNN50) e simpática (LF, lnLF) estavam significativamente (p<0,05) diminuídos nos pacientes Child B/C, tanto em relação ao grupo controle, como também em relação aos pacientes Child A. A avaliação individual mostrou a presença de disfunção parassimpática em 3 pacientes Child A (23,1%) e em 12 (57%; p=0,07) Child B/C. A diminuição da atividade simpática concomitante foi encontrada em 8 dos 12 pacientes Child B e C, com lesão parassimpática. Em relação ao TTOC, não houve diferença estatística entre os valores do TTOC no grupo Child A (52±17 minutos) e no grupo controle (52±13 minutos). Em contraste, os pacientes Child B/C apresentaram valores mais altos do TTOC (71±34minutos) em relação aos controles (p=0,02). Apenas dois pacientes apresentaram resultados sugestivos de supercrescimento bacteriano. O tempo de seguimento foi de 19±12 meses. Ao final do estudo, cinco pacientes (24%) Child B/C evoluíram para óbito. Os valores dos parâmetros representativos da atividade parassimpática (HF, lnHF) nesses pacientes foram significativamente (p=0,04) menores que os encontrados nos pacientes do grupo Child B/C que continuavam vivos. A encefalopatia foi a complicação mais freqüente, acometendo 42,8% dos pacientes durante o período de seguimento. Houve associação estatística entre a presença de DA e a incidência de encefalopatia hepática (p<0,05). Não houve correlação entre os parâmetros da atividade autonômica com os valores do TTOC. Também não houve associação entre TTOC prolongado e complicações da CH. Em conclusão, nossos resultados demonstraram que a DA é achado freqüente nos pacientes com CH de etiologia não alcoólica e está associada com o grau de disfunção hepática, sendo mais freqüente nos pacientes com CH Child B e C. Nossos dados não demonstraram associação entre a alteração da função autonômica e o prolongamento do trânsito intestinal observado nesses pacientes. A presença da DA é um fator predisponente para a ocorrência de encefalopatia hepática, e parece influir no prognóstico da doençaAbstract: Autonomic dysfunction (AD) is common in patients with alcoholic hepatic cirrhosis but information on its occurrence and clinical relevance in patients with non-alcoholic liver disease is contradictory. 24-hour heart rate variability (HRV) is considered to be more sensitive than the cardiovascular reflexes to detect autonomic damage. Only a few studies used this technique in the investigation of autonomic function in cirrhotic patients. Previous studies have demonstrated that intestinal transit is delayed in patients with cirrhosis, and that this alteration predisposes to bacterial overgrowth, bacterial translocation and risk of infections. The reasons for that remain unclear. Since the autonomic nervous system participates in the regulation of gastrointestinal motility, it seems likely that AD may play a role in the intestinal motility alterations observed in cirrhosis. Therefore, our aims were to assess autonomic function in patients with non-alcoholic hepatic cirrhosis, and to investigate the relationship of AD with severity of disease, delayed intestinal transit and the clinical outcome. Thirty four patients with non-alcoholic hepatic cirrhosis classified as Child¿s A (n=13) and Child¿ B/C (n=21) were studied. Autonomic function was assessed by using standard cardiovascular reflexes tests and 24- hour HRV analysis. Orocaecal transit time (OCTT) was measured using the lactulose hydrogen breath test. According to cardiovascular reflexes tests, 4 patients Child A (30.8%) and 6 patients Child B/C (28.4%), were found to have evidence of parasympathetic damage. The 24-hour HRV analysis showed that parameters reflecting parasympathetic (HF, lnHF, pNN50) and sympathetic (LF, lnLF) function were significantly decreased (p<0,05) in comparison with both controls and Child¿s A patients. Individual analysis showed parasympathetic damage in three patients Child A (23,1%) and in 12 (57%) Child B/C (p=0.07). Eight patients had combined sympathetic damage. No diference was found in OCTT values between Child¿ A patients (52±17 minutes) and controls (52±13 min). In contrast, OCTT values were significantly higher in Child¿ B/C patients (71±34minutes) than in controls. Bacterial overgrowth occurred in only two patients. The mean follow-up time was 19±12 months. At the end of the study, five Child¿s B/C patients (24%) have died. The values of parameters representative of parasympathetic function (HF, lnHF) were significantly lower (p<0.05) in these patients in comparison with survivors of Child¿s B/C group. Hepatic encephalopathy was the most frequent complication during follow-up, occurring in 42.8% of Child¿s B/C patients. AD was significantly associated with encephalopathy (p<0.05), but did not correlate with OCTT values. In conclusion, our study showed that autonomic dysfunction in common in patients with non-alcoholic liver disease and is related to the severity of hepatic dysfunction. Our results did not show a relationship between delayed intestinal transit and AD. The presence of autonomic damage predisposes these patients to the development of encephalopathy and may be associated to higher mortalityMestradoClinica MedicaMestre em Clinica Medic

Irritable bowel syndrome : clinical, psychological and nutricional features : association between prolonged orocecal transit time and small intestinal bacterial overgrowth

Orientador: Maria Aparecida MesquitaTese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: A síndrome do intestino irritável (SII) é um distúrbio funcional caracterizado por dor ou desconforto abdominal associado a alterações do hábito intestinal, podendo ser classificada em três subtipos: SII com diarreia (SII-D), constipação (SII-C), ou mista (SII-M). A fisiopatologia da SII e as características dos diferentes subtipos não foram ainda completamente esclarecidas. Os objetivos desse estudo foram avaliar: 1) Características clínicas, comorbidades e aspectos específicos relativos aos subtipos da SII; 2) Tempo de trânsito orocecal (TTOC); 3) Prevalência do supercrescimento bacteriano (SCB); 4) Prevalência da má absorção (MAL) e intolerância à lactose; 5) Intolerância a alimentos contendo glúten e sua associação com doença celíaca e contagem de linfócitos intraepiteliais no duodeno; 6) Associações entre os parâmetros acima, e sua relação com ansiedade, depressão e IMC. Foram estudados 113 pacientes com o diagnóstico de SII pelos critérios de Roma III, que responderam a questionários padronizados para a avaliação clínica e da intolerância a alimentos contendo lactose ou glúten. A presença de ansiedade e depressão foi avaliada pela escala HAD. Os pacientes foram submetidos a três testes respiratórios: com lactose, para a pesquisa da MAL; lactulose para avaliar o TTOC; e glicose para determinar a presença de SCB. A doença celíaca foi investigada pelo exame histológico das biópsias duodenais. Resultados: De acordo com os subtipos, 46% eram SII-D, 32% SII-C e 22% SII-M. A DRGE foi diagnosticada em 65,5% dos pacientes, dispepsia funcional em 48,7%, cefaleia em 40,7%, fibromialgia em 22,1%, ansiedade/depressão em 83,3% e sobrepeso ou obesidade em 61,1%. O subtipo SII-M se caracterizou pela maior frequência de distensão abdominal, e frequência similar à observada nos subtipos SII-C e SII-D de esforço evacuatório e urgência. Também apresentaram valores mais elevados de IMC e maior pontuação na subescala de ansiedade (OR: 1,2; 95%IC: 1,1-1,4). Os valores do TTOC nos pacientes (mediana:70 min) foram significativamente maiores do que no grupo controle. A análise individual demonstrou que 26 pacientes (28,9%) apresentaram TTOC prolongado. O SCB foi identificado em 15,5% dos pacientes, havendo associação com o sintoma de diarreia (p=0,03) e com TTOC prolongado (OR: 5,9; 95% IC: 1,7-20,1). MAL foi identificada em 71% dos pacientes. Os sintomas de intolerância à lactose nos pacientes com MAL se correlacionaram (p<0,05) com os valores da área sob a curva (ASC-H2 vs tempo), indicando sua relação com a produção de hidrogênio nos cólons. Já nos pacientes absorvedores os escores dos sintomas correlacionaram-se com os escores de ansiedade. Apesar de 78,4% dos pacientes terem relacionado seus sintomas com a ingestão de alimentos contendo glúten, não houve nenhum caso de doença celíaca ou de aumento dos linfócitos intraepiteliais. Conclusões: Os pacientes com SII se caracterizaram pela grande prevalência de comorbidades somáticas e psicológicas, alta frequência de intolerância alimentar e heterogeneidade das anormalidades encontradas. Esses resultados indicam a necessidade de uma abordagem individualizada para esses pacientes, levando em conta os aspectos psicológicos, dietéticos e nutricionais envolvidos. A associação entre SCB e TTOC prolongado sugere que o trânsito intestinal lento pode ser um fator predisponente para o SCBAbstract: Irritable bowel syndrome (IBS) is a functional intestinal disorder characterized by abdominal pain or discomfort associated with altered bowel habit, which may be classified into three subtypes: IBS with diarrhea (IBS-D), IBS with constipation (IBS-C) and mixed IBS (IBS-M). Both the physiopathology and specific characteristics of the subtypes have not been completely clarified. The aims of this study were to assess: 1) The clinical features, comorbidities and specific characteristics of IBS subtypes; 2) The orocecal transit time (OCTT); 3) The prevalence of small bowel bacterial overgrowth (SIBO); 4) The prevalence of lactose malabsorption (LM) and intolerance; 5) Intolerance symptoms related to ingestion of gluten containing foods and their association with celiac disease and intraepithelial lymphocytes counts in the duodenum; 6) The associations between the above parameters, and their relationships with anxiety, depression and BMI values. The study group was composed of 113 patients with IBS diagnosis according to Rome III criteria. Demographic and clinical data, and intolerance symptoms related to the ingestion of lactose or gluten containing foods were assessed by standardized questionnaires. The presence of anxiety and depression was assessed by the HAD scale. IBS patients underwent three breath tests with: lactose, for the assessment of LM; lactulose for assessment of OCTT; and glucose for assessment of SIBO. The presence of celiac disease was investigated by histological analysis of duodenal byopsies. Results: According to the classification in subtypes, 52 (46%) were IBS-D, 36 (32%) IBS-C and e 25 (22%) IBS-M. GERD was dignosed in 65.5% of patients, functional dyspepsia in 48.7%, headache in 40.7%, fibromyalgia in 22.1%, anxiety and/or depression in 83.3%. Most patients (61.1%) were overweight or obese. IBS-M showed a greater frequency of abdominal bloating, and the presence of symptoms of IBS-C constipation (straining) and IBS-D (urgency). Moreover, this subtype had higher BMI values and higher anxiety scores (OR: 1.2; 95%CI: 1.1-1.4). OCTT values (median: 70 min) in IBS patients were significantly higher than in controls. Individual analysis showed prolonged OCTT in 26 patients (28.9%). SIBO was found in 15.5% of patients, and was significantly associated with diarrhea (p=0.03) and prolonged OCTT (odds ratio: 5.9; 95% CI: 1.7-20.1). LM was present in 71% of IBS patients. In LM patients intolerance symptoms were significantly correlated with the area under the curve (AUC-H2 vs time), indicating a relationship with colonic H2 production. On the other hand, in lactose absorbers a significant correlation was found with anxiety scores. Despite the self-reported intolerance to gluten containing foods in 78.4% of IBS patients, no case of celiac disease and no increase in intraepithelial lymphocytes counts were found. In conclusion, IBS patients were characterized by a great frequency of food intolerance, somatic and psychological comorbidities. In addition, the presence of the detected abnormalities is heterogeneous. These results indicate that the clinical approach for these patiens should take into account individual characteristics and the contribution of psychological and nutritional factors. The association between SIBO and prolonged OCTT suggests that delayed intestinal transit may be a predisposing factor for SIBO in IBS patientsDoutoradoClinica MedicaDoutora em Ciência

Irritable bowel syndrome subtypes: clinical and psychological features, body mass index and comorbidities

Background: Irritable bowel syndrome (IBS) is classified into subtypes according to bowel habit. Objective: To investigate whether there are differences in clinical features, comorbidities, anxiety, depression and body mass index (BMI) among IBS subtypes. Methods: The study group included 113 consecutive patients (mean age: 48 ± 11 years; females: 94) with the diagnosis of IBS. All of them answered a structured questionnaire for demographic and clinical data and underwent upper endoscopy. Anxiety and depression were assessed by the Hospital Anxiety and Depression scale (HAD). Results: The distribution of subtypes was: IBS-diarrhea (IBS-D), 46%; IBS-constipation (IBS-C), 32%, and mixed IBS (IBS-M), 22%. IBS overlap with gastroesophageal reflux disease (GERD), functional dyspepsia, chronic headache and fibromyalgia occurred in 65.5%, 48.7%, 40.7% and 22.1% of patients, respectively. Anxiety and/or depression were found in 81.5%. Comparisons among subgroups showed that bloating was significantly associated with IBS-M compared to IBS-D (odds ratio-OR-5.6). Straining was more likely to be reported by IBS-M (OR 15.3) and IBS-C (OR 12.0) compared to IBS-D patients, while urgency was associated with both IBS-M (OR 19.7) and IBS-D (OR 14.2) compared to IBS-C. In addition, IBS-M patients were more likely to present GERD than IBS-D (OR 6.7) and higher scores for anxiety than IBS-C patients (OR 1.2). BMI values did not differ between IBS-D and IBS-C. Conclusion: IBS-M is characterized by symptoms frequently reported by both IBS-C (straining) and IBS-D (urgency), higher levels of anxiety, and high prevalence of comorbidities. These features should be considered in the clinical management of this subgroup

Localized gastrointestinal amyloidosis presenting with protein-losing enteropathy and massive hemorrhage

Amyloidosis of the gastrointestinal tract is usually a systemic disease. Localized gastrointestinal amyloidosis without evidence of extraintestinal involvement or an associated plasma cell dyscrasia is uncommon and does not usually cause death. We report a case of a patient with localized gastrointestinal amyloidosis who presented with protein-losing enteropathy and a fatal upper gastrointestinal bleed

Dyspeptic Symptoms In Patients With Type 1 Diabetes: Endoscopic Findings, Helicobacter Pylori Infection, And Associations With Metabolic Control, Mood Disorders And Nutritional Factors.

To evaluate, in a group of patients with long-standing type 1 diabetes (DM1), an association of dyspepsia symptoms with: changes in the gastroduodenal mucosa, infection by Helicobacter pylori, glycemic control, and psychological and nutritional factors. A total of 32 patient with DM1 were studied (age: 38 ± 9 years; females: 25; diabetes duration: 22 ± 5 years). All patients answered a standardized questionnaire for the evaluation of gastrointestinal symptoms and underwent upper gastrointestinal endoscopy, with gastric biopsies for the evaluation of Helicobacter pylori infection. The presence of anxiety and depression was evaluated by the HAD scale. Nutritional parameters were BMI, arm and waist circumference, skinfold measurement, and body fat percentage. Upper endoscopy detected lesions in the gastric mucosa in 34.4% of the patients, with similar frequency in those with (n = 21) and without dyspepsia (n = 11). The patients with dyspepsia complaints showed greater frequency of depression (60% vs. 0%; p = 0.001), higher values for HbA1c (9.6 ± 1.7 vs. 8.2 ± 1.3%; p = 0.01) and lower values for BMI (24.3 ± 4.1 vs. 27.2 ± 2.6 kg/m2; p = 0.02), body fat percentage (26.6 ± 6.2 vs. 30.8 ± 7.7%; p = 0.04), and waist circumference (78.7 ± 8 vs. 85.8 ± 8.1 cm; p = 0.02). No association was found between the symptoms and the presence of Helicobacter pylori. Dyspepsia symptoms in patients with long-standing DM1 were associated with glycemic control and depression, and they seem to negatively influence the nutritional status of these patients.59129-13

Dyspeptic symptoms in patients with type 1 diabetes: endoscopic findings, Helicobacter pylori infection, and associations with metabolic control, mood disorders and nutritional factors

Objectives To evaluate, in a group of patients with long-standing type 1 diabetes (DM1), an association of dyspepsia symptoms with: changes in the gastroduodenal mucosa, infection by Helicobacter pylori, glycemic control, and psychological and nutritional factors. Subjects and methods A total of 32 patient with DM1 were studied (age: 38 ± 9 years; females: 25; diabetes duration: 22 ± 5 years). All patients answered a standardized questionnaire for the evaluation of gastrointestinal symptoms and underwent upper gastrointestinal endoscopy, with gastric biopsies for the evaluation of Helicobacter pylori infection. The presence of anxiety and depression was evaluated by the HAD scale. Nutritional parameters were BMI, arm and waist circumference, skinfold measurement, and body fat percentage. Results Upper endoscopy detected lesions in the gastric mucosa in 34.4% of the patients, with similar frequency in those with (n = 21) and without dyspepsia (n = 11). The patients with dyspepsia complaints showed greater frequency of depression (60% vs. 0%; p = 0.001), higher values for HbA1c (9.6 ± 1.7 vs. 8.2 ± 1.3%; p = 0.01) and lower values for BMI (24.3 ± 4.1 vs. 27.2 ± 2.6 kg/m2; p = 0.02), body fat percentage (26.6 ± 6.2 vs. 30.8 ± 7.7%; p = 0.04), and waist circumference (78.7 ± 8 vs. 85.8 ± 8.1 cm; p = 0.02). No association was found between the symptoms and the presence of Helicobacter pylori. Conclusions Dyspepsia symptoms in patients with long-standing DM1 were associated with glycemic control and depression, and they seem to negatively influence the nutritional status of these patients