A specific link between migraine and functional GI disorders

A substantial body of published research over the past 40 years has established that functional gastrointestinal disorders have an unusually large overlap with several non-gastrointestinal pain syndromes, including fibromyalgia, chronic pelvic pain, and temporomandibular joint disorder. Migraine has also been found to have such excess comorbidity with functional gastrointestinal disorders. For example, a meta-analysis of six studies reported an overall odds ratio (OR) of 2·66 for migraine in individuals with irritable bowel syndrome (IBS)

Is hypnotherapy helpful for irritable bowel syndrome in primary and secondary care?

Gut-directed hypnotherapy has been investigated extensively over the past three decades as an intervention for irritable bowel syndrome (IBS) in adults. Almost 30 studies of clinical outcomes, including ten randomised controlled trials, have been published on the topic, with most showing that hypnotherapy significantly improved bowel symptoms and, often, the associated quality of life and emotional symptoms. On the basis of this body of research, multiple recent reviews have concluded that hypnotherapy is an effective treatment for IBS

Hypnosis and Cognitive Behavioral Therapies for the Management of Gastrointestinal Disorders

Purpose of Review: To review the nature, current evidence of efficacy, recent developments, and future prospects for cognitive behavioral therapy (CBT) and gut-directed hypnotherapy, the two best established psychological interventions for managing gastrointestinal (GI) disorders. Recent Findings: New large randomized controlled trials are showing that cost-effective therapy delivery formats (telephone-based, Internet-based, fewer therapist sessions, or group therapy) are effective for treating GI disorders. Summary: CBT and hypnotherapy can produce substantial improvement in the digestive tract symptoms, psychological well-being, and quality of life of GI patients. However, they have long been hampered by limited scalability and significant cost, and only been sufficiently tested for a few GI health problems. Through adoption of more cost-effective therapy formats and teletherapy, and by expanding the scope of efficacy testing to additional GI treatment targets, these interventions have the potential to become widely available options for improving clinical outcomes for patients with hard-to-treat GI disorders

An approach to the diagnosis and management of Rome IV functional disorders of chronic constipation

Introduction: Chronic constipation is highly prevalent, affecting between 10% and 15% of the population. The Rome IV criteria categorizes disorders of chronic constipation into four subtypes: (a) functional constipation, (b) irritable bowel syndrome with constipation, (c) opioid-induced constipation, and (d) functional defecation disorders, including inadequate defecatory propulsion and dyssynergic defecation. The initial management approach for these disorders is similar, focusing on diet, lifestyle and the use of standard over-the-counter laxatives. If unsuccessful, further therapy is tailored according to subtype. Areas covered: This review covers the definition, epidemiology, diagnostic criteria, investigations and management of the Rome IV disorders of chronic constipation. Expert opinion: By adopting a logical step-wise approach toward the diagnosis of chronic constipation and its individual subtypes, clinicians have the opportunity to tailor therapy accordingly and improve symptoms, quality of life, and patient satisfaction

Biomarkers to distinguish functional constipation from irritable bowel syndrome with constipation

Treatments for functional constipation (FC) and irritable bowel syndrome with constipation (IBS-C) differ, but symptom criteria do not reliably distinguish between them; some regard FC and IBS-C as parts of a single constipation spectrum. Our goal was to review studies comparing FC and IBS-C to identify possible biomarkers that separate them. A systematic review identified 15 studies that compared physiologic tests in FC vs IBS-C. Pain thresholds were lower in IBS-C than FC for 3/5 studies and not different in 2/5. Colonic motility was decreased more in FC than IBS-C for 3/3 studies, and whole gut transit was delayed more in FC than IBS-C in 3/8 studies and not different in 5/8. Pelvic floor dyssynergia was unrelated to diagnosis. Sympathetic arousal, measured in only one study, was greater in IBS-C than FC. The most reliable separation of FC from IBS-C was shown by a novel new magnetic resonance imaging technique described in this issue of the journal. These authors showed that drinking one liter of polyethylene glycol laxative significantly increased water content in the small intestine, volume of contents in the ascending colon, and time to first evacuation in FC vs IBS-C; and resulted in less colon motility and delayed whole gut transit in FC compared to IBS-C. Although replication is needed, this well-tolerated, non-invasive test promises to become a new standard for differential diagnosis of FC vs IBS-C. These data suggest that FC and IBS-C are different disorders rather than points on a constipation spectrum

Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice

Purpose of Review: The purpose of the review was to provide an update of the Rome IV criteria for colorectal disorders with implications for clinical practice. Recent Findings: The Rome diagnostic criteria are expert consensus criteria for diagnosing functional gastrointestinal disorders (FGIDs). The current version, Rome IV, was released in May of 2016 after Rome III had been in effect for a decade. It is the collective product of committees that included more than 100 leading functional GI experts. For functional bowel and anorectal disorders, the majority of changes relative to Rome III are relatively minor and will have little impact on clinical practice. However, notable changes with potential impact on clinical practice and research include the changes in the diagnostic criteria for IBS, the modified approach for subtyping of IBS, the view on functional bowel disorders as a spectrum of disorders, and the new definition of fecal incontinence. Summary: New features in the Rome IV diagnostic criteria for functional bowel and anorectal disorders will likely have modest influence on clinical practice, with a few exceptions

Treating Fecal Incontinence: An Unmet Need in Primary Care Medicine

Fecal incontinence affects up to 36% of primary care patients. Although effective treatments are available, doctors rarely screen for this condition and patients seldom volunteer complaints of fecal incontinence. Conservative management yields 60% improvement in symptoms and continence in 20% of patients. Referrals are currently being accepted for studies seeking to improve case detection and to support conservative management or self-care

Irritable bowel syndrome: what do the new Rome IV diagnostic guidelines mean for patient management?

The Rome criteria are universally used as inclusion criteria in pharmaceutical clinical trials and have therefore contributed to testing of several irritable bowel syndrome (IBS)-specific drugs. However, clinicians do not routinely use them because they are complex and consequently difficult to remember. Revised Rome diagnostic criteria for IBS and other functional gastrointestinal disorders (FGIDs) were published in May 2016

Best Practice Update: Incorporating Psychogastroenterology Into Management of Digestive Disorders

Chronic digestive diseases, including irritable bowel syndrome, gastroesophageal reflux disease, and inflammatory bowel diseases, cannot be disentangled from their psychological context—the substantial burden of these diseases is co-determined by symptom and disease severity and the ability of patients to cope with their symptoms without significant interruption to daily life. The growing field of psychogastroenterology focuses on the application of scientifically based psychological principles and techniques to the alleviation of digestive symptoms. In this Clinical Practice Update, we describe the structure and efficacy of 2 major classes of psychotherapy—cognitive behavior therapy and gut-directed hypnotherapy. We focus on the impact of these brain–gut psychotherapies on gastrointestinal symptoms, as well as their ability to facilitate improved coping, resilience, and self-regulation. The importance of the gastroenterologist in the promotion of integrated psychological care cannot be overstated, and recommendations are provided on how to address psychological issues and make an effective referral for brain–gut psychotherapy in routine practice

Management of the multiple symptoms of irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders. A stepwise management approach is advocated for patients with IBS. For a substantial proportion of patients with mild symptoms, general management principles, including making a confident diagnosis and offering explanation, reassurance, and dietary and lifestyle advice, are sufficient. However, many patients continue to have moderate-to-severe symptoms and are not satisfied solely with this approach. In these patients, use of pharmacotherapy on the basis of the predominant symptom (constipation, diarrhoea, pain, or bloating) or combination of symptoms is the next step. For patients with symptoms that are refractory to these initial treatment options and those who have comorbid conditions or psychological symptoms, a combination of therapies should be used, and the use of psychotropic drugs and psychological treatment alternatives is often effective. Finally, the key to successful treatment of patients with IBS is a good physician–patient relationship and use of person-centred care principles