Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome

How gut microbiota may impact ocular surface homeostasis and related disorders

Changes in the bacterial flora in the gut, also described as gut microbiota, are readily acknowledged to be associated with several systemic diseases, especially those with an inflammatory, neuronal, psychological or hormonal factor involved in the pathogenesis and/or the perception of the disease. Maintaining ocular surface homeostasis is also based on all these four factors, and there is accumulating evidence in the literature on the relationship between gut microbiota and ocular surface diseases. The mechanisms involved are mostly interconnected due to the interaction of central and peripheral neuronal networks, inflammatory effectors and the hormonal system. A better understanding of the influence of the gut microbiota on the maintenance of ocular surface homeostasis, and on the onset or persistence of ocular surface disorders could bring new insights and help elucidate the epidemiology and pathology of ocular surface dynamics in health and disease. Revealing the exact nature of these associations could be of paramount importance for developing a holistic approach using highly promising new therapeutic strategies targeting ocular surface diseases.

Prevalence of Fibromyalgia and Chronic Fatigue Syndrome among Individuals with Irritable Bowel Syndrome: An Analysis of United States National Inpatient Sample Database

Background and Aim: Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder associated with other somatic disorders. We studied the prevalence and predictors of fibromyalgia and chronic fatigue syndrome (CFS) in IBS patients. Methods: We used the National Inpatient Sample and included hospitalization of individuals with IBS, using ICD-10 codes, from 2016-2019. The prevalence and predictors of fibromyalgia and CFS in IBS patients were studied. Univariate and multivariate patient- and hospital-level regression models were used to calculate the adjusted odds of fibromyalgia and CFS in the IBS patient population. Results: Of 1,256,325 patients with an ICD-10 code of IBS included in the study, 10.73% (134,890) also had ICD-10 codes for fibromyalgia and 0.42% (5220) for CFS. The prevalence of fibromyalgia and CFS was significantly higher in IBS patients (adjusted odds ratio (AOR) 5.33, 95% confidence interval (CI) 5.24-5.41, p < 0.001, and AOR 5.40, 95% CI 5.04-5.78, p < 0.001, respectively) compared to the general adult population without IBS. IBS-diarrhea, IBS-constipation, and IBS-mixed types were independently associated with increased odds of fibromyalgia and CFS. Increasing age (AOR 1.02, 95% CI 1.01-1.04, p 0.003; AOR 1.02, 95% CI 1.01-1.03, p 0.001), female gender (AOR 11.2, 95% CI 11.1-11.4, p < 0.001; AOR 1.86, 95% CI 1.78-1.93, p < 0.001) and white race (AOR 2.04, 95% CI 1.95-2.12, p < 0.001; AOR 1.69, 95% CI 1.34-2.13, p < 0.001) were independent predictors of increased odds of fibromyalgia and CFS, respectively. Conclusions: It appears that IBS is associated with an increased prevalence of somatic disorders such as fibromyalgia and CFS.

TFOS Lifestyle: Impact of nutrition on the ocular surface

Nutrients, required by human bodies to perform life-sustaining functions, are obtained from the diet. They are broadly classified into macronutrients (carbohydrates, lipids, and proteins), micronutrients (vitamins and minerals) and water. All nutrients serve as a source of energy, provide structural support to the body and/or regulate the chemical processes of the body. Food and drinks also consist of non-nutrients that may be beneficial (e.g., antioxidants) or harmful (e.g., dyes or preservatives added to processed foods) to the body and the ocular surface. There is also a complex interplay between systemic disorders and an individual's nutritional status. Changes in the gut microbiome may lead to alterations at the ocular surface. Poor nutrition may exacerbate select systemic conditions. Similarly, certain systemic conditions may affect the uptake, processing and distribution of nutrients by the body. These disorders may lead to deficiencies in micro- and macro-nutrients that are important in maintaining ocular surface health. Medications used to treat these conditions may also cause ocular surface changes. The prevalence of nutrition-related chronic diseases is climbing worldwide. This report sought to review the evidence supporting the impact of nutrition on the ocular surface, either directly or as a consequence of the chronic diseases that result. To address a key question, a systematic review investigated the effects of intentional food restriction on ocular surface health; of the 25 included studies, most investigated Ramadan fasting (56%), followed by bariatric surgery (16%), anorexia nervosa (16%), but none were judged to be of high quality, with no randomized-controlled trials.

Fibromyalgia and Irritable Bowel Syndrome Interaction: A Possible Role for Gut Microbiota and Gut-Brain Axis

Fibromyalgia (FM) is a serious chronic pain syndrome, characterised by muscle and joint stiffness, insomnia, fatigue, mood disorders, cognitive dysfunction, anxiety, depression and intestinal irritability. Irritable Bowel Syndrome (IBS) shares many of these symptoms, and FM and IBS frequently co-exist, which suggests a common aetiology for the two diseases. The exact physiopathological mechanisms underlying both FM and IBS onset are unknown. Researchers have investigated many possible causes, including alterations in gut microbiota, which contain billions of microorganisms in the human digestive tract. The gut-brain axis has been proven to be the link between the gut microbiota and the central nervous system, which can then control the gut microbiota composition. In this review, we will discuss the similarities between FM and IBS. Particularly, we will focus our attention on symptomatology overlap between FM and IBS as well as the similarities in microbiota composition between FM and IBS patients. We will also briefly discuss the potential therapeutic approaches based on microbiota manipulations that are successfully used in IBS and could be employed also in FM patients to relieve pain, ameliorate the rehabilitation outcome, psychological distress and intestinal symptoms.

TFOS Lifestyle: Impact of lifestyle challenges on the ocular surface

Many factors in the domains of mental, physical, and social health have been associated with various ocular surface diseases, with most of the focus centered on aspects of dry eye disease (DED). Regarding mental health factors, several cross-sectional studies have noted associations between depression and anxiety, and medications used to treat these disorders, and DED symptoms. Sleep disorders (both involving quality and quantity of sleep) have also been associated with DED symptoms. Under the domain of physical health, several factors have been linked to meibomian gland abnormalities, including obesity and face mask wear. Cross-sectional studies have also linked chronic pain conditions, specifically migraine, chronic pain syndrome and fibromyalgia, to DED, principally focusing on DED symptoms. A systematic review and meta-analysis reviewed available data and concluded that various chronic pain conditions increased the risk of DED (variably defined), with odds ratios ranging from 1.60 to 2.16. However, heterogeneity was noted, highlighting the need for additional studies examining the impact of chronic pain on DED signs and subtype (evaporative versus aqueous deficient). With respect to societal factors, tobacco use has been most closely linked to tear instability, cocaine to decreased corneal sensitivity, and alcohol to tear film disturbances and DED symptoms.

Pelvic floor dysfunctions in women with fibromyalgia: A cross-sectional study

BACKGROUND

Fibromyalgia (FM) is a rheumatic syndrome that causes musculoskeletal disorders and is associated with several problems that affect quality of life. As the musculoskeletal system is affected, it can have an impact on the pelvic floor muscles, leading to pelvic floor dysfunction (PFD).

OBJECTIVE

Investigate the occurrence of PFD, such as urinary incontinence (UI) and anal incontinence (AI), sexual problems, and pelvic organ prolapse (POP), in women with FM compared to a control group composed of women without FM; and investigate the association between FM and PFD.

STUDY DESIGN

This was an online cross-sectional survey. Demographic and anthropometric data, the description of PFD (UI, nocturia, AI, genital-pelvic pain/penetration disorder, and POP), and previous obstetric history were collected through a web-based questionnaire. The groups were compared using the independent t-test for quantitative variables and the chi-square test for categorical variables. The association between FM and PFD was tested using logistic regression analysis.

RESULTS

A total of 175 women answered the questionnaire (97 with FM and 78 healthy controls). The women with FM reported significantly more UI, mixed urinary incontinence, AI, POP, and vaginismus than the healthy controls (p ≤ 0.05). FM was associated with mixed urinary incontinence (OR: 2.6; 95 % CI: 1.1-6.4; p = 0.04), anal incontinence (OR: 2.9; 95 % CI: 1.3-6.1; p = 0.01), and flatus incontinence (OR: 2.6; 95 % CI: 1.2-5.4; p = 0.01).

CONCLUSION

The prevalence of PFD was significantly higher in women with FM compared to healthy women. Indeed, the women with FM were 2.6-fold to 2.9-fold more likely to report mixed urinary incontinence, anal and flatus incontinence than those in the control group. The present findings show possible impairment of the pelvic floor musculature in women with FM.

Prevalence of fibromyalgia 10 years after infection with Giardia lamblia: a controlled prospective cohort study

OBJECTIVES

To investigate whether acute infection with Giardia lamblia is associated with fibromyalgia 10 years after infection and whether fibromyalgia is associated with irritable bowel syndrome (IBS) and chronic fatigue (CF) in this setting.

METHODS

A cohort study was established after an outbreak of G. lamblia in Bergen, Norway, 2004. Laboratory-confirmed cases and a matched control group were followed for 10 years. The main outcome was fibromyalgia 10 years after giardiasis, defined by the 2016 revisions of the fibromyalgia diagnostic criteria using the Fibromyalgia Survey Questionnaire (FSQ).

RESULTS

The prevalence of fibromyalgia was 8.6% (49/572) among Giardia exposed compared to 3.1% (21/673) in controls (p<0.001). Unadjusted odds for having fibromyalgia was higher for Giardia exposed compared to controls (odds ratio (OR): 2.91, 95% confidence interval (CI): 1.72, 4.91), but adjusted for IBS and CF it was not (OR: 1.05, 95% CI: 0.57, 1.95). Among participants without CF the odds for fibromyalgia was 6.27 times higher for participants with IBS than those without (95% CI: 3.31, 11.91) regardless of exposure. Among participants without IBS the odds for fibromyalgia was 4.80 times higher for those with CF than those without (95% CI: 2.75, 8.37).

CONCLUSIONS

We found a higher prevalence of fibromyalgia among Giardia exposed compared to controls 10 years after the acute infection. Fibromyalgia was strongly associated with IBS and CF, and the difference between the exposed and controls can be attributed to the high prevalence of IBS and CF among the Giardia exposed. Notably, this study was not designed to establish causality between Giardia exposure and the outcomes.

Association among Disorders of Gut-Brain Interaction (DGBI) and Fibromyalgia: A Prospective Study

The disorders of gut-brain interaction (DGBI) have been associated with Fibromyalgia (FM). However, there are no data about the relationship between FM and DGBI using Rome IV criteria. This study aimed to evaluate the prevalence of FM in patients with Irritable Bowel Syndrome (IBS) and/or Functional Dyspepsia (FD) and the prevalence of IBS and FD in FM patients using Rome IV criteria. DGBI patients and FM patients were recruited from two outpatient clinics devoted to DGBI and FM. All patients underwent a standardized gastrointestinal (GI) symptoms questionnaire. FM symptoms in DGBI patients were assessed through Fibromyalgia Rapid Screening Tool (FiRST) and Fibromyalgia Impact Questionnaire. Thereafter, the rheumatologists evaluated them. 49.0% of FM patients fulfilled the diagnostic criteria for IBS, 81.6% for FD with an overlap for both IBS/FD in 44.9%. IBS-C was the most prevalent IBS-subtype in DGBI patients, whereas IBS-M was the most prevalent in FM patients (p = 0.01). 45.3% of DGBI patients reported pathological FiRST scores. DGBI patients with FM showed the highest score at the standardized GI questionnaire followed by FM patients with DGBI and DGBI without FM. In conclusion DGBI are common in FM patients and vice versa. The presence of FD is extremely frequent in FM patients. A multidisciplinary approach should be routinely used for the management of these patients.

5'UTR polymorphism in the serotonergic receptor HTR3A gene is differently associated with striatal Dopamine D2/D3 receptor availability in the right putamen in Fibromyalgia patients and healthy controls-Preliminary evidence

BACKGROUND

Extensive literature has investigated the role of serotonin (5-HT) in the control of the central dopamine (DA) systems, and their dysfunction in the pathological conditions. 5-HT stimulates the local DA release in striatal regions via activation of various receptors including serotonin receptor-3 (5-HT3). Several studies have related polymorphisms (SNPs) in the serotonin receptor-3 (HTR3) genes to be associated with the pain modulation and endogenous pain suppression. A few studies suggested a functional role of 5'UTR SNP in the serotonergic receptor HTR3A gene (rs1062613) in the development of the chronic pain and Fibromyalgia syndrome (FMS) in particular. Here, we investigated the effect of a 5'UTR SNP in the serotonergic receptor HTR3A gene (rs1062613) on striatal dopamine D2/D3 receptor (DRD2) availability and reward-associated DA release in response to unpredictable monetary rewards in 23 women with FMS and 17 age-matched healthy female controls. Furthermore, we aimed to examine if SNP rs1062613 is associated with thermal pain and pain tolerance thresholds.

METHODS

We used PET and [¹¹ C]raclopride to assess the DRD2 availability. In the same participants we used the [¹¹ C]raclopride PET bolus-plus-infusion method to measure the [¹¹ C]raclopride receptor binding potential (ΔBP) between an unpredictable reward condition and a sensorimotor control condition. DRD2 availability and ΔBP were assessed in MRI-based striatal regions of interest. Thermal pain and pain tolerance thresholds were assessed outside the scanner.

RESULTS

The frequency of SNP rs1062613 genotype differed significantly between groups, indicating that CC homozygotes were more frequent in FMS patients (82.6%) than in healthy controls (41.3%). Our results showed a significant main effect of SNP rs1062613 on [¹¹ C]raclopride binding potential in the right caudate nucleus indicating a higher DRD2 receptor availability for CC-genotype of this SNP. Furthermore, we found a significant group × SNP interaction on [¹¹ C]raclopride binding potential in the right putamen, indicating a higher DRD2 availability in T-carriers compared to CC genotype of SNP rs1062613 in FMS patients, whereas this effect was not present in healthy controls. However, we did not find an influence of SNP rs1062613 on reward-related DA release. In addition, there was no association between SNP rs1062613 and pain threshold or pain tolerance threshold in our data.

CONCLUSION

These preliminary results indicate that SNP rs1062613 in the serotonergic receptor HTR3A gene possibly modulates the DRD2 receptor availability.

Eye Pain and Dry Eye in Patients with Fibromyalgia

Objectives

The aim of this study was to examine visual function and eye symptoms in fibromyalgia patients, with a particular focus on dry eye syndrome and eye pain.

Methods

A tertiary care center-based cross-sectional study was carried out in chronic musculoskeletal pain patients diagnosed with fibromyalgia. Chronic musculoskeletal pain patients without fibromyalgia were enrolled as a comparison group. Self-reported eye pain was investigated with the McGill pain questionnaire and the numeric rating scale. In addition, we assessed corrected visual acuity, vision-related quality of life, and self-reported dry eye syndrome.

Results

A total of 90 musculoskeletal pain patients were included, with 66 patients fulfilling American College of Rheumatology 1990 criteria for fibromyalgia. Sixty-seven percent (95% confidence interval [CI] = 56%-78%) of the fibromyalgia patients reported eye pain, and 62% (95% CI = 43%-81%) of those were without fibromyalgia diagnosis. Sixty-seven percent (95% CI = 56%-78%) of the fibromyalgia patients reported an experience of dry eye compared with 76% (95% CI = 57%-95%) in the nonfibromyalgia group. Vision-related quality of life was noticeably reduced in both groups.

Conclusions

Eye pain and dry eye are common in chronic pain patients, with comparable prevalence in musculoskeletal pain patients with and without fibromyalgia.

Comorbid fibromyalgia: A qualitative review of prevalence and importance

Fibromyalgia (FM) may be an unrecognized cause of suffering for persons with an array of medical conditions. This is especially true for illness that is characterized by pain of any nature. Once believed to be a unique diagnosis, FM is recently reported to occur concomitantly with various rheumatic diseases, and importantly adversely impacts global health status. However, there is increasing report of FM associated with other diseases that are not defined by chronic pain. This qualitative review examines the evidence for comorbid FM in illness, and where available the effect of FM on the primary disease. Other than for musculoskeletal disorders, the published literature reporting an association of FM with illness is limited with scanty reports for some neurological, gastrointestinal, mental health and other overlapping pain conditions. Comorbid FM adversely affects both health status and outcome for rheumatic diseases, but with limited study in other diseases. When unrecognized, comorbid FM may be mistaken as poor control of the primary disease, leading to incorrect treatment decisions. FM may be a neglected condition that pervades many conditions and may contribute to the burden of illness. Physicians should be alert to the possibility of comorbid FM, and symptoms of FM should be specifically addressed.

SIGNIFICANCE

Comorbid fibromyalgia (FM) in other medical conditions is largely unrecognized. When reported as accompanying rheumatic diseases, FM adversely affects global health status. With limited reports of comorbid FM with other conditions, neglect to diagnose comorbid FM may misdirect treatments.

The Frequency of Primary Sjogren's Syndrome and Fibromyalgia in Irritable Bowel Syndrome

OBJECTIVE

To determine the frequency of sicca complex, Sjogren's Syndrome (SS) and Fibromyalgia (FM) in patients with Irritable Bowel Syndrome (IBS).

METHODS

Seventy seven IBS patients who fulfilled the Rome-III criteria were included in the study. All patients were assessed for FM according to the American College of Rheumatology (ACR) 2010 criteria. After examination for objective evidence of sicca complex by Schirmer test, TBUT and Ocular Staining Score (OSS), serological tests were performed. And the diagnosis of SS was made according to the American College of Rheumatology (ACR) classification criteria for SS - 2012.

RESULTS

Thirteen (16.9%) of IBS patients had FM. Dry eye was detected in 20(26.0%), 7(9.1%) and 29(37.7%) patients by OSS, Schirmer test and TBUT, respectively. Of 77 patients with IBS, the diagnosis of SS was established in two patients (2.6%).

CONCLUSION

The frequency of Sjogren's Syndrome among patients with IBS is relatively higher than the general population. All IBS patients should be questioned for dryness of the mouth and eyes, and if necessary, should be evaluated for SS.

Irritable bowel syndrome might be associated with dry eye disease

Background

A possible association between dry eye disease (DED) and irritable bowel syndrome (IBS) has been hypothesized based on the fact that they both share an inflammatory pathogenesis.

Methods

Ninety-five patients with IBS and 276 healthy controls were enrolled in the study. All patients answered a questionnaire regarding DED symptoms and had a complete ophthalmic examination. DED signs were evaluated using Schirmer’s 1 and tear break-up time (tBUT) tests in both groups.

Results

Female IBS participants presented significantly lower Schirmer’s test and tBUT (P=0.002 and P<0.001 respectively) than controls. Both diagnostic tests in male IBS patients were also significantly lower than in controls (P<0.001). 72% of IBS patients gave at least 3 positive answers to the questionnaire compared with 42% of the control group (P<0.01).

Conclusion

Our results suggest a correlation between IBS and DED. DED symptoms can cause further complications in patients with IBS, and should be considered in their management. However, further research is needed to establish a possible pathophysiologic association.

Clinical Characteristics of Dry Eye Patients With Chronic Pain Syndromes

PURPOSE

To investigate clinical characteristics of dry eye disease (DED) patients with a chronic pain syndrome.

DESIGN

Cross-sectional study.

METHODS

Four hundred twenty-five patients of a tertiary care DED patient cohort in the Netherlands were included. Chronic pain syndromes irritable bowel syndrome, chronic pelvic pain, and fibromyalgia were assessed by questionnaires. Outcome variables were the Ocular Surface Disease Index (OSDI) symptom questionnaire, tear osmolarity, Schirmer test, tear breakup time, conjunctival hyperemia, staining of the cornea and conjunctiva, and amount of mucus. Outcomes were cross-sectionally compared between DED patients with a chronic pain syndrome and those without.

RESULTS

A total of 74 out of 425 DED patients (17%) had at least 1 chronic pain syndrome. The total symptom score was significantly higher in DED patients with a chronic pain syndrome than in those without (45.8 vs 33.8, P < .0005). Moreover, patients with a chronic pain syndrome scored higher on every single subscale of the 12-item OSDI symptom questionnaire. However, ocular signs were similar or even less severe in these patients. Similarly, in 64 DED patients from the population-based cohort TwinsUK, patients with a chronic pain syndrome (n = 24, 38%) had higher subscale and total (34.1 vs 14.4, P = .001) symptom scores.

CONCLUSION

In DED patients, chronic pain syndromes are common and are associated with increased severity of DED symptoms across all domains of the OSDI, even though objective ocular surface signs are no worse. In clinical practice, more awareness of chronic pain syndromes might help in understanding the discrepancy between signs and symptoms in DED.

Elevated levels of faecal calprotectin in primary Sjögren's syndrome is common and associated with concomitant organic gastrointestinal disease

Background

Primary Sjögren’s syndrome (pSS) is a systemic rheumatic disease in which gastrointestinal (GI) symptoms are common. Faecal calprotectin (FC) is a non-invasive biomarker that has been suggested to discriminate organic intestinal disease from functional disorders. The purpose of this study was to explore the usefulness of FC testing in patients with pSS.

Methods

In total, 56 consecutive patients with pSS and 29 healthy control subjects were included in this cross-sectional study. FC was measured with a commercially available enzyme-linked immunosorbent assay kit. GI symptoms were evaluated with the Rome III questionnaire and the Visual Analogue Scale for Irritable Bowel Syndrome. In patients with pSS, disease activity was estimated using the European League Against Rheumatism (EULAR) Sjögren’s Syndrome Disease Activity Index (ESSDAI), and patient-reported outcomes were evaluated with the EULAR Sjögren’s Syndrome Patient-Reported Index.

Results

Patients with pSS had higher levels of FC than healthy control subjects (median 54 μg/g, interquartile range [IQR 20–128]; vs. 20 μg/g [20–43]; p = 0.002). Concomitant organic GI disease was found in 14 patients with pSS and included inflammatory bowel disease (n = 3), colonic adenoma (n = 2) and GI lymphoma (n = 1). Patients with organic GI disease had higher FC levels than the other patients with pSS (median 274 μg/g [IQR 61–363] vs. median 34 μg/g [IQR 20–76]; p < 0.001). Although patients with pSS reported abdominal discomfort more frequently than healthy control subjects did, such symptoms were not associated with organic GI disease or elevated FC levels. FC correlated moderately with ESSDAI. Excluding patients with organic GI disease, we did not identify any significant association between ESSDAI and FC levels.

Conclusions

GI symptoms are frequent in pSS. Contrary to patient-reported outcomes, elevated FC levels in pSS indicate possible organic GI disease that warrants further investigation.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0907-8) contains supplementary material, which is available to authorized users.

Intrathecal urocortin I in the spinal cord as a murine model of stress hormone-induced musculoskeletal and tactile hyperalgesia

Stress is antinociceptive in some models of pain, but enhances musculoskeletal nociceptive responses in mice and muscle pain in patients with fibromyalgia syndrome. To test the hypothesis that urocortins are stress hormones that are sufficient to enhance tactile and musculoskeletal hyperalgesia, von Frey fibre sensitivity and grip force after injection of corticotropin-releasing factor (CRF), urocortin I and urocortin II were measured in mice. Urocortin I (a CRF1 and CRF2 receptor ligand) produced hyperalgesia in both assays when injected intrathecally (i.t.) but not intracerebroventricularly, and only at a large dose when injected peripherally, suggesting a spinal action. Morphine inhibited urocortin I-induced changes in nociceptive responses in a dose-related fashion, confirming that changes in behaviour reflect hyperalgesia rather than weakness. No tolerance developed to the effect of urocortin I (i.t.) when injected repeatedly, consistent with a potential to enhance pain chronically. Tactile hyperalgesia was inhibited by NBI-35965, a CRF1 receptor antagonist, but not astressin 2B, a CRF2 receptor antagonist. However, while urocortin I-induced decreases in grip force were not observed when co-administered i.t. with either NBI-35965 or astressin 2B, they were even more sensitive to inhibition by astressin, a non-selective CRF receptor antagonist. Together these data indicate that urocortin I acts at CRF receptors in the mouse spinal cord to elicit a reproducible and persistent tactile (von Frey) and musculoskeletal (grip force) hyperalgesia. Urocortin I-induced hyperalgesia may serve as a screen for drugs that alleviate painful conditions that are exacerbated by stress.

[Correlation of the microbiota and intestinal mucosa in the pathophysiology and treatment of irritable bowel, irritable eye, and irritable mind syndrome]

Accumulating clinical evidence supports co-morbidity of irritable bowel, irritable eye and irritable mind symptoms. Furthermore, perturbation of the microbiota-host symbiosis (dysbiosis) is considered a common pathogenic mechanism connecting gastrointestinal, ocular and neuropsychiatric symptoms. Consequently, maintaining or restoring microbiota-host symbiosis represents a new approach to treat these symptoms or to prevent their relapses. Current treatment approach assigned a primary role to live probiotics alone or in combination with prebiotics to enhance colonization of beneficial bacteria and to strengthen the symbiosis. However, several papers showed major benefits of heat-killed probiotics as compared to their live counterparts on both intestinal and systemic symptoms. Recently, in addition to killing probiotics, in a proof of concept study lysates (fragments) of probiotics in combination with vitamins A, B, D and omega 3 fatty acids were successfully tested. These findings suggested a conceptual change in the approach addressed to both the microbiota and host as targets for intervention.

Review of overlap between thermoregulation and pain modulation in fibromyalgia

Fibromyalgia (FM) syndrome is characterized by widespread pain that is exacerbated by cold and stress but relieved by warmth. We review the points along thermal and pain pathways where temperature may influence pain. We also present evidence addressing the possibility that brown adipose tissue activity is linked to the pain of FM given that cold initiates thermogenesis in brown adipose tissue through adrenergic activity, whereas warmth suspends thermogenesis. Although females have a higher incidence of FM and more resting thermogenesis, they are less able to recruit brown adipose tissue in response to chronic stress than males. In addition, conditions that are frequently comorbid with FM compromise brown adipose activity making it less responsive to sympathetic stimulation. This results in lower body temperatures, lower metabolic rates, and lower circulating cortisol/corticosterone in response to stress--characteristics of FM. In the periphery, sympathetic nerves to brown adipose also project to surrounding tissues, including tender points characterizing FM. As a result, the musculoskeletal hyperalgesia associated with conditions such as FM may result from referred pain in the adjacent muscle and skin.

The severity of irritable bowel syndrome or the presence of fibromyalgia influencing the perception of visceral and somatic stimuli

BACKGROUND

Fibromyalgia Syndrome (FMS) is a frequent comorbidity in Irritable Bowel Syndrome (IBS) patients with a higher functional bowel disorder severity index (FBDSI). We tested the possibility that mild to severe IBS patients without FMS would have a graduated visceral and somatic perception, and the presence of FMS would further enhance somatic, but conversely attenuate visceral perception.Our aim was to study visceral and somatic sensitivity in mild IBS patients and in severe IBS patients with or without FMS.

METHODS

Eleven mild IBS and 19 severe IBS with and without FMS patients were studied. Somatic and visceral stimuli were applied in each patient by means of electrical stimulations at active and control sites and by means of an electronic barostat in the rectum. Thresholds for discomfort and perception cumulative scores were measured.

RESULTS

Mild and severe IBS patients without FMS demonstrated a significantly lower somatic perception cumulative score than severe IBS patients with FMS at active site. Conversely only severe IBS patients without FMS had significantly lower visceral thresholds for discomfort than mild IBS patients and severe IBS patients with FMS.

CONCLUSIONS

The presence of co-existing FMS or greater FBDSI affects somatic and visceral perception in a graded fashion across IBS patients.

Irritable bowel syndrome: Relations with functional, mental, and somatoform disorders

This review describes the conceptual and clinical relations between irritable bowel syndrome (IBS), other functional, somatoform, and mental disorders, and points to appropriate future conceptualizations. IBS is considered to be a functional somatic syndrome (FSS) with a considerable symptom overlap with other FSSs like chronic fatigue syndrome or fibromyalgia syndrome. IBS patients show an increased prevalence of psychiatric symptoms and disorders, especially depression and anxiety. IBS is largely congruent with the concepts of somatoform and somatic symptom disorders. Roughly 50% of IBS patients complain of gastrointestinal symptoms only and have no psychiatric comorbidity. IBS concepts, treatment approaches, as well as health care structures should acknowledge its variability and multidimensionality by: (1) awareness of additional extraintestinal and psychobehavioral symptoms in patients with IBS; (2) general and collaborative care rather than specialist and separated care; and (3) implementation of “interface disorders” to abandon the dualistic classification of purely organic or purely mental disorders.

Irritable eye syndrome: neuroimmune mechanisms and benefits of selected nutrients

Previous studies showed comorbidity of some ocular, enteral, and affective symptoms comprising irritable eye syndrome. Aims of the present study were to learn more about the pathogenic mechanisms of this syndrome and to evaluate benefits of food supplements on these disorders. In in vitro assay, Lactobacillus acidophilus lysate inhibited interleukin (IL)-1β and tumor necrosis factor (TNF)-α generation of lipopolysaccharide (LPS)-stimulated macrophages in dose- and size-dependent manner. For a prospective, open-label phase I/II controlled clinical trial, 40 subjects affected by ocular dysesthesia and hyperesthesia and comorbid enteral and anxiety-depression symptoms were randomly assigned either into the treated group, which received a composition containing probiotic lysate, vitamins A, B, and D and omega 3 fatty acids, or into the control group, which received vitamins and omega 3 fatty acids. For reference, 20 age- and sex-matched healthy subjects were also selected. White blood count (WBC) and lymphocyte and monocyte counts, as well as IL-6 and TNF-α levels, were significantly above the reference levels in both treated and control groups. After 8 weeks, WBC and lymphocyte and monocyte counts, and cytokine levels significantly decreased, and ocular, enteral, and anxiety-depression symptoms significantly improved in the treated group as compared to the control group. This proof-of-concept study suggested that subclinical inflammation may be a common mechanism connecting ocular, enteral, and anxiety/depression symptoms, and supplements affecting dysbiosis may be a new approach to treating this syndrome.

Synesthesia, pseudo-synesthesia, and irritable bowel syndrome

BACKGROUND AND AIMS

Synesthesia is a sensory disorder where the stimulation of one sensory modality can lead to a reaction in another which would not usually be expected to respond; for instance, someone might see a color on hearing a word such as a day of the week. Disordered perception of sensory information also appears to contribute to the pathophysiology of irritable bowel syndrome (IBS). The purpose of this exploratory study was to ascertain whether these two conditions might be linked in any way.

METHODS

Two hundred consecutive IBS outpatients were screened for synesthesia and compared with 200 matched healthy volunteers (controls). Positive responders were tested for two types of synesthesia (grapheme-color and music-color/shape) using a questionnaire which was repeated after 3 months to test for reproducibility.

RESULTS

Of the 200 IBS outpatients screened, 26 (13%) patients and six (3%) controls claimed to be synesthetic (P < 0.001). Reproducibility was more variable in IBS patients than controls but despite this variability, 15 (7.5%) patients compared with 5 (2.5%) controls had greater than 75% consistency (P = 0.036), and 19 (9.5%) patients and 6 (3%) controls had greater than 50% consistency (P = 0.012). A reproducibility of less than 50% was observed in seven (3.5%) patients and no controls (0%) (P = 0.015), and these individuals were classified as having pseudo-synesthesia.

CONCLUSION

IBS patients clearly differ from controls in terms of claiming to have synesthetic experiences. These results justify additional studies on the relationship between IBS and synesthesia to further understand the neural mechanisms underpinning these two conditions and to establish whether they may be linked.

The prevalence of fibromyalgia in other chronic pain conditions

Central sensitivity syndromes (CSS) include fibromyalgia syndrome (FMS), irritable bowel syndrome, temporomandibular disorder, restless legs syndrome, chronic fatigue syndrome, and other similar chronic painful conditions that are based on central sensitization (CS). CSS are mutually associated. In this paper, prevalence of FMS among other members of CSS has been described. An important recent recognition is an increased prevalence of FMS in other chronic pain conditions with structural pathology, for example, rheumatoid arthritis, systemic lupus, ankylosing spondylitis, osteoarthritis, diabetes mellitus, and inflammatory bowel disease. Diagnosis and proper management of FMS among these diseases are of crucial importance so that unwarranted use of such medications as corticosteroids can be avoided, since FMS often occurs when RA or SLE is relatively mild.

Prevalence of functional gastrointestinal disorders in patients with fibromyalgia and the role of psychologic distress

BACKGROUND & AIMS

Fibromyalgia is a rheumatologic disorder associated with somatic and psychologic conditions. Although fibromyalgia is associated with irritable bowel syndrome, its relationship with other functional gastrointestinal disorders (FGID) is unclear. We evaluated the prevalence of FGID in patients with fibromyalgia and the role of psychologic factors in this relationship.

METHODS

From a Spanish population, 100 patients with fibromyalgia and 100 matched controls completed the Rome II Integrative Questionnaire to assess the prevalence of FGID and the Symptom Checklist-90 Revised (SCL-90R) to evaluate psychologic distress. Patients completed the Fibromyalgia Impact Questionnaire to evaluate the overall impact of fibromyalgia and controls filled out the Chronic Widespread Pain Questionnaire to detect potential cases of fibromyalgia.

RESULTS

Ninety-three percent of the total study population was female, with a mean age of 50 years. We identified 6 cases of widespread pain among controls. The average Fibromyalgia Impact Questionnaire score for patients was 67.28 +/- 14.25. All gastrointestinal symptoms except for vomiting were more frequent in patients. Ninety-eight percent of patients with fibromyalgia had at least one FGID, compared with only 39% of controls. Fibromyalgia was correlated most highly with irritable bowel syndrome. Patients presented with significantly higher scores of psychologic distress than controls, especially those with fecal incontinence.

CONCLUSIONS

There is a prevalence of FGID in patients with fibromyalgia and a wider distribution of such symptoms along the gastrointestinal tract compared with controls. We propose that an increased degree of psychologic distress in these patients predisposes them to FGID, especially significant for anorectal syndromes.

Cow's milk protein sensitivity assessed by the mucosal patch technique is related to irritable bowel syndrome in patients with primary Sjögren's syndrome

Introduction

Patients with primary Sjögren's syndrome (pSS) are reported to have a variety of gastrointestinal symptoms partly attributed to an overrepresentation of celiac disease. We have observed that irritable bowel syndrome (IBS)-like symptoms are frequent complaints in this patient group. Allergic manifestations to various drugs are also common in pSS. A role of food allergy in IBS has been proposed.

Objective

This study is aimed at evaluating the mucosal response to rectal challenge with cow's milk protein (CM) in patients with pSS and relates possible CM reactivity to their intestinal symptoms.

Methods

A rectal challenge with CM was performed in 21 patients with pSS and 18 healthy controls. Fifteen hours after challenge the mucosal production of nitric oxide (NO) and the release of myeloperoxidase (MPO) as signs of mucosal inflammatory reaction were measured using the mucosal patch technique.

Results

Eight out of 21 patients with pSS had a definite increase of mucosal NO synthesis and the luminal release of MPO after rectal CM challenge. This sign of milk sensitivity was not linked to IgG/IgA antibodies to milk proteins. The symptoms for IBS according to Rome III criteria were fulfilled in 13 patients. All patients who were CM sensitive suffered from IBS. In a small open study, patients reactive to CM reported an improvement of intestinal symptoms on a CM-free diet.

Conclusion

A rectal mucosal inflammatory response after CM challenge is seen in 38% of patients with pSS as a sign of CM sensitivity. IBS-like symptoms were common in pSS, linked to CM sensitivity.

Movement-evoked hyperalgesia induced by lipopolysaccharides is not suppressed by glucocorticoids

Systemic exposure to lipopolysaccharides (LPS) produces a variety of effects, including movement-evoked hyperalgesia that can be measured using the grip force assay in mice. Because both lethality and enhanced sensitivity to cutaneous pain following exposure to endotoxins have each been attributed to inflammatory mediators, we explored the possibility that LPS-induced movement-evoked hyperalgesia is also sensitive to manipulations of glucocorticoids that regulate these other LPS responses. We found that the hyperalgesic effect of LPS (5mg/kg s.c.) in mice that were adrenalectomized did not differ from that in control mice that were sham operated, even though mortality after LPS was potentiated by adrenalectomy. The development of tolerance to the movement-evoked hyperalgesic effect of LPS also did not differ between adrenalectomized and sham-operated control mice. In addition, mifepristone (25mg/kg s.c.), a glucocorticoid antagonist, did not attenuate the hyperalgesic effect of LPS (2mg/kg s.c.), yet this dose of mifepristone was sufficient to enhance the incidence of lethality induced by LPS. Enhancement of glucocorticoid activity by two injections of dexamethasone (1mg/kg s.c.) had no effect on the degree of hyperalgesia in mice injected with LPS (5mg/kg s.c.), yet this dose of dexamethasone was sufficient to attenuate the incidence of mortality induced by LPS in adrenalectomized mice. Finally, morphine (10mg/kg i.p.) reversed the decrease in grip force caused by LPS (5mg/kg i.p.), supporting the interpretation that decreases in grip force produced by LPS reflect muscle hyperalgesia that is not sensitive to glucocorticoids.

Is there a predisposition for the development of autoimmune diseases in patients with fibromyalgia? Retrospective analysis with long term follow-up

The objectives of the study were to evaluate the prevalence of antinuclear antibodies (ANA) in patients with fibromyalgia (FM) and the probability of the development of clinically overt connective tissue diseases. Four hundred and fifty FM patients were compared to 129 healthy matched blood donors. ANA testing was performed by immunofluorescence on rat tissue sections; in case of highly positive results, ANA were specified further by ELISA and immunodiffusion. All ANA positive FM patients were invited for a control examination. The ANA negative patients received a questionnaire, which was designed to identify those patients with possible connective tissue diseases (CTD). There was no significant difference in the frequency of ANA or thyroid antibodies between patients and controls (11.6% vs. 7%). Two patients had developed SLE: one was already ANA/anti-dsDNA positive at time of first diagnosis of FM; in the other, specific antibodies and SLE-related symptoms developed after 4.5 years. The probability for FM patients to develop CTD (SLE) within one year is 0.0027%, which is comparable to the incidence of SLE in the general population (0.005%). The risk of CTD is not increased in FM. The detection of ANA does not predict the development of CTD. However, in individual cases, FM may be an early sign of an autoimmune disease.

Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes

OBJECTIVES

To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS).

METHODS

A critical overview of the literature and incorporation of the author's own views.

RESULTS

The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms.

CONCLUSIONS

CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.

High somatic symptom burdens and functional gastrointestinal disorders

BACKGROUND & AIMS

Unexplained, multi-system somatic symptoms and syndromes, the hallmark features of somatization, are prevalent in patients with functional gastrointestinal disorders (FGIDs). We studied outpatients attending a gastroenterology clinic to see whether current somatic symptom burdens (a somatization state measure) or number of prior functional diagnoses (a somatization trait measure) could predict the presence of an FGID over structural gastrointestinal disease, and whether the predictive value was dependent on comorbid depression or anxiety disorders.

METHODS

Clinical data from 327 consecutive new referrals to an outpatient gastroenterology practice were reviewed, 187 with an FGID and 140 with a structural illness. Somatization state and trait were measured by using self-reported current symptoms and functional diagnoses recorded in the medical history, respectively. Psychiatric comorbidity (depression or anxiety disorders) was extracted from chart review.

RESULTS

FGID subjects endorsed more somatization state symptoms, had more somatization trait diagnoses, and had greater likelihood of psychiatric comorbidity (P < .001 for each). Logistic regression analysis adjusting for age and sex differences showed that each of these features independently predicted the likelihood of an FGID over structural disease (P < .05 for each). When high ratings on the somatization measures were present together with psychiatric comorbidity, the positive predictive value exceeded 0.95.

CONCLUSIONS

Higher burdens of either current somatic symptoms or functional diagnoses in the medical history are strong predictors of an FGID in outpatients presenting with gastrointestinal complaints. The mechanism is not solely dependent on a relationship with affective disorders, which independently predicts FGID, at least in part, through another path.

Convergence of sensory pathways in the development of somatic and visceral hypersensitivity

Sensory neurons innervating different tissues converge onto second-order neurons in the spinal cord. We examined whether inflammation or transient overexpression of nerve growth factor (NGF) in one tissue triggers hypersensitivity in referral sites. Thresholds to mechanical and thermal stimulation of the hindpaw, visceromotor responses to colorectal distension, and cystometrograms were performed in appropriate controls and mice with experimentally induced cystitis, inflammation of the hindpaw or front paw, or injection of viral vectors encoding NGF or green fluorescent protein (GFP). Cystitis and NGF but not GFP overexpression in the bladder triggered bladder hyperactivity associated with mechanical and thermal hypersensitivity in cutaneous referral sites and enhanced responses to colorectal distension. Hindpaw inflammation and injection of the NGF- but not GFP-encoding viral vector or front paw inflammation induced mechanical and thermal hyperalgesia in the affected hindpaw and increased responses to colorectal distension without altering the micturition reflex. In conclusion, sensitization of sensory pathways by inflammation or NGF contributes to the development of hypersensitivity in neighboring organs and cutaneous referral sites and provides a potential mechanism underlying the coexistence of pain syndromes in patients with functional diseases.

Perception of electrocutaneous stimuli in irritable bowel syndrome

BACKGROUND AND AIM

Irritable bowel syndrome (IBS) and fibromyalgia syndrome (FMS) are common conditions with some similarities, but different perceptual responses to somatic and visceral stimuli. The purpose of this study was to assess in a large group of IBS patients the somatic perception by transcutaneous electrical nerve stimulation (TENS) and its relation to the level of severity and presence of FMS.

METHODS

In 99 patients grouped by the validated functional bowel disorder severity index (FBDSI) in mild, moderate, and severe IBS and in 33 healthy controls (HC), we studied discomfort thresholds and perception of somatic stimuli at control (hands and elbows) and active (trapezius) sites by TENS and by using a specific questionnaire.

RESULTS

The use of TENS showed that IBS showed significant higher thresholds and lower perception cumulative score compared to HC. The severity of IBS is significantly associated with age and mean control site values for discomfort and borderline associated with gender in the ordinal model constructed for the ascending series protocol. The severity of IBS is also significantly associated with the active cumulative perception score in the long stimulus protocol. Due to limited sample size of IBS men with FMS, analyses of discomfort thresholds and cumulative perception score by FMS were done only for women. IBS women without FMS had significantly higher mean control site values for discomfort and significantly lower active cumulative perception score than HC. IBS women with FMS had significantly lower mean active site values for discomfort thresholds than IBS women without FMS (Dunn's test p < 0.05).

CONCLUSIONS

IBS patients showed somatic hypoalgesia to electrical stimuli. The severity of IBS and the presence of FMS influence the perception of somatic stimuli induced by TENS.

Experimental colitis in mice and sensitization of converging visceral and somatic afferent pathways

Chronic pain syndromes affecting different organs often coexist. We hypothesized that sensitization of one afferent pathway may affect converging input from other areas of the body. We induced colitis in mice with 2,4,6-trinitrobenzenesulfonic acid (TNBS); control animals were treated with equal volumes of vehicle (50% ethanol) only. Visceromotor responses to graded colorectal distension, cystometrograms, and response thresholds to mechanical and thermal stimulation of both hind paws were determined on days 7 and 14. Inflammation of colon and bladder was assessed with validated histological markers and scores. TNBS caused significant colitis on day 7 that resolved by day 14; there was no evidence of bladder inflammation. There was a significant hypersensitivity to colorectal distension on day 7, which returned to normal on day 14. This was associated with bladder overactivity, as demonstrated by early onset of micturition and more frequent micturition on day 7 after TNBS administration. Colitis also significantly altered responses to mechanical and thermal stimulation of both hind paws on day 7 but not day 14. We conclude that cross talk between afferent visceral and somatic pathways may contribute to the coexistence of pain syndromes.

A case–control study of risk factors for arm pain presenting to primary care services

OBJECTIVES

To investigate the association of occupational activities, mental health and comorbidity with care seeking for arm pain, and to test the hypothesis that specific disorders arise from physical risk factors and non-specific pain from psychological ones.

METHODS

Patients with a new episode of arm pain and matched controls were recruited from eight general practices. A questionnaire about risk factors was completed and cases were classified using a validated examination schedule. Questions were asked about occupational activities and psychosocial stressors. Mental health was assessed using the Hospital Anxiety Depression Scale, elements of the Brief Symptom Inventory (somatizing tendency) and the Whiteley Index (health anxiety); comorbidity from chronic fatigue syndrome (CFS) and chronic widespread pain (CWP) was ascertained using standard definitions. Associations were explored using logistic regression and summarized as odds ratios (ORs) with 95% confidence intervals (95% CIs).

RESULTS

Altogether, 132 cases and 127 controls were studied. Consulting with arm pain was strongly associated with all of the mental health variables and with CFS and CWP, irrespective of the site of arm pain or diagnosis. The OR in those with >3 versus <3 distressing somatic symptoms was 3.9 (95% CI 1.7-9.0). There were several significant associations with physical activity, but none with occupational psychosocial stressors. Repeated wrist/finger movements and carrying weights were more strongly associated with specific diagnoses than with non-specific pain.

CONCLUSIONS

Somatizing tendency, health anxiety, low mood, CFS and CWP are more common in arm pain consulters. Certain mechanical activities are also overrepresented, particularly in those with specific pathology.

Tolerance develops to the effect of lipopolysaccharides on movement-evoked hyperalgesia when administered chronically by a systemic but not an intrathecal route

Single exposures to lipopolysaccharides (LPS) produce deep tissue pain in humans and cutaneous hyperalgesia in rodents. While tolerance develops to many effects of LPS, sensitization to hyperalgesia is documented after a single injection. To determine the effect of long-term exposure to LPS, we explored the chronic effect of LPS on movement-evoked pain using a new assay based on grip force in mice. We found that a single systemic injection of LPS (i.p. or s.c.) induced a dose-related decrease in forelimb grip force responses beginning 6-8 h after injection and peaking between 9 and 24 h. The consequence of LPS is likely hyperalgesia rather than weakness as these decreases were rapidly attenuated by either 10 mg/kg of morphine i.p. or 10 microg of morphine injected intrathecally (i.t.). Complete tolerance to this hyperalgesia developed after repeated injections of LPS at doses of 0.9 mg/kg i.p. or 5 mg/kg s.c. Tolerance began after a single injection and was fully developed after as few as four injections of 5 mg/kg of LPS delivered s.c. The concentration of circulating LPS 5 h after a single parenteral injection was less in LPS-tolerant mice than naïve controls, suggesting that tolerance may result from a more efficient clearance of LPS from the circulation. Injected i.t., LPS also induced hyperalgesia, however, tolerance did not develop to multiple injections by this route. There was no cross-tolerance between s.c. and i.t. injections of LPS. These data indicate that decreases in grip force are a sensitive measure of LPS-induced movement-evoked hyperalgesia and that tolerance develops to parenteral but not central hyperalgesic effects of LPS.

Is female predominance in irritable bowel syndrome related to fibromyalgia?

Irritable bowel syndrome (IBS) and fibromyalgia (FM) are common functional diseases in adult women. The aim of this study was to investigate whether female predominance in IBS is related to FM. Fifty patients with IBS and 50 healthy controls were enrolled. All participants answered questionnaires including personal and medical history. In addition, psychiatric interviews were conducted. Patients were divided into two groups according to the coexistence of FM ( IBS+FM or IBS only). The data obtained from patients with or without FM and the control group were compared. There was a significant female predominance in patients with IBS+FM (83.4%, F:M=5:1), but IBS-only patients consisted mainly of males (59.4%, F:M=2:3) ( P<0.01). Comparison of IBS+FM and IBS-only patients showed no significant difference in depression and anxiety status. However, both anxiety and depression scores were found to be higher in female IBS patients than their male counterparts ( P<0.01 and P<0.05, respectively). Our findings suggest that the female predominance in IBS patients may result from coexisting FM.

The epidemiology of chronic generalized musculoskeletal pain

Chronic widespread musculoskeletal pain has been subjected to several epidemiological studies during the last decade. According to these, approximately 10% of the general population report such complaints, clearly indicating chronic widespread musculoskeletal pain as a major health problem in the Western world. Almost unanimously, all studies found higher rates of such complaints among women compared with men, but the mechanisms responsible for the skewed gender ratio remain unknown.Chronic widespread musculoskeletal pain is the clinical hallmark of fibromyalgia and has been the subject of numerous epidemiological studies. The prevalence of fibromyalgia is reportedly 3-5%, again with a significant female predominance. Although the aetiopathogenesis of both fibromyalgia and chronic widespread musculoskeletal pain without other features of fibromyalgia remains an enigma, there is a body of evidence suggesting psychological and sociocultural factors as important for contracting such pain syndromes.

Number of responses on a review of systems questionnaire predicts the diagnosis of functional gastrointestinal disorders

GOALS

We evaluated whether the number of positive responses on a review of systems questionnaire predicted the diagnosis of functional gastrointestinal (GI) disorders.

STUDY

New patients to the University of Michigan GI clinics fill out a standardized questionnaire that includes a comprehensive review of systems which lists 87 items under 11 headings. We determined the number of items circled on the review of systems from the first 100 new patients seen in GI clinic in the year 2000. After a mean of 14 months follow-up, the final diagnoses in these patients were compared with the number of items circled on the review of systems.

RESULTS

Completed questionnaires were available for review in 82/100 patients. Twenty-six patients were diagnosed with a functional GI disorder, 53 patients had a nonfunctional diagnosis, and 3 patients had no diagnosis determined. The mean number of items circled on the review of systems was 15.9 (SD = 11.2) for the functional GI group, compared with 5.9 (SD = 6.9) for the nonfunctional GI diagnosis group ( < 0.005). When the symptom headings were analyzed individually, the differences in general, gastroenterological, cardiovascular, urinary, neurological, eye, ear, nose and throat, and psychiatric symptoms were statistically significant.

CONCLUSIONS

Patients with functional GI disorders have a significantly greater number of GI and non-GI symptoms on review of systems. If seven positive symptoms is used as a threshold, the standardized review of systems questionnaire had a sensitivity of 92% and specificity of 80% in detecting patients with functional GI disorders.

Gastrointestinal perception: pathophysiological implications

Physiological gut stimuli during the digestive process are not normally perceived. However, gut stimuli activate a variety of afferent pathways and in some circumstances may induce conscious sensations. Experimental evidence gathered during the past decade suggests that patients with functional gut disorders and unexplained abdominal symptoms may have a sensory dysfunction of the gut, so that physiological stimuli would induce symptoms. Assessment of visceral sensitivity is still poorly developed, but in analogy to somatosensory testing, differential stimulation of visceral afferents may be achieved by a combination of stimulation techniques, which may help to characterize sensory dysfunctions. Visceral afferent input is modulated by a series of mechanisms at different levels of the brain gut axis, and conceivably, a dysfunction of these regulatory mechanisms could cause hyperalgesia. The sensory dysfunction in functional patients seems associated to altered reflex activity, and both mechanisms may interact to produce the symptoms. Evidence of a gut sensory-reflex dysfunction as a common pathophysiological mechanism in different functional gastrointestinal disorders, would suggest that they are different forms of the same process, and that the clinical manifestations depend on the specific pathways affected.

Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications?

BACKGROUND & AIMS

Comorbid or extraintestinal symptoms occur frequently with irritable bowel syndrome and account for up to three fourths of excess health care visits. This challenges the assumption that irritable bowel is a distinct disorder. The aims of this study were to (1) assess comorbidity in 3 areas: gastrointestinal disorders, psychiatric disorders, and nongastrointestinal somatic disorders; and (2) evaluate explanatory hypotheses.

METHODS

The scientific literature since 1966 in all languages cited in Medline was systematically reviewed.

RESULTS

Comorbidity with other functional gastrointestinal disorders is high and may be caused by shared pathophysiological mechanisms such as visceral hypersensitivity. Psychiatric disorders, especially major depression, anxiety, and somatoform disorders, occur in up to 94%. The nongastrointestinal nonpsychiatric disorders with the best-documented association are fibromyalgia (median of 49% have IBS), chronic fatigue syndrome (51%), temporomandibular joint disorder (64%), and chronic pelvic pain (50%).

CONCLUSIONS

Multivariate statistical analyses suggest that these are distinct disorders and not manifestations of a common somatization disorder, but their strong comorbidity suggests a common feature important to their expression, which is most likely psychological. Some models explain the comorbidity of irritable bowel with other disorders by suggesting that each disorder is the manifestation of varying combinations of interacting physiological and psychological factors. An alternative hypothesis is that the irritable bowel diagnosis is applied to a heterogeneous group of patients, some of whom have a predominantly psychological etiology, whereas others have a predominantly biological etiology, and that the presence of multiple comorbid disorders is a marker for psychological influences on etiology.

Quality of life in irritable bowel syndrome

Quality-of-life (QOL) assessment is becoming increasingly important in the evaluation of the impact of disease and the effect of therapy. This is particularly so forirritable bowel syndrome (IBS) where there is often a tendency for a chronic clinical course, but with no associated mortality. Instruments used to study quality of life may be generic or disease specific, and care needs to be taken to ensure that the instrument used has been adequately validated for the purpose intended. Several disease-specific instruments [Irritable Bowel Syndrome Quality of Life (IBS-QOL, IBSQOL) and Functional Digestive Disorders Quality of Life (FDDQL)], in addition to generic measures, are now available for use in IBS. Quality of life in patients with IBS is surprisingly poor, particularly in the population seeking healthcare, where it can be compared with conditions which carry a high mortality, such as ischaemic heart disease, heart failure and diabetes mellitus. Pain severity appears to be an important factor in determining quality of life in IBS, although bowel disturbance and psychological difficulties are also likely to be important. There is limited data on the effect of treatment of IBS on quality of life. Improvement has been reported with dietry modification, drug treatments and hypnotherapy. It is likely that, in the future, QOL measures will become increasingly used as secondary end-points in therapeutic trials in IBS.