Prevalence of functional dyspepsia and its subgroups in patients with eating disorders

Clinical characterization of Co-morbid autoimmune disease and eating disorders: a retrospective chart review

Research suggests a link between autoimmune illnesses (AI) and eating disorders (ED). We retrospectively reviewed charts of adolescent patients presenting for eating disorder treatment. We compared the presentation and treatment course for those with an ED and comorbid AI [with (GI-AI, N = 59) or without (non-GI, N = 21) gastrointestinal inflammation] with matched ED-only cases. The sample was overwhelmingly female, with an average age of 15.40. Weight gain trajectories differed across groups, with similar rates of weight gain between controls and non GI-AI cases and with a lower rate of weight gain for individuals with comorbid GI-AI. Over half (56%) of patients reported an AI diagnosis prior to ED; 38% reported an AI diagnosis following ED, and 6% reported ED and AI simultaneous diagnosis. On presentation, ED-only controls had higher rates of comorbid anxiety than cases in either AI group, while those with non-GI AI were more likely to report depression. Mean total GI symptoms, % goal weight at presentation, vital sign instability, and markers of refeeding syndrome did not differ across groups. Health care professionals treating patients with either condition should have a low threshold for asking additional questions to identify the presence of the other condition.

[Food Intolerance]

The term food intolerance has been used non-specifically to define a wide range of disorders related to food intake. Recently, the use of the term "non-immunological adverse reactions to foods" (RANIAs) was recommended as a more correct clinical definition. The pathophysiological mechanisms can be diverse, sometimes unknown, and there are no validated diagnostic tests, making it difficult to obtain accurate data. The clinical manifestations of non-immunological adverse reactions to foods affect more than one organ or system; and gastrointestinal symptoms (pain, abdominal distension, flatulence, and diarrhea) are the most common. Non-immunological adverse reactions to foods are divided into independent and dependent on host factors. Foods may contain chemicals with pharmacological activity and be present naturally, such as vasoactive amines (histamine) and salicylates, or added for preservation, to improve appearance or flavor (monosodium glutamate, tartrazine, sulfites, and benzoates). In some cases, these types of reactions may be like to hypersensitivity reactions. Concomitant alcohol consumption may worsen symptoms by inhibiting histamine breakdown and increasing intestinal permeability. In patients diagnosed with non-immunological adverse reactions to foods, it is important to rule out some psychological problems: aversions or eating disorders.

[Differential diagnosis in food allergy]

It is important to establish the differential diagnosis of food allergy with other disorders, for example: toxic reactions that occur in any person exposed to a sufficient amount of some allergen, and non-toxic reactions that depend on individual susceptibility (food allergy or intolerance). The differential diagnosis is decisive to establish the appropriate treatment. Food intolerance involves adverse reactions to foods without any immunological response involved, and commonly manifests with gastrointestinal symptoms (malaise, abdominal pain or diarrhea). Food allergy is an exaggerated reaction of the immune system, often mediated by IgE, that can trigger serious symptoms (hives, inflammation, respiratory distress, even anaphylaxis). The complex thing is because the symptoms sometimes overlap. To establish an accurate diagnosis, exhaustive clinical evaluation, laboratory tests and, in some cases, controlled provocation tests are required. It is important to understand these distinctions, because treatment and management vary significantly. Food intolerance involves the elimination or reduction of the food that triggers the allergic reaction and requires rigorous measures (complete avoidance of the allergen and availability of epinephrine in cases of severe reactions).

Preliminary data that psychological treatment and baseline anxiety are associated with a decrease in postprandial fullness and early satiation for individuals with bulimia nervosa and related other specified feeding or eating disorder

OBJECTIVE

Gastrointestinal symptoms, particularly postprandial fullness, are frequently reported in eating disorders. Limited data exist evaluating how these symptoms change in response to outpatient psychological treatment. The current study sought to describe the course of postprandial fullness and early satiation across psychological treatment for adults with bulimia nervosa and related other specified feeding or eating disorders and to test if anxiety moderates treatment response.

METHODS

Secondary data analysis was conducted on questionnaire data provided by 30 individuals (80% white, M(SD)age  = 31.43(13.44) years; 90% female) throughout treatment and six-month follow-up in a pilot trial comparing mindfulness and acceptance-based treatment with cognitive-behavioral therapy for bulimia nervosa. Participants completed items from the Rome IV Diagnostic Questionnaire for Adult Functional Gastrointestinal Disorders and the State Trait Anxiety Inventory.

RESULTS

Postprandial fullness and early satiation both significantly decreased over time (ds = 1.23-1.54; p's < .001). Baseline trait anxiety moderated this outcome, such that greater decreases were observed for those with higher baseline anxiety (p = .02).

DISCUSSION

Results extend prior work in inpatient samples by providing preliminary data that postprandial fullness and early satiation decrease with outpatient psychological treatment for bulimia nervosa. Baseline anxiety moderated this effect for postprandial fullness. Future work should replicate findings in a larger sample and test anxiety as a mechanism underlying postprandial fullness in eating disorders.

PUBLIC SIGNIFICANCE

The current study found that common gastrointestinal symptoms (postprandial fullness and early satiation) decrease over the course of outpatient psychotherapy for adults with full and subthreshold bulimia nervosa. Postprandial fullness decreased more across time for those high in anxiety.

Microbiota in anorexia nervosa: potential for treatment

Anorexia nervosa (AN) is characterised by the restriction of energy intake in relation to energy needs and a significantly lowered body weight than normally expected, coupled with an intense fear of gaining weight. Treatment of AN is currently based on psychological and refeeding approaches, but their efficacy remains limited since 40% of patients after 10 years of medical care still present symptoms of AN. The intestine hosts a large community of microorganisms, called the "microbiota", which live in symbiosis with the human host. The gut microbiota of a healthy human is dominated by bacteria from two phyla: Firmicutes and, majorly, Bacteroidetes. However, the proportion in their representation differs on an individual basis and depends on many external factors including medical treatment, geographical location and hereditary, immunological and lifestyle factors. Drastic changes in dietary intake may profoundly impact the composition of the gut microbiota, and the resulting dysbiosis may play a part in the onset and/or maintenance of comorbidities associated with AN, such as gastrointestinal disorders, anxiety and depression, as well as appetite dysregulation. Furthermore, studies have reported the presence of atypical intestinal microbial composition in patients with AN compared with healthy normal-weight controls. This review addresses the current knowledge about the role of the gut microbiota in the pathogenesis and treatment of AN. The review also focuses on the bidirectional interaction between the gastrointestinal tract and the central nervous system (microbiota-gut-brain axis), considering the potential use of the gut microbiota manipulation in the prevention and treatment of AN.

Challenges of considering both extremities of the weight status spectrum to better understand obesity: insights from the NUTRILEAN project in constitutionally thin individuals

BACKGROUND/OBJECTIVES

While the physiology of obesity has been so extensively investigated to date, only an extremely small number of studies (less than 50) have focused on the other extremity of the weight spectrum: constitutional thinness. Yet, this important state of underweight in the absence of any eating disorders provides a mirror model of obesity that might be particularly insightful in understanding obesity. Nevertheless, important methodological and recruitment-related issues appear when it comes to this complex constitutionally thin phenotype, as experienced by our research group with the realization of the ongoing NUTRILEAN clinical trial. To face this challenge, the present paper aims at identifying, analyzing, and discussing the quality of such recruitment processes in publications about constitutional thinness.

METHODS

In this order, a group of experts collectively created a new grading system to assess the level of rigour and quality achieved by each study based on different criteria.

RESULTS

The main results were that (i) metabolic-related biasing criteria were poorly observed despite being crucial, (ii) recruitment processes were not detailed enough and with sufficient explicitness, and (iii) recruiting among already identified patients would be associated with both higher sample sizes and better scores of quality.

CONCLUSIONS

The present work encourages investigators to adopt a high level of rigour despite the complexity and duration of recruitment processes for this specific population, and readers to pay close attention to the quality of recruitment when interpreting the data. To better understand obesity and its physiological adaptations, it seems essential not only to compare it to normal-weight conditions, but also to the other extremity of the weight status spectrum represented by constitutional thinness.

Gut-Brain Interaction Disorders and Anorexia Nervosa: Psychopathological Asset, Disgust, and Gastrointestinal Symptoms

BACKGROUND

Gastrointestinal (GI) symptoms are very common in subjects with eating disorders (EDs). This study aimed to (a) investigate the prevalence of gut-brain interaction disorders (DGBIs) in anorexia nervosa (AN) patients, according to ROME IV criteria; and (b) explore AN psychopathological assets and disgust that might impact GI symptoms.

METHODS

Thirty-eight female patients consecutively diagnosed with untreated AN (age 19.32 ± 5.59) in an outpatient clinic devoted to EDs underwent Eating Disorder Inventory-3 (EDI-3), Hospital Anxiety and Depression Scale (HADS), Social Phobia Anxiety Scale (SPAS), Body Uneasiness Test (BUT), and Disgust Scale (DS) questionnaires. The presence of DGBIs was evaluated and GI symptoms were assessed using a standardized intensity-frequency questionnaire.

RESULTS

A total of 94.7% of our sample met the diagnostic criteria for functional dyspepsia (FD), of which 88.8% presented the postprandial distress syndrome (PDS) subtype and 41.6% presented the epigastric pain syndrome (EPS) subtype. In addition, 52.6% of the sample met the diagnostic criteria for irritable bowel syndrome (IBS), while for functional constipation (FC), prevalence reached 7.9%. All participants presented a pathological score on the disgust scale. Significant correlations were found between several GI symptoms and psychopathological asset and disgust.

CONCLUSIONS

AN is a multifactorial disorder. It is necessary to implement studies with an integrated approach, taking into account DGBIs, as well as to monitor the emotional-cognitive structure that acts as a factor in maintaining the disorder.

History of trying exclusion diets and association with avoidant/restrictive food intake disorder in neurogastroenterology patients: A retrospective chart review

BACKGROUND

Exclusion diets for gastrointestinal symptom management have been hypothesized to be a risk factor for avoidant/restrictive food intake disorder (ARFID; a non-body image-based eating disorder). In a retrospective study of pediatric and adult neurogastroenterology patients, we aimed to (1) identify the prevalence and characteristics of an exclusion diet history and (2) evaluate if an exclusion diet history was concurrently associated with the presence of ARFID symptoms.

METHODS

We conducted a chart review of 539 consecutive referrals (ages 6-90, 69% female) to adult (n = 410; January-December 2016) and pediatric (n = 129; January 2016-December 2018) neurogastroenterology clinics. Masked coders (n = 4) retrospectively applied DSM-5 criteria for ARFID and a separate coder assessed documentation of exclusion diet history. We excluded patients with no documentation of diet in the chart (n = 35) or who were not orally fed (n = 9).

RESULTS

Of 495 patients included, 194 (39%) had an exclusion diet history, and 118 (24%) had symptoms of ARFID. Of reported diets, dairy-free was the most frequent (45%), followed by gluten-free (36%). Where documented, exclusion diets were self-initiated by patients/parents in 66% of cases, and recommended by gastroenterology providers in 30%. Exclusion diet history was significantly associated with the presence of ARFID symptoms (OR = 3.12[95% CI 1.92-5.14], p < 0.001).

CONCLUSIONS

History of following an exclusion diet was common and was most often patient-initiated among pediatric and adult neurogastroenterology patients. As patients with self-reported exclusion diet history were over three times as likely to have ARFID symptoms, providers should be cognizant of this potential association when considering dietary interventions.

The intersection between eating disorders and gastrointestinal disorders: a narrative review and practical guide

Eating disorders include a spectrum of disordered thinking patterns and behaviours around eating. There is increasing recognition of the bi-directional relationship between eating disorders and gastrointestinal disease. Gastrointestinal symptoms and structural issues might arise from eating disorders, and gastrointestinal disease might be a risk factor for eating disorder development. Cross-sectional research suggests that individuals with eating disorders are disproportionately represented among people seeking care for gastrointestinal symptoms, with avoidant-restrictive food intake disorder in particular garnering attention for high rates among individuals with functional gastrointestinal disorders. This Review aims to describe the research to date on the relationship between gastrointestinal disorders and eating disorders, highlight research gaps, and provide brief, practical guidance for the gastroenterology provider in detecting, potentially preventing, and treating gastrointestinal symptoms in eating disorders.

Assessment and management of disorders of gut-brain interaction in patients with eating disorders

Disorders of gut-brain interaction (DBGI), also known as functional gastrointestinal disorders, are common in individuals with eating disorders, and may precede or perpetuate disordered eating. Understanding the pathophysiology of common gastrointestinal symptoms in DGBI can be important for the care of many patients with eating disorders. In this review, we summarize the literature to date on the complex relationship between DBGI and eating disorders and provide guidance on the assessment and management of the most common symptoms of DBGI by anatomic region: esophageal symptoms (globus and functional dysphagia), gastroduodenal symptoms (functional dyspepsia and nausea), and bowel symptoms (abdominal pain, bloating and constipation).

Unrecognized Functional Dyspepsia Among Those With Refractory Chronic Constipation: Analysis of a Tertiary Cohort

BACKGROUND AND AIMS

Patients with functional constipation (FC) are frequently dissatisfied with current treatment options which may be related to persistent, unaddressed symptoms. We hypothesized that refractory FC may actually represent functional dyspepsia (FD) overlap. Among adults presenting with refractory FC, we sought to (1) identify the prevalence of concurrent FD and (2) identify the symptoms and presentations most frequently associated with concurrent FD and FC.

METHODS

We assembled a retrospective cohort of 308 patients sequentially presenting to a tertiary neurogastroenterology clinic for evaluation of refractory FC, defined as having failed first-line therapy. Using Rome IV criteria, trained raters identified the presence and characteristics of concurrent FD in addition to demographics, presenting complaints, and psychological comorbidities.

RESULTS

Among 308 patients presenting with refractory FC (average of 3.0 ± 2.3 constipation treatments tried unsuccessfully), 119 (38.6%) had concurrent FD. Aside from meeting FD criteria, the presence of concurrent FD was associated with patient complaints of esophageal symptoms (Odds ratio = 3.1; 95% confidence interval, 1.80-5.42) and bloating and distension (Odds ratio = 2.67; 95% confidence interval, 1.50-4.89). Patients with concurrent FD were more likely to have a history of an eating disorder (21.0% vs 12.7%) and were also more likely to present with current avoidant/restrictive food intake disorder-related symptoms (31.9% vs 21.7%).

CONCLUSION

Almost 40% of adult patients referred for refractory FC met criteria for concurrent FD in a tertiary-level cohort. The presence of both FC and FD was associated with greater esophageal symptoms and bloating/distention. Determining presence of concurrent FD may represent an additional therapeutic opportunity in refractory patients who may attribute symptoms to FC alone.

Gastrointestinal symptoms, gut microbiome, probiotics and prebiotics in anorexia nervosa: A review of mechanistic rationale and clinical evidence

Recent research has revealed the pivotal role that the gut microbiota might play in psychiatric disorders. In anorexia nervosa (AN), the gut microbiota may be involved in pathophysiology as well as in the gastrointestinal (GI) symptoms commonly experienced. This review collates evidence for the potential role of gut microbiota in AN, including modulation of the immune system, the gut-brain axis and GI function. We examined studies comparing gut microbiota in AN with healthy controls as well as those looking at modifications in gut microbiota with nutritional treatment. Changes in energy intake and nutritional composition influence gut microbiota and may play a role in the evolution of the gut microbial picture in AN. Additionally, some evidence indicates that pre-morbid gut microbiota may influence risk of developing AN. There appear to be similarities in gut microbial composition, mechanisms of interaction and GI symptoms experienced in AN and other GI disorders such as inflammatory bowel disease and functional GI disorders. Probiotics and prebiotics have been studied in these disorders showing therapeutic effects of probiotics in some cases. Additionally, some evidence exists for the therapeutic benefits of probiotics in depression and anxiety, commonly seen as co-morbidities in AN. Moreover, preliminary evidence for the use of probiotics in AN has shown positive effects on immune modulation. Based on these findings, we discuss the potential therapeutic role for probiotics in ameliorating symptoms in AN.

Associations among perceived taste and smell sensitivity, gastrointestinal symptoms, and restrictive eating in a community sample of adults

Restrictive eating is associated with several poor health outcomes. Exteroceptive sensory modalities, including taste and smell, are employed while eating and disturbances in exteroceptive sensitivity may influence eating behavior. Meal-related gastrointestinal disturbances, such as early satiety and postprandial fullness, are well-documented in eating disorders and may influence eating behavior. This study examined the relationships of perceived sensitivity to taste or smell and gastrointestinal symptoms with restrictive eating, and potential interactions between gastrointestinal symptoms and perceived sensitivity to taste or smell. Adults aged 18-65 were recruited via ResearchMatch.org (N = 420) and completed questionnaires assessing restrictive eating, perceived sensitivity to taste and smell, and gastrointestinal symptom severity. There was a weak relationship between restrictive eating and perceived sensitivity to taste (r = -0.115, p = .022) and smell (r = -0.101, p = .039). There was a strong relationship between gastrointestinal symptom severity and restrictive eating (r = 0.583, p < .001). Gastrointestinal symptom severity moderated the relationship between perceived sensitivity to taste and restrictive eating, such that this relationship was strongest at lower levels of gastrointestinal symptom severity (Estimate = -0.136, p = .014). There was no observed interaction between perceived sensitivity to smell and gastrointestinal symptoms (Estimate = 0.001, p = .156). Results indicate that increased perceived sensitivity to taste, smell, and gastrointestinal symptom severity were each associated with greater restrictive eating. The relationship between perceived sensitivity to taste and restrictive eating is strongest at lower gastrointestinal symptom severity. Future research should examine whether tailoring treatments for individuals who present with elevated perceived sensitivity to taste or smell, gastrointestinal symptoms, or both is effective in reducing restrictive eating.

Gastrointestinal complaints in patients with anorexia nervosa in the timecourse of inpatient treatment

BACKGROUND

In patients with anorexia nervosa (AN), gastrointestinal (GI) symptoms are common and usually improve during or after nutritional rehabilitation. It is unclear when exactly GI symptoms change in the timecourse of treatment and to which extent. In this study, we analyzed the timecourse of GI symptoms and their relation to disease-specific, demographic, anthropometric, and psychological factors in inpatients with AN.

METHODS

In weekly intervals, the Gastrointestinal Symptom Rating Scale (GSRS) was completed, and body weight was measured over a mean of 9.5 weeks in inpatients with AN. A total of four self-report questionnaires assessing psychological factors were completed before and after inpatient treatment. Data from 38 inpatients with AN were analyzed using mixed linear models.

RESULTS

Abdominal pain and constipation improved significantly in the timecourse with 0.085 (p = 0.002) and 0.101 (p = 0.004) points per week on the GSRS and were predicted to normalize after 13 (p = 0.002) and 17 (p = 0.004) weeks, respectively. Total GI symptoms tended to normalize after 25 weeks (p = 0.079). Indigestion (borborygmus, abdominal distension, eructation, flatulence) was the most severely pathological symptom at admission and did not improve significantly (p = 0.197). Diarrhea and reflux were, on average, not pathological at admission and remained stable during treatment. In addition to treatment time, the strongest predictors were ED pathology at admission for the development of abdominal pain, constipation, reflux, and total GI symptoms; stress for the development of constipation and total GI symptoms; and depression for constipation.

CONCLUSIONS

Informing patients with AN about the course of GI symptoms and their improvement during weight rehabilitation may help support compliance during treatment.

Is constitutional thinness really different from anorexia nervosa? A systematic review and meta-analysis

A growing interest in constitutional thinness has been observed in the last decades, but the publications however cover various fields of study and report equivocal results. The present work systematically reviewed any clinical trials enrolling participants with constitutional thinness and bibliographic researches were performed between December 2018 and June 2020. From a total of 1 212 records initially identified, 402 records were removed as duplicates, 381 articles were excluded based on titles or abstracts and 390 references were excluded against eligibility criteria. Thirty-nine articles were finally included in the systematic review. The results showed that constitutionally thin people seem to be underweight but not underfat and present a fat-free mass as blunted as anorexic patients, despite being a little less underweight. The meta-analysis confirmed that constitutionally thin people present normal energy intake and revealed a trend toward a higher resting metabolic rate to fat-free mass ratio which suggests a highly metabolic fat-free mass. Contrary to patients with anorexia nervosa, constitutionally thin people present normal levels of insulin-like growth factor 1, estradiol, growth hormone, follicle-stimulating hormone, and luteinizing hormone. An intermediate level of leptin between anorexic and control participants was however observed in constitutional thinness. While all the studies reported normal free triiodothyronine and cortisol levels in constitutionally thin individuals, a higher fasting free triiodothyronine level (p = 0.033) and a lower 24 h mean cortisol level (p = 0.005) were observed for the first time. Present results give robust evidence that constitutionally thin people present an atypical phenotype highly different from anorexia nervosa.

Underweight but not underfat: is fat-free mass a key factor in constitutionally thin women?

Constitutional thinness is defined as a state of severe underweight with a body mass index similar to anorectic patients (BMI < 17.5 kg/m²), in the absence of any eating disorders or other obvious disruptive factors impacting energy balance. The analysis of body composition is essential as a first approach to characterize constitutional thinness and might help identify new discriminating differences between constitutional thinness and anorexia nervosa. A meta-analytical approach was performed to compare body composition of constitutionally thin, anorectic, and normal-weight subjects from all available studies found in the literature. The statistical analysis was carried out on large sample sizes: n = 205 females with constitutional thinness, n = 228 normal-weight control females, and n = 258 females with anorexia nervosa. Despite being as underweight as anorectic patients, constitutionally thin participants paradoxically presented higher percentages of fat mass than anorectic patients (18.9% vs. 11.4%, respectively; SMD [95% CI]: 1.62 [1.16; 2.08]), even found in the normal healthy ranges. Constitutionally thin people, however, display as low fat-free mass as anorectic patients. These observations question the use of high-fat diets in this population and bring new insights for nutrition and/or training strategies directed toward muscle mass gain. The present results give new elements to further distinguish constitutional thinness from anorexia nervosa and reinforce the need to better investigate the atypical phenotype of constitutional thinness.

Anorexia nervosa and the gastrointestinal tract

Anorexia nervosa (AN) is a complex eating disorder associated with a high morbidity and mortality, however, there is a lack of dedicated training for healthcare professionals outside of mental health specialities. There has been a reported increase in acute admissions of patients with AN, which may have been precipitated by the isolation and loss of support networks created by the COVID-19 pandemic. The purpose of this review is to highlight that AN can present with a wide variety of signs and symptoms relating to both the hollow and solid organs of the gastrointestinal (GI) tract some of which may even be life threatening. The overlap of symptoms with several other functional and organic GI diseases makes diagnosis challenging. Gastroenterologists and allied healthcare professionals need to be aware of the wide array of possible GI manifestations not only to help rationalise investigations but to also facilitate early involvement of the relevant multidisciplinary teams. Many of the GI manifestations of AN can be reversed with careful nutritional therapy under the guidance of nutrition support teams.

Disorders of the brain-gut interaction and eating disorders

BACKGROUND

Eating disorders (ED) involve both the nervous system and the gastrointestinal tract. A similar double involvement is also found in disorders of the brain-gut interaction (DGBI) and symptoms are sometimes similar.

AIM

To find out where there is an association and a cause-effect relationship, we looked for the comorbidity of DGBI and ED.

METHODS

A systematic review was undertaken. A literature search was performed. Inclusion criteria for the articles retained for analysis were: Observational cohort population-based or hospital-based and case-control studies, examining the relationship between DGBI and ED. Exclusion criteria were: Studies written in other languages than English, abstracts, conference presentations, letters to the Editor and editorials. Selected papers by two independent investigators were critically evaluated and included in this review.

RESULTS

We found 29 articles analyzing the relation between DGBI and ED comprising 13 articles on gastroparesis, 5 articles on functional dyspepsia, 7 articles about functional constipation and 4 articles on irritable bowel syndrome.

CONCLUSION

There is no evidence for a cause-effect relationship between DGBI and ED. Their common symptomatology requires correct identification and a tailored therapy of each disorder.

Irritable bowel syndrome and functional dyspepsia in patients with eating disorders - a systematic review

OBJECTIVES

The prevalence of eating disorders is rising worldwide. The low body weight in anorexia nervosa as well as the increase in body mass index due to binge eating disorder are contributing to a strikingly high morbidity and mortality. In a similar pattern, the prevalence and burden of the disease of functional gastrointestinal disorders such as functional dyspepsia and irritable bowel syndrome is increasing. As gastrointestinal complaints are commonly reported by patients with eating disorders, the question arose whether there is a relationship between eating disorders and functional gastrointestinal disorders.

METHODS

To address the need to better understand the interplay between eating disorders and functional gastrointestinal disorders as well as factors that might influence this connection, the data bases Medline, Web of Science and Embase were systematically searched.

RESULTS

After removal of duplicates the search yielded 388 studies which were screened manually. As a result, 36 publications were selected for inclusion in this systematic review.

CONCLUSION

The occurrence of functional gastrointestinal disorders like irritable bowel syndrome and functional dyspepsia in patients with eating disorders is considerably high and often associated with psychological, hormonal and functional alterations. In the future, further research addressing the underlying mechanisms accounting for this relationship is required.

Disorders of gut-brain interaction common among outpatients with eating disorders including avoidant/restrictive food intake disorder

OBJECTIVE

Little research exists on Rome IV disorders of gut-brain interaction (DGBI; formerly called functional gastrointestinal disorders) in outpatients with eating disorders (EDs). These data are particularly lacking for avoidant/restrictive food intake disorder (ARFID), which shares core features with DGBI. We aimed to identify the frequency and nature of DGBI symptoms among outpatients with EDs.

METHOD

Consecutively referred pediatric and adult patients diagnosed with an ED (n = 168, 71% female, ages 8-76 years) in our tertiary care ED program between March 2017 and July 2019 completed a modified Rome IV Questionnaire for DGBI and psychopathology measure battery.

RESULTS

The majority (n = 122, 72%) of participants reported at least one bothersome gastrointestinal symptom. Sixty-six (39%) met criteria for a DBGI, most frequently functional dyspepsia-post-prandial distress syndrome subtype (31%). DGBI were surprisingly less frequent among patients with ARFID (30%) versus EDs that are associated with shape or weight concerns (45%; X² [1] = 3.61, p = .058, Cramer's V = .147). Among those with ARFID, DGBI presence was associated with the fear of aversive consequences prototype and multiple comorbid prototype presence.

DISCUSSION

We demonstrated notable overlap between DGBI and EDs, particularly post-prandial distress symptoms. Further research is needed to examine if gastrointestinal symptoms predict or are a result of greater ED pathology, including ARFID prototypes.

The intersect of gastrointestinal symptoms and malnutrition associated with anorexia nervosa and avoidant/restrictive food intake disorder: Functional or pathophysiologic?-A systematic review

OBJECTIVE

Although multiple pathophysiologic changes develop within the gastrointestinal (GI) system in the setting of malnutrition, the etiology of the reported multitude of symptoms in those with anorexia nervosa and avoidant restrictive intake disorder, as well as their contribution toward disordered eating, remain poorly understood. This systematic review seeks to better understand how these physiologic changes of malnutrition of the esophagus, stomach, intestines, and pancreas contribute toward the reported GI symptoms, as well as better understand how celiac disease, inflammatory bowel disease, pelvic floor dysfunction, and Ehlers-Danlos syndrome contribute toward disordered eating.

METHODS

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used to structure and complete the review.

RESULTS

A total of 146 articles were used for the review. The majority of studies were observational or case reports/case series.

DISCUSSION

Pathophysiologic changes of the esophagus, stomach, and intestines develop with malnutrition, although these changes do not consistently correlate with expressed GI symptoms in patients with restrictive eating disorders. Celiac disease and inflammatory bowel disease also contribute to disordered eating through the associated somatic GI complaints, while pelvic floor dysfunction and Ehlers-Danlos syndrome contribute through both somatic symptoms and functional symptoms. Indeed, functional GI symptoms remain problematic during the course of treatment, and further research is required to better understand the extent to which these symptoms are functional in nature and remit or remain as treatment ensues.

Food Allergy and Intolerance: A Narrative Review on Nutritional Concerns

Adverse food reactions include immune-mediated food allergies and non-immune-mediated intolerances. However, this distinction and the involvement of different pathogenetic mechanisms are often confused. Furthermore, there is a discrepancy between the perceived vs. actual prevalence of immune-mediated food allergies and non-immune reactions to food that are extremely common. The risk of an inappropriate approach to their correct identification can lead to inappropriate diets with severe nutritional deficiencies. This narrative review provides an outline of the pathophysiologic and clinical features of immune and non-immune adverse reactions to food-along with general diagnostic and therapeutic strategies. Special emphasis is placed on specific nutritional concerns for each of these conditions from the combined point of view of gastroenterology and immunology, in an attempt to offer a useful tool to practicing physicians in discriminating these diverging disease entities and planning their correct management. We conclude that a correct diagnostic approach and dietary control of both immune- and non-immune-mediated food-induced diseases might minimize the nutritional gaps in these patients, thus helping to improve their quality of life and reduce the economic costs of their management.

Impaired decision-making under risk in patients with functional dyspepsia

INTRODUCTION

The cognitive processing in patients with functional dyspepsia (FD) has not been well established. Decision-making is an important component of cognitive function. Most brain regions involved in decision-making are abnormal in FD patients. This study aimed to investigate the decision-making under ambiguity and risk in FD patients.

METHODS

We recruited 40 FD patients meeting Rome III criteria and 40 healthy controls (HCs) matched for age, sex, marital status, and education level. The Hamilton Anxiety Scale (HAMA) and the 17-item Hamilton Depression Scale (HAMD-17) were used to evaluate their anxiety and depression emotions. The Iowa Gambling Task (IGT) and Game of Dice Task (GDT) were used to evaluate decision-making under ambiguity and risk, respectively. Helicobacter pylori status, disease duration, dyspeptic symptom score, and the Nepean Dyspepsia Life Quality Index (NDLQI) were obtained from all patients.

RESULTS

In IGT, FD patients had a lower total net score, chose more adverse choices, and showed a slower response to change their behavior than HCs. However, there was no significant difference in the net score of the first 2 blocks between the two groups. In GDT, FD patients had a lower total net score, higher risk score, and lower use of negative feedback than HCs. In addition, FD patients showed better GDT performance than those without early satiation.

CONCLUSIONS

FD patients showed impaired decision-making under risk. The deficiency might be related to dyspeptic symptoms of FD patients.

Eating disorders in patients with irritable bowel syndrome

INTRODUCTION

Eating disorders (ED) constitute an important group of conditions that commonly occur in adolescents. Gastrointestinal complaints are frequently reported in ED patients. Few studies assessed the association of irritable bowel syndrome (IBS) with ED. The aim of the current study is to determine the prevalence of ED in a group of IBS patients and compare it with a healthy control group and assess the relationship of IBS sub-types, it's duration and severity with ED.

PATIENTS AND METHODS

100 IBS patients diagnosed according to the Rome-IV criteria and a control group consisting of 100 healthy adults, between 18 and 65 years old, were enrolled in this study. Sub-type, duration and severity of IBS were determined. All participants were requested to fill questionnaires to screen for ED.

RESULTS

200 subjects participated in the study. 118(59%) were female and 92(41%) were male. The Eating Attitudes Test (EAT) score was significantly higher in the IBS group (Odds ratio: 5.3 CI 95%:4.3-9.3; p<0.001). The number of subjects with EAT score >30 was significantly higher in the IBS group (p<0.001). EAT scores were significantly higher in female IBS patients and in younger patients (p=0.013 and p=0.043; respectively). No significant association between the IBS sub-type and EAT score was found (p>0.05). However, IBS severity and duration positively correlated with EAT scores.

DISCUSSION

ED should be considered in the management of IBS patients. Since many psychological factors can exacerbate IBS symptoms a multidisciplinary approach consisting of medical and behavioral therapeutic modalities should be employed for a better management of these patients.

Definition and diagnosis of constitutional thinness: a systematic review

The existing literature about the definition and diagnostic criteria of constitutional thinness (CT) appears equivocal. The present work systematically reviewed the criteria used in the diagnosis of adult individuals with CT (PROSPERO registration number: CRD42019138236). Five electronic bibliographic databases were searched between December 2018 and November 2019: MEDLINE, Embase, CENTRAL (Cochrane Library), Google Scholar and Clinical Trials. Search terms were combined with Medical Subject Headings terms. The search strategy included any clinical trials that enrolled adults with CT. Studies were systematically excluded if the state of thinness was not due to a well-identified constitutional origin. From the 689 references after duplicate removal, 199 studies were excluded based on title and 164 based on abstract. According to the inclusion and exclusion criteria, 291 other studies were removed. Finally, thirty-five studies remained at the end of the process. The analysis of these studies showed high heterogeneity in the diagnostic criteria of CT. A real need emerged to adopt a common terminology and to systematically exclude potential non-constitutional origins of thinness such as eating disorders, associated pathology or over-exercising, with validated tools. Weight history, physiological menses and weight gain resistance are also important criteria to consider. The present systematic review revealed that our medical and scientific approaches of CT need to be harmonised in terms of terminology and diagnostic criteria. Although further studies are needed, we finally proposed recommendations and a decision tree to help in the recognition and diagnosis of CT.

Eating Disorders and Gastrointestinal Diseases

Eating disorders (ED) are frequently associated with a wide range of psychiatric or somatic comorbidities. The most relevant ED are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorders (BED). Patients with ED exhibit both upper and lower gastrointestinal (GI) symptoms. Evidence of alterations throughout the GI tract in ED will be analyzed given the role of the GI tract in food intake and its regulation. It remains a matter of debate whether GI disorders are inherent manifestations of ED or the results of malnutrition occurring from ED. Moreover, recent clinical studies have highlighted the growing role of intestinal microbiota in the pathogenesis of ED, making it possible to hypothesize a modulation of intestinal microbiota as a co-adjuvant to standard therapy. The aim of this review is to analyze the link between ED and GI diseases and to present, where known, the potential key factors underlying these conditions. Conclusions: The presence of GI disorders should be investigated in patients with ED. Screening for ED should also be encouraged in individuals seeking treatment for unexplained GI complaints to better address therapeutic issues that surround these difficult medical conditions.

Eating Disorders and Gastrointestinal Diseases

Eating disorders (ED) are frequently associated with a wide range of psychiatric or somatic comorbidities. The most relevant ED are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorders (BED). Patients with ED exhibit both upper and lower gastrointestinal (GI) symptoms. Evidence of alterations throughout the GI tract in ED will be analyzed given the role of the GI tract in food intake and its regulation. It remains a matter of debate whether GI disorders are inherent manifestations of ED or the results of malnutrition occurring from ED. Moreover, recent clinical studies have highlighted the growing role of intestinal microbiota in the pathogenesis of ED, making it possible to hypothesize a modulation of intestinal microbiota as a co-adjuvant to standard therapy. The aim of this review is to analyze the link between ED and GI diseases and to present, where known, the potential key factors underlying these conditions. Conclusions: The presence of GI disorders should be investigated in patients with ED. Screening for ED should also be encouraged in individuals seeking treatment for unexplained GI complaints to better address therapeutic issues that surround these difficult medical conditions.

The central mechanism of acupuncture treatment with a long-lasting effect for functional dyspepsia: study protocol for a randomized controlled trial

Background

The mechanism of the long-lasting effect and the relationship between the long-lasting effect and the deqi sensation, which is the key of achieving the acupuncture effect, has not been well investigated. This trial focuses on investigating the possible central mechanism of the long-lasting effect influenced by the deqi sensation.

Methods

A randomized controlled functional brain imaging trial is currently being conducted in Sichuan, China. In total 105 functional dyspepsia (FD) patients will be allocated into three groups: an acupuncture with deqi group, an acupuncture without deqi group, and a wait-list group. This trial will include a 2-week baseline period, a 4-week treatment period, and a 4-week follow-up period. During the 4-week treatment, patients in two acupuncture groups will receive 20 sessions of acupuncture treatment with or without deqi. The Nepean Dyspepsia Index (NDI) and the short form Leeds Dyspepsia Questionnaire (SF-LDQ) will be used to evaluate the clinical efficacy of acupuncture treatment at baseline, the end of treatment, and the end of the follow-up. Functional magnetic resonance imaging (fMRI) scans will be performed to detect cerebral functional changes in 25 patients in each group at three time points mentioned above. The clinical data and fMRI data will be analyzed, respectively. Correlation analysis will be conducted to investigate the relationship between cerebral functional changes and symptom improvement.

Discussion

The results of this trial will allow us to compare the changes of acupuncture therapeutic effect at three time points (the baseline vs. the end of treatment vs. the end of follow-up), and investigate the potential central mechanism of the long-lasting effect influenced by acupuncture with deqi. This trial aims to re-identify the long-lasting effect of acupuncture and investigate its central mechanism, and to further explore the central influence of deqi sensation on the long-lasting effect.

Trial registration

Chinese Clinical Trial Registry, IDF: ChiCTR-IOR-15006523. Registered on 5 June 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2742-0) contains supplementary material, which is available to authorized users.

Differential Diagnoses of Food-Related Gastrointestinal Symptoms in Patients with Anorexia Nervosa and Bulimia Nervosa: A Review of Literature

OBJECTIVES

The present review investigates the prevalence and medical causes of food-related gastrointestinal symptoms in eating disorder (ED) patients and recommends a diagnostic algorithm based on the current literature.

METHODS

A literature search was conducted, which included publications from January 2000 until January 2017 Results: Over 90% of ED patients suffer from food-related symptoms. There is no evidence for a higher prevalence of immunological or structural gastrointestinal disorders in ED patients compared to the healthy population. Most food-related symptoms in ED patients are likely to be functional.

CONCLUSIONS

Diagnostic work-up of food-related symptoms in ED patients needs to be based on clinical history. Only if timing and quality of symptoms point towards a disorder independent from the ED is a comprehensive diagnostic work-up necessary.

Functional dyspepsia

Functional dyspepsia is one of the most prevalent functional gastrointestinal disorders. Functional dyspepsia comprises three subtypes with presumed different pathophysiology and aetiology: postprandial distress syndrome (PDS), epigastric pain syndrome (EPS) and a subtype with overlapping PDS and EPS features. Functional dyspepsia symptoms can be caused by disturbed gastric motility (for example, inadequate fundic accommodation or delayed gastric emptying), gastric sensation (for example, sensations associated with hypersensitivity to gas and bloating) or gastric and duodenal inflammation. A genetic predisposition is probable but less evident than in other functional gastrointestinal disorders, such as irritable bowel syndrome (IBS). Psychiatric comorbidity and psychopathological state and trait characteristics could also play a part, although they are not specific to functional dyspepsia and are less pronounced than in IBS. Possible differential diagnoses include Helicobacter pylori infection and peptic ulceration. Pharmacological therapy is mostly based on the subtype of functional dyspepsia, such as prokinetic and fundus-relaxing drugs for PDS and acid-suppressive drugs for EPS, whereas centrally active neuromodulators and herbal drugs play a minor part. Psychotherapy is effective only in a small subset of patients, whereas quality of life can be severely affected in nearly all patients. Future therapies might include novel compounds that attempt to treat the underlying gastric and duodenal inflammation.

Patterns of medical utilization before the first hospitalization for women with anorexia nervosa in Taiwan

OBJECTIVE

The aim of this paper was to analyze medical utilization patterns of female patients with anorexia nervosa before their first inpatient care visit for anorexia nervosa using the National Health Insurance Research Database (NHIRD) of Taiwan.

METHOD

We selected female anorexia nervosa patients (n=239) and control participants hospitalized for peptic ulcers (n=478) or appendectomy (n=478) who were matched by age and incident year from two subsets of the NHIRD. The number of visits, specialists, diagnosis distribution, and selected procedures used in ambulatory services during the 2-year period before the index admission were identified and compared. Healthcare service expenditures were also analyzed.

RESULTS

Compared to the control groups, the female anorexia nervosa patients used more outpatient services (anorexia nervosa, 58.6±45.0 visits; peptic ulcers, 45.3±37.3 visits; appendectomy, 32.5±26.0 visits), mainly due to psychiatric visits. Anorexia nervosa patients were more likely to have received a diagnosis of digestive, endocrine/metabolic, and mental disorders than patients in the control groups. Although nearly equal percentages of patients in the three groups had obtained a diagnosis of a digestive disease, anorexia nervosa patients received digestive disease diagnoses with greater frequency.

CONCLUSIONS

We posit that the various physical symptoms of anorexia nervosa patients and physicians' low level of suspicion of anorexia nervosa led to delayed diagnoses and greater medical utilization than that of the controls groups. Education to raise awareness of anorexia nervosa and other eating disorders among physicians is warranted.

Relationship of body weight with gastrointestinal motor and sensory function: studies in anorexia nervosa and obesity

Background

Whether gastrointestinal motor and sensory function is primary cause or secondary effect of abnormal body weight is uncertain. Moreover, studies relating continuous postprandial sensations of satiation to measurable pathology are scarce. This work assessed postprandial gastrointestinal function and concurrent sensations of satiation across a wide range of body weight and after weight change.

Methods

Patients with anorexia nervosa (AN) and obesity (OB) were investigated in reference to normal weight controls (HC). AN were additionally investigated longitudinally. Gastric emptying, antral contractions and oro-cecal transit after ingestion of a solid meal were investigated by MRI and ¹³C-lactose-ureide breath test. The dependency of self-reported sensations of satiation on the varying degree of stomach filling during gastric emptying was compared between groups.

Results

24 AN (BMI 14.4 (11.9–16.0) kg/m²), 16 OB (34.9 (29.6–41.5) kg/m²) and 20 HC (21.9 (18.9–24.9) kg/m²) were studied. Gastric half-emptying time (t₅₀) was slower in AN than HC (p = 0.016) and OB (p = 0.007), and a negative association between t₅₀ and BMI was observed between BMI 12 and 25 kg/m² (p = 0.007). Antral contractions and oro-cecal transit were not different. For any given gastric content volume, self-reported postprandial fullness was greater in AN than in HC or OB (p < 0.001). After weight rehabilitation, t₅₀ in AN tended to become shorter (p = 0.09) and postprandial fullness was less marked (p < 0.01).

Conclusions

A relationship between body weight and gastric emptying as well as self-reported feelings of satiation is present. AN have slower gastric emptying and heightened visceral perception compared to HC and OB. Longitudinal follow-up after weight rehabilitation in AN suggests these abnormalities are not a primary feature, but secondary to other factors that determine abnormal body weight.

Trial registration

Registered July 20, 2009 at ClinicalTrials.gov (NCT00946816).

Electronic supplementary material

The online version of this article (doi:10.1186/s12876-016-0560-y) contains supplementary material, which is available to authorized users.

Gastrointestinal complications associated with anorexia nervosa: A systematic review

OBJECTIVE

A systematic review identifying gastrointestinal (GI) complications attributable to anorexia nervosa (AN) was completed.

METHOD

Studies of any design exploring the pathogenesis of complications and treatment strategies were included. The review was completed in accordance with PRISMA standards.

RESULTS

A total of 123 articles were retained, including one randomized control trial. The majority of included studies were case reports and case series. Controlled studies demonstrated that patients with AN were more likely to have delays in gastric motility, gastric emptying and intestinal transit than comparator groups although results were not uniform across all studies. Published reports suggest that complications can occur at any segment of the GI tract. These issues may derive as a consequence of severe malnourishment, from eating disorder related symptoms such as self-induced purging or from the refeeding process itself. Multiple studies noted that patients with AN report high rates of GI symptoms although in the few cases where medical testing was undertaken, correlations between self-reported symptoms and measurable pathology were not demonstrated.

DISCUSSION

GI complications may occur throughout the entire GI tract in patients with AN. It is recommended that clinicians use careful judgment when pursuing targeted investigation or introducing symptom specific treatments in response to GI complaints. Evidence suggests that most GI complications resolve with refeeding and cessation of ED symptoms.

Dental erosion in patients seeking treatment for gastrointestinal complaints: a case series

INTRODUCTION

Eating disorders which embrace anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified can be life-threatening due to general medical complications; however, the diagnosis of eating disorder is often delayed due to a low suspicion index. Gastroenterologists are health care providers who may come into contact with patients with undiagnosed eating disorders; it has been previously demonstrated that patients with eating disorders frequently have a significant association with functional dyspepsia. Signs of dental erosion have been described in patients with eating disorders; hence, they may help to identify eating disorders in patients who present with functional dyspepsia and deny having an eating disorder.

CASE PRESENTATION

In this report we describe three cases (a 25-year-old white woman, a 24-year-old white woman, and a 40-year-old white man) with undiagnosed eating disorders, in which a more comprehensive approach, such as the recognition of dental erosion joined with a careful gastrointestinal investigation, was performed to reach a final diagnosis of an eating disorder.

CONCLUSIONS

The screening for dental erosion in patients seeking or receiving medical treatment for dyspeptic symptoms in a gastrointestinal out-patient clinic could be an aid for gastroenterologists to recognize the presence of an underlying eating disorder. A close collaboration with dentists, in addition to psychiatrists, could provide a more favorable treatment outcome.

Gastrointestinal symptoms and disorders in patients with eating disorders

The two most clinically serious eating disorders are anorexia nervosa and bulimia nervosa. A drive for thinness and fear of fatness lead patients with anorexia nervosa either to restrict their food intake or binge-eat then purge (through self-induced vomiting and/or laxative abuse) to reduce their body weight to much less than the normal range. A drive for thinness leads patients with bulimia nervosa to binge-eat then purge but fail to reduce their body weight. Patients with eating disorders present with various gastrointestinal disturbances such as postprandial fullness, abdominal distention, abdominal pain, gastric distension, and early satiety, with altered esophageal motility sometimes seen in patients with anorexia nervosa. Other common conditions noted in patients with eating disorders are postprandial distress syndrome, superior mesenteric artery syndrome, irritable bowel syndrome, and functional constipation. Binge eating may cause acute gastric dilatation and gastric perforation, while self-induced vomiting can lead to dental caries, salivary gland enlargement, gastroesophageal reflux disease, and electrolyte imbalance. Laxative abuse can cause dehydration and electrolyte imbalance. Vomiting and/or laxative abuse can cause hypokalemia, which carries a risk of fatal arrhythmia. Careful assessment and intensive treatment of patients with eating disorders is needed because gastrointestinal symptoms/disorders can progress to a critical condition.

Sasang constitution affects the prevalence of functional dyspepsia

Background

Functional dyspepsia (FD), which is a very common disorder worldwide, is known to be caused by multiple factors including environmental and genetic factors. Sasang constitutional medicine (SCM) is a component of traditional Korean medicine that emphasizes inherited characteristics of the physical and psychological patterns of a patient. This study investigated whether the prevalence of FD differs depending on Sasang classification.

Methods

A total 517 subjects (190 males and 327 females) were recruited, and interviewed for the presence of FD using a Rome III-based questionnaire. The Sasang constitution of all subjects were diagnosed using a Sasang constitutional analytical tool (SCAT). A Chi-square test was performed to compare prevalence of DF among different Sasang constitutional types.

Results

Of the 517 subjects, 115 (22.2 %) met the diagnostic criteria for FD, and the prevalence was significantly higher in females (26.9 %) than males (14.2 %, p < 0.01). The Sasang-constitution-based prevalence among all subjects was 27.5 % for Taeumin, 23.1 % for Soumin, and 16.4 % for Soyangin (p = 0.055). When compared by sex, the prevalence of FD among Sasang types showed significantly different patterns between males and females (p < 0.05); in females with FD, Taeumin predominated (32.5 % compared with 29.5 % and 18.8 % for Soumin and Soyangin, respectively; p < 0.05), whereas males with FD displayed a higher prevalence of Soumin (17.3 % compared with 9.1 % and 11.3 % for Taeumin and Soyangin, respectively; p > 0.05).

Conclusions

This study identified significant differences in FD prevalence depending on Sasang constitution and sex. Our findings provide data to guide future research on the prevention and management of FD.

Incidence and psychological-behavioral characteristics of refractory functional dyspepsia: A large, multi-center, prospective investigation from China

AIM: To explore the incidence and psychological and behavioral characteristics of refractory functional dyspepsia (RFD) in China.

METHODS: The subjects of this study were 1341 new outpatients with functional dyspepsia (FD) who were diagnosed according to the Rome III criteria at four hospitals in Guangdong Province between June and September 2012, and 100 healthy volunteers. All subjects completed questionnaires and scales administered.

RESULTS: Three-hundred and twenty-seven of the 1341 patients with FD had RFD (24.4%). Patients with RFD had a longer disease duration and a more severe form of the disease than patients with non-refractory FD (NRFD). The prevalence of depression and anxiety symptoms was higher in patients with RFD than in patients with NRFD. The prevalence of unhealthy eating behaviors, lack of physical activity, and sleeping disorders was higher in patients with RFD than in patients with NRFD. Patients with RFD sought medical advice on more occasions and spent more money on treatment than patients with NRFD. Finally, patients with RFD had poorer quality of life than patients with NRFD.

CONCLUSION: RFD is not rare in clinical practice and should get attention by patients and doctors because of its long duration, severe symptoms, and associations with abnormal psychology and poor quality of life.

Unhealthy dietary behavior in refractory functional dyspepsia: a multicenter prospective investigation in China

OBJECTIVE

To determine the association of dietary behavior with refractory functional dyspepsia (RFD) and its subtypes in Chinese patients.

METHODS

The medical records of patients admitted to the Outpatient Department of Gastroenterology of four hospitals in Mainland China for upper gastrointestinal (GI) symptoms from June to September 2012 were reviewed and their characteristics were collected. Functional dyspepsia (FD) was diagnosed based on the Rome III criteria. RFD was defined as FD with continuous symptoms for at least 6 months that was unresponsive to at least two kinds of medications. Another 100 healthy volunteers were included as controls. The participants' dietary behaviors were investigated using a questionnaire survey.

RESULTS

Overall, 1341 FD patients were enrolled in the study, including 327 RFD and 1014 non-RFD (NRFD). Unhealthy dietary behaviors were more prevalent in both RFD and NRFD than in the healthy controls. Skipping meals, eating extra meals and a preference to sweet food and gas-producing food were more common in the RFD patients. Compared with NRFD, RFD-epigastric pain syndrome (EPS) patients preferred spicy food, whereas those with postprandial distress syndrome (PDS) preferred sweet food and gas-producing food, and those with both EPS and PDS were found to skip meals and take extra meals more often. Logistic regression analysis showed that skipping meals, eating extra meals and a preference to sweet food and gas-producing food were risk factors for RFD.

CONCLUSION

Unhealthy dietary behaviors, especially skipping meals, eating extra meals and a preference to sweet food and gas-producing food, were correlated with RFD and its subtypes.

Functional gastrointestinal disorders in eating disorder patients: Altered distribution and predictors using ROME III compared to ROME II criteria

AIM: To compare the prevalence of Functional gastrointestinal disorders (FGIDs) using ROME III and ROME II and to describe predictors of FGIDs among eating disorder (ED) patients.

METHODS: Two similar cohorts of female ED inpatients, aged 17-50 years, with no organic gastrointestinal or systemic disorders, completed either the ROME III (n = 100) or the ROME II (n = 160) questionnaire on admission for ED treatment. The two ROME cohorts were compared on continuous demographic variables (e.g., age, BMI) using Student’s t-tests, and on categorical variables (e.g., ED diagnosis) using χ²-tests. The relationship between ED diagnostic subtypes and FGID categories was explored using χ²-tests. Age, BMI, and psychological and behavioural predictors of the common (prevalence greater than 20%) ROME III FGIDs were tested using logistic regression analyses.

RESULTS: The criteria for at least one FGID were fulfilled by 83% of the ROME III cohort, and 94% of the ROME II cohort. There were no significant differences in age, BMI, lowest ever BMI, ED diagnostic subtypes or ED-related quality of life (QOL) scores between ROME II and ROME III cohorts. The most prevalent FGIDs using ROME III were postprandial distress syndrome (PDS) (45%) and irritable bowel syndrome (IBS) (41%), followed by unspecified functional bowel disorders (U-FBD) (24%), and functional heartburn (FH) (22%). There was a 29% or 46% increase (depending on presence or absence of cyclic vomiting) in functional gastroduodenal disorders because of the introduction of PDS in ROME III compared to ROME II. There was a 35% decrease in functional bowel disorders (FBD) in Rome III (excluding U-FBD) compared to ROME II. The most significant predictor of PDS was starvation (P = 0.008). The predictor of FH (P = 0.021) and U-FBD (P = 0.007) was somatisation, and of IBS laxative use (P = 0.025). Age and BMI were not significant predictors. The addition of the 6-mo duration of symptoms requirement for a diagnosis in ROME III added precision to many FGIDs.

CONCLUSION: ROME III confers higher precision in diagnosing FGIDs but self-induced vomiting should be excluded from the diagnosis of cyclic vomiting. Psychological factors appear to be more influential in ROME II than ROME III.

Bloating and functional gastro-intestinal disorders: Where are we and where are we going?

Bloating is one of the most common and bothersome symptoms complained by a large proportion of patients. This symptom has been described with various definitions, such as sensation of a distended abdomen or an abdominal tension or even excessive gas in the abdomen, although bloating should probably be defined as the feeling (e.g. a subjective sensation) of increased pressure within the abdomen. It is usually associated with functional gastrointestinal disorders, like irritable bowel syndrome, but when bloating is not part of another functional bowel or gastrointestinal disorder it is included as an independent entity in Rome III criteria named functional bloating. In terms of diagnosis, major difficulties are due to the lack of measurable parameters to assess and grade this symptom. In addition, it is still unclear to what extent the individual patient complaint of subjective bloating correlates with the objective evidence of abdominal distension. In fact, despite its clinical, social and economic relevance, bloating lacks a clear pathophysiology explanation, and an effective management endorsement, turning this common symptom into a true challenge for both patients and clinicians. Different theories on bloating etiology call into questions an increased luminal contents (gas, stools, liquid or fat) and/or an impaired abdominal empting and/or an altered intra-abdominal volume displacement (abdomino-phrenic theory) and/or an increased perception of intestinal stimuli with a subsequent use of empirical treatments (diet modifications, antibiotics and/or probiotics, prokinetic drugs, antispasmodics, gas reducing agents and tricyclic antidepressants). In this review, our aim was to review the latest knowledge on bloating physiopathology and therapeutic options trying to shed lights on those processes where a clinician could intervene to modify disease course.

Distributions of Sasang constitutions and six syndromes in patients with functional dyspepsia and healthy subjects

OBJECTIVE

To investigated the characteristics of patients with functional dyspepsia (FD) in terms of Sasang constitutional medicine.

METHODS

A total of 116 patients with FD were recruited based on diagnosis by gastroscopy and symptomatic measurements. The distributions of Sasang constitutions and six syndromes in terms of TKM theory in the patients was compared with those from 1423 healthy subjects.

RESULTS

The distribution of Sasang constitutions for the patients with FD significantly differed from that for healthy subjects, especially among women; 36.7% vs 45.6% for Taeumin, 28.9% vs 33.9% for Soumin, and 34.4% vs 20.4% for Soyangin. Our results assumed a high prevalence of Soyangin women (around 1.7 folds), and Soumin (45.2%), in particular, had a high prevalence of "deficiency and coldness of spleen and stomach" compared with Taeumin (14.9%) and Soyangin types (15.7%).

CONCLUSION

This study identified a trend for the frequency of FD and the Sasang constitutions. The findings may provide new ideas for the study of prevention and management of FD,

Assessment of proximal gastric accommodation in patients with functional dyspepsia

Impaired gastric accommodation is one of the most important etiologic factors in the pathophysiology of functional dyspepsia. Ultrasound is a potential alternative method to study changes in gastric volume as a reflection of gastric accommodation. Ultrasound is suitable for patients because it is a non-invasive, easily repeated and non-radioactive procedure, and a previous study has demonstrated the feasibility of 3-dimensional ultrasound in examining functional dyspepsia. The brief article by Fan et al demonstrated that both the proximal gastric area and volume, measured by 2- and 3-dimensional ultrasound respectively, were significantly smaller in patients with functional dyspepsia than in healthy controls. These results are very interesting, but we raise the relevant point that it should have been mandatory to study both changes in gastric volume and their relationship with upper gastrointestinal symptoms in functional dyspepsia. In fact, the relationship between cardinal symptoms and several pathophysiologic mechanisms in functional dyspepsia remains a matter of debate. Moreover, further evaluation of distal gastric volume that has been previously implicated in the origin of functional dyspeptic symptoms is advisable. Therefore, impaired gastric accommodation does not serve as a clear marker of the cardinal symptoms experienced by patients with functional dyspepsia in daily life.

Prevalence of functional gastrointestinal disorders according to Rome III criteria in Italian morbidly obese patients

The relationship between GI symptoms and obesity has yet to be completely clarified.

AIM

To determine in a morbidly obese southern Italy adult population the prevalence of Functional Gastrointestinal Disorders (FGID) and its association with the presence of a Binge Eating (BE) behavior pattern.

METHODS

Consecutive obese patients eligible for bariatric surgery and 100 Healthy Controls (HC) were recruited. All participants were questioned and scored for the presence of FGID according to Rome III criteria and for the presence or the frequency-intensity of a number of upper and lower GI symptoms. BE behavior pattern was assessed.

RESULTS

One-hundred obese patients met the inclusion criteria. The prevalence of FGID was similar between obese patients and HC. There was a significant association between obese patients with BE behavior and postprandial distress syndrome (P = 0.04). Moreover, a significantly higher frequency-intensity score for epigastric fullness (1.23 ± 0.45 versus 0.35 ± 0.13, P = 0.01) was found in obese patients with BE behavior compared to obese patients without.

CONCLUSIONS

Obese patients with a BE behavior pattern showed a significantly higher prevalence of postprandial distress syndrome. A greater knowledge of the GI symptoms associated with obesity along with the pathophysiological mechanisms underlying will be important in the clinical management of these patients.

Life events and the onset of celiac disease from a patient's perspective

Stressful events have been investigated in various immune-mediated diseases but not in celiac disease. Our aim was to examine the relationship of stressful events assessed by the standardized interview of Paykel with the diagnosis of celiac disease in comparison to patients, with a diagnosis of gastroesophageal reflux disease used as the control group. Adults with celiac disease (n = 186) reported more frequent and more severe life events in the years prior to the diagnosis than control patients (n = 96) (67.2% vs. 37.5%, p < 0.001, mean Paykel score 11.5 vs. 13.4, p = 0.001, respectively). Findings were not significantly different between celiac disease and control patients for the time lapse between the event and the diagnosis (mean 5.5 vs. 5.7 months). Pregnancy was defined as a negative event by 20.3% of celiac women, but never by control women. Findings were confirmed when analyses were repeated in the subgroup of patients of both groups with diagnosis made within one year of onset of symptoms. Data indicate that, before diagnosis, the number of stressful events in celiac disease was more frequent although less severe than in the control group suggesting that life events may favor the clinical appearance of celiac disease or accelerate its diagnosis.

Functional dyspepsia--symptoms, definitions and validity of the Rome III criteria

Dyspepsia refers to a heterogeneous group of symptoms that are localized in the epigastric region. Typical dyspeptic symptoms include postprandial fullness, early satiation, epigastric pain and epigastric burning, but other upper gastrointestinal symptoms such as nausea, belching or abdominal bloating often occur. Functional dyspepsia is defined as the presence of dyspeptic symptoms in the absence of an organic cause that readily explains them. The Rome III consensus proposed the subdivision of functional dyspepsia into postprandial distress syndrome (PDS), characterized by postprandial fullness and early satiation, and epigastric pain syndrome (EPS), characterized by epigastric pain or burning. Epidemiological studies in the USA and Europe confirmed the presence of both subgroups, with good separation between EPS and PDS. By contrast, other studies have found major overlap between EPS and PDS in patients with functional dyspepsia in specialist care centres in Europe and Asia. Preliminary pathophysiological studies suggest that PDS might be characterized by a higher prevalence of impaired gastric accommodation than EPS and raised duodenal eosinophil counts. Whether different treatment approaches are needed for EPS and PDS is currently unclear; only acotiamide, a new drug for the treatment of functional dyspepsia, has been found to be efficacious in PDS but not in EPS. Further randomized controlled trials testing treatment response by subgroup are urgently needed.