Confirmatory validation of the patient health questionnaire - 4 (PHQ-4) for gastrointestinal disorders: A large-scale cross-sectional survey

OBJECTIVE

Using the large Rome Foundation Global Epidemiology Survey dataset, the aim of this study was to evaluate the construct and convergent validity and internal consistency of the PHQ-4 across both gastrointestinal and non-gastrointestinal condition cohorts. Another aim was to provide descriptive information about the PHQ-4 including means, confidence intervals and percentage of caseness using a large representative sample.

METHODS

A cross-sectional survey was conducted in 26 countries. Confirmatory factor and internal consistency analyses were conducted across subsamples of patients with gastrointestinal conditions (i.e., disorders of gut-brain interaction [DGBI; any DGBI, individual DGBI, and DGBI region], gastroesophageal reflux disease (GERD), coeliac disease, diverticulitis, inflammatory bowel disease (IBD), cancer anywhere in the gastrointestinal tract, peptic ulcer) and those without a gastrointestinal condition. Convergent validity was also assessed via a series of Pearson's correlation coefficients with PROMIS (physical and mental quality of life), and PHQ-12 (somatisation).

RESULTS

Based on 54,127 participants (50.9% male; mean age 44.34 years) confirmatory factor analysis indicated acceptable to excellent model fits for the PHQ-4 across all subsamples and individual DGBI and DGBI region (Comparative Fit Index >0.950, Tucker-Lewis Index >0.950, Root Mean Squared Error of Approximation <0.05, and Standardised Root Mean Square Residual <0.05). The PHQ-4 was found to demonstrate convergent validity (Pearson's correlation coefficients >±0.4), and good internal consistency (Cronbach's α > 0.75).

CONCLUSIONS

This study provides evidence that the PHQ-4 is a valid and reliable tool for assessing mental health symptomology in both gastrointestinal and non-gastrointestinal cohorts.

Worldwide population prevalence and impact of sub-diagnostic gastrointestinal symptoms

BACKGROUND

The Rome Foundation Global Epidemiology Study (RFGES) found that 40.3% of adults in 26 internet-surveyed countries met Rome IV criteria for disorders of gut-brain interaction (DGBI). However, additional people not meeting DGBI criteria may also be burdened by frequent gastrointestinal symptoms.

AIMS

To explore the prevalence and demographic distribution of sub-diagnostic gastrointestinal symptoms, and the hypothesised associated effects on quality of life (QoL), life functioning and healthcare needs.

METHODS

We analysed data from the RFGES survey, which included the Rome IV diagnostic questionnaire and QoL, psychological, work productivity and healthcare questions.

RESULTS

Of the 50,033 people without a history of organic gastrointestinal disorders, 25.3% classified in the sub-diagnostic group (no DGBI but one or more frequent gastrointestinal symptoms), 41.4% had DGBI and 33.4% had no frequent gastrointestinal symptoms (non-GI group). Sub-diagnostic prevalence in different world regions ranged from 22.2% (North America) to 30.5% (Middle East), was slightly higher among males than females and decreased with age. The sub-diagnostic group was intermediate between the non-GI and DGBI groups, and significantly different from both of them on QoL, anxiety, depression, somatisation, healthcare utilisation and life and work impairment.

CONCLUSIONS

One in four adults without organic gastrointestinal disorders or DGBI report frequent gastrointestinal symptoms. This sub-diagnostic group has reduced QoL, greater psychological and non-GI bodily symptoms, impaired work productivity and life activities and greater healthcare use compared to non-GI individuals. This suggests that many in this sub-diagnostic group might benefit from healthcare services or symptom self-management advice.

The aging gut: Symptoms compatible with disorders of gut-brain interaction (DGBI) in older adults in the general population

BACKGROUND

Little is known about changes in gastrointestinal symptoms compatible with disorders of gut-brain interaction (DGBI) with increasing age at the population level. The objective of this study was to describe the patterns of DGBI in individuals 65 years of age and above and contrasting them with those of younger adults.

METHODS

A community sample of 6300 individuals ages 18 and older in the US, UK, and Canada completed an online survey. Quota-based sampling was used to ensure equal proportion of sex and age groups (40% aged 18-39, 40% aged 40-64, 20% aged 65+) across countries, and to control education distributions. The survey included the Rome IV Diagnostic Questionnaire for DGBI, demographic questions, questionnaires measuring overall somatic symptom severity and quality of life, and questions on healthcare utilization, medications, and surgical history.

RESULTS

We included 5926 individuals in our analyses; 4700 were 18-64 years of age and 1226 were ages 65+. Symptoms compatible with at least one DGBI were less prevalent in participants ages 65+ vs. ages 18-64 years (34.1% vs. 41.3%, p < 0.0001). For symptoms compatible with upper GI DGBI, lower prevalence for most disorders was noted in the 65+ group. For lower GI DGBI, a different pattern was seen. Prevalence was lower in ages 65+ for irritable bowel syndrome and anorectal pain, but no differences from younger participants for the disorders defined by abnormal bowel habits (constipation and/or diarrhea) were seen. Fecal incontinence was the only DGBI that was more common in ages 65+. Having a DGBI was associated with reduced quality of life, more severe non-GI somatic symptoms, and increased healthcare seeking, both in younger and older participants.

CONCLUSION

Symptoms compatible with DGBI are common, but most of these decrease in older adults at the population level, with the exception of fecal incontinence which increases. This pattern needs to be taken into account when planning GI health care for the growing population of older adults.

Global Prevalence of Psychological Distress and Comorbidity With Disorders of Gut-Brain Interactions

INTRODUCTION

This study focused on defining the global prevalence of clinically relevant levels of psychological distress and somatic symptoms and the prevalence of coexistence between these symptoms and disorders of gut-brain interaction (DGBI). We also analyzed how clinically relevant psychological distress and somatic symptoms and coexistent DGBI are associated with health-related outcomes.

METHODS

We included a representative sample of 54,127 adult participants (49.1% women; mean age of 44.3 years) from 26 countries worldwide. Participants completed an Internet survey (the Rome Foundation Global Epidemiology Study) with validated self-report questionnaires.

RESULTS

Clinically relevant psychological distress and/or somatic symptom severity was reported by 37.5% of the sample. These participants had 4.45 times higher odds to have at least one DGBI than individuals without psychological distress and/or somatic symptoms. Compared with participants with psychological distress and/or somatic symptoms with vs without DGBI, participants with a DGBI reported increased healthcare and medication utilization (with OR from 1.6 to 2.8). Coexistent DGBI in participants with psychological distress and/or somatic symptoms was the variable most strongly associated with reduced mental (β = -0.77; confidence interval [-0.86 to -0.68]) and physical (β = -1.17; confidence interval [-1.24 to -1.10]) quality of life.

DISCUSSION

This global study shows that psychological distress, somatic symptoms, and DGBI are very common and frequently overlap. The coexistence between psychological distress/somatic symptoms and DGBI seems to be especially detrimental to quality of life and healthcare utilization. Individuals with psychological distress/somatic symptoms and DGBI coexistence seem to be a group vulnerable to psychosocial problems that should be studied further and would likely benefit from psychological/psychiatric interventions.

Prevalence and Associated Factors of Bloating: Results From the Rome Foundation Global Epidemiology Study

BACKGROUND & AIMS

Bloating is a common symptom in the general population and among disorders of gut-brain interaction, although its prevalence has not been well characterized. The aim of this study was to report the prevalence of bloating as a symptom in the worldwide population and to identify factors associated with this symptom in the general population.

METHODS

Rome Foundation Global Epidemiology Study internet survey data were analyzed. After excluding respondents with potential organic causes of bowel symptoms, the current analysis included 51,425 individuals in 26 countries. Data included diet, medical history, quality of life, and Rome IV diagnostic questions. Presence of bloating was defined as experiencing bloating at least once per week for the last 3 months. Descriptive statistics estimated prevalence by country, region, and disorder of gut-brain interaction diagnosis. Logistic regression evaluated predictors of bloating.

RESULTS

Nearly 18% of the global study population reported bloating (ranging from 11% in East Asia to 20% in Latin America). Prevalence decreased with age and women were approximately twice as likely as men to report bloating. More than one-half of respondents who reported weekly epigastric pain (71.39%), nausea (59.7%), or abdominal pain (61.69%) also reported bloating at least once per week. In logistic regression, the strongest associations were with abdominal pain (odds ratio, 2.90) and epigastric pain (odds ratio, 2.07).

CONCLUSIONS

Bloating is common throughout the world. Nearly 18% of the general population experience bloating at least once per week. Reported bloating prevalence is lower in older age groups, most common in women, and strongly associated with abdominal pain.

Work productivity and activity impairment in disorders of gut-brain interaction: Data from the Rome Foundation Global Epidemiology Study

BACKGROUND

Disorders of Gut-Brain Interaction (DGBI) are highly prevalent worldwide, but their effect on work productivity has not gained much attention.

AIMS AND METHODS

We aimed to compare work productivity and activity impairment (WPAI) in persons with and without DGBI in a large population-based cohort and identify factors independently associated with WPAI in subjects with DGBI. Data were collected from Germany, Israel, Italy, Japan, the Netherlands, Poland, Spain and Sweden via Internet surveys as part of the Rome Foundation Global Epidemiology Study. Apart from the Rome IV diagnostic questionnaire, questionnaires evaluating WPAI related to general health (WPAI:GH), psychological distress (PHQ-4), somatic symptom severity (PHQ-15) and other factors were assessed.

RESULTS

Of the 16,820 subjects, 7111 met the criteria for DGBI according to the Rome IV diagnostic questionnaire. Subjects with DGBI were younger (median (interquartile range) age 43 (31-58) vs. 47 (33-62)) and more often female (59.0% vs. 43.7%) compared to subjects without DGBI. Subjects with DGBI had higher absenteeism, presenteeism (poor work productivity due to illness), overall work impairment and activity impairment (p < 0.001) compared with subjects without. For subjects with DGBI affecting more than one anatomical region, WPAI was incrementally higher for each additional region. There were significant differences in WPAI for subjects with DGBI in different countries. Subjects from Sweden had the highest overall work impairment and from Poland the lowest. Using multiple linear regression, male sex, fatigue, psychological distress, somatic symptom severity and number of anatomical regions were independently associated with overall work impairment (p < 0.05 for all).

CONCLUSION

In the general population, people with DGBI have substantial WPAI compared with those without DGBI. The reasons for these findings should be explored further, but having multiple DGBI, psychological distress, fatigue and somatic symptom severity seem to contribute to this impairment associated with DGBI.

Factor Analysis of the Rome IV Criteria for Major Disorders of Gut-Brain Interaction (DGBI) Globally and Across Geographical, Sex, and Age Groups

BACKGROUND & AIMS

The Rome criteria are widely accepted for diagnosing disorders of gut-brain interaction, but their global applicability has been debated. This study aimed to evaluate the validity of the Rome IV criteria by factor analysis globally, across geographical regions, by sex, and by age groups.

METHODS

Data were collected in 26 countries using the Rome IV questionnaire. Forty-nine ordinal variables were used in exploratory factor analysis (EFA) to identify clusters of inter-correlated variables (factors) within the data set. Confirmatory factor analysis with predefined factors of the disorders of gut-brain interaction was compared with the factors in the EFA. Analyses were performed globally, for each geographical region (North and Latin America, Western and Eastern Europe, Middle East, Asia), sex, and age groups (18-34, 35-49, 50-64, ≥65).

RESULTS

A total of 54,127 people were included. The EFA identified 10 factors accounting for 57% of the variance: irritable bowel syndrome, constipation, diarrhea, upper gastrointestinal symptoms, globus, regurgitation/retching, chest pain, nausea/vomiting, and 2 right upper quadrant pain factors. Most factors had close correspondence to a Rome IV criteria diagnosis, but notably, functional dysphagia and heartburn symptoms were often included in the same factor and/or in upper gastrointestinal symptoms. Most factors were consistent across geographical regions, sex, and age groups, and compatible to the global results. All prespecified factors in the confirmatory analysis had a loading ≥0.4, indicating validity of the Rome IV criteria.

CONCLUSIONS

The results indicate that the Rome IV criteria for irritable bowel syndrome, functional dyspepsia, functional constipation, globus, and biliary pain are globally valid and represent universal diagnostic entities that are similar across sex and age groups.

Characteristics of disorders of gut-brain interaction in the Japanese population in the Rome Foundation Global Epidemiological Study

BACKGROUND

The aims were to use Japanese data from the Rome Foundation Global Epidemiological Study (RFGES) to test the hypotheses that severity of gastrointestinal (GI) symptoms and psychosocial disturbance are ordered as Rome IV irritable bowel syndrome (IBS) > Rome III IBS > DGBI, not IBS > others.

METHODS

Subjects were 2504 Japanese in the RFGES. We assessed DGBI/IBS diagnoses with Rome IV/III, IBS Symptom Severity Scale (IBS-SSS), Patient Health Questionnaire (PHQ) for anxiety/depression and non-GI somatic symptoms, PROMIS-10 for quality of life (QOL), Work Productivity and Activity Impairment (WPAI) Questionnaire, parts of Self-reported IBS Questionnaire (SIBSQ) for meal effect and stress effect, Food Frequency Questionnaire, and medication questions.

KEY RESULTS

The prevalence of Rome IV DGBI was as follows; IBS-C 0.5%, IBS-D 0.8%, IBS-M 0.8%, IBS-U 0.1%, unspecified functional bowel disorder 10.7%, postprandial distress syndrome 2.2%, and epigastric pain syndrome 0.3%. Rome III IBS prevalence; IBS-C 3.0%, IBS-D 3.1%, IBS-M 2.7%, and IBS-U 0.6%. Comparison among Rome IV IBS (n = 54), Rome III IBS (n = 197), other DGBI (n = 746), others (n = 1389) revealed significant order as Rome IV IBS > Rome III IBS > other DGBI > others in IBS-SSS, anxiety/depression, activity impairment, non-GI symptoms, physical QOL, mental QOL, exacerbated symptoms by meals and perceived stress (all p < 0.001).

CONCLUSIONS & INFERENCES

These findings support the study hypotheses. Data from Japan as a culturally homogenous country suggest Rome IV IBS is more severe and hence has more gut-brain psychobehavioral involvement than Rome III IBS.

The epidemioflogy and psychological comorbidity of disorders of gut-brain interaction in Australia: Results from the Rome Foundation Global Epidemiology Study

BACKGROUND

The Rome Foundation Global Epidemiology Study on the disorders of gut-brain interaction (DGBI) was used to assess the national prevalence of all 22 DGBI, the percentage of respondents meeting diagnostic criteria for at least one DGBI, and the rates of comorbid anxiety, depression, and somatization in Australia and 25 other countries.

METHODS

The survey was conducted in Australia and 25 other countries through the Internet and included the Rome IV Diagnostic Questionnaire and an in-depth supplemental questionnaire.

KEY RESULTS

Two thousand thirty-six Australian adults completed the survey nationwide: mean age 47.34 ± 17.00 years, 50.15% males. Overall, 38.67% of Australians met criteria for at least one DGBI, with unspecified functional bowel disorder (8.01%) and then functional constipation (7.71%) being the most prevalent. For those Australians with at least one DGBI, rates of anxiety, depression, and somatization where high (26.58%, 28.96%, and 63.10%, respectively), with functional chest pain having the highest rates of anxiety (55.00%) and depression (57.50%), and irritable bowel syndrome (mixed) having the highest somatization rate (75.86%). The odds of having a DGBI increased with greater anxiety (OR: 1.09, CI 95%: 0.97, 1.23), depression (OR: 1.17, CI 95%: 1.04, 1.32), and somatization (OR: 1.17, CI 95%: 1.14, 1.20) symptom severity.

CONCLUSIONS AND INFERENCES

The current study represents the most comprehensive epidemiological exploration of DGBI and mental health in Australia to date, including their prevalence and distributions across sex and age, associations between DGBI and anxiety, depression, and somatization. The findings warrants future comparisons between population characteristics and health care systems differences in order to reduce the burden of DGBI and mental illness worldwide.

Face-to-face interviews versus Internet surveys: Comparison of two data collection methods in the Rome foundation global epidemiology study: Implications for population-based research

BACKGROUND AND AIMS

The Rome Foundation Global Epidemiology Study (RFGES) assessed the prevalence, burden, and associated factors of Disorders of Gut-Brain Interaction (DGBI) in 33 countries around the world. Achieving worldwide sampling necessitated use of two different surveying methods: In-person household interviews (9 countries) and Internet surveys (26 countries). Two countries, China and Turkey, were surveyed with both methods. This paper examines the differences in the survey results with the two methods, as well as likely reasons for those differences.

METHODS

The two RFGES survey methods are described in detail, and differences in DGBI findings summarized for household versus Internet surveys globally, and in more detail for China and Turkey. Logistic regression analysis was used to elucidate factors contributing to these differences.

RESULTS

Overall, DGBI were only half as prevalent when assessed with household vs Internet surveys. Similar patterns of methodology-related DGBI differences were seen within both China and Turkey, but prevalence differences between the survey methods were dramatically larger in Turkey. No clear reasons for outcome differences by survey method were identified, although greater relative reduction in bowel and anorectal versus upper gastrointestinal disorders when household versus Internet surveying was used suggests an inhibiting influence of social sensitivity.

CONCLUSIONS

The findings strongly indicate that besides affecting data quality, manpower needs and data collection time and costs, the choice of survey method is a substantial determinant of symptom reporting and DGBI prevalence outcomes. This has important implications for future DGBI research and epidemiological research more broadly.

Prevalence and impact of disorders of Gut-Brain interaction in Sweden

BACKGROUND

Previous epidemiologic studies in Sweden have only covered some of the disorders of gut-brain interaction (DGBI) and are not representative of the general population. This study aimed to define the prevalence and impact of DGBI in Sweden.

METHODS

We used Swedish data from the Rome Foundation Global Epidemiology Study which include information on DGBI diagnoses, psychological distress, quality of life (QoL), healthcare utilization, and the impact of stress on GI symptoms.

KEY RESULTS

The prevalence of having any DGBI was 39.1% (95% CI 37.0-41.2); esophageal disorders 6.1% (5.1-7.3), gastroduodenal disorders 10.7% (9.3-12.0), bowel disorders 31.6% (29.6-33.6), and anorectal disorders 6.0% (5.1-7.2). Subjects with a DGBI more commonly reported anxiety and/or depression, reduced mental and physical QoL, and more frequent doctor visits due to health problems. Subjects with a DGBI reported bothersome gastrointestinal (GI) symptoms to a greater extent and more than 1/3 had visited a doctor due to GI problems and of those 1/3 had seen multiple doctors. Prescription medications were available among 36.4% (31.0-42.0) who had bothersome GI symptoms and a DGBI, with sufficient symptom relief in 73.2% (64.0-81.1). Psychological factors and eating were reported to worsen GI symptoms and stress during the last month was greater in subjects with a DGBI.

CONCLUSIONS AND INFERENCES

DGBI prevalence and its impact in Sweden is in line with global data, including increased healthcare utilization. GI symptoms are commonly affected by psychological factors and eating, and a high proportion of those on prescription medication report sufficient GI symptom relief.

The national prevalence of disorders of gut brain interaction in the United Kingdom in comparison to their worldwide prevalence: Results from the Rome foundation global epidemiology study

BACKGROUND

There are minimal epidemiological data comparing the burden of disorders of gut brain interaction (DGBI) in the UK with other countries. We compared the prevalence of DGBI in the UK with other countries that participated in the Rome Foundation Global Epidemiology Study (RFGES) online.

METHODS

Participants from 26 countries completed the RFGES survey online including the Rome IV diagnostic questionnaire and an in-depth supplemental questionnaire with questions about dietary habits. UK sociodemographic and prevalence data were compared with the other 25 countries pooled together.

KEY RESULTS

The proportion of participants with at least one DGBI was lower in UK participants compared with in the other 25 countries (37.6% 95% CI 35.5%-39.7% vs. 41.2%; 95% CI 40.8%-41.6%, p = 0.001). The UK prevalence of 14 of 22 Rome IV DGBI, including irritable bowel syndrome (4.3%) and functional dyspepsia (6.8%), was similar to the other countries. Fecal incontinence, opioid-induced constipation, chronic nausea and vomiting, and cannabinoid hyperemesis (p < 0.05) were more prevalent in the UK. Cyclic vomiting, functional constipation, unspecified functional bowel disorder, and proctalgia fugax (p < 0.05) were more prevalent in the other 25 countries. Diet in the UK population consisted of higher consumption of meat and milk (p < 0.001), and lower consumption of rice, fruit, eggs, tofu, pasta, vegetables/legumes, and fish (p < 0.001).

CONCLUSIONS AND INFERENCES

The prevalence and burden of DGBI is consistently high in the UK and in the rest of the world. Opioid prescribing, cultural, dietary, and lifestyle factors may contribute to differences in the prevalence of some DGBI between the UK and other countries.

Epidemiology of disorders of gut-brain interaction in Belgium and differences between two language groups: Results from the Rome foundation global epidemiology study

BACKGROUND

The Rome Foundation carried out a worldwide epidemiology study on DGBI according to the Rome IV criteria in 33 countries, including Belgium. DGBI prevalence varied between continents and countries, but prevalence differences within language groups in a single country have not yet been described.

METHODS

We analyzed the prevalence rates of 18 DGBI and their psychosocial impact in Belgium in the French and Dutch language groups.

KEY RESULTS

DGBI prevalence was similar in the French-speaking and Dutch-speaking population. Having one or more DGBI was negatively associated with psychosocial well-being. The scores for depression were lower in the Dutch-speaking participants with one or more DGBI compared to the French-speaking participants. Interestingly, we also found significantly lower scores in the general Dutch-speaking versus the French-speaking population for depression and non-gastrointesinal somatic symptoms, and higher global physical health and mental health quality-of-life component scores. In the Dutch-speaking group, medication use for gastric acid was lower, but use of prescribed analgesics was more common. Nevertheless, the use of non-prescribed pain medication was higher in the French-speaking group. Anxiety and sleep medication use was also higher in the latter group.

CONCLUSIONS & INTERFERENCES

The results of this first in-depth analysis of Rome IV DGBI in Belgium show a higher prevalence for some DGBI in the French-speaking cohort, and a larger associated disease burden. These differences between language/culture groups in the same country support the psychosocial pathophysiological model of DGBI.

Pictograms to assess bloating and distension symptoms in the general population in Mexico: Results of The Rome Foundation Global Epidemiology Study

BACKGROUND

There is no term for bloating in Spanish and distension is a very technical word. "Inflammation"/"swelling" are the most frequently used expressions for bloating/distension in Mexico, and pictograms are more effective than verbal descriptors (VDs) for bloating/distension in general GI and Rome III-IBS patients. However, their effectiveness in the general population and in subjects with Rome IV-DGBI is unknown. We analyzed the use of pictograms for assessing bloating/distension in the general population in Mexico.

METHODS

The Rome Foundation Global Epidemiology Study (RFGES) in Mexico (n = 2001) included questions about the presence of VDs "inflammation"/"swelling" and abdominal distension, their comprehension, and pictograms (normal, bloating, distension, both). We compared the pictograms with the Rome IV question about the frequency of experiencing bloating/distension, and with the VDs.

KEY RESULTS

"Inflammation"/"swelling" was reported by 51.5% and distension by 23.8% of the entire study population; while 1.2% and 25.3% did not comprehend "Inflammation"/"swelling" or distension, respectively. Subjects without (31.8%) or not comprehending "inflammation"/"swelling"/distension (68.4%) reported bloating/distension by pictograms. Bloating and/or distension by the pictograms were much more frequent in those with DGBI: 38.3% (95%CI: 31.7-44.9) vs. without: 14.5% (12.0-17.0); and in subjects with distension by VDs: 29.4% (25.4-33.3) vs. without: 17.2% (14.9-19.5). Among subjects with bowel disorders, those with IBS reported bloating/distension by pictograms the most (93.8%) and those with functional diarrhea the least (71.4%).

CONCLUSIONS & INFERENCES

Pictograms are more effective than VDs for assessing the presence of bloating/distension in Spanish Mexico. Therefore, they should be used to study these symptoms in epidemiological research.

Comparisons of the Rome III and Rome IV criteria for diagnosis of irritable bowel syndrome in Indian and Bangladeshi communities and internal shifts in the diagnostic categories of bowel disorders of gut-brain interactions

BACKGROUND

Although the Rome IV criteria are the most recent criteria to diagnose irritable bowel syndrome (IBS), their sensitivity has been shown to be low in Chinese and Western populations. There are scanty data comparing the Rome III and Rome IV criteria in diagnosis of IBS in the Indian and Bangladeshi populations where abdominal pain, an essential component of diagnosis of IBS by the Rome IV criteria, is less in frequency and of lower severity.

METHODS

We analyzed the Indian and Bangladeshi data from the Rome Global Epidemiology Study to compare diagnostic sensitivity of the Rome III and Rome IV criteria for IBS, internal shifts in diagnostic categories of disorders of gut-brain interaction (DGBI), the severity of IBS diagnosed by the Rome III and Rome IV criteria, and consultation patterns in these populations.

KEY RESULTS

The Rome IV criteria were less sensitive than the Rome III criteria to diagnose IBS in these populations, and the subjects with Rome III IBS shifted internally to other DGBI when the Rome IV criteria were applied. Moreover, Rome IV IBS subjects had greater symptom severity than the Rome III IBS. A third of people fulfilling diagnostic criteria for IBS consulted doctors, and those diagnosed using Rome IV criteria, those with higher anxiety and depression symptom score, lower global physical health score, and greater IBS symptom severity score had greater correlation coefficients with doctors' consultation.

CONCLUSIONS AND INFERENCES

The Rome IV diagnostic criteria for IBS are less sensitive than the Rome III criteria in Indian and Bangladesh communities. Application of the Rome IV criteria to people who meet the Rome III IBS criteria selects a subgroup of people with greater severity of symptoms, and hence, Rome IV IBS is more strongly associated with physician consultation. These findings may have important bearing in future iterations of the Rome criteria for a broader global applicability.

Prevalence and description of disorders of gut-brain interaction in Spain according to the results of the Rome Foundation Global Epidemiology Study

BACKGROUND

Data for Spain from the Rome Foundation Global Epidemiology Study on the disorders of gut-brain interaction (DGBI) were used to assess the national and regional prevalence of all 22 DGBI, the percentage of respondents meeting diagnostic criteria for at least one DGBI, and the impact on burden of disease in our country.

METHODS

Data were collected through an anonymous, nationwide, and secure Internet survey with multiple built-in quality-assurance techniques that included the Rome IV diagnostic questionnaire and an in-depth supplemental questionnaire.

KEY RESULTS

The survey was completed by 2072 adult Spanish participants (50.2% female) with a mean age of 45.67 ± 15.44 years with a good representative national distribution. 43.6% (41.5%-45.8%) met diagnostic criteria for at least one DGBI, with 8.2% for any esophageal disorder, 12.1% for any gastroduodenal disorder, 30.1% for any bowel disorder, and 11.5% for any anorectal disorder. Functional constipation was the most prevalent DGBI in Spain (12.8%). We found that proctalgia fugax (9.3%), unspecified bowel disorders (10.8%), and functional dysphagia (5.6%) showed unexplained high rates in our country. DGBI rates were higher for women. Having any DGBI was negatively associated with psychosocial variables (including quality of life, somatization, and concern about digestive problems), and associated with increased healthcare utilization.

CONCLUSIONS & INFERENCES

We provide the first comprehensive data on the prevalence and burden of all DGBI in Spain using the Rome IV criteria. The enormous burden of DGBI in Spain highlights the need for specialized training and future research.

Negative Impact of Disorders of Gut-Brain Interaction on Health-Related Quality of Life: Results From the Rome Foundation Global Epidemiology Survey

BACKGROUND & AIMS

This study used the database from the Rome Foundation Global Epidemiology Survey to assess the differences in quality of life overall, and by age and sex, across individual disorders of gut-brain interaction (DGBI), gastrointestinal anatomical region(s), and number of overlapping DGBI.

METHODS

Data were collected via the Internet in 26 countries, using the Rome IV diagnostic questionnaire and a supplemental questionnaire including the Patient-Reported Outcomes Measurement Information Systems Global-10 quality of life measure. Factorial analyses of variance were used to explore physical and mental quality of life, adjusting for multiple comparisons.

RESULTS

Among the 54,127 respondents, quality of life deteriorated significantly with increasing number of overlapping DGBI, with respondents reporting ≥2 DGBI having significantly poorer quality of life than those with only 1 DGBI or those without any DGBI. Men with DGBI reported better quality of life than women, and those aged ≥65 years reported better quality of life than those <65 years. Age, sex, number of overlapping DGBI, somatization, anxiety, depression, and functional experiences (concern, embarrassment, or stress associated with bowel functioning) relating to DGBI, were significant predictors of poorer physical and mental quality of life.

CONCLUSIONS

This study is the most comprehensive assessment of quality of life to date in adults living with a DGBI. It provides a representative picture of DGBI impact on adults in the global adult population and highlights the significant detrimental impact of living with a DGBI on quality of life.

Comparison of the epidemiology of disorders of gut-brain interaction in four Latin American countries: Results of The Rome Foundation Global Epidemiology Study

BACKGROUND

In Latin America, there are scarce data on the epidemiology of DGBI. The Rome Foundation Global Epidemiology Study (RFGES) Internet survey included 26 countries, four from Latin America: Argentina, Brazil, Colombia, and Mexico, with a 40.3% prevalence of Rome IV DGBI. We aimed at comparing the prevalence of DGBI and associated factors among these countries.

METHODS

The frequency of DGBI by anatomical region, specific diagnoses, sex, age, diet, healthcare access, anxiety, depression, and HRQOL, were analyzed and compared.

RESULTS

Subjects included Argentina n = 2057, Brazil = 2004, Colombia = 2007, and Mexico = 2001. The most common DGBI were bowel (35.5%), gastroduodenal (11.9%), and anorectal (10.0%). Argentina had the highest prevalence of functional diarrhea (p = 0.006) and IBS-D; Brazil, esophageal, gastroduodenal disorders, and functional dyspepsia; Mexico functional heartburn (all <0.001). Overall, DGBI were more common in women vs. men and decreased with age. Bowel disorders were more common in the 18-39 (46%) vs. 40-64-year (39%) groups. Diet was also different between those with DGBI vs. those without with subtle differences between countries. Subjects endorsing criteria for esophageal, gastroduodenal, and anorectal disorders from Mexico, more commonly consulted physicians for bowel symptoms vs. those from Argentina, Brazil, and Colombia. General practitioners were the most frequently consulted, by Mexicans (50.42%) and Colombians (40.80%), followed by gastroenterologists. Anxiety and depression were more common in DGBI individuals in Argentina and Brazil vs. Mexico and Colombia, and they had lower HRQOL.

CONCLUSIONS

The prevalence of upper and lower DGBI, as well as the burden of illness, psychological impact and HRQOL, differ between these Latin American countries.

Sex- and gender-related differences in the prevalence and burden of disorders of gut-brain interaction in Poland

BACKGROUND

The aim of the study was to assess sex- and gender-related differences in the epidemiology and impact of disorders of gut-brain interaction (DGBI) in Poland.

METHODS

Data used for the current analysis were derived from the Polish population sample of 2057 subjects (1030 F, 1027 M) collected via the Internet survey that included the Rome IV diagnostic questionnaire and 80 supplementary questions.

KEY RESULTS

The overall prevalence of DGBI in Poland was 46.0% (51.7% in women and 40.3% in men, p < 0.001). Comparing women versus men, esophageal disorders were observed in 6.3% vs. 6.0%, respectively (p > 0.05), gastroduodenal disorders in 14.0% vs. 7.8% (p < 0.001), bowel disorders in 44.3% vs. 33.9% (p < 0.001), and anorectal disorders in 9.9% vs. 7.7% (p > 0.05). The six most common DGBI included functional constipation 14.2%, functional dyspepsia 8.3%, proctalgia fugax 6.6%, functional bloating 4.8%, functional diarrhea 4.5%, and irritable bowel syndrome (IBS) 4.4%. All these disorders, except for functional diarrhea, were more common in women. The DGBI overlap was significantly higher in women than in men (16.7% vs. 11.2%, p < 0.001). A higher number of overlapping DGBI correlated positively with IBS severity, higher level of somatization, anxiety and depression, poorer quality of life (QoL), and increased healthcare utilization.

CONCLUSIONS AND INFERENCES

This is the first comprehensive report on significant sex/gender-related differences in the prevalence and burden of DGBI in Poland. The revealed differences between women and men with DGBI in the clinical profile, psychosocial variables, and healthcare utilization may have important diagnostic and therapeutic implications.

The epidemiology and impact of disorders of gut-brain interaction in Canada: Results from the Rome Foundation Global Epidemiologic Study

BACKGROUND

Using data from the Rome Foundation Global Epidemiology Study examining prevalence of disorders of gut-brain interaction (DGBI) in 33 countries, this study explored the prevalence of all 22 disorders in Canada. It examined differences related to geography and sociodemographic factors, health impact and compared these findings to other countries.

METHODS

The Rome Foundation survey was conducted through the Internet, targeting 2000 Canadian participants. The survey used the validated ROME IV diagnostic questionnaire to identify the 22 DGBI and an in-depth supplemental questionnaire that included quality assurance techniques.

KEY RESULTS

There were 2029 respondents with a mean age of 48 years and 50% females. Diagnostic criteria for at least one of the 22 DGBI were met by 41.3%, similar to other countries. Functional constipation, functional diarrhea, and unspecified functional bowel disorders were most common. Irritable bowel syndrome prevalence was 4.2% using Rome IV and 10.1% using ROME III criteria. DGBI were associated with poorer quality of life and increased psychological symptom scores. Prevalence of DGBI ranged from 48% in Quebec to 36% in British Columbia. Prescription pain medication was reported by 17% with DGBI compared to 9% without DGBI and correlated negatively with mental health and physical well-being. Quebecers and francophones were in limited number but reported higher DGBI prevalence and symptom severity compared to others.

CONCLUSIONS & INFERENCES

A large proportion of Canadians suffer from DGBI which seriously impact their well-being. Findings highlight the need for further research and education, including understanding whether significant regional and cultural differences contribute to DGBI.

The Rome Foundation Global Epidemiology study: Conception, implementation, results, and future potential

BACKGROUND

Methodological problems have impeded successful epidemiological research into disorders of gut-brain interactions (DGBI), as previous studies were limited in terms of study population, diagnostic criteria, number of disorders assessed, data collection methods, and geographic area. Most prevalence estimates were based on pooling data from heterogeneous studies using inappropriate pooling methods, seriously limiting the relevance of the results. The Rome Foundatiion Global Epidemiology Study (RFGES) aimed to rectify these limitations using rigorous methodology to survey the prevalence of 22 DGBI in large population samples in 33 countries. Its aims were to conduct a comprehensive, multinational epidemiological study using rigorous research methodology, gain a better understanding of the burden of the DGBI, gain reliable regional estimates of DGBI prevalence, and advance our understanding of the pathophysiology of IBS. The study questionnaire consisted of the 89-item Rome IV Adult Diagnostic Questionnaire enabling the diagnosis of 22 DGBI, and an 80-item supplemental questionnaire that enabled analyses of the association of multiple factors with DGBI diagnoses.

PURPOSE FOR REVIEW ARTICLE

This review paper introduces a special issue on the Rome Foundation Global Epidemiology study (RFGES) with a narrative description of its conception, development, and implementation, its outcomes to date, and its potential contribution to neurogastroenterology. It includes 15 papers that reflect the range of RFGES studies from single country papers to intra-regional studies, to inter-regional studies, and one global study.

Prevalence and associated factors of disorders of gut-brain interaction in the United States: Comparison of two nationwide Internet surveys

BACKGROUND

No comprehensive assessment of disorders of gut-brain interaction (DGBI) in the United States (US) national population has been published in the past three decades. We aimed to provide an updated picture of DGBI in the United States and associated factors, using data from two national Internet surveys.

METHODS

Data were analyzed from 1949 people surveyed in 2015, and 2023 people surveyed in 2017 as a part of the Rome Foundation Global Epidemiology Study (RFGES). The surveys had nearly identical methodology and included the Rome IV Diagnostic Questionnaire and questions on demographics, quality of life (QoL), emotional symptoms, and healthcare utilization.

KEY RESULTS

The prevalence of having any DGBI was 36.0% and 39.9% in the two surveys. Prevalence estimates for the 22 DGBI assessed were broadly comparable between the surveys, as their 95% confidence intervals overlapped for every disorder. Females had DGBI more commonly than males in both surveys (odds ratios 1.66 and 1.52), and people of age 65 and older had lower DGBI prevalence than younger age groups. Having DGBI was associated in both surveys with significant QoL impairment, elevated anxiety, depression and somatization symptoms, and increased doctor visits.

CONCLUSIONS AND INFERENCES

Approximately 4 out of every 10 US adults have a DGBI; more commonly women and people under the age of 65. DGBI adversely affect QoL and emotional well-being and increase healthcare needs. The similarity of findings between the two surveys supports the reliability of DGBI prevalence estimates obtained with the Internet survey method used globally in the RFGES.

A comparative study of disorders of gut-brain interaction in Western Europe and Asia based on the Rome foundation global epidemiology study

OBJECTIVE

Many studies have been published on disorders of the gut-brain interaction (DGBI) in Asia and Western Europe, but no previous study has directly assessed the difference between the two regions. The aim was to compare the prevalence of DGBI in Asia and Western Europe.

METHODS

We used data collected in a population-based Internet survey, the Rome Foundation Global Epidemiology Study, from countries in Western Europe (Belgium, France, Germany, Netherlands, Italy, Spain, Sweden, and the United Kingdom) and Asia (China, Japan, South Korea, and Singapore). We assessed DGBI diagnoses (Rome IV Adult Diagnostic Questionnaire), anxiety/depression (Patient Health Questionnaire-4, PHQ-4), non-GI somatic symptoms (PHQ-12), and access to and personal costs of doctor visits.

RESULTS

The study included 9487 subjects in Asia and 16,314 in Western Europe. Overall, 38.0% had at least one DGBI; younger age, female sex, and higher scores on PHQ4 and PHQ12 were all associated with DGBI. The prevalence of having at least one DGBI was higher in Western Europe than in Asia (39.1% vs 36.1%, OR 1.14 [95% CI 1.08-1.20]). This difference was also observed for DGBI by anatomical regions, most prominently esophageal DGBI (OR 1.67 [1.48-1.88]). After adjustment, the difference in DGBI prevalence diminished and psychological (PHQ-4) and non-GI somatic symptoms (PHQ-12) had the greatest effect on the odds ratio estimates.

CONCLUSION

The prevalence of DGBI is generally higher in Western Europe compared to Asia. A considerable portion of the observed difference in prevalence rates seems to be explained by more severe psychological and non-GI somatic symptoms in Western Europe.

Global patterns of prescription pain medication usage in disorders of gut-brain interactions

BACKGROUND

Forty percent of individuals globally meet Rome IV criteria for a disorder of gut-brain interaction (DGBI). The global burden of pain across these disorders has not been characterized.

METHODS

Our study included 54,127 respondents from the 26 Internet survey countries. Prescription pain medication usage was selected as the proxy for pain. The associations between prescription pain medications and the environmental, sociodemographic, psychosocial, and DGBI diagnosis variables were investigated using the multivariate generalized robust Poisson regression model.

KEY RESULTS

Respondents with DGBI used prescription pain medications at higher rates than those without a DGBI diagnosis with pooled prevalence rate of 14.8% (95% confidence interval [CI], 14.4-15.3%), varying by country from 6.8% to 25.7%. The pooled prevalence ratio of prescription pain medication usage in respondents with and without DGBI was 2.2 (95% CI: 2.1-2.4). Factors associated with higher prevalence of pain medication usage among respondents with a DGBI diagnosis included living in a small community, increased anxiety, depression or somatization, increased stress concern or embarrassment about bowel functioning and having more than one anatomic DGBI diagnosis.

CONCLUSION

14.8% of patients globally with at least one diagnosis of DGBI were on prescription pain medications with wide geographic variation, about twice as many as their counterparts without a diagnosis of DGBI. Environmental, sociodemographic, and individual factors may influence clinicians to consider personalized, multimodal approaches to address pain in patients with DGBI.

Epidemiology and Burden of Disorders of Gut-Brain Interaction in Romania: A Subgroup Analysis of the Rome Foundation Global Epidemiology Study

BACKGROUND AND AIMS

Disorders of gut-brain interaction (DGBI) are a group of chronic illnesses that are crucial to public health because they are widespread, influence patients' quality of life and functional level, and exert a major socioeconomic impact. We assessed the national prevalence of all 22 DGBI, the percentage of respondents satisfying diagnostic criteria for at least one DGBI, and the impact on the disease burden in Romania using data from the Rome Foundation Global Epidemiology Study.

METHODS

Data were collected through an anonymous, nationwide, and secure online survey, which evaluated the prevalence of any DGBI as well as over 22 different DGBI. The Rome IV diagnostic questionnaire and an in-depth supplemental questionnaire were included in the survey, which was completed through the Internet with numerous built-in quality-assurance measures.

RESULTS

The survey was completed by 2,049 participants (mean age 42.29±13.11 years) with a representative national distribution. Diagnostic criteria for any DGBI were met in 40.1% of the subjects, while 28.6% met criteria for only one DGBI (no overlap), and 11.5% met criteria for DGBIs in two, three, or four overlapping gastrointestinal anatomical regions. Females had a substantially higher predominance of DGBI than males. Psychosocial characteristics (such as quality of life, somatization, and concern about digestive problems) and healthcare utilization (such as physician visits and medication use) were associated with having any DGBI.

CONCLUSIONS

We provide the first comprehensive evaluation of the prevalence and burden of DGBI in Romania using the Rome IV criteria. The burden of DGBI in Romania is substantial, with 40.1% of the 2,049 participants meeting diagnostic criteria for any DGBI. These findings demonstrate the importance of patient care, and the need for training and future research.

Worldwide prevalence and burden of gastroparesis-like symptoms as defined by the United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis

BACKGROUND/OBJECTIVES

The global epidemiology of gastroparesis is unknown. The European UEG and European Society for Neurogastroenterology and motility consensus defines Gastroparesis as a condition characterized by delayed gastric emptying in the absence of mechanical obstruction, with a symptom pattern of nausea and/or vomiting and overlapping postprandial distress syndrome (PDS). Real-world evidence of this gastroparesis-like symptom pattern is a crucial step in understanding the epidemiology of gastroparesis.

METHODS

In the Rome Foundation Global Epidemiology Study, 54,127 respondents from 26 countries completed the Rome IV Diagnostic Questionnaire and variables associated with disorders of gut-brain interaction via Internet. We selected subjects with gastroparesis-like symptoms (GPLS) (nausea and/or vomiting ≥1 day/week and simultaneous PDS). Patients reporting organic gastrointestinal disease, or fulfilling criteria for self-induced vomiting, cyclic vomiting or cannabinoid hyperemesis syndrome were excluded. We determined prevalence, associated comorbidities, quality of life (QoL) (PROMIS Global-10), symptoms of anxiety and depression (PHQ-4), somatic symptoms (PHQ-12), and healthcare utilization.

RESULTS

The global prevalence of GPLS was 0.9% overall and 1.3% among diabetic individuals. Subjects with GPLS showed frequent overlapping of epigastric pain syndrome and irritable bowel syndrome. Subjects with GPLS had significantly lower body mass index, QoL, more non-gastrointestinal somatic complaints, symptoms of anxiety and depression, higher medication usage and doctor visits in the overall and diabetic population, compared to subjects without these symptoms.

CONCLUSIONS

GPLS are common worldwide and more common in diabetic patients. The symptom complex is associated with multiple aspects of illness and an increased healthcare consumption.

Epidemiology of disorders of Gut-Brain interaction in Israel: Results from the Rome Foundation global epidemiology study

BACKGROUND

Data for Israel from the Rome Foundation Global Epidemiology Study on the disorders of gut-brain interaction (DGBI) were used to assess the national prevalence of all 22 DGBI, the percentage of respondents meeting diagnostic criteria for at least one DGBI, and the impact on burden of disease in Israel.

METHODS

The survey was conducted through the Internet with multiple built-in quality-assurance techniques and included the Rome IV diagnostic questionnaire and an in-depth supplemental questionnaire.

KEY RESULTS

2012 Israeli participants completed the survey nationwide: mean age 44.6 ± 16.4 years, 50% females. The national distribution was very close to the latest Israeli census. 36.4% (95% CI 34.3, 38.4) met diagnostic criteria for at least one DGBI, with 4.4% for any esophageal disorder, 6.5% for any gastroduodenal disorder, 30.8% for any bowel disorder, and 5.3% for any anorectal disorder. The rates were higher for women. Having any DGBI was associated negatively with psychosocial variables (including quality of life, somatization, and concern about digestive problems), and healthcare utilization (including doctor visits, use of medications, and abdominal surgeries).

CONCLUSIONS & INFERENCES

The results of this study provide the first in-depth assessment of the prevalence and burden of Rome IV DGBI in Israel and facilitate comparisons with other countries. As 36.4% of the 2,012 participants met diagnostic criteria for at least one DGBI, and 23.5% of those met criteria for more than one DGBI, the burden of DGBI in Israel is high, indicating a need to focus on research and training for patient care.

Disorders of gut-brain interaction: Highly prevalent and burdensome yet under-taught within medical education

Background and Objective

To determine the population prevalence and associated health impairment of disorders of gut‐brain interaction (DGBI) across Great Britain, and the emphasis placed upon them within medical education.

Methods

An Internet‐based cross‐sectional health survey was completed by 1906 general population adults across Great Britain without self‐reported organic GI disease. The survey enquired for demographics, symptom‐based criteria for Rome IV DGBI, healthcare use, non‐GI somatic symptoms, and quality of life. As a separate analysis, we evaluated which DGBI are considered core knowledge at undergraduate medical school level and post‐graduate specialization level for Gastroenterologists and General Practitioners.

Results

The overall prevalence of DGBI across Great Britain was 37%, being similar for England (37%), Scotland (33%), and Wales (36%); p = 0.66. There was no difference between English regions (range 33%–43%, p = 0.26). The prevalence of DGBI was highest in those aged 18–40 years (40%), then 40–64 years (37%), and least amongst those ≥65 years (29%); p < 0.001. The most common DGBI were bowel disorders (30%), followed by gastroduodenal (10.5%), anorectal (8.1%) and oesophageal disorders (6.2%). Individuals with DGBI were significantly more likely than those without DGBI to have increased GI‐related healthcare visits, medication use, surgical interventions, non‐GI somatic symptoms, and reduced quality of life. One‐in‐three people with DGBI had multiple GI organ regions involved and this correlated with increased health impairment (p < 0.001).

The only DGBI mentioned across all medical training curricula is irritable bowel syndrome, while the General Practitioner and Gastroenterology Curricula also recognise the outdated term non‐ulcer dyspepsia (as opposed to functional dyspepsia). The 2010 Gastroenterology Curriculum also includes functional constipation and disordered defecation, with the incoming 2022 iteration adding in functional upper GI syndromes, functional abdominal pain, and opioid‐induced GI disturbances.

Conclusion

Disorders of gut‐brain interaction are common across Great Britain and incur substantial health impairment. However, they are generally under‐taught within the British medical education system. Increasing awareness and education of disorders of gut‐brain interaction might improve patient outcomes.

Functional Gastrointestinal Disorders and Associated Health Impairment in Individuals with Celiac Disease

BACKGROUND & AIMS

Individuals with celiac disease (CD) can experience persisting gastrointestinal symptoms despite adhering to a gluten-free diet (GFD). This may be due to functional gastrointestinal disorders (FGIDs), although there is little data on its prevalence and associated factors.

METHODS

An online health questionnaire was completed by adult members of Celiac UK in October 2018. The survey included validated questions on Rome IV FGIDs, nongastrointestinal somatic symptoms, anxiety, depression, quality of life, health care use, GFD duration, and its adherence using the celiac dietary adherence test score (with a value ≤ 13 indicating optimal adherence). The prevalence of FGIDs and associated health impairment in the celiac cohort was compared against an age- and sex-matched population-based control group.

RESULTS

Of the 863 individuals with CD (73% female; mean age, 61 years), all were taking a GFD for at least 1 year, with 96% declaring that they have been on the diet for 2 or more years (2-4 years, 20%; ≥5 years, 76%). The adherence to a GFD was deemed optimal in 61% (n = 523), with the remaining 39% (n = 340) nonadherent. Those adhering to a GFD fulfilled criteria for a FGID in approximately one-half of cases, although this was significantly lower than nonadherent subjects (51% vs 75%; odds ratio [OR], 2.0; P < .001). However, the prevalence of FGIDs in GFD-adherent subjects was significantly higher than in matched population-based controls (35%; OR, 2.0; P < .001). This was accounted for by functional bowel (46% vs 31%; OR, 1.9; P < .0001) and anorectal disorders (14.5% vs 9.3%; OR, 1.7; P = .02) but not functional esophageal (7.6% vs 6.1%; P = .36) or gastroduodenal disorders (8.7% vs 7.4%; P = .47). Finally, GFD-adherent subjects with FGIDs were significantly more likely than their counterparts without FGIDs to have abnormal levels of anxiety (5% vs 2%; OR, 2.8; P = .04), depression (7% vs 2%; OR, 3.6; P = .01), somatization (31% vs 8%; OR, 5.1; P < .0001), and reduced quality of life (P < .0001).

CONCLUSION

One in 2 people with CD, despite having been on a GFD for a number of years and demonstrating optimal adherence, have ongoing symptoms compatible with a Rome IV FGID. This is 2-fold the odds of FGIDs seen in age- and sex-matched controls. The presence of FGIDs is associated with significant health impairment, including psychological comorbidity. Addressing disorders of gut-brain interaction might improve outcomes in this specific group of patients.

Greater Overlap of Rome IV Disorders of Gut-Brain Interactions Leads to Increased Disease Severity and Poorer Quality of Life

BACKGROUND AND AIMS

Conditions such as irritable bowel syndrome (IBS), functional dyspepsia, and functional constipation are among the prevalent gastrointestinal (GI) disorders classified as disorders of gut-brain interaction (DGBI), which can adversely affect the lives of sufferers. This study aimed to assess the degree and consequences of overlapping DGBI in a large population-based global scale.

METHODS

Internet survey data from 54,127 adults (49.1% women) in 26 countries were analyzed by 4 GI anatomic regions (esophageal, gastroduodenal, bowel, and anorectal). The number of DGBI-affected GI regions was assessed, including associations with sex, age, disease severity, quality of life, psychosocial variables, and health care utilization.

RESULTS

A total of 40.3% of surveyed individuals met Rome IV criteria for a DGBI. The percentages with 1-4 DGBI-affected GI regions were 68.3%, 22.3%, 7.1%, and 2.3%, respectively. The IBS symptom severity score increased significantly from 1 (207.6) to 4 (291.6) regions, as did non-GI symptom reporting (somatization), anxiety and depression, concerns and embarrassment about bowel function, doctor visits, medications, and abdominal surgeries (all P < .0001). Quality of life decreased with increasing number of DGBI regions (P < .0001). In a logistic mixed model, non-GI symptoms (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.08-1.10), being very vs not concerned (OR, 2.55; 95% CI, 2.27-2.90), being very vs not embarrassed about bowel function (OR, 1.20; 95% CI, 1.08-1.33), and mean number of doctor visits (OR, 1.23; 95% CI, 1.115-1.32) were most strongly associated with number of DGBI regions.

CONCLUSIONS

DGBI in multiple anatomic GI regions is associated with increased psychological comorbidity, health care utilization, and IBS severity. Physician awareness of overlap could improve quality of care, prevent unnecessary interventions, and yield more positive health outcomes.

Global Prevalence and Impact of Rumination Syndrome

BACKGROUND & AIMS

Rumination syndrome is a Disorder of Gut-Brain Interaction (DGBI) of unknown etiology. We aimed to assess its global prevalence and potential associations with other medical conditions.

METHODS

Data were collected via the Internet in 26 countries. Subjects were evenly distributed by country, sex, and age groups and were invited for a "health survey" using the Rome IV diagnostic questionnaire and a supplementary questionnaire addressing factors potentially associated with DGBI.

RESULTS

In all, 54,127 subjects completed the survey (51% male; mean age, 44.3 years). The overall prevalence of rumination syndrome was 3.1% (95% confidence interval [CI], 3.0-3.3%). It was highest in Brazil (5.5% CI, 4.5-6.5) and lowest in Singapore (1.7% CI, 1.1-2.2). The mean age of people with rumination syndrome was 44.5 years (standard deviation, 15.6) and it was more common in females (54.5% vs 45.5%). Factors independently associated with rumination syndrome were depression (odds ratio [OR], 1.46), anxiety (OR, 1.8), body mass index (OR, 1.04), and female sex (OR, 1.19). Subjects with multiple DGBI were at increased risk of having rumination syndrome, with the highest risk in subjects with 4 gastrointestinal regions with DGBI (OR, 15.9 compared with none). Quality of life (QoL) was lower in subjects with rumination syndrome compared with the rest of the cohort (PROMIS-10 score: physical QoL mean 12.9 vs 14.5; mental QoL mean 12.0 vs 13.6).

CONCLUSIONS

The prevalence of rumination syndrome is higher than reported in most previous population studies and is likely underdiagnosed in clinical practice. Awareness of rumination syndrome should be raised among clinicians to improve care for these patients.

Global prevalence and burden of meal-related abdominal pain

BACKGROUND

Patients with disorders of gut-brain interaction (DGBI) report meal intake to be associated with symptoms. DGBI patients with meal-related symptoms may have more severe symptoms overall and worse health outcomes, but this subgroup has not been well characterized. We aimed to describe the global prevalence of meal-related abdominal pain and characterize this subgroup.

METHODS

The data analyzed originated from the Internet survey component of the population-based Rome Foundation Global Epidemiology Study, completed in 26 countries (n = 54,127). Adult subjects were asked whether they had abdominal pain and how often this was meal-related. Respondents were categorized into "no," "occasional," and "frequent" meal-related abdominal pain groups based on 0%, 10-40%, and ≥50% of the pain episodes being meal-related, respectively. DGBI diagnoses, frequency of other GI symptoms, psychological distress, non-GI somatic symptoms, quality of life, and healthcare utilization were compared between groups. Mixed linear and ordinal regression was used to assess independent associations between psychological distress, non-GI somatic symptoms, quality of life, other GI symptoms, and meal-related abdominal pain.

RESULTS

Overall, 51.9% of the respondents reported abdominal pain in the last 3 months, and 11.0% belonged to the group with frequent meal-related abdominal pain, which included more females and younger subjects. DGBI diagnoses were more common in subjects with frequent meal-related abdominal pain, and the frequency of several GI symptoms was associated with having more frequent meal-related abdominal pain. Having meal-related abdominal pain more frequently was also associated with more severe psychological distress, non-GI somatic symptoms, and a poorer quality of life. The group with frequent meal-related abdominal pain also more often consulted a doctor for bowel problems compared to the other groups of meal-related abdominal pain.

CONCLUSION

Reporting frequent meal-related abdominal pain is common across the globe and associated with other GI and non-GI somatic symptoms, psychological distress, healthcare utilization, and a poorer quality of life. Individuals who frequently experience meal-related abdominal pain also more frequently fulfill the diagnostic criteria for DGBI. Assessing meal-related symptoms in all DGBI patients could be of major importance to improve and individualize symptom management.

Review article: epidemiology of IBS and other bowel disorders of gut-brain interaction (DGBI)

The disorders of gut-brain interactions (DGBI) are a spectrum of gastrointestinal (GI) disorders that involve the entire GI tract and are usually categorised into four major anatomic GI regions, oesophageal, gastroduodenal, bowel and anorectal. Irritable bowel syndrome (IBS), a bowel DGBI, is one of the most researched DGBI and has been the subject of copious epidemiological studies. Prevalence rates are based on diagnostic criteria. In the case of IBS, there are three central obstacles to attaining a clear picture of prevalence: the absence of biomarkers, the multitude of diagnostic criteria used over the years, and the heterogeneous nature of the methodology used in epidemiologic surveys. When the results of multiple studies, conducted over a long period of time, using different diagnostic criteria and different research methodology, and involving different study populations are pooled to determine a single summary prevalence rate it is difficult to interpret the results and to determine their reliability and significance. This pitfall is insufficiently recognised and unfortunate because prevalence rates are important for understanding the burden of disease, for allocating healthcare and research resources, and for incentivising and prioritising new treatments. The aims of the present paper are to highlight our knowledge and understanding of IBS epidemiology within the context of other DGBI, and to present strategies to improve epidemiological research, especially in advance of the new Rome V criteria, to be published in 2026.

Health care utilization of individuals with Rome IV irritable bowel syndrome in the general population

BACKGROUND

Irritable bowel syndrome (IBS) is highly prevalent worldwide but mechanisms for healthcare seeking behaviours in this patient group are poorly understood.

OBJECTIVE

To describe healthcare utilization and identify factors associated with seeking healthcare amongst IBS subjects in the general population.

METHODS

An internet survey was completed by 6,300 individuals equally distributed between United States, United Kingdom and Canada. The Rome IV diagnostic questionnaire was used to identify subjects with IBS. Data on demographics, medical history, gastrointestinal (GI) and non-GI symptoms, quality of life and health care consumption was collected.

RESULTS

A total of 5,931 subjects were included; 274 (4.6%) IBS subjects and 5657 (95.3%) non-IBS controls. IBS subjects reported more doctor consultations for both GI and other health problems as well as increased use of medication and rate of abdominal surgery (appendectomy excluded). Having healthcare insurance or access to free public healthcare (adjusted odds ratio (AOR) 4.49, 95% confidence interval (CI) 1.31-15.44), followed by high frequency of bloating (AOR 2.65, 95% CI 1.42-4.93) and increasing age (AOR 1.02, 95% CI 1.01-1.05) were found to be independently associated with being an IBS consulter while doctor-diagnosed IBS subjects were more likely to be female and to report abdominal pain as their most bothersome GI symptom than other consulters with IBS.

CONCLUSION

IBS subjects have higher healthcare utilization than non-IBS controls, medication use and abdominal surgery included. Furthermore, consulters with and without an IBS diagnosis differ in sex distribution and symptom profiles. Hence, awareness of the possibility of unnecessary medical and surgical treatment in IBS subjects and a sex-related diagnostic bias by doctors is warranted.

Epidemiology and Burden of Irritable Bowel Syndrome: An International Perspective

Irritable bowel syndrome (IBS) prevalence rates are based on diagnostic criteria, the basis for case definitions. Diagnostic criteria have a substantial impact on prevalence rates, which are significant for understanding burden of disease, comparing global subpopulations, generating pathophysiologic research, allocating of health care and research resources, and incentivizing and prioritizing new treatments. There are substantial methodological pitfalls in epidemiologic research, so determining regional and global IBS prevalence rates is problematic. The Rome Foundation Global Epidemiology Study was designed to resolve these problems and achieve more valid results. The results of this study are presented in detail; future directions are discussed.

Psychological defense mechanisms and use of corporeal discourse: a comparison between patients with irritable bowel syndrome, medical personnel and healthy volunteers

OBJECTIVE

The aim of this study was to compare the use of psychological defense mechanisms and corporeal discourse among patients with irritable bowel syndrome (IBS), medical personnel and healthy volunteers.

METHODS

All participants completed an identical battery of questionnaires: a demographic questionnaire, the Corporeal Discourse Questionnaire, the Defense Style Questionnaire and a Visual Analogue Scale for situational anxiety and depression. Patients and medical personnel were recruited from the Rabin Medical Center, a tertiary university-affiliated hospital. Findings were analyzed according to the study variables and compared among the groups.

RESULTS

Questionnaires were completed by 40 patients with IBS, 39 medical personnel and 40 healthy volunteers. Correlations between the study variables within the entire study group (all study participants, N = 119) revealed that corporeal discourse was found to be significantly correlated with the immature and neurotic class of defense mechanisms (r = 0.41, P < 0.01 and r = 0.20, P < 0.05, respectively), depression (r = 0.46, P < 0.05) and anxiety (r = 0.46, P < 0.05). Differences between IBS and the other two groups were significant for corporeal discourse, depression, anxiety and use of immature defense mechanisms. Posthoc analyses showed that medical personnel differed from IBS patients in all of these measures. Healthy volunteers had an inconsistent pattern of differences from the other two groups.

CONCLUSION

Maturity level of defense mechanisms and the tendency to use corporeal discourse are expressed among IBS patients in a diverse and unique manner. These findings may indicate additional psychological mechanisms that could explain the use of somatic complaints in IBS and support the implementation of tailored psychological interventions.

Rome IV Functional Gastrointestinal Disorders and Health Impairment in Subjects With Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome

BACKGROUND & AIMS

Individuals with hypermobility spectrum disorder or hypermobile Ehlers-Danlos Syndrome (HSD/hEDS) are increasingly encountered by gastroenterologists and pose complex clinical challenges. Uncontrolled studies have found functional gastrointestinal disorders (FGIDs) to be common in patients with HSD/hEDS. Some patients have somatic symptoms (medically unexplained symptoms) that might affect FGIDs. We performed a case-control study to determine the prevalence of and factors associated with Rome IV FGIDs in subjects with HSD/hEDS compared with age- and sex- matched population-based controls.

METHODS

An online general health survey was completed by 603 individuals with HSD/hEDS in October 2018 (cases) and 603 matched individuals from the population of the United Kingdom (controls) in 2015. The mean participant age was 39 yrs, and 96% were women. The survey included questions about Rome IV FGIDs, non-GI and non-musculoskeletal somatic symptoms (maximum number, 10), quality of life, medical history and healthcare use. The prevalence of FGIDs was compared between cases and controls, with subsequent logistic regression models - adjusting for the number of somatic symptoms - used to determine the associations for FGIDs in HSD/hEDS compared with controls.

RESULTS

Nearly all subjects (98%) with HSD/hEDS fulfilled symptom-based criteria for 1 or more Rome IV FGIDs, compared with 47% of controls (P < .0001). The gastrointestinal regions most commonly affected by FGIDs in individuals with HSD/hEDS and control subjects were the bowel (90% vs 40% of controls), gastroduodenal (70% vs 13% of controls), esophageal (56% vs 6% of controls), and anorectal (53% vs 9% of controls); P < .0001. A higher proportion of subjects with HSD/hEDS had FGIDs in 2 or more regions (84% vs 15% of controls; P < .0001). Subjects with HSD/hEDS also reported a significantly higher number of non-GI and non-musculoskeletal somatic symptoms (7.1 vs 3.3 in controls), lower quality of life, and greater healthcare use, including abdominal surgeries and medication use (for example, 84% used analgesics compared with 29% of controls). Almost 40% of subjects with HSD/hEDS reported a diagnosis of chronic fatigue syndrome and/or fibromyalgia. Following adjustments for somatic symptoms, the association for FGIDs in subjects with HSD/hEDS was reduced by as much as 4-fold and in some instances was eliminated.

CONCLUSIONS

In a large case-control study of persons with HSD/hEDS, almost all of the cases met criteria for Rome IV FGIDs, incurred considerable health impairment, and had high healthcare use. Patients with HSD/hEDS frequently have somatic symptoms that should be treated to reduce the high burden of gastrointestinal illness in this population.

Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study

BACKGROUND & AIMS

Although functional gastrointestinal disorders (FGIDs), now called disorders of gut-brain interaction, have major economic effects on health care systems and adversely affect quality of life, little is known about their global prevalence and distribution. We investigated the prevalence of and factors associated with 22 FGIDs, in 33 countries on 6 continents.

METHODS

Data were collected via the Internet in 24 countries, personal interviews in 7 countries, and both in 2 countries, using the Rome IV diagnostic questionnaire, Rome III irritable bowel syndrome questions, and 80 items to identify variables associated with FGIDs. Data collection methods differed for Internet and household groups, so data analyses were conducted and reported separately.

RESULTS

Among the 73,076 adult respondents (49.5% women), diagnostic criteria were met for at least 1 FGID by 40.3% persons who completed the Internet surveys (95% confidence interval [CI], 39.9-40.7) and 20.7% of persons who completed the household surveys (95% CI, 20.2-21.3). FGIDs were more prevalent among women than men, based on responses to the Internet survey (odds ratio, 1.7; 95% CI, 1.6-1.7) and household survey (odds ratio, 1.3; 95% CI, 1.3-1.4). FGIDs were associated with lower quality of life and more frequent doctor visits. Proportions of subjects with irritable bowel syndrome were lower when the Rome IV criteria were used, compared with the Rome III criteria, in the Internet survey (4.1% vs 10.1%) and household survey (1.5% vs 3.5%).

CONCLUSIONS

In a large-scale multinational study, we found that more than 40% of persons worldwide have FGIDs, which affect quality of life and health care use. Although the absolute prevalence was higher among Internet respondents, similar trends and relative distributions were found in people who completed Internet vs personal interviews.

Functional gastrointestinal disorders are increased in joint hypermobility-related disorders with concomitant postural orthostatic tachycardia syndrome

BACKGROUND

Individuals with hypermobility spectrum disorders/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) frequently fulfill criteria for Rome IV functional gastrointestinal disorders (FGIDs). Postural orthostatic tachycardia syndrome (POTS) is also commonly reported in HSD/hEDS and may impact on co-morbidity with and severity of FGIDs, although this remains to be studied. We determined the impact of concomitant POTS and HSD/hEDS on their association with Rome IV FGIDs.

METHODS

With the help of the charity organization Ehlers-Danlos Support UK, an online cross-sectional health survey was completed by individuals with HSD/hEDS. The survey enquired for (a) self-reported doctor diagnosis of POTS, chronic fatigue syndrome, and fibromyalgia, (b) the presence and symptom frequency of Rome IV FGIDs, and (c) anxiety and depression scores.

KEY RESULTS

Of 616 subjects with HSD/hEDS, 37.5% reported a doctor diagnosis of POTS. POTS-positive individuals were significantly younger than POTS-negative subjects (37 vs 40 years, P = 0.002), more likely to report chronic fatigue syndrome (44% vs 31%, P < 0.0001), and showed a trend toward increased prevalence of fibromyalgia (44% vs 37%, P = 0.06) and higher depression score (P = 0.07). POTS-positive subjects were also more likely to fulfill criteria for Rome IV FGIDs across various organ domains and experienced both upper and lower gastrointestinal symptoms significantly more frequently. The increased associations for FGIDs and GI symptom frequency remained unchanged in HSD/hEDS subjects with POTS following adjustments for age, chronic fatigue syndrome, fibromyalgia, and depression scores.

CONCLUSIONS AND INFERENCES

The high FGID burden in HSD/hEDS is further amplified in the presence of POTS. Future studies should elucidate the mechanism by which POTS arises in HSD/hEDS and is associated with increased GI symptoms.

Irritable bowel syndrome

Irritable bowel syndrome is a functional gastrointestinal disorder with symptoms including abdominal pain associated with a change in stool form or frequency. The condition affects between 5% and 10% of otherwise healthy individuals at any one point in time and, in most people, runs a relapsing and remitting course. The best described risk factor is acute enteric infection, but irritable bowel syndrome is also more common in people with psychological comorbidity and in young adult women than in the rest of the general population. The pathophysiology of irritable bowel syndrome is incompletely understood, but it is well established that there is disordered communication between the gut and the brain, leading to motility disturbances, visceral hypersensitivity, and altered CNS processing. Other less reproducible mechanisms might include genetic associations, alterations in gastrointestinal microbiota, and disturbances in mucosal and immune function. In most people, diagnosis can be made on the basis of clinical history with limited and judicious use of investigations, unless alarm symptoms such as weight loss or rectal bleeding are present, or there is a family history of inflammatory bowel disease or coeliac disease. Once the diagnosis is made, an empathetic approach is key and can improve quality of life and symptoms, and reduce health-care expenditure. The mainstays of treatment include patient education about the condition, dietary changes, soluble fibre, and antispasmodic drugs. Other treatments tend to be reserved for people with severe symptoms and include central neuromodulators, intestinal secretagogues, drugs acting on opioid or 5-HT receptors, or minimally absorbed antibiotics (all of which are selected according to predominant bowel habit), as well as psychological therapies. Increased understanding of the pathophysiology of irritable bowel syndrome in the past 10 years has led to a healthy pipeline of novel drugs in development.

Burnout, but not job strain, is associated with irritable bowel syndrome in working adults

OBJECTIVE

Although stress is an important component of irritable bowel syndrome (IBS) pathophysiology, the possibility that work-related stress is implicated in the pathophysiology of IBS has not been widely studied. This study aimed to examine whether job strain (a combination of high job demands and low control at work) and/or burnout, the outcome of a gradual depletion of energetic resources resulting from chronic exposure to work-related stress, are associated with IBS.

METHODS

Fifty-five patients fulfilling the Rome III criteria for IBS and 214 matched healthy controls (HC) participated in this cross-sectional study. All participants completed a job strain measure, the Shirom - Melamed Burnout Measure (SMBM), and dietary and health questionnaires.

RESULTS

There was no significant difference in the prevalence of job strain between IBS patients and HC (25.5% vs. 23.0%, respectively). Job strain was not associated with increased IBS prevalence (adjusted OR = 1.99, 95% CI: 0.54-7.33). In contrast, the mean burnout score in the IBS group was significantly higher than in HC (2.9 ± 1.1 vs. 2.1 ± 0.8, p < .001). Burnout was associated with a 2.41-fold elevated prevalence of IBS (95% CI: 1.16-5.02), after adjusting for potential confounding variables including job strain. Moreover, the odds of having IBS increased in patients with a high burnout level (adjusted OR = 3.3, 95% CI:1.09-10.03).

CONCLUSION

Burnout, but not job strain, is associated with the prevalence of IBS in working adults.

Prevalence of Rome IV Functional Bowel Disorders Among Adults in the United States, Canada, and the United Kingdom

BACKGROUND & AIMS

Little is known about the population prevalence or demographic distributions of Rome IV functional bowel disorders (FBDs) or their effects on quality of life. We examined these in a multinational survey.

METHODS

We analyzed data from a population-based survey of adults in the United States, Canada, and United Kingdom (5931 valid responders; 49.2% female; mean age, 47.4 years; range, 18-92 years). The survey included the Rome IV Diagnostic Questionnaire, Rome III irritable bowel syndrome (IBS) and constipation questions, and the SF-8 quality of life questionnaire.

RESULTS

The prevalence values of census-adjusted Rome IV FBDs were similar among the 3 countries; ranges were: 4.4%-4.8% for IBS, 7.9%-8.6% for functional constipation, 3.6%-5.3% for functional diarrhea, 2.0%-3.9% for functional bloating or distention, 1.1%-1.9% for opioid-induced constipation, 7.5%-10.0% for unspecified FBDs, and 28.6%-31.7% for any Rome IV FBD. FBDs were less common in older individuals, and all except functional diarrhea were more common in women. IBS was only half as prevalent by Rome IV as by Rome III criteria (4.6% vs 9.0% overall), primarily due to higher Rome IV minimum pain frequency. Functional diarrhea and functional constipation were more prevalent by Rome IV than Rome III criteria. Subjects with FBD had significant reductions in quality of life and reported more gastrointestinal doctor consultations than other subjects.

CONCLUSIONS

More than 1 in 4 adults in the general population meet the Rome IV criteria for FBDs. These disorders affect quality of life and increase use of gastrointestinal health care. The switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.

Fecal Incontinence Diagnosed by the Rome IV Criteria in the United States, Canada, and the United Kingdom

BACKGROUND & AIMS

The diagnostic criteria for fecal incontinence (FI) were made more restrictive in the Rome IV revision. We aimed to determine the characteristics of FI patients defined by the Rome IV criteria, assess how FI frequency and amount affect quality of life, identify risk factors, and compare prevalence values among countries.

METHODS

We performed an internet-based survey of 5931 subjects in the United States, Canada, and the United Kingdom, from September to December 2015. Subjects were stratified by country, sex, and age. Responders answered questions about diagnosis, health care use, and risk factors. We performed multivariate linear regression analysis to identify risk factors for FI.

RESULTS

FI was reported by 957 subjects (16.1%) but only 196 (3.3%) fulfilled the Rome IV criteria. Frequency of FI was less than twice a month for 672/957 subjects (70.2%) and duration was less than 6 months for 285/957 subjects (29.8%). Quality of life was significantly impaired in all subjects with FI compared to subjects with fecal continence. The strongest risk factors for FI were diarrhea, urgency to defecate, and abdominal pain. FI was more prevalent in the United States than in the United Kingdom. Between-country differences were due to less diarrhea and urgency in the United Kingdom.

CONCLUSIONS

Rome IV FI prevalence is lower than previous estimates because the new criteria exclude many individuals with less frequent or short duration FI. These excluded patients have impaired quality of life. It might be appropriate to make a diagnosis of FI for all patients with FI ≥2 times in 3 months and to provide additional information on frequency, duration, and amount of stool lost to assist clinicians in treatment selection.

Subgroups of IBS patients are characterized by specific, reproducible profiles of GI and non-GI symptoms and report differences in healthcare utilization: A population-based study

BACKGROUND

In a previous clinical sample of IBS patients, subgroups characterized by profiles of GI and non-GI symptoms were identified. We aimed to replicate these subgroups and symptom associations in participants fulfilling IBS diagnostic criteria from a population-based study and relate them to healthcare utilization.

METHODS

An Internet-based health survey was completed by general population adults from United States, Canada, and UK. Respondents fulfilling IBS diagnosis (Rome III and IV) were analyzed for latent subgroups using Gaussian mixture model analysis. Symptom measures were derived from validated questionnaires: IBS-related GI symptoms (Rome IV), extraintestinal somatic symptoms (PHQ-12), and psychological symptoms (SF-8).

KEY RESULTS

A total of 637 respondents fulfilled Rome III criteria (average age 46 years, range 18-87, 66% females) and 341 Rome IV criteria (average age 44, range 18-77, 64% female) for IBS. Seven subgroups were identified in the Rome III cohort, characterized by profiles of GI symptoms (constipation-related, diarrhea-related, and mixed, respectively), and further distinguished by the presence or absence of non-GI comorbidities. The Rome IV cohort showed five similar but less distinct subgroups with a preponderance of mixed symptom profiles. Higher severity of non-GI comorbidities was associated with more frequent healthcare visits and medication usage.

CONCLUSIONS AND INFERENCES

In line with previous findings in a clinical IBS cohort, we were able to identify population-based subgroups characterized by a combination of GI symptoms with the additional distinction made by varying severity of non-GI symptoms and with differences in healthcare utilization.

Serum cholinesterase activity is elevated in female diarrhea-predominant irritable bowel syndrome patients compared to matched controls

BACKGROUND

Micro-inflammation is involved in the pathogenesis of irritable bowel syndrome (IBS). The parasympathetic nervous system, via acetylcholine (ACh), and its hydrolytic enzymes, plays a role in regulating inflammation. Increased serum cholinesterase activity, named cholinergic Status (CS), is associated with decreased inflammatory inhibition (ie, pro-inflammation). We assessed the association between IBS diarrhea-predominant (IBS-D) symptoms, CS, and inflammatory biomarkers.

METHODS

Women with IBS-D were prospectively recruited. Serum acetylcholinesterase (AChE), CS, and high-sensitivity C-reactive protein (hs-CRP) levels were analyzed and fecal calprotectin (FC) in a subgroup of patients. The control group included women attending routine health checkups (matched by age and BMI).

KEY RESULTS

Ninety-four women with IBS-D were compared to matched controls (1:1). Serum CS, AChE, and the AChE/butyrylcholinesterase (BChE) ratios were significantly increased in the IBS-D group compared to matched controls (P = 0.018, P = 0.001, and P = 0.004, respectively). Using a multiple logistic regression model, IBS-D was almost twice as likely in women with high CS compared to women with low CS (adjusted OR=1.84 (95% CI: 1.01-3.33), P = 0.045). Furthermore, IBS-D patients with higher hs-CRP levels demonstrated lower CS and BChE activity and elevated AChE and AChE/BChE ratios compared to patients with lower hs-CRP levels (P = 0.026, P = 0.036, P = 0.002; and P = 0.0007, respectively). CS was not correlated with the IBS symptoms score.

CONCLUSIONS AND INFERENCES

This is the first study to explore the potential role of serum CS in IBS-D. The findings emphasize the possible role of the autonomic nervous system and its anti-inflammatory properties in IBS.

Oesophageal symptoms are common and associated with other functional gastrointestinal disorders (FGIDs) in an English-speaking Western population

BACKGROUND

The prevalence and frequency of oesophageal symptoms suggestive of a functional oesophageal disorder according to the Rome IV criteria are unknown.

OBJECTIVE

We aimed to describe the prevalence and risk factors for oesophageal symptoms compatible with functional oesophageal disorders in the general population.

METHODS

Data were analysed from a population-based online survey of 6300 individuals aged ≥ 18 years in the USA, UK and Canada with equal demographic proportions across countries. Questions included the Rome IV diagnostic questionnaire, demographics, medication, somatization, quality of life, and organic gastrointestinal (GI) disease. Multivariate analysis was used to identify factors independently related to oesophageal symptoms.

RESULTS

Data from 5177 participants (47.8% female; mean age 46.7 years) were available for analysis. Symptom prevalence was 8.1% for globus, 6.5% for heartburn, 4.5% for dysphagia and 5.2% for chest pain, and 17.0% reported at least one oesophageal symptom. Oesophageal symptoms were independently associated with younger age, female gender, previous abdominal surgery and the presence of other functional GI disorders. Reporting oesophageal symptoms was associated with reduced quality of life.

CONCLUSION

Oesophageal symptoms are common in the general population and important predictors include other functional GI disorders, age and gender. Oesophageal symptoms are associated with poorer quality of life.

Factor Analysis Defines Distinct Upper and Lower Gastrointestinal Symptom Groups Compatible With Rome IV Criteria in a Population-based Study

BACKGROUND & AIMS

The Rome IV criteria define functional gastrointestinal (GI) disorders by specific combinations of symptoms. It is possible to empirically evaluate these symptom combinations by factor analysis (a statistical procedure that groups variables that correlate). However, this analysis has not been performed for the Rome IV criteria, and factor analyses based on the previous versions of the Rome criteria did not use population-based data. We therefore investigated symptom grouping by the Rome IV questionnaire using factor analysis of a population-based sample.

METHODS

The Rome IV questionnaire was completed online in English by 5931 respondents from the United Kingdom, United States, and Canada (49% female, age range, 18-92 years). We performed an exploratory factor analysis on the Rome IV questions. Next, we performed a confirmatory factor analysis to compare the exploratory factor result to that of the Rome IV criteria.

RESULTS

The exploratory factor analysis identified 8 factors that accounted for 45% of the variance in response: constipation, diarrhea, irritable bowel syndrome, abdominal pain, heartburn, nausea or vomiting, globus, and other upper GI symptoms. Most factors corresponded to distinct functional GI disorders defined by the Rome IV criteria-exceptions included abdominal pain and upper GI symptoms. In confirmatory factor analysis, the exploratory model fitted slightly better than that based on the Rome IV criteria (root mean square error of approximation, 0.063 vs 0.077).

CONCLUSIONS

We used factor analysis to identify distinct upper and lower GI symptom groups that are compatible with the Rome IV criteria. Our findings support the use of the Rome IV criteria in research and clinical practice as a basis for development of diagnostics and management of patients.

A double-blind, placebo-controlled study to assess the effect of a probiotic mixture on symptoms and inflammatory markers in women with diarrhea-predominant IBS

BACKGROUND

Micro-inflammation is considered an element in the pathogenesis of irritable bowel syndrome (IBS). High-sensitivity C reactive protein (hs-CRP) was previously shown to be higher in IBS compared to healthy controls, albeit within the normal range. Since probiotics may suppress micro-inflammation in the gut, we tested if they reduce symptoms and inflammatory markers (hs-CRP and fecal calprotectin (FC) in diarrhea-predominant IBS (IBS-D). The aim of this study was to assess the clinical and laboratory effects of BIO-25, a multispecies probiotic, in women with IBS-D.

METHODS

A double-blind, placebo-controlled study. Following a 2-week run-in, eligible women were assigned at random to a probiotic capsule or an indistinguishable placebo, twice daily for 8 weeks. IBS symptoms and stool consistency were rated daily by Visual Analogue Scales (VAS) and the Bristol Stool Scale (BSS). High-sensitivity C reactive protein was tested at baseline, 4 and 8 weeks. FC was tested at baseline and 8 weeks.

KEY RESULTS

One hundred and seventy-two IBS-D patients were recruited and 107 eligible patients were allocated to the intervention (n=54) or placebo (n=53) group. All symptoms improved in both groups with no significant difference between them in symptom improvement, hs-CRP or FC levels.

CONCLUSIONS & INFERENCES

An 8-week treatment with BIO-25 improved symptoms in women with IBS-D, but was not superior to placebo. This rigorously designed and executed study supports the findings of other studies that did not demonstrate superiority of probiotics over placebo in IBS. High quality clinical studies are necessary to examine the efficacy of other specific probiotics in IBS-D patients since data are still conflicting.

The global prevalence of IBS in adults remains elusive due to the heterogeneity of studies: a Rome Foundation working team literature review

OBJECTIVES

The global prevalence of IBS is difficult to ascertain, particularly in light of the heterogeneity of published epidemiological studies. The aim was to conduct a literature review, by experts from around the world, of community-based studies on IBS prevalence.

DESIGN

Searches were conducted using predetermined search terms and eligibility criteria, including papers in all languages. Pooled prevalence rates were calculated by combining separate population survey prevalence estimates to generate an overall combined meta-prevalence estimate. The heterogeneity of studies was assessed.

RESULTS

1451 papers were returned and 83, including 288 103 participants in 41 countries, met inclusion criteria. The mean prevalence among individual countries ranged from 1.1% in France and Iran to 35.5% in Mexico. There was significant variance in pooled regional prevalence rates ranging from 17.5% (95% CI 16.9% to 18.2%) in Latin America, 9.6% (9.5% to 9.8%) in Asia, 7.1% (8.0% to 8.3%) in North America/Europe/Australia/New Zealand, to 5.8% (5.6% to 6.0%) in the Middle East and Africa. There was a significant degree of heterogeneity with the percentage of residual variation due to heterogeneity at 99.9%.

CONCLUSIONS

The main finding is the extent of methodological variance in the studies reviewed and the degree of heterogeneity among them. Based on this, we concluded that publication of a single pooled global prevalence rate, which is easily calculated, would not be appropriate or contributory. Furthermore, we believe that future studies should focus on regional and cross-cultural differences that are more likely to shed light on pathophysiology.