A39 HEALTHY FIRST-DEGREE RELATIVES FROM MULTIPLEX FAMILIES VERSUS SIMPLEX HARBOR A HIGHER RISK OF DEVELOPING CROHN'S DISEASE AND ARE ASSOCIATED WITH SUBCLINICAL INFLAMMATION AND ALTERED MICROBIOME COMPOSITION

Background

Healthy individuals within families with multiple affected members (multiplex families) with Crohn’s disease (CD) have a notably high risk of developing CD. No large prospective pre-disease cohort has assessed differences in preclinical intestinal inflammation, permeability, fecal microbiome, and genetics in healthy at-risk subjects from multiplex families.

Purpose

We aimed to assess differences in subclinical gut inflammation, genetic risk, gut barrier function, and fecal microbiota composition between first-degree relatives (FDRs) from families with 2 or more affected members (multiplex) and families with only one affected member (simplex). Also, we aimed to assess the risk of future CD onset in subjects from multiplex versus simplex families.

Method

We utilized the GEM Project cohort of healthy FDRs of CD patients. Subclinical gut inflammation was assessed using fecal calprotectin (FCP) at recruitment. Gut barrier function was assessed using the lactulose-to-mannitol ratio (LMR). For assessment of the CD-related genetic risk, CD-polygenic risk scores (CD-PRS) were calculated. Microbiome composition was assessed by sequencing fecal 16S ribosomal RNA. Generalized estimating equations logistic regression and LEfSe (PMID: 21702898) were used to assess the associations between multiplex status and different outcomes. A Cox proportional hazards model was used to assess time-related risk of future onset of CD.

Result(s)

4385 subjects were included. Median age was 17 [IQR 12-24] years, 52.9% were female, 69.4% were siblings and 30.6% were offspring. 4052 (92.4%) and 333 (7.6 %) were simplex and multiplex subjects, respectively. After adjusting for age, sex, family size, and relation to proband, multiplex status was significantly associated with higher baseline FCP (p=0.038), but was not associated with either baseline LMR or CD-PRS (p=0.19 and p=0.33, respectively).

We found no significant differences in alpha diversity (Shannon index) (p=0.57) between simplex and multiplex subjects. Beta diversity analysis assessed by the Bray-Curtis dissimilarity index did not reveal significant differences (R2=3e-04, p=0.607). The genera Eisenbergiella, Eggerthellaceae uncultured, and Morganella, were significantly more abundant in multiplex subjects, whereas Lachnospira, Sutterella, Lachnospiraceae_NK4A136_group, and Lachnospiraceae_UCG_004 less abundant.

The risk of CD onset was significantly higher in multiplex subjects. In multivariable analysis, multiplex status at recruitment was associated with increased risk of CD onset (adjusted HR 3.41, 95% CI 1.70-6.87, p=0.00055), after adjusting for demographics, FCP, LMR, and CD-PRS.

Conclusion(s)

Multiplex status compared to simplex is associated with a 3.4-fold increased risk of CD onset, a higher FCP, and fecal bacterial composition. A comprehensive assessment of environmental factors that increase CD risk in multiplex families remains to be elucidated in future studies.

Disclosure of Interest

None Declared

A176 ASSOCIATIONS OF ANTIBIOTICS, HORMONAL THERAPIES, ORAL CONTRACEPTIVES, AND LONG-TERM NSAIDS WITH INFLAMMATORY BOWEL DISEASE: RESULTS FROM THE PROSPECTIVE URBAN RURAL EPIDEMIOLOGY (PURE) STUDY

Background

The pathogenesis of inflammatory bowel disease (IBD) which includes Crohn’s disease (CD) and ulcerative colitis (UC), is believed to involve activation of the intestinal immune system in response to the gut microbiome among genetically susceptible hosts. IBD has been historically regarded as a disease of developed nations, though in the past two decades there has been a reported shift in the epidemiological pattern of disease. High-income nations with known high prevalence of disease are seeing a stabilization of incident cases, while a rapid rise of incident IBD is being observed in developing nations. This suggests that environmental exposures may play a role in mediating the risk of developing IBD. The potential environmental determinants of IBD across various regions is vast, though medications have been increasingly recognized as one broad category of risk factors.

Purpose

Several medications have been considered to contribute to the etiology of IBD. This study assessed the association between medication use and risk of developing IBD using the Prospective Urban Rural Epidemiology (PURE) cohort.

Method

This was a prospective cohort study of 133,137 individuals between the ages of 20-80 from 24 countries. Country-specific validated questionnaires documented baseline and follow-up medication use. Participants were followed prospectively at least every 3 years. The main outcome was development of IBD, including CD and UC. Short-term (baseline but not follow-up use) and long-term use (baseline and subsequent follow-up use) was evaluated. Results are presented as adjusted odds ratios (aOR) with 95% confidence intervals (CI).

Result(s)

During the median follow-up of 11.0 years [interquartile range (IQR) 9.2-12.2], we recorded 571 incident cases of IBD (143 CD and 428 UC). Higher risk of incident IBD was associated with baseline antibiotic use [aOR: 2.81 (95% CI: 1.67-4.73), p=0.0001] and hormonal medication use [aOR: 4.43 (95% CI: 1.78-11.01), p=0.001]. Among females, previous or current oral contraceptive use was also associated with IBD development [aOR: 2.17 (95% CI: 1.70-2.77), p=5.02E-10]. NSAID users were also observed to have increased risk of IBD [aOR: 1.80 (95% CI: 1.23-2.64), p=0.002], which was driven by long-term users [aOR: 5.58 (95% CI: 2.26-13.80), p<0.001]. All significant results were consistent in direction for CD and UC with low heterogeneity.

Conclusion(s)

Antibiotics, hormonal medications, oral contraceptives, and long-term NSAID use were associated with increased odds of incident IBD after adjustment for covariates.

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Other

Please indicate your source of funding below:

Salim Yusuf is supported by the Heart & Stroke Foundation/Marion W. Burke Chair in Cardiovascular Disease. The PURE Study is an investigator-initiated study funded by the Population Health Research Institute, the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Ontario, support from CIHR’s Strategy for Patient Oriented Research (SPOR) through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies, with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithkline, and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries; these include: Argentina: Fundacion ECLA; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de la Frontera; China: National Center for Cardiovascular Diseases; Colombia: Colciencias, grant number 6566-04-18062; India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia, grant numbers 100 -IRDC/BIOTEK 16/6/21 (13/2007) and 07-05-IFN-BPH 010, Ministry of Higher Education of Malaysia grant number 600 -RMI/LRGS/5/3 (2/2011), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the UN Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research & Development; Poland: Polish Ministry of Science and Higher Education grant number 290/W-PURE/2008/0, Wroclaw Medical University; Saudi Arabia: the Deanship of Scientific Research at King Saud University, Riyadh, Saudi Arabia (research group number RG -1436-013); South Africa: the North-West University, SANPAD (SA and Netherlands Programme for Alternative Development), National Research Foundation, Medical Research Council of SA, The SA Sugar Association (SASA), Faculty of Community and Health Sciences (UWC); Sweden: grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V’s and Queen Victoria Freemasons Foundation, AFA Insurance, Swedish Council for Working Life and Social Research, Swedish Research Council for Environment, Agricultural Sciences and Spatial Planning, grant from the Swedish State under the Läkar Utbildnings Avtalet agreement, and grant from the Västra Götaland Region; Turkey: Metabolic Syndrome Society, AstraZeneca, Turkey, Sanofi Aventis, Turkey; United Arab Emirates (UAE): Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai UAE.

Disclosure of Interest

C. Pray: None Declared, N. Narula Grant / Research support from: Neeraj Narula holds a McMaster University Department of Medicine Internal Career Award. Neeraj Narula has received honoraria from Janssen, Abbvie, Takeda, Pfizer, Merck, and Ferring, E. C. Wong: None Declared, J. K. Marshall Grant / Research support from: John K. Marshall has received honoraria from Janssen, AbbVie, Allergan, Bristol-Meyer-Squibb, Ferring, Janssen, Lilly, Lupin, Merck, Pfizer, Pharmascience, Roche, Shire, Takeda and Teva., S. Rangarajan: None Declared, S. Islam: None Declared, A. Bahonar: None Declared, K. F. Alhabib: None Declared, A. Kontsevaya: None Declared, F. Ariffin: None Declared, H. U. Co: None Declared, W. Al Sharief: None Declared, A. Szuba: None Declared, A. Wielgosz: None Declared, M. L. Diaz: None Declared, R. Yusuf: None Declared, L. Kruger: None Declared, B. Soman: None Declared, Y. Li: None Declared, C. Wang: None Declared, L. Yin: None Declared, M. Erkin: None Declared, F. Lanas: None Declared, K. Davletov: None Declared, A. Rosengren: None Declared, P. Lopez-Jaramillo: None Declared, R. Khatib: None Declared, A. Oguz: None Declared, R. Iqbal: None Declared, K. Yeates: None Declared, Á. Avezum: None Declared, W. Reinisch Consultant of: Speaker for Abbott Laboratories, Abbvie, Aesca, Aptalis, Astellas, Centocor, Celltrion, Danone Austria, Elan, Falk Pharma GmbH, Ferring, Immundiagnostik, Mitsubishi Tanabe Pharma Corporation, MSD, Otsuka, PDL, Pharmacosmos, PLS Education, Schering-Plough, Shire, Takeda, Therakos, Vifor, Yakult, Consultant for Abbott Laboratories, Abbvie, Aesca, Algernon, Amgen, AM Pharma, AMT, AOP Orphan, Arena Pharmaceuticals, Astellas, Astra Zeneca, Avaxia, Roland Berger GmBH, Bioclinica, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Covance, Danone Austria, DSM, Elan, Eli Lilly, Ernest & Young, Falk Pharma GmbH, Ferring, Galapagos, Genentech, Gilead, Grünenthal, ICON, Index Pharma, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, LivaNova, Mallinckrodt, Medahead, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nash Pharmaceuticals, Nestle, Nippon Kayaku, Novartis, Ocera, Omass, Otsuka, Parexel, PDL, Periconsulting, Pharmacosmos, Philip Morris Institute, Pfizer, Procter & Gamble, Prometheus, Protagonist, Provention, Robarts Clinical Trial, Sandoz, Schering-Plough, Second Genome, Seres Therapeutics, Setpointmedical, Sigmoid, Sublimity, Takeda, Therakos, Theravance, Tigenix, UCB, Vifor, Zealand, Zyngenia, and 4SC, Advisory board member for Abbott Laboratories, Abbvie, Aesca, Amgen, AM Pharma, Astellas, Astra Zeneca, Avaxia, Biogen IDEC, Boehringer-Ingelheim, Bristol-Myers Squibb, Cellerix, Chemocentryx, Celgene, Centocor, Celltrion, Danone Austria, DSM, Elan, Ferring, Galapagos, Genentech, Grünenthal, Inova, Janssen, Johnson & Johnson, Kyowa Hakko Kirin Pharma, Lipid Therapeutics, MedImmune, Millenium, Mitsubishi Tanabe Pharma Corporation, MSD, Nestle, Novartis, Ocera, Otsuka, PDL, Pharmacosmos, Pfizer, Procter & Gamble, Prometheus, Sandoz, Schering-Plough, Second Genome, Setpointmedical, Takeda, Therakos, Tigenix, UCB, Zealand, Zyngenia, and 4SC, P. Moayyedi: None Declared, S. Yusuf: None Declared

A218 ASSOCIATIONS BETWEEN ADHERENCE TO LITERATURE-DERIVED DIETARY INDICES AND PRE-DISEASE BIOMARKERS: IMPLICATIONS FOR CROHN’S DISEASE PREVENTION

Background

The incidence of Crohn’s disease (CD) is increasing globally, indicating a significant environmental influence such as diet. A plethora of dietary adherence (DA) patterns exist in the literature: the Mediterranean Diet (MD), Empirical Dietary Inflammatory Pattern (EDIP), Specific Carbohydrate Diet (SCD), and low Fermentable Oligosaccharide, Disaccharide, Monosaccharide, or Polyol diet (FODMAP) are all potential candidates to maintain a reduced level of inflammation, improving gastrointestinal function. Contrary, the Westernized diet (WD) is generally reported as a diet promoting inflammation in humans.

Purpose

To determine if DA to literature-derived dietary indices in a cohort of first-degree relatives (FDRs) of CD patients can modulate pre-disease biomarkers.

Method

We used food frequency questionnaire (FFQ) data from 2,696 healthy FDR subjects of the Crohn’s Colitis Canada- Genes, Environment, Microbial (CCC-GEM) project. We rederived each of the following scores using our FFQ data, utilizing originally described methods for the MD, EDIP, SCD, low FODMAP, and WD to obtain DA. Each diet was correlated pairwise via Kendall’s Tau.

We fit multivariable regression models to identify the association of DA (top quintile vs remaining) and: i) intestinal permeability using urinary fractional excretion of lactulose to mannitol ratio (LMR), LMR≥0.03 defined abnormal; ii) subclinical inflammation using fecal calprotectin (FCP) measured with BÜHLMANN fCAL® ELISA, FCP≥250µg/g defined inflammation; and iii) fecal microbiome richness and composition using 16S rRNA sequencing. Two-sided p<0.05 for primary and q<0.05 for secondary analysis defined significance.

Result(s)

There were positive correlations between the MD, SCD, and low FODMAP, these diets negatively correlated with the WD. The EDIP negatively correlated with the SCD and low FODMAP, did not correlate with the MD, and positively correlated with the WD. No diet was associated with abnormal LMR or FCP. Only the SCD was associated with increased microbial richness (q=0.03). All diets were associated with microbial genera: the MD (n=18 taxa, (2.0^-7<q-values< 0.04), EDIP (n=9, [2.8^-4-0.05]), SCD (n=13, [3.7^-11-0.05]), low FODMAP (n=14, [1.3^-7-0.05]), and WD (n=1, [0.03]).

Conclusion(s)

This study shows that literature-derived dietary indices correlate generally with each other, yet none were not associated with abnormal LMR or FCP. However, we found that diet can impact microbiome richness and composition. Thus, it is tempting to speculate that diet is a possible intervention capable of maintain microbiome homeostasis to reduce future risk of CD.

Submitted on behalf of the CCC-GEM consortium.

Funding

Crohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III

The Leona M. and Harry B. Helmsley Charitable Trust

Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Disease

Disclosure of Interest

None Declared

A19 INVESTIGATING MECHANISMS THAT DRIVE SYMPTOMS IN IRRITABLE BOWEL SYNDROME PATIENTS WITH PERCEIVED GLUTEN SENSITIVITY

Background

Patients with irritable bowel syndrome (IBS) often report gastrointestinal symptoms after consuming wheat and gluten-containing foods. It is, however, unclear whether gluten is the main driver of symptoms, as other immunogenic peptides, such as amylase trypsin inhibitors (ATI), poorly digestible fiber (inulin, part of FODMAP) or even the nocebo effect may contribute to symptom generation.

Purpose

To evaluate whether whole wheat containing ATIs and/or purified gluten trigger gastrointestinal symptoms compared to nocebo in patients with IBS adopting a gluten-free diet (GFD).

Method

We conducted a double-blind, randomized, nocebo-controlled crossover study in adult IBS patients (Rome IV criteria) who previously perceived improvement of symptoms while on a GFD. The study was approved by the Hamilton Research Ethics Board (HiREB #4367). Participants were challenged for 7 days with whole wheat, purified gluten, and nocebo (gluten-free flour) added to low FODMAP cereal bars. Each challenge was followed by a 2-week washout. Patients remained on a GFD throughout the study, diet adherence was assessed by a dietitian and stool gluten immunogenic peptides (GIP; Biomedal). Gastrointestinal symptoms were assessed by IBS Symptom Severity Score (IBS-SSS); increases >50 points were considered a significant worsening. Blood samples were collected to assess immune markers and celiac (HLA DQ2, DQ8 and DQ7) genotype. Statistical comparisons used Friedman rank sum tests and paired Wilcoxon signed rank tests.

Result(s)

Twenty-nine IBS patients (27 female, mean age=42, SD=14.4 years) were enrolled in the study; 1 dropped. Similar proportions of patients reacted symptomatically to wheat (11/28, 39.3%), gluten (10/28, 35.7%) and nocebo (8/28, 28.6%). However, there was an overall significant increase in IBS symptoms after wheat (+39.5 on IBS-SSS; p=0.030) but not after gluten (+27.5; p=0.051) or nocebo (+5.5; p=0.236) challenges (Figure 1). Ten participants experienced IBS-SSS symptoms >175 during baseline and did not worsen further during the challenges. TNF-α trended from 1.35 pg/mL after nocebo, 1.47 pg/mL after gluten, to 1.57 pg/mL after wheat; however, this was not significant. Baseline adherence to a GFD was rated excellent in 19 (68%), good in 6 (21%), and fair in 3 (11%) participants. Median GIP levels were 0.584 µg/g after wheat, 0.432 µg/g after gluten, and 0.095 µg/g after nocebo; p<0.0001. Celiac predisposition genes were present in 19/24 participants (10/24 had DQ2, 2/24 had DQ8, and 9/24 had DQ7).

Image

Conclusion(s)

IBS patients self-reporting wheat or gluten sensitivity had worse symptoms after whole wheat, but not purified gluten or nocebo challenge. However, similar proportions of IBS patients reacted to each intervention, suggesting that central mechanisms play an important role in symptom genesis. Furthermore, one third of patients had high symptoms during a GFD and did not react to wheat or gluten challenges, suggesting that other mechanisms are driving their IBS symptoms.

Please acknowledge all funding agencies by checking the applicable boxes below

CIHR, Other

Please indicate your source of funding;

Society for the Study of Celiac Disease (Nestle); Canadian Digestive Health Foundation

Disclosure of Interest

None Declared

A238 BILE ACID COMPOSITION AND DIETARY FAT: IMPLICATIONS FOR CROHN’S DISEASE IN A COHORT OF HEALTHY FIRST-DEGREE RELATIVES

Background

Crohn’s disease (CD) is a chronic relapsing inflammatory disease of the gastrointestinal tract. The etiology of CD may arise from complex interactions including host genetics, diet, and the intestinal microbiome. Increased consumption of saturated fats, characteristic of the Western diet, is a known risk factor for CD. Dietary fat (DF) is absorbed by the host through the release of primary bile acids (PBAs) and bio-transformed by the microbiome into secondary bile acids (SBAs). Altogether, bile acids (BAs) can act as signaling molecules involved in host immune regulation and potentially in CD onset.

Purpose

To investigate the relationship between CD risk, BAs, and DF, and evaluate the predictive performance of CD onset of these factors by developing machine learning models.

Method

We used samples healthy first-degree relatives (FDRs) recruited as part of the Crohn’s Colitis Canada- Genes, Environment, Microbial (GEM) project. Those who developed CD (n=87) were matched 1:4 by age, sex, follow-up time, and geographic location with control FDRs remaining healthy (n=347).

Serum, urine, and stool BA were measured using ultrahigh Performance Liquid Chromatography-Tandem Mass Spectroscopy. DF types were derived from food frequency questionnaire data. We used conditional logistic regressions to identify associations between CD onset, BAs (n=93), and DFs (n=9). We further explored the relationships of significant CD-related BAs and DF via Generalized Estimation Equations. Finally, we used a tree-based machine-learning algorithm (XGBoost) with 5-fold cross-validation to assess the prediction performance of CD onset using BA from all sources as well as DF. Two-sided p<0.05 was considered significant.

Result(s)

In total, 10 of 93 BAs, and two of nine DFs were significantly associated with increased odds of CD onset (p<0.05). Additionally, five BAs were significantly associated with DF (p<0.05). Serum-derived BAs had the best predictive performance for CD, with a mean AUC of 0.70 [95% CI: 0.63;0.76], followed by stool derived BAs with a mean AUC= 0.65 [0.55;0.75], and followed by urine derived Bas with a mean AUC= 0.57 [0.48;0.66]. Lastly DF was not a predictive marker of CD onset with a mean AUC= 0.50 [0.41;0.60].

Conclusion(s)

This study suggests that BAs are associated with the pathogenesis of CD and the effects may be influenced by DF. Serum-derived BAs may be able to better predict the risk of CD than other stool or urine derived BA, while DF is not directly implicated in CD risk.

Submitted on behalf of the CCC-GEM consortium.

Funding

Crohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III

The Leona M. and Harry B. Helmsley Charitable Trust

Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

The International Organization for the Study of Inflammatory Bowel Diseases (IOIBD)

Jingcheng Shao is the recipient of a Data Science Institute Summer Undergraduate Data Science award

Disclosure of Interest

None Declared

A172 PSYCHOSOCIAL VARIABLES RELATED TO J-POUCH SURGERY FOR INFLAMMATORY BOWEL DISEASE: A SCOPING REVIEW

Background

Ulcerative Colitis (UC) and Crohn’s Disease (CD) are subtypes of Inflammatory Bowel Disease (IBD) which is a condition with an unclear etiology causing inflammation of the small and large intestine (Public Health Agency of Canada, 2021). IBD is treated by diet, medications, and/or surgeries, with the most common surgery recommended to UC patients being j-pouch surgery (Crohn’s and Colitis Canada, n.d.). J-pouch surgery is often accompanied by numerous side effects (e.g., leakage, pouchitis), but it has been shown to help manage symptoms and restore function (Crohn’s and Colitis Canada, n.d.). While noteworthy research has examined the functional and biological outcomes of j-pouch surgery (e.g., Kayal et al., 2020), far less has considered the perioperative psychosocial implications.

Aims

The aim of this scoping review is to assess the current literature concerning psychosocial factors related to j-pouch surgery for patients with IBD.

Methods

We used the PRISMA-ScR (Tricco et al., 2018) and JBI recommendations (Peters et al., 2020) as methodological guidelines for conducting this review. We conducted our search during the summer and fall of 2021 and searched the following sources: Medline, PsychInfo, CINAHL, EBM Reviews, ProQuest Dissertations and Theses Global, ResearchGate, Prospero, and PrePubMed. We included articles from 1980-September 13, 2021.

Results

Our initial search produced 718 articles. Of those that met our inclusion criteria, the majority discussed quality of life as their sole psychosocial variable. Among these studies, however, many used quality of life measures (e.g., IBDQ, SF-36) that prioritize health-related factors, with only a subset of questions directly addressing quality of life. The second most investigated psychosocial variables were those related to sexual health and functioning. When considering the levels of evidence, very few of our results were randomized control trials (RCT), while many were reviews (but not exclusively of RCT) and non-randomized controlled studies.

Conclusions

We have identified a substantial need for studies examining psychosocial implications of and for j-pouch surgery among patients with IBD. In our discussion, we identify common variables and outline the strongest articles in the current literature, investigate the disadvantages of currently used measures, and propose specific directions for future research.

Funding Agencies

None

A238 ALTERED GUT MICROBIOME COMPOSITION AND FUNCTION ARE ASSOCIATED WITH GUT BARRIER DYSFUNCTION IN HEALTHY RELATIVES OF CROHN’S DISEASE PATIENTS

Background

The gut microbiome may play a role in gut barrier homeostasis including epithelial barrier function, but data are scarce and limited to animal studies

Aims

To assess if alterations in gut microbiome are associated with gut barrier function

Methods

We utilized the Genetic Environmental Microbial (CCC GEM) cohort of healthy first-degree relatives (FDRs) of Crohn’s disease (CD) patients. Gut barrier function was assessed using the ratio of urinary fractional excretion of lactulose to mannitol (LMR). Stool bacterial DNA was extracted and sequenced for the V4 hypervariable region of the 16S rRNA gene using MiSeq and processed using QIIME2. Microbial functions were imputed using PICRUSt2. The cohort was divided into a North American discovery cohort (n=2,472) and non-North American external validation cohort (n=655). LMR>0.025 was defined as abnormal. LMR-microbiome associations were assessed using multivariable regression model and Random Forest (RF) classifier algorithm. q<0.05 was considered significant when multiple tests were performed

Results

The median age of the entire cohort was 17.0 years [IQR 12.0; 24.0], 52.6% were females and 25.4% had LMR>0.025. In the discovery cohort, subjects with LMR>0.025 had markedly reduced alpha diversity (Chao1 index, estimate= -0.0037, p=4.0e-04) and altered beta diversity (Bray-Curtis dissimilarity index, PERMANOVA: pseudo-F statistic = 2.99, p=1.0e-03). We identified eight bacterial genera and 52 microbial pathways associated with LMR>0.025 (q<0.05). Four genera (decreased Adlercreutzia [odds ratio(OR)=0.74, 95% confidence interval (CI) 0.6–0.91], Clostridia-UCG-014 [OR=0.71, 95%CI 0.59–0.86], and Clostridium-sensu-stricto-1 [OR=0.75, 95%CI 0.61–0.92] and increased Colidextribacter [OR=1.65, 95%CI 1.2–2.26]) and eight pathways (including decreased biosynthesis of glutamate [OR=0.4, 95%CI 0.21–0.74], tryptophan [OR=0.06, 95%CI 0.01–0.27] and threonine [OR=0.038, 95%CI 0.003–0.41]) were replicated. Bacterial community composition was associated with gut barrier homeostasis as defined by the RF analysis (p= 1.4e-6)

Conclusions

Gut microbiome community and pathways are associated with gut barrier function. These findings may identify potential microbial targets to modulate barrier function

Submitted on behalf of the CCC-GEM Consortium

Funding Agencies

CCC, CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III; The Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A157 DEFINITIONS OF MEDITERRANEAN DIET INCONSISTENTLY ASSOCIATE WITH MARKERS OF GUT BARRIER FUNCTION OR SUBCLINICAL INFLAMMATION IN A POPULATION-BASED COHORT

Background

The Mediterranean Diet (MD) is proposed to reduce the risk of Crohn’s disease (CD) onset in cohort studies, with inconsistent results. This inconsistency may be due to heterogeneity in defining MD scores. Additionally, relationships between MD compliance and intestinal permeability or sub-clinical inflammation are not defined.

Aims

We examined correlations between different MD scores, and determined associations between MD compliance and intestinal permeability or subclinical inflammation in a cohort of first degree relatives of CD patients.

Methods

We used food frequency questionnaire data from 2,112 subjects of the Crohn’s Colitis Canada- Genes, Environment, Microbial (CCC-GEM) project. We obtained 12 MD definitions from the literature and calculated daily percent compliance, we further compared MD scores via pairwise correlations (Kendall’s Tau). We measured intestinal permeability via urinary fractional excretion ratio of lactulose to mannitol (LMR) (LMR≥0.03 defined abnormal), and subclinical inflammation via fecal calprotectin (FCP) measured with BÜHLMANN fCAL® ELISA (FCP≥250 defined abnormal). We fit multivariable regression models between MD compliance and abnormal LMR and FCP, respectively. Two-sided p&lt;0.05 defined significance.

Results

There was large variation in cross-correlations among MD scores, from nil (t=0.0, p=0.54) to highly significant (t=0.97, p&lt;2.2e-16). Associations of MD compliance and abnormal LMR or FCP were in both directions of effect, largely non-significant. Of the 12 MD scores, none associated with abnormal LMR, while 4 associated with abnormal FCP-Odds Ratios =1.22, 1.23, 1.24, and 1.30; p=0.02, 0.02, 0.01, and 0.009, and 95% Confidence Intervals = [1.03,1.45], [1.04,1.45], [1.05,1.47], and [1.07,1.59] respectively. No diet remained significant after correcting for multiple testing.

Conclusions

Currently MD definitions vary widely. Despite discrepancies, we expected consistent directions of effect for MD compliance on LMR or FCP. The largely non-significant associations between MDs suggest limitations in definition, interpretation, and relation to biological outcomes.

Submitted on behalf of the CCC-GEM consortium.

Funding Agencies

CIHRCrohn’s and Colitis Canada Genetics Environment Microbial (CCC-GEM) III;The Leona M. and Harry B. Helmsley Charitable Trust; Justine Timpano is a recipient of a fellowship award from Mount Sinai Hospital; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases

A236 ASSOCIATION OF STOOL METABOLOMIC PROFILE AND MICROBIOME COMPOSITION RISK SCORE WITH FUTURE ONSET OF CROHN’S DISEASE

Background

Microbial composition-based risk score (MRS) was recently developed and validated to predict future risk of developing Crohn’s disease (CD) among healthy first-degree relatives (FDR) of CD patients. We hypothesized that stool metabolomic profiles, some of which are linked to the gut microbiome, are associated with future risk of CD.

Aims

To assess the association of stool metabolomic profile with onset of CD and to determine the correlation between stool metabolites and the MRS

Methods

Healthy FDR of CD patients were recruited as part of the nested case-control cohort of the CCC-GEM Project. Healthy FDRs who later developed CD (n=56) were matched approximately 1:1 by age, sex, follow-up duration, and geographical location with control FDRs remaining healthy (n=66). Stool metabolomics were assessed using the Metabolon’s DiscoveryHD4™ platform, and the stool microbiome characterised by 16s rDNA amplicon sequencing. We fitted a multivariable conditional logistic regression model on the disease status as a function of individual stool metabolites. We additionally performed Spearman correlation between each stool metabolite and the MRS.

Results

Among 1,029 stool metabolites that were analyzed, 79 were associated with future risk of CD (p&lt;0.05); however, none remained significant after multiple testing correction (FDR correction). Considering the exploratory nature of this study with limited sample size, we focused on the top seven metabolites associated with CD onset (p&lt;0.01). Of these, two stool metabolites (dimethylglycine, methylmyristate) were associated with increased risk of CD onset while five (cytosine, guanine, cytidine, hydroxyglutarate, nervonate) were associated with decreased risk of developing CD. The two metabolites positively associated with CD onset were positively correlated with the MRS, while the five metabolites negatively associated with CD onset, were negatively correlated with the MRS. Meanwhile, 24 stool metabolites had significant correlation with MRS (FDR-corrected p&lt;0.2). Among those, a total of four stool metabolites (cytosine, guanine, methymyristate, cytidine) overlapped with the top seven stool metabolites associated with CD onset.

Conclusions

Stool metabolite profiles may predict future risk of CD. A subset of these metabolites have significant correlation with the MRS with consistent direction of effect. This may suggest that stool metabolites mediate the putative effect of the gut microbiome on CD risk. Further validation in the full GEM cohort is warranted.

Funding Agencies

CCC, CIHRThe Leona M. and Harry B. Helmsley Charitable Trust; Kenneth Croitoru is the recipient of the Canada Research Chair in Inflammatory Bowel Diseases; Sun-Ho Lee is a recipient of the Imagine/ CIHR/CAG Fellowship Award; Sun-Ho Lee, Juan Antonio Raygoza Garay, and Williams Turpin are recipients of fellowship awards from the Department of Medicine, Mount Sinai Hospital, Toronto, Canada.

Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial

Background

Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks.

Aim

The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN

Methods

The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN.

Results

A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment.

Conclusion

The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.

A39 CULTURE-ENRICHED METAGENOMICS REVEALED MICROBIAL ENGRAFTMENT FOLLOWING FMT IN PATIENTS WITH ULCERATIVE COLITIS

NOT PUBLISHED AT AUTHOR’S REQUEST

Funding Agencies: CIHRImagine SPOR

A108 PROBIOTICS FOR CELIAC DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Background

Celiac disease is a chronic autoimmune disorder triggered by dietary gluten. The only available treatment for celiac disease is strict compliance to the gluten-free diet. Despite adherence to a gluten-free diet, many celiac patients still experience symptoms which may be mediated by the gut microbiota. Different studies have assessed the use of probiotics as an adjuvant treatment for celiac disease.

Aims

We performed a systematic review and meta-analysis to evaluate the efficacy of probiotics in improving gastrointestinal symptoms and quality of life in patients with celiac disease.

Methods

We searched MEDLINE (1966 to February 2019), EMBASE (1974 to February 2019), CINAHL, Web of Science, CENTRAL, DARE, and Sigle up to February 2019 for randomized controlled trials (RCTs) assessing the effects of probiotics on celiac disease. We collected data on gastrointestinal symptoms, quality of life, adverse events, serum tumor necrosis factor α (TNF-α), intestinal permeability, and microbiota composition.

Results

Out of 2831 records screened, 7 articles from 6 RCTs with a total of 279 participants were eligible for quantitative analysis. Probiotic supplementation for a minimum of 2 weeks improved gastrointestinal symptoms when assessed by the Gastrointestinal Symptoms Rating Scale (GSRS) (2 studies; 131 participants; mean difference (MD) symptom reduction: -28.7%; 95% CI -43.96 to -13.52; P=0.0002). No differences in gastrointestinal symptoms after probiotics were observed when pooling data from the GSRS, Celiac Symptoms Index (CSI), and the Celiac Disease Questionnaire (CDQ) (4 studies; 197 participants; standardized mean difference (SMD) symptom reduction: -0.48; 95% CI -1.21 to +0.25; P=0.20). TNF-α levels did not change after probiotics (SMD: -0.52; 95% CI -1.08 to +0.04; P=0.07). Levels of Bifidobacteria species increased (MD: increase by 0.85 log CFU/g; 95% CI +0.38 to +1.32 log CFU/g; P=0.0003) but there was no difference in Lactobacilli species (MD: change of 1.13 log CFU/g; 95% CI -0.67 to +2.93 log CFU/g; P=0.22) after probiotic supplementation. No difference in quality of life or adverse events was observed after probiotics. There was insufficient evidence to assess the effects of probiotics on intestinal permeability. The overall quality of the evidence ranged from very low to low.

Conclusions

Probiotics may improve gastrointestinal symptoms in patients with celiac disease; however, our confidence in these results is limited by the low quality of the evidence. Further large clinical trials with a more rigorous design are needed to improve the quality of the evidence.

Funding Agencies

None

A140 UNDERSTANDING PATIENTS’ PERCEPTIONS OF FECAL MICROBIOTA TRANSPLANT

Background

Fecal microbiota transplantation (FMT) is under active investigation as a popular treatment option for a variety of diseases, including ulcerative colitis (UC). Despite increasing evidence for its therapeutic role, the current literature is limited in its scope to assess firsthand patient experiences.

Aims

To exlore perceptions, attitudes, and experiences of patients who chose to pursue FMT and patients who declined FMT in favor of conventional medications.

Methods

Using qualitative descriptive design, eligible patients were invited to participate in face-to-face semi-structured interviews before and after FMT treatment. Interviews were audiotaped, transcribed, and analyzed using thematic analysis.

Results

Main baseline themes across the FMT (n=9) and non-FMT (n=8) groups included: (i) knowledge of FMT, (ii) attitudes around FMT, and (iii) factors contributing to the decision to pursue FMT. Post-FMT themes included: (i) experiences with FMT, and (ii) perceived response to treatment. We found a poor general understanding of FMT across both cohorts, suggesting a need for improving patient education. Non-FMT patients were less likely to have heard or researched FMT in the past due to feelings of “it just sounds weird”. Similar concerns were found across both groups, including fear of transmissible infections, cost of an experimental therapy, and aversion to stool. Expectations varied between the two groups, with feelings of hope and a sense of “last resort” driving patients to pursue FMT. In contrast, the non-FMT cohort felt a need to further research FMT, explore other treatment options before committing to FMT, and were more likely to describe their disease activity as “not at the severe end”. This demonstrates that FMT may be perceived as a “last ditch effort”. Despite initial aversion, the non-FMT group demonstrated interest in learning more about FMT and felt more open to the possibility of pursuing FMT in the future. The FMT group was more likely to harbor a positive view of natural medicine and classify FMT as natural, while the non-FMT cohort expressed “I’m not really into the weird stuff”. Post-FMT, some patients expressed delight in the perceived changes in their symptoms, including improved quality of life, decreased urgency, and less concerns with accidents.

Conclusions

Our results suggest that important motivating factors for pursuing FMT are a perception of naturality and a sense of last resort. With improved education, FMT may pose an acceptable and tolerable treatment option for patients with UC.

Funding Agencies

Canadian IBD (CANIBD) Nursing

A194 PRESENCE OF CELIAC DISEASE IN PATIENTS WITH BARRETT’S ESOPHAGUS IS ASSOCIATED WITH FASTER DEVELOPMENT OF DYSPLASIA AND HIGHER RATES OF ESOPHAGEAL ADENOCARCINOMA

Background

Celiac disease (CD) has an estimated prevalence of 1% worldwide, including North America. Barrett’s esophagus (BE) is a complication of chronic gastroesophageal reflux disease (GERD), which predisposes to development of dysplasia, which can transition to esophageal adenocarcinoma (EAC). GERD is commonly found in patients with CD and there is evidence that reflux symptoms improve after starting the gluten-free diet. However, the prevalence of CD in patients with BE, and its impact on progression to EAC have not been studied.

Aims

To assess the prevalence of CD in patients with BE and its impact on development of dysplasia and EAC.

Methods

We performed a retrospective review of medical records of patients attending the Digestive Diseases Clinic and the specialized Barrett’s Clinic at McMaster University Medical Centre. We collected information related to demographics, esophageal and duodenal biopsies, as well as CD serological markers. CD diagnosis was based on the presence of Marsh III lesions in duodenal biopsies and/or positive tissue transglutaminase IgA antibodies (TTG). Categorical data was presented as n/N and %, continuous data as mean ±SD. Logistic regression was performed to estimate the association between BE and CD. For dysplasia development, Kaplan Meyer Breslow survival curve was used.

Results

CD was found in 1.8% of patients attending the Digestive Diseases Clinic (n=4800). Two hundred and sixteen patients with BE from the Digestive Diseases Clinic and the Barret’s Clinic (age 63 ±11.2, 70.3% males; follow-up period 7.0 ±5.5 years) were included in the analysis. Patients with or without CD were similar in demographic factors, concomitant diseases or previous surgeries, use of PPI, presence of symptoms and duration of treatment. The prevalence of CD was increased 5-fold in patients with BE (OR=6.0; 95% CI 2.1–17.4; p=0.006). BE patients with CD developed dysplasia earlier than those without CD (Long Rank 0.004; mean 6.0; 95% CI 3.0–4.97[PB1]). The risk of EAC was higher in BE patients with CD compared to those without CD (2/11 vs 2/205; OR=22.5; 95% CI 2.8–178.8; p= 0.003). The mean time for development of EAC from the time of BE diagnosis [PB2] was 1.5 years in patients with CD and 6.5 years in patients without CD.

Conclusions

The prevalence of CD is higher in patients with BE compared with the population attending a tertiary gastroenterology clinic, and with the general population. Patients with BE and concomitant CD are at increased risk of accelerated development of dysplasia and EAC, suggesting that both conditions may have a synergic detrimental effect.

Funding Agencies

CIHR

Derivation and validation of a diagnostic test for irritable bowel syndrome using latent class analysis

BACKGROUND

The accuracy of symptom-based diagnostic criteria for irritable bowel syndrome (IBS) is modest.

AIMS

To derive and validate a new test that utilises latent class analysis.

METHODS

Symptom, colonoscopy, and histology data were collected from 1981 patients and 360 patients in two cohorts referred to secondary care for investigation of their gastrointestinal symptoms in Canada and the UK, respectively. Latent class analysis was used to identify naturally occurring clusters in patient-reported symptoms in the Canadian dataset, and the latent class model derived from this was then applied to the UK dataset in order to validate it. Sensitivity, specificity, and positive and negative likelihood ratios (LRs) were calculated for the latent class models.

RESULTS

In the Canadian cohort, the model had a sensitivity of 44.7% (95% CI 40.0-50.0) and a specificity of 85.3% (95% CI 83.4-87.0). Positive and negative LRs were 3.03 (95% CI 2.57-3.56) and 0.65 (95% CI 0.59-0.71) respectively. A maximum positive LR of 3.93 was achieved following construction of a receiver operating characteristic curve. The performance in the UK cohort was similar, with a sensitivity and specificity of 52.5% (95% CI 42.2-62.7) and 84.3% (95% CI 79.3-88.6), respectively. Positive and negative LRs were 3.35 (95% CI 2.38-4.70) and 0.56 (95% CI 0.45-0.68), respectively, with a maximum positive LR of 4.15.

CONCLUSIONS

A diagnostic test for IBS, utilising patient-reported symptoms incorporated into a latent class model, performs as accurately as symptom-based criteria. It has potential for improvement via addition of clinical markers, such as coeliac serology and faecal calprotectin.

Poor predictive value of lower gastrointestinal alarm features in the diagnosis of colorectal cancer in 1981 patients in secondary care

BACKGROUND

Clinicians are advised to refer patients with lower gastrointestinal (GI) alarm features for urgent colonoscopy to exclude colorectal cancer (CRC). However, the utility of alarm features is debated.

AIM

To assess whether performance of alarm features is improved by using a symptom frequency threshold to trigger referral, or by combining them into composite variables, including minimum age thresholds, as recommended by the National Institute for Health and Care Excellence (NICE).

METHODS

We collected data prospectively from 1981 consecutive adults with lower GI symptoms. Assessors were blinded to symptom status. The reference standard to define CRC was histopathological confirmation of adenocarcinoma in biopsy specimens from a malignant-looking colorectal lesion. Controls were patients without CRC. Sensitivity, specificity, positive predictive values (PPVs) and negative predictive values were calculated for individual alarm features, as well as combinations of these.

RESULTS

In identifying 47 (2.4%) patients with CRC, individual alarm features had sensitivities ranging from 11.1% (family history of CRC) to 66.0% (loose stools), and specificities from 30.5% (loose stools) to 75.6% (family history of CRC). Using higher symptom frequency thresholds improved specificity, but to the detriment of sensitivity. NICE referral criteria also had higher specificities and lower sensitivity, with PPVs above 4.8%. More than 80% of those with CRC met at least one of the NICE referral criteria.

CONCLUSIONS

Using higher symptom frequency thresholds for alarm features improved specificity, but sensitivity was low. NICE referral criteria had PPVs above 4.8%, but sensitivities ranged from 2.2% to 32.6%, meaning many cancers would be missed.

Management of Helicobacter pylori infection-the Maastricht V/Florence Consensus Report

Important progress has been made in the management of Helicobacter pylori infection and in this fifth edition of the Maastricht Consensus Report, key aspects related to the clinical role of H. pylori were re-evaluated in 2015. In the Maastricht V/Florence Consensus Conference, 43 experts from 24 countries examined new data related to H. pylori in five subdivided workshops: (1) Indications/Associations, (2) Diagnosis, (3) Treatment, (4) Prevention/Public Health, (5) H. pylori and the Gastric Microbiota. The results of the individual workshops were presented to a final consensus voting that included all participants. Recommendations are provided on the basis of the best available evidence and relevance to the management of H. pylori infection in the various clinical scenarios.

An index with improved diagnostic accuracy for the diagnosis of Crohn's disease derived from the Lennard-Jones criteria

BACKGROUND

The Lennard-Jones criteria are considered the gold standard for diagnosing Crohn's disease (CD) and include the items granuloma, macroscopic discontinuity, transmural inflammation, fibrosis, lymphoid aggregates and discontinuous inflammation on histology. The criteria have never been subjected to a formal validation process.

AIM

To develop a validated and improved diagnostic index based on the items of Lennard-Jones criteria.

METHODS

Included were 328 adult patients with long-standing CD (median disease duration 10 years) from three centres and classified as 'established', 'probable' or 'non-CD' by Lennard-Jones criteria at time of diagnosis. Controls were patients with ulcerative colitis (n = 170). The performance of each of the six diagnostic items of Lennard-Jones criteria was modelled by logistic regression and a new index based on stepwise backward selection and cut-offs was developed. The diagnostic value of the new index was analysed by comparing sensitivity, specificity and accuracy vs. Lennard-Jones criteria.

RESULTS

By Lennard-Jones criteria 49% (n = 162) of CD patients would have been diagnosed as 'non-CD' at time of diagnosis (sensitivity/specificity/accuracy, 'established' CD: 0.34/0.99/0.67; 'probable' CD: 0.51/0.95/0.73). A new index was derived from granuloma, fibrosis, transmural inflammation and macroscopic discontinuity, but excluded lymphoid aggregates and discontinuous inflammation on histology. Our index provided improved diagnostic accuracy for 'established' and 'probable' CD (sensitivity/specificity/accuracy, 'established' CD: 0.45/1/0.72; 'probable' CD: 0.8/0.85/0.82), including the subgroup isolated colonic CD ('probable' CD, new index: 0.73/0.85/0.79; Lennard-Jones criteria: 0.43/0.95/0.69).

CONCLUSION

We developed an index based on items of Lennard-Jones criteria providing improved diagnostic accuracy for the differential diagnosis between CD and UC.

No increase in prevalence of somatization in functional vs organic dyspepsia: a cross-sectional survey

BACKGROUND

Psychological factors are associated with functional gastrointestinal (GI) disorders. Literature suggests that somatization is associated with functional dyspepsia (FD). However, the relationship between organic dyspepsia (OD), FD, and FD subtypes and somatization is poorly described. We aimed to examine this issue in a cross-sectional study of secondary care patients.

METHODS

Demographic and GI symptom data were collected from 4224 adult patients via the Rome III questionnaire. Somatization data were collected using the patient health questionnaire-12. Mean somatization score and number of somatic symptoms were compared between patients with organic and FD, and between FD subtypes using analysis of variance. The same comparison was undertaken for the proportion of patients reporting individual somatic symptoms.

KEY RESULTS

Exactly, 783 patients met criteria for dyspepsia, of whom 231 (29.5%) had organic disease following upper GI endoscopy. Mean somatization scores and number of somatic symptoms were no higher in functional vs OD (p = 0.23; p = 0.19). In addition, while the prevalence of somatization in FD was relatively high, there was no difference in severity of somatization in FD subgroups.

CONCLUSIONS & INFERENCES

Somatization is associated with functional and OD to the same degree. Overall severity of somatization did not appear to vary according to FD subtype.

Irritable bowel syndrome is significantly associated with somatisation in 840 patients, which may drive bloating

BACKGROUND

Psychological factors may influence persistence and perceived severity of symptoms in irritable bowel syndrome (IBS). Literature suggests that somatisation is associated with IBS. However, the relationship between IBS subtype, symptoms of IBS and somatisation is unclear.

AIM

To examine this issue in a large cohort of secondary care patients.

METHODS

Demographic and gastrointestinal (GI) symptom data were collected from 4224 adult patients via the Rome III questionnaire. Somatisation data were collected using the patient health questionnaire-12. Mean somatisation score and number of somatic symptoms were compared between IBS patients and controls with minimal GI symptoms, and between IBS subtypes using analysis of variance. Effect of level of somatisation on symptom frequency was compared according to IBS subtype using a χ(2) test.

RESULTS

840 patients met Rome III criteria for IBS, controls were 2137 patients with GI symptoms without IBS. Mean somatisation scores and number of somatic symptoms were higher in IBS vs. controls (P < 0.001), and in mixed stool pattern IBS (IBS-M), vs. IBS with constipation (IBS-C) or diarrhoea (IBS-D) (P < 0.001). High levels of somatisation were more prevalent in IBS-M (31.7%) vs. IBS-C (22.5%) or IBS-D (20.8%) (P = 0.003). For all IBS subtypes, high levels of somatisation were associated with a greater frequency of bloating or abdominal distension prior to logistic regression.

CONCLUSIONS

IBS is strongly associated with higher levels of somatisation, particularly IBS-M. Bloating may be associated with higher levels of somatisation, perhaps explaining why it can be difficult to treat.

Bead study: a novel method to measure gastrointestinal transit in mice

BACKGROUND

Intestinal transit assessment in mice using existing methods requires long recording periods or euthanization of animals to localize a tracer. We have developed a novel in vivo method to assess gastrointestinal (GI) transit in mice based on a clinically used 'shapes study'.

METHODS

Mice (n = 70) were gavaged with 5 steel beads and barium 3 h before, with another dose of barium gavaged 10 min before imaging. Mice were fluoroscoped for 20-60 s, and then most of them were euthanized and the GI tract removed to confirm the localization of the beads fluoroscopically. The in vivo and postmortem recordings were analyzed and each bead was scored depending on its location; a total score was calculated by adding individual bead scores. Total scores obtained from the two methods were compared. A group of mice (n = 10) were examined on three occasions, before and after treatment with loperamide or prucalopride.

KEY RESULTS

The stomach and cecum were consistently outlined by barium, serving as reference landmarks. There was an excellent overall correlation between in vivo and postmortem transit scores (r = 0.93). Analysis of scores for individual gut segments revealed high agreement for stomach, cecum, and expelled beads, and moderate agreement for the small bowel and colon. Gastrointestinal transit scores were decreased by loperamide and increased by prucalopride compared with baseline.

CONCLUSIONS & INFERENCES

Metallic beads are reliably localized by videofluoroscopy in vivo within the GI tract. This novel imaging method enables repetitive measurements of GI transit in vivo and detects changes induced by motility-modifying agents.

Characteristics of functional bowel disorder patients: a cross-sectional survey using the Rome III criteria

BACKGROUND

There is some evidence that, despite attempts to classify them separately, functional bowel disorders are not distinct entities and that such divisions are artificial.

AIM

To examine this issue in a large cohort of secondary care patients.

METHODS

Consecutive, unselected adults with gastrointestinal (GI) symptoms attending out-patient clinics at two hospitals in Hamilton, Ontario were recruited. Demographic data, symptoms and presence of anxiety, depression or somatisation were collected prospectively. We used validated questionnaires, including the Rome III questionnaire, with patients categorised as having irritable bowel syndrome (IBS), functional diarrhoea or chronic idiopathic constipation (CIC). We compared data between these disorders, and measured degree of overlap between them by suspending their mutual exclusivity.

RESULTS

Of 3656 patients providing complete lower GI symptom data, 1551 (42.4%) met criteria for a functional bowel disorder. Diarrhoea-predominant IBS (IBS-D) patients were younger, and more were female, met criteria for anxiety, and reported somatisation-type behaviour, compared with functional diarrhoea. Only loose, mushy or watery stools were more common in functional diarrhoea. When mutual exclusivity was suspended, overlap occurred in 27.6%. Constipation-predominant IBS (IBS-C) patients were younger, and more were female, had never married, reported anxiety type symptoms and exhibited somatisation-type behaviour. One in five CIC patients reported abdominal pain or discomfort. All constipation symptoms were more common in IBS-C. When the mutual exclusivity was suspended, overlap occurred in 18.1%.

CONCLUSIONS

There were significant differences in demographics between individuals with functional bowel disorders. Despite this, the Rome III classification system falls short of describing unique entities.

Guide wire-assisted cannulation for the prevention of post-ERCP pancreatitis: a systematic review and meta-analysis

BACKGROUND AND STUDY AIMS

Cannulation techniques are recognized to be important in causing post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, considerable controversy exists about the usefulness of the guide wire-assisted cannulation technique for the prevention of PEP. This systematic review of randomized controlled trials (RCTs) aimed to compare the guide wire-assisted cannulation technique with the contrast-assisted cannulation technique.

METHODS

CENTRAL, MEDLINE, EMBASE, CINAHL, and abstracts from Digestive Disease Week and the United European Gastroenterology Week were searched up to February 2012 for RCTs comparing the guide wire-assisted ERCP cannulation technique with the conventional contrast-assisted ERCP cannulation technique. The risk of bias was assessed, and outcomes were pooled by meta-analysis (random-effects model). The primary outcome measure was PEP. Secondary outcome measures included severity of PEP, primary common bile duct (CBD) cannulation success, overall CBD cannulation success, precut sphincterotomy, and other ERCP-related complications.

RESULTS

In total, 12 RCTs (3450 patients) were included. The guide wire-assisted cannulation technique significantly reduced PEP compared with the contrast-assisted cannulation technique (risk ratio [RR] 0.51, 95 % confidence interval [CI] 0.32 - 0.82). In addition, the guide wire-assisted cannulation technique was associated with greater primary cannulation success (RR 1.07, 95 %CI 1.00 - 1.15), fewer precut sphincterotomies (RR 0.75, 95 %CI 0.60 - 0.95), and no increase in other ERCP-related complications. Subgroup analyses indicated that this significant risk reduction in PEP with the guide wire-assisted cannulation technique existed only in "non-crossover" trials (RR 0.22, 95 %CI 0.12 - 0.42). The results were robust in sensitivity analyses.

CONCLUSION

Compared with the contrast-assisted cannulation technique, the guide wire-assisted cannulation technique increases the primary cannulation rate and reduces the risk of PEP, and therefore appears to be the most appropriate first-line cannulation technique.

The impact of intensifying acid suppression on sleep disturbance related to gastro-oesophageal reflux disease in primary care

BACKGROUND

Sleep disturbance is common in patients with GERD but there has been little evaluation of this problem in primary care in patients already taking therapy.

AIM

To evaluate the impact of administering a questionnaire (PASS test) to identify patients with sleep problems and evaluate the efficacy of esomeprazole to improve sleep disturbance in patients with GERD.

METHODS

This was a primary care based cluster-randomised, open-label study where practices were assigned to intervention or control groups. PASS test failures continued current therapy (control) or were switched to 4 weeks' once-daily esomeprazole 20 or 40 mg (intervention). Patients were evaluated at the end of 4 weeks and the outcomes that were assessed were the sleep questions from the Quality of Life in Reflux and Dyspepsia (QOLRAD) questionnaire and the presence or absence of sleep disturbance from the PASS test questionnaire.

RESULTS

A total of 1388 patients with evaluable data at 4 weeks were included in the analysis and 825 reported GERD-related sleep disturbance at baseline. At 4 weeks, 161 of 291 of control patients (55%) reported continued sleep disturbance compared to 120 of 534 (22.5%) of intervention patients [number needed to treat of 3: 95% confidence intervals (CI): 2.5-4]. There was a mean improvement in QOLRAD scores related to sleep in the intervention patients compared to control patients (mean improvement = 4.91; 95% CI: 3.73-6.09).

CONCLUSION

A PASS strategy identifies GERD patients with sleep disturbance in primary care that will benefit from a change in acid-suppressive therapy. ClinicalTrials.gov identifier: NCT00392002; study code: D9612L00096.

The natural history of gastro-oesophageal reflux symptoms in the community and its effects on survival: a longitudinal 10-year follow-up study

BACKGROUND

Gastro-oesophageal reflux symptoms (GERS) are common in the community. However, few studies have examined their long-term natural history, or impact on survival.

AIM

To examine these issues in individuals recruited into a community-based screening programme for Helicobacter pylori in 1994.

METHODS

Data on mortality and cause of death at 10 years were obtained from the Office for National Statistics. Baseline demographic data, lifestyle factors, gastrointestinal symptoms and quality of life were recorded at study entry. The effect of all these factors on persistent and new-onset GERS, and 10-year mortality, were examined using univariate and multivariate analysis, with results expressed as odds ratios (ORs) or hazard ratios (HR) with 99% confidence intervals (CI).

RESULTS

Of 3967 individuals providing complete GERS data at baseline and 10 years, 549 (13.8%) had GERS at baseline. Of these, 183 (33.3%) had persistent symptoms. Among 3418 individuals asymptomatic at baseline, approximately 0.8% per year developed new-onset GERS. No predictors of persistent GERS were identified. New-onset symptoms were associated with lower quality of life or presence of irritable bowel syndrome (IBS) at baseline, and higher body mass index (BMI) at 10 years. There were 8331 (99.1%) of 8407 subjects providing complete GERS data at baseline, 1289 (15.5%) of whom were symptomatic. Presence of GERS at baseline did not affect survival (HR: 0.84; 99% CI: 0.44-1.59).

CONCLUSIONS

Gastro-oesophageal reflux symptoms persisted in one-third of individuals, whilst new-onset gastro-oesophageal reflux symptoms were associated with poor quality of life, irritable bowel syndrome and higher body mass index. Gastro-oesophageal reflux symptoms did not impact adversely on survival.

Review article: current treatment options and management of functional dyspepsia

BACKGROUND

Functional dyspepsia (FD), a common functional gastrointestinal disorder, is defined by the Rome III criteria as symptoms of epigastric pain or discomfort (prevalence in FD of 89-90%), postprandial fullness (75-88%), and early satiety (50-82%) within the last 3 months with symptom onset at least 6 months earlier. Patients cannot have any evidence of structural disease to explain symptoms and predominant symptoms of gastroesophageal reflux are exclusionary. Symptoms of FD are non-specific and the pathophysiology is diverse, which explains in part why a universally effective treatment for FD remains elusive.

AIM

To present current management options for the treatment of FD (therapeutic gain/response rate noted when available).

RESULTS

The utility of Helicobacter pylori eradication for the treatment of FD is modest (6-14% therapeutic gain), while the therapeutic efficacy of proton pump inhibitors (PPI) (7-10% therapeutic gain), histamine-type-2-receptor antagonists (8-35% therapeutic gain), prokinetic agents (18-45%), tricyclic antidepressants (TCA) (response rates of 64-70%), serotonin reuptake inhibitors (no better than placebo) is limited and hampered by inadequate data. This review discusses dietary interventions and analyses studies involving complementary and alternative medications, and psychological therapies.

CONCLUSIONS

A reasonable treatment approach based on current evidence is to initiate therapy with a daily PPI in H. pylori-negative FD patients. If symptoms persist, a therapeutic trial with a tricyclic antidepressant may be initiated. If symptoms continue, the clinician can possibly initiate therapy with an anti-nociceptive agent, a prokinetic agent, or some form of complementary and alternative medications, although evidence from prospective studies to support this approach is limited.

Meta-analysis: factors affecting placebo response rate in the irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract with a significant placebo response.

AIM

To conduct a systematic review and meta-analysis examining the magnitude of placebo response rate in treatment trials for IBS.

METHODS

MEDLINE, EMBASE and the Cochrane central register of controlled trials were searched to identify randomized controlled trials (RCTs) comparing pharmacological therapies with placebo in adult IBS patients. Studies reported either global assessment of IBS symptom cure or improvement or abdominal pain cure or improvement. Data were extracted as intention-to-treat analyses with drop-outs assumed to be treatment failures and pooled using a random-effects model. Proportion of placebo patients experiencing symptom improvement or resolution was reported with a 95% confidence interval (CI). Effect of trial characteristics on magnitude of placebo response was examined.

RESULTS

In all, 73 RCTs were eligible, including 8364 patients with IBS allocated to placebo. Pooled placebo response rate across all RCTs was 37.5% (95% CI 34.4-40.6%). Rates were higher in European RCTs, RCTs that used physician-reported outcomes and RCTs using shorter duration of therapy.

CONCLUSIONS

Placebo response rates across RCTs of pharmacological therapies in IBS were high. Future research should identify patient characteristics predicting placebo response.

Cost-utility analysis of proton pump inhibitors and other gastro-protective agents for prevention of gastrointestinal complications in elderly patients taking nonselective nonsteroidal anti-inflammatory agents

BACKGROUND

The use of proton pump inhibitors (PPIs) among elderly patients using nonselective nonsteroidal anti-inflammatory drugs (nsNSAIDs) has increased; the price of PPIs is higher than that of majority of alternative treatment strategies.

AIM

To evaluate the cost-effectiveness of nsNSAIDS + PPIs relative to alternative gastroprotective regimens in the prevention of GI complications among elderly patients (aged > or = 65 years).

METHODS

An incremental cost-utility analysis, comparing PPIs with alternative gastroprotective regimens was conducted using a decision analytical model. Clinical outcomes, costs and utilities were derived from recently published studies. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the results to variation in model inputs and assumptions.

RESULTS

The incremental cost-utility ratio (ICUR) of PPIs, relative to nsNSAID alone, was $206,315 per QALY gained or were more costly and less effective. Other co-prescribed treatment options had higher costs per QALY gained. In patients with a history of a complicated or uncomplicated ulcer, PPIs had ICURs of $24,277 and $40,876, respectively.

CONCLUSIONS

Use of PPIs in all elderly patients taking nsNSAIDs is unlikely to represent an efficient use of finite healthcare resources. Co-prescribing PPIs, however, to elderly patients taking nsNSAIDs who have a history of complicated or uncomplicated ulcers appears to be economically attractive.

The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review

INTRODUCTION

Probiotics may benefit irritable bowel syndrome (IBS) symptoms, but randomised controlled trials (RCTs) have been conflicting; therefore a systematic review was conducted.

METHODS

MEDLINE (1966 to May 2008), EMBASE (1988 to May 2008) and the Cochrane Controlled Trials Register (2008) electronic databases were searched, as were abstracts from DDW (Digestive Diseases Week) and UEGW (United European Gastroenterology Week), and authors were contacted for extra information. Only parallel group RCTs with at least 1 week of treatment comparing probiotics with placebo or no treatment in adults with IBS according to any acceptable definition were included. Studies had to provide improvement in abdominal pain or global IBS symptoms as an outcome. Eligibility assessment and data extraction were performed by two independent researchers. Data were synthesised using relative risk (RR) of symptoms not improving for dichotomous data and standardised mean difference (SMD) for continuous data using random effects models.

RESULTS

19 RCTs (18 papers) in 1650 patients with IBS were identified. Trial quality was generally good, with nine reporting adequate methods of randomisation and six a method of concealment of allocation. There were 10 RCTs involving 918 patients providing outcomes as a dichotomous variable. Probiotics were statistically significantly better than placebo (RR of IBS not improving=0.71; 95% CI 0.57 to 0.88) with a number needed to treat (NNT)=4 (95% CI 3 to 12.5). There was significant heterogeneity (chi(2)=28.3, p=0.001, I(2)=68%) and possible funnel plot asymmetry. Fifteen trials assessing 1351 patients reported on improvement in IBS score as a continuous outcome (SMD=-0.34; 95% CI -0.60 to -0.07). There was statistically significant heterogeneity (chi(2)=67.04, p<0.001, I(2)=79%), but this was explained by one outlying trial.

CONCLUSION

Probiotics appear to be efficacious in IBS, but the magnitude of benefit and the most effective species and strain are uncertain.

Meta-analysis: yield of diagnostic tests for coeliac disease in dyspepsia

BACKGROUND

The prevalence of coeliac disease (CD) may be increased in individuals with dyspepsia, but evidence is conflicting.

AIMS

To conduct a systematic review and meta-analysis of studies reporting prevalence of CD in dyspepsia.

METHODS

MEDLINE, EMBASE, and CINAHL were searched up to February 2009. Case series and case-control studies applying serological tests and/or distal duodenal biopsy for CD to unselected adults with dyspepsia were eligible. Prevalence of positive coeliac serology and biopsy-proven CD were pooled for all studies and compared between cases and controls using an odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Fifteen studies were identified. Prevalence of positive coeliac serology was higher in cases with dyspepsia (7.9%) compared with controls (3.9%), but not significantly so (OR for positive endomysial antibodies or tissue transglutaminase 1.89; 95% CI 0.90-3.99). Prevalence of biopsy-proven CD following positive serology was also higher (3.2% in cases vs. 1.3% in controls), but again this was not statistically significant (OR 2.85; 95% CI 0.60-13.38). Prevalence of biopsy-proven CD was 1% in ten studies performing duodenal biopsy first-line.

CONCLUSION

Prevalence of biopsy-proven CD in subjects with dyspepsia was 1% and was higher than in controls, although this difference was not statistically significant.

Diagnosis and management of non-erosive reflux disease--the Vevey NERD Consensus Group

BACKGROUND/AIMS

Although considerable information exists regarding gastroesophageal reflux disease with erosions, much less is known of non-erosive reflux disease (NERD), the dominant form of reflux disease in the developed world.

METHODS

An expert international group using the modified Delphi technique examined the quality of evidence and established levels of agreement relating to different aspects of NERD. Discussion focused on clinical presentation, assessment of clinical outcome, pathobiological mechanisms, and clinical strategies for diagnosis and management.

RESULTS

Consensus was reached on 85 specific statements. NERD was defined as a condition with reflux symptoms in the absence of mucosal lesions or breaks detected by conventional endoscopy, and without prior effective acid-suppressive therapy. Evidence supporting this diagnosis included: responsiveness to acid suppression therapy, abnormal reflux monitoring or the identification of specific novel endoscopic and histological findings. Functional heartburn was considered a separate entity not related to acid reflux. Proton pump inhibitors are the definitive therapy for NERD, with efficacy best evaluated by validated quality-of-life instruments. Adjunctive antacids or H(2) receptor antagonists are ineffective, surgery seldom indicated.

CONCLUSIONS

Little is known of the pathobiology of NERD. Further elucidation of the mechanisms of mucosal and visceral hypersensitivity is required to improve NERD management.

Canadian consensus guidelines on long-term nonsteroidal anti-inflammatory drug therapy and the need for gastroprotection: benefits versus risks

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used, but are not without risks.

AIM

To provide evidence-based management recommendations to help clinicians determine optimal long-term NSAID therapy and the need for gastroprotective strategies based on an assessment of both gastrointestinal (GI) and cardiovascular (CV) risks.

METHODS

A multidisciplinary group of 21 voting participants revised and voted on the statements and the strength of evidence (assessed according to GRADE) at a consensus meeting.

RESULTS

An algorithmic approach was developed to help manage patients who require long-term NSAID therapy. The use of low-dose acetylsalicylic acid in patients with high CV risk was assumed. For patients at low GI and CV risk, a traditional NSAID alone may be acceptable. For patients with low GI risk and high CV risk, full-dose naproxen may have a lower potential for CV risk than other NSAIDs. In patients with high GI and low CV risk, a COX-2 inhibitor plus a proton pump inhibitor (PPI) may offer the best GI safety profile. When both GI and CV risks are high and NSAID therapy is absolutely necessary, risk should be prioritized. If the primary concern is GI risk, a COX-2 inhibitor plus a PPI is recommended; if CV risk, naproxen 500 mg b.d. plus a PPI would be preferred. NSAIDs should be used at the lowest effective dose for the shortest possible duration.

CONCLUSION

More large, long-term trials that examine clinical outcomes of complicated and symptomatic upper and lower GI ulcers are needed.

Efficacy of antidepressants and psychological therapies in irritable bowel syndrome: systematic review and meta-analysis

OBJECTIVE

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder. Evidence for treatment of the condition with antidepressants and psychological therapies is conflicting.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs). MEDLINE, EMBASE and the Cochrane Controlled Trials Register were searched (up to May 2008).

SETTING

RCTs based in primary, secondary and tertiary care.

PATIENTS

Adults with IBS.

INTERVENTIONS

Antidepressants versus placebo, and psychological therapies versus control therapy or "usual management".

MAIN OUTCOME MEASURES

Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy, with a 95% confidence interval (CI). The number needed to treat (NNT) was calculated from the reciprocal of the risk difference.

RESULTS

The search strategy identified 571 citations. Thirty-two RCTs were eligible for inclusion: 19 compared psychological therapies with control therapy or "usual management", 12 compared antidepressants with placebo, and one compared both psychological therapy and antidepressants with placebo. Study quality was generally good for antidepressant but poor for psychological therapy trials. The RR of IBS symptoms persisting with antidepressants versus placebo was 0.66 (95% CI, 0.57 to 0.78), with similar treatment effects for both tricyclic antidepressants and selective serotonin reuptake inhibitors. The RR of symptoms persisting with psychological therapies was 0.67 (95% CI, 0.57 to 0.79). The NNT was 4 for both interventions.

CONCLUSIONS

Antidepressants are effective in the treatment of IBS. There is less high-quality evidence for routine use of psychological therapies in IBS, but available data suggest these may be of comparable efficacy.

Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis

OBJECTIVE

Colorectal cancer is the second most common cause of cancer death in Europe and North America. Alarm features are used to prioritize access to urgent investigation, but there is little information concerning their utility in the diagnosis of colorectal cancer.

METHODS

A systematic review and meta-analysis of the published literature was carried out to assess the diagnostic accuracy of alarm features in predicting colorectal cancer. Primary or secondary care-based studies in unselected cohorts of adult patients with lower gastrointestinal symptoms were identified by searching MEDLINE, EMBASE and CINAHL (up to October 2007). The main outcome measures were accuracy of alarm features or statistical models in predicting the presence of colorectal cancer after investigation. Data were pooled to estimate sensitivity, specificity, and positive and negative likelihood ratios. The quality of the included studies was assessed according to predefined criteria.

RESULTS

Of 11 169 studies identified, 205 were retrieved for evaluation. Fifteen studies were eligible for inclusion, evaluating 19 443 patients, with a pooled prevalence of colorectal carcinoma of 6% (95% CI 5% to 8%). Pooled sensitivity of alarm features was poor (5% to 64%) but specificity was >95% for dark red rectal bleeding and abdominal mass, suggesting that the presence of either rules the diagnosis of colorectal cancer in. Statistical models had a sensitivity of 90%, but poor specificity.

CONCLUSIONS

Most alarm features had poor sensitivity and specificity for the diagnosis of colorectal carcinoma, whilst statistical models performed better in terms of sensitivity. Future studies should examine the utility of dark red rectal bleeding and abdominal mass, and concentrate on maximising specificity when validating statistical models.

Fluctuation of gastrointestinal symptoms in the community: a 10-year longitudinal follow-up study

BACKGROUND

There are few studies examining the stability of gastrointestinal symptoms during prolonged periods of follow-up.

AIM

To examine this issue in individuals previously recruited into a community screening programme for Helicobacter pylori providing symptom data at study entry.

METHODS

All traceable participants were sent dyspepsia and IBS questionnaires by post at 10 years. Symptom subgroups were assigned at baseline and 10-year follow-up. Individuals symptomatic at both time points who changed subgroup were compared with those symptomatic and remaining in the same subgroup.

RESULTS

Three-thousand eight hundred and nineteen individuals provided data. At baseline, 2417 (63%) were asymptomatic or did not meet diagnostic criteria for a subgroup. Of these, 1648 (68%) remained asymptomatic at 10 years, whilst 769 (32%) reported symptoms. Of the 1402 individuals symptomatic at baseline, 404 (29%) remained in the same subgroup at 10 years, 603 (43%) changed subgroup and symptoms resolved or did not meet criteria for a subgroup in 395 (28%). Symptom stability was more likely in males [odds ratio (OR): 1.50; 99% confidence interval (CI): 0.97-2.31] and older subjects (OR per year: 1.09; 99% CI: 1.01-1.17).

CONCLUSION

Of those subjects symptomatic at baseline, almost three-quarters remained symptomatic at 10 years, but over 40% changed symptom subgroup.

Meta-analysis: Helicobacter pylori'test and treat' compared with empirical acid suppression for managing dyspepsia

BACKGROUND

Which of Helicobacter pylori'test and treat' or empirical acid suppression should be preferred for the initial management of uncomplicated dyspepsia is controversial. Aim To conduct an individual patient data meta-analysis of randomized controlled trials (RCTs) of 'test and treat' vs. empirical acid suppression in adults with uncomplicated dyspepsia in primary care.

METHODS

Investigators provided original data sets for analysis. Effect of management strategy on symptom status and dyspepsia-related resource use at 12-month follow-up was examined by pooling symptom and cost data to obtain relative risk (RR) of remaining symptomatic at 12 months and weighted mean difference (WMD) in costs between the two strategies with 95% confidence intervals (CI).

RESULTS

We identified three eligible RCTs containing 1547 patients, 791 (51%) of whom were assigned to 'test and treat'. There was no difference detected in symptom-cure at 12 months (RR = 0.99; 95% CI: 0.95-1.03). There was a nonsignificant trend towards cost-savings with 'test and treat' (WMD in costs = - 28.91 pound; 95% CI: - 68.48 pound to 10.65 pound).

CONCLUSIONS

There was little difference in symptom-resolution or costs between the two strategies. A combination of patient and physician preference should determine the initial approach to the management of uncomplicated dyspepsia.

Clinical trial design in adult reflux disease: a methodological workshop

BACKGROUND

The development of well-tolerated acid suppressant drugs has stimulated substantial growth in the number of trials assessing therapy options for gastro-oesophageal reflux disease (GERD).

AIM

To develop consensus statements to inform clinical trial design in adult patients with GERD.

METHODS

Draft statements were developed employing a systematic literature review. A modified Delphi process including three rounds of voting was used to reach consensus. Between voting, statements were revised based on feedback from the Working Group and additional literature reviews. The final vote was at a face-to-face meeting that included discussion time. Voting was conducted using a six-point scale.

RESULTS

At the last vote, 93% of the final 102 statements achieved consensus (defined a priori as being supported by >or=75% of the votes). The Working Group strongly supported the development of validated patient-reported outcome instruments. Symptom assessments carried out by the investigator were considered unacceptable. There was agreement that exclusion from clinical trials should be minimized to improve generalizability, that prospective evaluation ideally requires electronic timed/dated methods and that endoscopists should be blinded to patient symptom status.

CONCLUSIONS

Implementation of the consensus statements will improve the quality and comparability of trials, and make them compatible with regulatory requirements.

Mortality rates in patients with Barrett's oesophagus

BACKGROUND

Patients with Barrett's oesophagus are at increased risk of oesophageal adenocarcinoma. Observational studies have suggested increase in overall mortality also but data are conflicting.

AIM

To assess the cause of death in patients with Barrett's oesophagus compared with the general population.

METHODS

Patients with Barrett's oesophagus were identified retrospectively in four hospitals in Leicestershire, UK using electronic endoscopy and histopathology records from 1997 to 2003. Data on deaths from this cohort of patients were identified through the Office of National Statistics and compared with age- and gender-adjusted mortality in the Leicestershire region.

RESULT

In all, 1272 Barrett's patients were identified with 245 deaths in this cohort. Overall mortality was found to be increased [male standardized mortality ratio (SMR) = 552, 95% CI = 466-638; female SMR 455, 95% CI = 357-552]. The main disease areas that were responsible for this increase were oesophageal adenocarcinoma (n = 25, male SMR = 2171, 95% CI = 991-3351; female SMR = 1300, 95% CI = 26-2574), bronchopneumonia (n = 70, male SMR = 146, 95% CI = 55-236; female SMR = 436, 95% CI = 272-601) and ischaemic heart disease (n = 51, male SMR = 186, 95% CI = 97-2748; female SMR = 205, 95% CI = 105-306).

CONCLUSIONS

Patients with Barrett's oesophagus die more commonly of bronchopneumonia and ischaemic heart disease compared with oesophageal adenocarcinoma, and overall mortality in this group may be increased.

Clinical trial: knowledge of negative Helicobacter pylori status reduces subsequent dyspepsia-related resource use

BACKGROUND

Screening for Helicobacter pylori reduces dyspepsia and dyspepsia-related costs in positive individuals.

AIMS

To assess effect of knowledge of H. pylori status on healthcare-seeking in negative individuals.

METHODS

H. pylori-negative subjects in a community screening programme were randomized to placebo triple therapy or informed of their negative H. pylori status. Dyspepsia-related resource data were extracted from primary care records at 2 years, and National Health Service reference costs were applied to calculate the total cost per subject. Proportions of individuals incurring any cost were compared using a relative risk (RR) and 95% confidence interval (CI). Differences in costs were compared using an independent sample t-test.

RESULTS

A total of 1353 H. pylori-negative individuals were randomized to placebo whilst 1355 were informed of their infection status. In the placebo arm, 212 (16%) subsequently incurred any dyspepsia-related cost compared to 172 (13%) informed of their infection status (RR of incurring cost = 0.81; 95% CI: 0.67-0.97). Those informed of their infection status incurred lower costs (mean saving per individual = pound 11.02; 95% CI: - pound 3.52 to 25.56).

CONCLUSIONS

H. pylori-negative individuals informed of infection status sought health care for dyspepsia less often than those who were unaware. Population screening may reduce dyspepsia-related costs in uninfected, as well as infected individuals.

The Short-Form Leeds Dyspepsia Questionnaire validation study

BACKGROUND

Assessment of symptoms should be the primary outcome measure in dyspepsia clinical trials. This requires a reliable, valid and responsive questionnaire that measures the frequency and severity of dyspepsia. The Leeds Dyspepsia Questionnaire fulfils these characteristics, but is long and was not designed for self-completion, so a shorter questionnaire was developed (the Short-Form Leeds Dyspepsia Questionnaire).

AIM

To assess the acceptability, interpretability, internal consistency, reliability, validity and responsiveness of the Short-Form Leeds Dyspepsia Questionnaire in primary and secondary care.

METHODS

Unselected primary and secondary care patients completed the Short-Form Leeds Dyspepsia Questionnaire. Test-retest reliability was assessed after 2 days. Validity was measured by comparison with general practitioners' diagnosis. Sensitivity analysis and logistic regression were employed to determine the most valid scoring system. Responsiveness was determined before and after treatment for endoscopically proven disease.

RESULTS

The Short-Form Leeds Dyspepsia Questionnaire was administered to 388 primary care and 204 secondary care patients. The Pearson coefficient for test-retest reliability was 0.93. The Short-Form Leeds Dyspepsia Questionnaire had a sensitivity of 77% and a specificity of 75%. A highly significant response to change was observed (P < 0.005).

CONCLUSIONS

The Short-Form Leeds Dyspepsia Questionnaire is a reliable, valid and responsive self-completed outcome measure for quantifying the frequency and severity of dyspepsia symptoms, which is shorter and more convenient than the Leeds Dyspepsia Questionnaire.