Functional Bowel Disease Research Articles

Clostridium difficile Infection in a Pediatric Population

Background: The risks for chronic gastrointestinal illness (GI) when relocated short-term to other countries and when taking antibiotic prophylaxis in areas where malaria is endemic are unknown. A cluster of Australian Federal Police officers returning from overseas duty reported acute and chronic GI illnesses and some were diagnosed with inflammatory bowel disease. Aims: To examine the associations of deployment to developed or developing countries and exposure to doxycycline with the new onset of acute GI illness, functional bowel disorder (FBD) and inflammatory bowel disease (IBD). Methods: A cross-sectional web-based survey of all current and past members of the Australian Federal Police Association was undertaken. Independent predictors of gastrointestinal illness were examined by logistic regression analysis relative to those not deployed without exposure to doxycycline. Results: Of 1300 respondents (response rate 34%), 133 were excluded due to pre-existing chronic GI illness. Median age range was 36 to 45 years old with male predominance. 590 had episodes of overseas deployment for a median duration of 6.5 (range 0.1-149) months. 18 (3%) of those not deployed took doxycycline compared with 171 (30%) of those deployed. Those deployed abroad vs those not deployed reported gastroenteritis in 9.7% vs 0.7% (P<0.001), FBD in 4.7% vs 2.3% (P<0.001) and IBD 1.7% vs 1.4% (p=ns). Results of the multivariate analyses are shown in the table below. Conclusions: Being deployed abroad rather than doxycycline exposure is a risk factor for acute GI illness. The use of doxycycline in those deployed overseas is associated with the onset of FBD and possibly IBD. Doxycycline as a risk factor for chronic gastrointestinal illness warrants a prospective larger scale study.

Gastroesophageal Reflux Disease (GERD) is Strongly Associated With Psychological Disorders in the General Population: A Community-Based Study

Background: The risks for chronic gastrointestinal illness (GI) when relocated short-term to other countries and when taking antibiotic prophylaxis in areas where malaria is endemic are unknown. A cluster of Australian Federal Police officers returning from overseas duty reported acute and chronic GI illnesses and some were diagnosed with inflammatory bowel disease. Aims: To examine the associations of deployment to developed or developing countries and exposure to doxycycline with the new onset of acute GI illness, functional bowel disorder (FBD) and inflammatory bowel disease (IBD). Methods: A cross-sectional web-based survey of all current and past members of the Australian Federal Police Association was undertaken. Independent predictors of gastrointestinal illness were examined by logistic regression analysis relative to those not deployed without exposure to doxycycline. Results: Of 1300 respondents (response rate 34%), 133 were excluded due to pre-existing chronic GI illness. Median age range was 36 to 45 years old with male predominance. 590 had episodes of overseas deployment for a median duration of 6.5 (range 0.1-149) months. 18 (3%) of those not deployed took doxycycline compared with 171 (30%) of those deployed. Those deployed abroad vs those not deployed reported gastroenteritis in 9.7% vs 0.7% (P<0.001), FBD in 4.7% vs 2.3% (P<0.001) and IBD 1.7% vs 1.4% (p=ns). Results of the multivariate analyses are shown in the table below. Conclusions: Being deployed abroad rather than doxycycline exposure is a risk factor for acute GI illness. The use of doxycycline in those deployed overseas is associated with the onset of FBD and possibly IBD. Doxycycline as a risk factor for chronic gastrointestinal illness warrants a prospective larger scale study.

Association of Doxycyline Use With the Development of Acute and Chronic Gastrointestinal Illness in Australians Deployed Abroad

Background: The risks for chronic gastrointestinal illness (GI) when relocated short-term to other countries and when taking antibiotic prophylaxis in areas where malaria is endemic are unknown. A cluster of Australian Federal Police officers returning from overseas duty reported acute and chronic GI illnesses and some were diagnosed with inflammatory bowel disease. Aims: To examine the associations of deployment to developed or developing countries and exposure to doxycycline with the new onset of acute GI illness, functional bowel disorder (FBD) and inflammatory bowel disease (IBD). Methods: A cross-sectional web-based survey of all current and past members of the Australian Federal Police Association was undertaken. Independent predictors of gastrointestinal illness were examined by logistic regression analysis relative to those not deployed without exposure to doxycycline. Results: Of 1300 respondents (response rate 34%), 133 were excluded due to pre-existing chronic GI illness. Median age range was 36 to 45 years old with male predominance. 590 had episodes of overseas deployment for a median duration of 6.5 (range 0.1-149) months. 18 (3%) of those not deployed took doxycycline compared with 171 (30%) of those deployed. Those deployed abroad vs those not deployed reported gastroenteritis in 9.7% vs 0.7% (P<0.001), FBD in 4.7% vs 2.3% (P<0.001) and IBD 1.7% vs 1.4% (p=ns). Results of the multivariate analyses are shown in the table below. Conclusions: Being deployed abroad rather than doxycycline exposure is a risk factor for acute GI illness. The use of doxycycline in those deployed overseas is associated with the onset of FBD and possibly IBD. Doxycycline as a risk factor for chronic gastrointestinal illness warrants a prospective larger scale study.

COMPARATIVE EVALUATION IDENTIFICATION OF INFLAMMATORY BOWEL DISEASE AND TUMOR ON THE BASIS OF LACTOFERRIN AND CALPROTECTIN

The study was a comparative evaluation of the identification of inflammatory bowel disease and tumor on the basis of fecal lactoferrin and fecal calprotectin. 40 patients with colorectal cancer, 52 patients with ulcerative colitis, 45 patients with irritable bowel syndrome and 19 healthy volunteers are included in study group. Diagnoses were exposed on the basis of clinical, laboratory, endoscopic and morphological data. Healthy volunteers had no symptoms of bowel disease and were not subjected to abdominal surgical interventions. Active ulcerative colitis was assessed by an index Schroeder (Mayo Clinic UC DAI). Lactoferrin was determined in stool samples taken from a stool, enzyme immunoassay (ELISA) using kits ELISA TEST KIT Hycult Biotechnology (Netherlands). Calprotectin were determined in stool samples of patients taken from a stool, immunnofermentnym analysis using a standard set of firm «Nova Tec Immundiagnostica GmbH», Germany. Established that the diagnostic value of faecal calprotectin in the diagnosis of colorectal cancer (AUC: 0,945 ± 0,0262) and ulcerative colitis (AUC: 0,893 ± 0,032) did not differ from lactoferrin (p = 0,9547 and p = 0,9645 respectively). In the differential diagnosis of organic and functional bowel disease markers also had no reliable statistical differences on this parameter (AUC: 0,938 ± 0,0207; p = 0,8124).

46. Increased eosinophils and mast cells in the irritable bowel syndrome

Background Irritable bowel syndrome is a functional bowel disorder, the aetiopathogenesis of which has been poorly understood. It appears to be multifactorial and to involve altered gastrointestinal motor function, enhanced perception of visceral stimuli and psychosocial factors. Only a few studies have analysed the involvement of inflammatory cells in this condition. The aim of this study was to determine whether eosinophils and mast cells were increased in the colonic mucosa in irritable bowel syndrome compared to controls. Method Slides of 20 colonic biopsy materials of patients with irritable bowel syndrome who had endoscopically and histologically normal colonic mucosa were analysed. Twenty normal controls that had random colonic biopsies with macroscopic and histologic normal colonic mucosa and no organic or functional bowel disease were enrolled. Quantification of eosinophils and mast cells was performed on three non-overlapping fields of lamina propria at ×40 magnification. Eosinophil degranulation was semi-quantitatively estimated assessing the extent of free granules within the lamina propria. Results Among the total of 20 tests and 20 controls, the majority were females (75% and 65%, respectively). Diarrhoea predominant irritable bowel syndrome was the most common mode of presentation. Eosinophil number, degranulation and mast cell count were significantly high in colonic biopsies obtained from irritable bowel syndrome compared to control. Comment Elevated mast cells have already been reported in the colonic and ileal biopsies and there were a few proposals predicting the involvement of eosinophils in the pathogenesis of the irritable bowel syndrome. This study supports this finding and explains the possible neural – mast cell – eosinophil interaction in generating the symptoms of functional gastrointestinal disorders including irritable bowel syndrome.

Ischemic Hypersensitivity in Irritable Bowel Syndrome Patients

Mixed evidence exists regarding whether irritable bowel syndrome (IBS) patients show increased somatic pain perception compared with controls. The current study used a deep, tonic somatic pain stimulus (ischemic pain) to evaluate somatic hypersensitivity in IBS patients. A total of 27 diarrhea-predominant and 15 constipation-predominant IBS patients, and 29 controls participated in the study. The modified submaximal effort tourniquet procedure was performed to induce ischemic arm pain, and the time required to reach pain threshold and pain tolerance were recorded in seconds. All subjects completed the Functional Bowel Disease Severity Index (FBDSI) scale as well as several psychosocial instruments. Group differences for threshold and tolerance were determined using a series of one-way anova tests followed by Tukey comparisons. IBS patients had a shorter time to ischemic threshold (F = 34.606, P < 0.001) and tolerance (F = 38.656, P < 0.001) compared with controls; however, the groups did not differ on ratings of pain at the time of tolerance. IBS patients had a higher rating on the FBDSI scale compared with controls (P < 0.001), and ischemic pain threshold was negatively correlated with the FBDSI score. The results of this study suggest that a widespread alteration in central pain processing in IBS patients may be present as they display hypersensitivity to ischemic arm pain, and ischemic pain threshold was associated with clinical symptoms. These findings could reflect a dysfunction in inhibitory pain systems in IBS patients, as ischemic (deep) pain may be under tonic inhibitory control.

Determining the Optimum Outcome for Trials Evaluating Symptom Improvement in Functional Gastrointestinal Disorders

Purpose: Functional bowel diseases are common and therapy remains suboptimal. Trials often use how much the patients' symptoms have improved as an outcome but the optimum cut off that defines improvement is unclear. This has hampered the development of treatments for functional dyspepsia (FD) and irritable bowel syndrome (IBS) and an FDA report has highlighted the need for validated, well-defined outcome measures in these disorders. We have evaluated whether the stringency of definition of symptom improvement (e.g. improvement in symptoms versus absence of symptoms) impacts on the outcome of trials in a systematic review. Methods: We identified all placebo controlled randomized controlled trials (RCTs) that evaluated pharmacological therapy in FD or IBS from Cochrane systematic reviews. Eligible studies reported on pain or global symptom improvement as a dichotomous outcome and gave at least two cut-off points with different stringencies for symptom improvement. Interventions where there were four or more eligible RCTs were synthesized using a random effects model with relative risk (RR) of remaining symptomatic as the outcome. Heterogeneity was determined by the I squared statistic. Results: 132 RCTs were identified, 95 studies were excluded and 37 were eligible. There were 5 different intervention/functional disease combinations. In all cases the most stringent definition of symptom improvement resulted in a greater treatment effect and 2/5 comparisons the more stringent definition gave a statistically significant result in favor of active treatment whilst the less stringent definition did not (table). In 3/5 cases the more stringent definition gave less heterogeneity between studies, in one case the heterogeneity remained very similar and in one case the less stringent definition resulted in the least heterogeneity (Table).Table: [1334] Outcomes according to stringency of symptomatic improvementsConclusion: A systematic review of available data suggests that a stringent definition of symptoms, such complete absence of symptoms, is the best at differentiating active treatment from placebo in RCTs of functional gastrointestinal diseases and should be considered as the primary outcome in future trials of therapy. Disclosure: Dr Paul Moayyedi has been on the advisory boards for AstraZeneca, Nycomed and Johnson and Johnson. He has also accepted speaker fees from these companies as well as Wyeth and Takeda. His chair is funded in part by an unrestricted donation given to McMaster University by AstraZeneca. Dr Grigorios Leontiadis has acted as a consultant for AstraZeneca and Axcan Pharma and has received speaking honoraria from AstraZeneca, Sanofi-Aventis, Janssen-Cilag, and GlaxoSmithKline. Alexander Ford - None. Dixuan Zhang - None. Racquel Simpson - None. Karen Dearness - None.

Defining Normal Bowel Function Relative to GI Disease: A Systematic Review of the Literature

Purpose: Gastrointestinal diseases are often studied and compared to healthy control subjects. While textbook definitions of normal bowel habits range between 3 bowel movements per week to 3 bowel movements per day, this definition is uni-dimensional since there is no determination of change in function and no accounting for stool form. Thus there are various perceptions of normal in the clinic and in research. However, it is nearly impossible to define clinical disease in the absence of a clear definition of normal. This is especially true in conditions such as irritable bowel syndrome where the diagnosis is purely based on symptoms. In this study, we aim to systematically review the terms used to define normal in the study of gastrointestinal disease. Methods: A systematic review of the literature was conducted between 1950 and April, 2010 using search terms that sought case control citations in gastrointestinal disease. Title, abstract and full paper reviews were focused on identifying the papers for final inclusion based on confirming a control group with >10 subjects, a comparator group of confirmed disease (true case control study) and not a review article. The final papers were then reviewed for the definition of normal control used for the study. Results: Using the initial search terms, 340 abstract titles were identified. After applying the a priori defined inclusion and exclusion criteria, 58 papers met criteria for the systematic review. Of the 58 papers, 44 compared controls to functional bowel disease. The remaining abstracts compared controls to organic disease. In both instances, the most common definition for normal was that they did not meet criteria for the disease to be studied. The second most common definition was just the term “healthy” with no real explanation of what that term meant. Thus in over 80% of studies, the definition of normal was not provided in detail. In a minority of studies was there a definition used which detailed stool form and frequency. However, even in these instances, there was heterogeneity among different studies on the definition of normal. Conclusion: There is no uniform definition of healthy controls in the study of gastrointestinal disease. In the absence of a uniform definition of normal bowel function, the interpretation of the GI literature in case-control studies is suspect.Table

A Combination of Rifaximin and Neomycin Is Most Effective in Treating Irritable Bowel Syndrome Patients With Methane on Lactulose Breath Test

There is a growing interest in methane and its association with constipation in functional bowel disease. Neomycin-based treatment of methane-positive subjects has resulted in improvement of constipation. Rifaximin, although superior for the treatment of irritable bowel syndrome compared with other antibiotics, seems less effective in methane-positive subjects. In this study, we evaluate 3 different antibiotic treatments in patients who have a methane-positive breath test: rifaximin only, neomycin only, and the combination of neomycin and rifaximin. A retrospective chart review was conducted on patients with methane on their lactulose breath test (> or =3 ppm of methane) who received one of the following antibiotic treatments: 500 mg b.i.d. for 10 days of neomycin alone, 400 mg t.i.d. for 10 days of rifaximin alone, or a combination of both rifaximin and neomycin for 10 days. All patients must have received antibiotic treatment after their initial consultation at the medical center and, in addition, had at least 1 follow-up to evaluate the effects of the treatment. After inclusion/exclusion criteria were met, all charts were evaluated to determine if the subject was a responder to the antibiotic therapy. This included clinical symptom improvement and eradication of methane on their breath test. Of the subjects receiving the treatment of rifaximin and neomycin (n=27), 85% had a clinical response, compared with 63% of subjects in the neomycin only group (n=8) (P=0.15) and 56% of subjects in the rifaximin only group (n=39) (P=0.01). When comparing the neomycin group with the rifaximin group, the difference was nonsignificant. When evaluating methane eradication results, 87% of subjects taking the rifaximin and neomycin combination eradicated the methane on their breath test. This is compared with 33% of subjects in the neomycin group that eradicated the methane (P=0.001), and only 28% of subjects in the rifaximin group (P=0.001). Of the patients who did not eliminate the methane with only rifaximin treatment, 66% of those who subsequently used the rifaximin and neomycin treatment were able to normalize their breath test. The combination of rifaximin and neomycin is more effective in treating methane-producing subjects-in both clinical response and methane elimination.

Lactose Intolerance and the Role of the Lactose Breath Test

1GI Motility Program, Cedars–Sinai Medical Center, Los Angeles, California, USA 2Harbor–UCLA Medical Center, Torrance, California, USA Correspondence: Mark Pimentel, MD, FRCP(C), GI Motility Program, Cedars–Sinai Medical Center, 8730 Alden Drive, Suite 225E, Los Angeles, California 90048, USA. E-mail: [email protected]

Undiagnosed coeliac disease in patients with emphysema: a fortuitous association?

To the Editors: Chronic obstructive pulmonary disease (COPD) is characterised by progressive and poorly reversible airflow obstruction due to small airway disease and emphysema. Cigarette smoking is the major cause of COPD, but the disease also occurs in nonsmokers. In nonsmokers, environmental factors ( e.g. second-hand smoking and inhalation of toxic gas), genetic factors ( e.g. the rare α1-antitrypsin deficiency) and infectious factors ( e.g. HIV infection) have been implicated in the pathogenesis of the disease. We report on two cases of COPD with emphysema in nonsmokers with long-standing undiagnosed coeliac disease. A 71-yr-old female was referred to our hospital (Hopital Cochin, Assistance Publique-Hopitaux de Paris, Paris, France) for dyspnoea and cough, which had evolved over 5 yrs. She had suffered from alternating diarrhoea and constipation for many years, ascribed to functional bowel disease. She had never been exposed to inhaled toxics and had never smoked. Examination revealed a body mass index (BMI) of 18 kg·m−2 and a chest computed tomography (CT) image revealed pulmonary distension and emphysema (fig. 1). Spirometry revealed severe airflow limitation (table 1). Serum α1-antitrypsin was normal. Treatment with long-acting bronchodilators was initiated. After 7 yrs of follow-up, the patient complained of progressive weight loss (BMI 15 kg·m−2 …

The ‘Draw‐the‐Family Test’ in the preoperative assessment of patients with anorectal diseases and psychological distress: a prospective controlled study

Some benign anorectal diseases may have psychosomatic aetiology, but patients often refuse direct psychological counselling. The Draw-the-Family Test (DFT) is a simple indirect investigation. The aim of this study was to evaluate the DFT in patients with psychological problems undergoing surgery for benign anorectal disease and to correlate the results with surgical outcome. DFT was administered prior to surgery to 62 patients with benign anorectal disease who admitted psychological problems at the time of the outpatient visit. Of these 18 (29%) had functional disease, mainly obstructed defecation (OD) while 44 (71%) had organic disease (haemorrhoids, fissures, pilonidal sinus or fistula). DFT was also administered to 40 healthy control subjects. Each DFT was judged as normal or pathological according to 10 parameters. Patients were followed up for a median of 12 months (range 3-64) and divided into two outcome groups, success (n = 58) and failure (n = 12) according to the results of a questionnaire. The DFT of all patients was then correlated with the outcome. None of the patients refused DFT. All DFT parameters but one (animal/things instead of human beings) were more frequent in patients compared with controls (P < 0.05). When comparing separately organic or functional disease patients with controls, one parameter (absence of patient in the drawing) was only pathological in the organic disease group (P < 0.05). Another parameter (schematic figures) was more frequently altered in the organic disease group compared with the functional disease group (P = 0.01). Eight out of 10 parameters were more frequently pathological in patients who failed after treatment, but none reached statistical significance. Results of DFT in patients with anorectal disease admitting to psychological problems are markedly different from healthy controls. Patients with organic disease and those with functional bowel disease have different DFT profiles. In our study group, DFT had an excellent compliance but could not predict the outcome of surgery.

Faecal calprotectin in differentiating between functional and organic bowel diseases

Background and study aims There is a frequent overlap between the clinical presentation of functional and organic bowel disorders. The aim of this study was to assess the role of faecal calprotectin in differentiating between both groups of patients in order avoid the use of invasive diagnostic procedures in patients with low probability of having functional disorders. Patients and methods We prospectively studied 39 patients presenting with lower gastrointestinal symptoms. On the basis of clinical and colonoscopic criteria 20 had functional and 19 had organic bowel disorder (10 had inflammatory bowel disease and 9 had organic non-inflammatory bowel diseases). Ten healthy subjects were included as controls. Faecal calprotectin was measured in patients and controls by enzyme linked immunosorbent assay. Results Patients with inflammatory bowel disease had faecal calprotectin levels of 379.2 ± 177.9 μg/g (mean ± SD); this was higher than in patients with functional bowel disease [(27.97 ± 15.2 μg/g); p: 0.004] and healthy controls [(21.64 ± 11.3 μg/g); p: 0.0002]. Patients with organic non-inflammatory bowel disease had faecal calprotectin levels of 273.4 ± 157.8 μg/g, which is higher than in patients with functional bowel disorders [(27.97 ± 15.2 μg/g); p: 0.002] and healthy controls [(21.64 ± 11.3 μg/g); p: 0.0001]. There was no statistically significant difference between faecal calprotectin in patients with functional bowel disease and healthy controls ( p: 0.264), and between both groups with organic bowel disease ( p: 0.312). Conclusion Faecal calprotectin is a sensitive non-invasive method which can be used to identify patients with organic bowel disorders. It is not, however, able to differentiate between different types of organic bowel diseases.

W1000 Characterization of Norovirus-Associated Travelers' Diarrhea

Recent studies suggest an association between detectable methane during breath testing and constipation. These studies have also demonstrated a correlation between the degree of methane and severity of constipation and improved constipation after antibiotics. This study aims to conduct a systematic review and meta-analysis to examine the evidence supporting an association between methane and constipation. Methods: Articles were searched in Pubmed, Medline, Ovid Journals, and Cumulative Index for nursing and allied health literature from 1950 to November 2009. Search terms included methane, breath test, constipation, motility, transit, and irritable bowel syndrome. Studies in the final analysis needed to demonstrate the prevalence of methane in a population and comparison to the presence or absence of constipation as a symptom. As part of the review, studies that also measured intestinal transit in methane and non-methane subjects were examined. To accomplish the analysis, two reviewers independently searched and extracted data. Pooled odds ratios and corresponding 95% CI were estimated using a random effects model. Results: The initial search terms generated 705 reference articles. From these, 44 relevant articles were fully reviewed with 9 studies meeting inclusion criteria for the primary meta-analysis. Among these 9 studies, 1277 subjects were examined by breath testing (including N=319 methane producers and N=958 methane non-producers). Seven of nine studies involved IBS patients only, and one study involved children. The remaining study examined non-IBS functional constipation. Pooling all 9 studies, there was a significant association between methane on breath test and constipation (OR=3.51, CI=2.00-6.16). When only adults were considered, methane was still significantly associated with constipation (OR=3.47, CI=1.84-6.54). Similar results were seen when examining only subjects with IBS (OR=3.60, CI=1.61-8.06) For all 9 studies, heterogeneity was moderate and Harbord's modified test suggested no significant publication bias (P=0.887). In addition, the systematic review identified 9 papers examining intestinal transit. While studies could not be combined for meta-analysis due to markedly different techniques (bowel frequency, orocecal and whole gut transit time), all 9 studies demonstrated that methane was associated with slow intestinal transit. Conclusion: This meta-analysis demonstrates that methane is significantly related to constipation in both IBS and functional constipation. This lends further support to the role of gut bacteria and their products in functional bowel disease and may lead to new directed therapies for constipation.

S1313 Adherence to Treatment Guidelines for Chronic Constipation Varies by Physician Gender and Practice Setting

The overall prevalence of chronic idiopathic constipation(CIC) approximates 15% and up to 24% in those 65 yo. We hypothesize the initial approach (colonoscopy vs. empiric Tx) and choice of firstline and subsequent medical therapies varies greatly despite published guidelines. Purpose: To survey practicing gastroenterologists regarding their firstline and 2o Tx choices for CIC as compared to guidelines (AGA, 2000). Methods: Using the AGA membership, we identified full and trainee domestic practitioners. A SurveyMonkey questionnaire was sent by email on 2 occasions (separated by 1 month) designed with 5 cases, each representing a highly probable scenario for CIC. All cases underwent external review by 2 experts independent of the protocol. The cases varied by age and gender but all described <3 bowel movements / wk for 1 yr after failing fiber Tx. Recent normal colonoscopy was reported for cases 50 yo. We first asked questions related to the initial approach: colonoscopy or empiric Tx. Regardless of their 1st choice, follow-up questions asked for subsequent Tx's including: osmotic laxative (PEG), stimulant laxative (senna), castor oil (CO) or a type-2 Cl channel activator (lubiprostone). Assuming firstline Tx was titrated to higher doses, 2o Tx options included switching or using combination Tx's. Responses were categorized as adhering to current guidelines based on choosing empiric Tx vs. colonoscopy and prescribing PEG. Results: Of 6,182 surveyed, 403 responded [μ=48±11 yo; male 84%; academic 43%, private practice 49%, mixed 8%; μ yrs in practice=15±12 yrs] of which 333 were complete. The table describes Tx recommendations for each case. The odds ratio (OR) for female physicians adhering to guidelines was 2.1(1.1-3.8,95%CI), and 0.5(0.3-0.9) for male physicians. Private practice physicians were less likely to follow guidelines with an OR=0.6(0.4-0.98,95%CI). Conclusion: Regardless of practice setting, empiric Tx was favored for cases with suspected functional bowel disease except for our 41 yo cases. Initial Tx greatly favored osmotic laxatives regardless of the age. Failure of initial Tx resulted in great ambiguity of a dominant 2o Tx strategy. We conclude that there is incomplete adherence to national guidelines that is influenced by physician gender and practice setting.

T1830 Emerging Parasitic Infection Mimicking Functional Bowel Disease

T1830 Emerging Parasitic Infection Mimicking Functional Bowel Disease

OC-090 To determine the negative predictive value of faecal calprotectin in predicting future organic gastrointestinal disease

Introduction Faecal calprotectin (FC) levels can be used to predict the likelihood of relapse in patients with inflammatory bowel disease (IBD)1 and as a non-invasive marker to predict organic gastrointestinal disease (OGID)2 However, long-term follow-up of patients with low FC levels has not been done. Our aim was to determine whether patients with low FC levels develop OGID over a 5-year period. Methods York Hospital serves a population of approximately 280 000 and has measured FC where clinically indicated in patients since 2004. Records of patients with a normal FC ( 1 cm, IBD) in the 5 years subsequent to the index FC measurement. The assay used was the PhiCal Calprotectin Elisa kit with a clinical sensitivity of 74% and specificity of 84% at 50 μg/g.3 Results 118 patients (39 male and 79 female) were identified. The mean age was 40.4 years (SEM 1.3); median age was 41 years (range 15–83). The mean FC level was 13.95 μg/g (SEM 1.04). The median was 10 μg/g (range 5–48). 84 patients were diagnosed with Functional Bowel Disease. No patients during the 5-year follow-up period developed OGID. Conclusion A normal FC has an extremely high negative predictive value for developing OGID over the subsequent 5 years.

OC-013 Clinical utility of faecal calprotectin in diagnosing inflammatory bowel disease during first presentation to the gastroenterology clinic: a novel investigative algorithm: Abstract OC-013

Introduction Faecal calprotectin (FC) has been shown to distinguish reliably between functional and inflammatory bowel diseases (IBD) in a number of studies of patients with established gastrointestinal disease. However, it is a poor screening test for colorectal cancer. Presently, diagnostic algorithms incorporating FC at first presentation to the gastroenterology clinic are lacking. Methods This study aimed to determine the optimal use of FC, in conjunction with serum markers, in the initial diagnostic workup of patients aged 16–50 years. Patients >50 years were excluded, as they require colonoscopy to exclude malignancy. Detailed clinical, laboratory, endoscopic and radiological parameters were collected. Patients with a prior GI diagnosis were excluded. All stool samples were analysed in the same laboratory using the same FC assay (Calpro ELISA). ROME III and Lennard-Jones criteria were used. Patients were followed up for a minimum of 12 months. Results The Edinburgh FC Register comprises data on 7512 patients (2005–2008) from across Lothian. 1838/7512 were managed at 2 Edinburgh teaching hospitals, and aged 16–50 years at time of FC; 851 were excluded, mostly due to pre-established diagnosis of IBD. 987 (mean±SD age 33.5±9.0 years; 64.8% female) met the strict inclusion criteria. In patients presenting primarily with bloody diarrhoea (n=68), median FC was 690 μg/g (IQR: 72–2323), in contrast to watery diarrhoea (n=325, FC 30 μg/g (20–90), p 50 μg/g with bloody diarrhoea OR raised CRP/low albumin – combined radiological and endoscopic evaluation. Conclusion In this study, the largest on the clinical utility of FC, we were able to develop clear investigative strategies in adults

Prevalence of Restless Leg Syndrome in Patients With Functional Bowel Disease in the Community

Prevalence of Restless Leg Syndrome in Patients With Functional Bowel Disease in the Community

Intraepithelial CD3+ and CD4+ Cells as Unique Surrogate Markers for Mucosal Immunity in Irritable Bowel Syndrome

Purpose: Irritable Bowel Syndrome (IBS) is the most common functional bowel disease in the world, particularly in the western society. The estimated prevalence is 10-20%. The exact etiology is still not elucidated. It is multifactorial with various etiologies postulated including discordant communication in the brain gut axis, genetic, environmental, infectious, stress and possible intra mucosal immune disarray. Mast cell proctopathy has been described in diarrheal type of IBS (IBS-D). Tight junction dysfunction has been proposed for the constipation type of IBS (IBS-C). Intra epithelial predominance of immune cell activation has also been observed. We proposed a clinico-pathological pilot study to correlate mucosal immune activity (intraepithelial CD3+, CD4+ and mast cells) quantitatively with subsets of IBS (IBS-C and IBS-D). Methods: Sixty (N=60) patients (age range: 29 to 45) satisfying ROME III criteria for IBS were enrolled from an urban community practice with diverse ethnicity in New York City, equally divided into IBS-D (n=20), IBS-C (n=20) and twenty patients (n=20) without IBS or Inflammatory Bowel Disease(IBD) as age-matched controls. Initial Blood work and stool samples were taken to rule out any concomitant inflammatory bowel disease or other active bowel infections. All patients underwent flexible sigmoidoscopy and four quadrant proximal descending colonic biopsies. All samples were evaluated for mast cells in high power with Tryptase stain and a quantitative immuno-histochemical stain for CD3+ and CD4+ in lamina propria. (Caris Laboratories, Irving, Texas) Exclusions: Patients with HIV, IBD, Microscopic and lymphocytic colitis, Celiac disease, bacterial or parasitic gastrointestinal Infections or infestations, those on drugs altering Gut immunity (steroids, Chemotherapy, radiotherapy, Interferons, TNF Alfa antagonists, immunosuppressives etc.) Results:Tables 1 and 2.Table 1Table 2Conclusion: This study demonstrates that intra-epithelial immune activity plays a definite role in IBS population. Further statistical analysis reveals no significant difference between IBS-D and IBS-C subsets. Larger prospective studies will further establish immune activity and its role in induction of symptoms in IBS and its subsets.