Functional GI Symptoms Research Articles

The Low FODMAP Diet for Children with Inflammatory Bowel Disease and Overlapping Functional Gastrointestinal Symptoms – a Case Series

The low FODMAP diet (LFD) is a dietary intervention<strong> </strong>developed for and<strong> </strong>used particularly for<strong> </strong>the management of functional GI symptoms (FGIS) in adults with irritable bowel syndrome (IBS).<strong> </strong>It has also been proposed to improve coincident<strong> </strong>functional gut symptoms in adults with inflammatory bowel disease (IBD). This report describes the outcomes of the LFD in a series of children with IBD with concurrent<strong> </strong>FGIS. This study included children aged between 7-14 years with quiescent IBD and overlapping FGIS. All<strong> </strong>participants received three dietetic consultations in line with best practice recommendations. The IBS Global Improvement Scale was used to assess symptom outcomes. Mean (standard deviation [SD]) and number (percentage) were calculated for continuous and categorical data. Seven (77.7%) of the nine children experienced GI symptom improvement after completing the LFD for four weeks. All seven children had recurrence of symptoms in response to challenge with fructans and three also experienced symptoms of lactose intolerance. The LFD may be considered as a dietary option to help alleviate overlapping FGIS in children with quiescent IBD when provided by a qualified paediatric gastroenterology dietitian. Further studies are now required to support these findings.

ECT FOR THE TREATMENT OF SOMATIC SYMPTOM DISORDER AND UNINTENTIONAL WEIGHT LOSS IN OLDER ADULTS: 2 CASE REPORTS

Introduction Somatoform disorders occur in up to 13% of those over age 65 and symptoms often cause significant impairment and disability (Hilderink et al. 2013; Leong et al. 2015). Unintentional weight loss in the elderly is also common and associated with increased morbidity and mortality (Hajek et al. 2017; McMinn et al. 2011). Studies show that depression is often comorbid with both somatoform disorders and unintentional weight loss in the elderly (Leong et al. 2015; Thompson and Morris 1991). Electroconvulsive therapy (ECT) is an effective treatment for severe depression, especially in older adults. However, there is limited of evidence regarding the use of ECT in elderly patients for the treatment of somatic symptom disorders (with predominant GI symptoms) or unintentional weight loss. Three case reports have been documented of women in their seventh decade of life with functional GI symptoms that responded to ECT (Cooper 2016; Cybulska 1997; Dols et al. 2012). Leong et?al reported a case series of 28 patients with somatic symptoms disorder who were successfully treated with ECT, examining the primary endpoint of improvement in somatic symptoms. However, only 2 of these cases included functional GI symptoms, and neither of the patients were over the age of 50 (Leong et al. 2015). Methods We report 2 cases of patients over age 65 who were psychiatrically hospitalized for co-morbid depressive symptoms, somatic symptom disorder (with predominant GI symptoms), and unintentional weight loss. Due to inability to tolerate medications and severity of depressive and somatic symptoms, both received an acute course of ECT. Results Both patients had gastrointestinal medical history (dumping syndrome, gastroparesis, irritable bowel syndrome), but extensive medical workup did not account for the severity of somatic symptoms, most notably nausea, or weight loss at the time of psychiatric admission. Both patients had diagnoses of major depressive episodes with PHQ-9 scores in the moderate range on admission (14 and 15). Both patients completed a full acute course of bitemporal ECT and reported subjective improvement in their somatic symptoms, appetite, and depressive symptoms (PQH-9 scores 0 and 1 respectively) following the course of ECT. Both also objectively gained a weight from time of admission to long-term follow-up without subsequent ECT treatment. Patient A's BMI on admission was 17.1 and increased to 23.81 at 8 month follow-up. Patient B's BMI on admission was 25.6 and increased to 29.17 at 7 month follow-up. In these two cases, ECT was well tolerated with reported side effects of mild headache, body aches, and mild to moderate memory loss. Of note, both patients had a rapid and robust response to ECT with remission of depressive symptoms and significant improvement in gastrointestinal symptoms after 5 bitemporal treatments. Conclusions Due to the higher rate of co-morbid medical conditions that could potentially contribute to somatic symptoms, it can be more challenging to diagnose somatic symptoms disorder in older adults (Wijeratne et al. 2003). When older adults present with somatic symptoms that are not fully explained by medical pathology, somatic symptom disorder should be considered and appropriate treatment initiated. Given the adverse outcomes and higher mortality in elderly individuals with unexplained weight loss, timely treatment is imperative. This case report suggests that ECT may be a well-tolerated and highly effective treatment for elderly patients with medically unexplained gastrointestinal disorders/somatic symptom disorder and significant weight loss with comorbid depression. This research was funded by: Not Applicable

P062 For Which Subsets of IBD Patients Are Integrated Behavioral Services Most Useful Within the IBD Medical Home?

BACKGROUND: Patients with inflammatory bowel disease (IBD) have higher rates of psychiatric comorbidity which can impact adherence to treatment plans, medical response, and overall quality of life. Integrated behavioral management within an IBD-specific medical home (MH) shows promise in improving clinical outcomes. Effective behavioral interventions may differ depending on source of symptoms (active vs inactive disease). Study aims are to: 1) characterize behavioral complexity in adults with moderate to severe IBD symptoms at the time of enrollment in the IBD MH; and 2) evaluate the relationship between use of behavioral services and medical and behavioral self-reported measures over a 6-month period. METHODS: The sample consisted of adults with moderate to severe IBD symptoms, enrolled in the IBD MH from 2018 to 2019 with at least two office visits over a 6-month period. Clinical data from the electronic health records were included. Patient-reported depression (PHQ9), generalized anxiety disorder 7 (GAD-7), quality of life (QoL; SIBDQ), and IBD severity (HBI/UCAI) were recorded at baseline and subsequent office visits. These scores were used to calculate the IBD Biopsychosocial Complexity Grid, a tool which organizes this health information into biological, psychological, and nutritional domains and serves as the basis for algorithm-driven treatment planning within the IBD MH. Psychiatric diagnoses and patient engagement in behavioral services within the IBD MH were recorded. RESULTS: 62 IBD patients with high baseline IBD symptoms were examined. All but one of these patients had at least one psychiatric diagnosis and 13 had ≥3 psychiatric diagnoses. All but 2 patients engaged in at least one encounter with behavioral providers within the MH. Approximately half (n = 30) of the 62 patients had active inflammation noted on colonoscopy at baseline. Of these 30 patients, 47% (n = 14) had significant improvement of their IBD inflammation, symptoms, and behavioral outcomes over the 6-month period. While 53% (n = 16) of patients with persistent active inflammation, also showed significant improvement in IBD symptoms and behavioral scores. All 30 patients engaged with behavioral providers. Another 30 patients had no active inflammation noted at their first and second visits yet reported high levels of IBD symptoms. These patients with more functional GI symptoms had more comorbid psychiatric diagnoses and even though they utilized behavioral services, showed less improvement in depression/anxiety scores compared to those with high baseline IBD inflammation. IBD patients with high baseline and continued active inflammation noted on colonoscopy all utilized behavioral health services at high rates and had improvement in PHQ9, GAD7, SIBDQ, and HBI/UCAI scores. None of the sample had a surgical intervention during the study period. CONCLUSION(S): IBD patients with moderate-severe reported symptoms had significant psychiatric comorbidity and utilized behavioral health providers in the IBD MH at equally high rates, regardless of symptom source (active inflammation or functional symptoms). Patients with active inflammation showed improvement in psychosocial functioning despite no disease improvement, suggesting that an integrated approach benefits patients with active disease even when disease markers do not improve. Patients with functional symptoms had more psychiatric complexity, and distress persisted despite behavioral interventions, suggesting patients with functional symptoms may benefit from different and possibly more intensive psychosocial care.

Prevalence and clinical characteristics of refractoriness to optimal proton pump inhibitor therapy in non-erosive reflux disease.

The real size of the gastro-oesophageal reflux disease (GERD) population not responding to proton pump inhibitor (PPI) therapy has still not been fully elucidated. Causes of PPI refractoriness include incorrect diagnosis and lack of adherence to therapy, in terms of incorrect dosage and timing. To evaluate the prevalence of refractoriness to optimal PPI therapy and the contribution of non-erosive reflux disease (NERD), reflux hypersensitivity, and functional heartburn, to PPI refractoriness. The association of functional GI symptoms in non-responders was evaluated. Frequency and severity of GERD symptoms (heartburn, regurgitation, chest pain), dysphagia, belching, epigastric pain, postprandial distress, irritable bowel syndrome (IBS), globus, and ear nose and throat (ENT) symptoms were evaluated in patients previously classified as non-responders. Patients with at least one of the oesophageal symptoms with a frequency ≥3 /week were treated with esomeprazole 40mg once daily for 8weeks and then re-evaluated. Non-responders (patients with oesophageal symptoms ≥3 times per week) underwent 24hour multichannel intraluminal impedance-pH monitoring. Of 573 consecutive patients, 92 with oesophageal symptoms and classified as PPI-refractory underwent the esomeprazole trial; 60 did not respond. IBS, epigastric pain, and post-prandial distress episodes were associated with a poor response on multivariate analysis. NERD, reflux hypersensitivity, and functional heartburn patients constituted 32%, 42%, and 26%, respectively of the PPI-refractory group. True refractoriness in patients with GERD symptoms attending a secondary care setting is lower than previously reported. Following a careful history and optimal PPI dosing, the rate of refractoriness was 20%. True NERD constitutes only a third of the PPI-refractory group.

Insight into Pathogenesis of Diverticular Disease, Evaluation of Colonic Motility With Wireless Motility Capsule

Introduction: The pathogenesis of diverticular disease (DD) is incompletely understood. Prior colonic manometry studies have implicated increased colonic motility as one of the contributing factors in the development of DD. However, these studies were performed the purged state after colonoscopy prep. Colonic motility has not been examined under physiological conditions in unprepared colons. Wireless motility capsule (WMC) assesses colonic pressure profiles and regional gut transit and may provide insight into the pathogenesis of DD. Aim: To evaluate and compare regional, whole gut transit time and colonic pressure profiles in the patients with and without diverticulosis. Methods: Patients with functional GI symptoms over 4 years who underwent WMC testing were evaluated. Non-diverticulosis group comprised of patients with normal colonoscopy. Patients with CT scan or colonoscopy evidence of diverticulosis comprised the diverticulosis group. Regional and whole gut transit time (WGTT) were measured. The entire colonic transit and 8 hours prior to WMC expulsion pressure parameters including motility index (MI), number of contraction, contraction frequency, sum of amplitude and wide contraction number were collected and compared. Results: We evaluated 48 patients (37F, mean age=60 years, 24 DD patients). There were no demographic differences between the two groups. CTT and WGTT were significantly faster in diverticulosis group (37.2 VS 61.9; 49.5 VS 72.1, P<0.05). Colonic motility index (Ouyang) and colonic contraction frequency were significantly higher in diverticulosis group [110(68.9-166.8) VS 75.2(21.6-122.6); 0.55 (0.41-0.71) VS 0.32(0.17-0.53) times/min, P<0.05]. Conclusion: We found that CTT was more rapid and colonic motility is higher in diverticulosis than those without diverticulosis.Our study was performed in unprepared colons under physiological conditions. This study confirms excessive colonic motility in diverticulosis and implicates prolonged excessive colonic circular muscle contractility, leading to muscular hypertrophy and pulsion diverticula. We also substantiated the previous studies by showing significant increase of contraction frequency, motility index, subsequently shortening colonic transit time, all contributing to development of DD.Table: Table. Comparison of Demographic Data, Gut Transit Time and Colonic Motility Profile between Diverticulosis VS Control

6 - Response to Optimal PPI Therapy, Association with Atypical and Functional GI Symptoms in NERD Patients: Results from Nerone Study

6 - Response to Optimal PPI Therapy, Association with Atypical and Functional GI Symptoms in NERD Patients: Results from Nerone Study

Empirically Supported Use of Psychiatric Medications in Adolescents and Adults with IBD.

The use of psychotropic medications, particularly antidepressants, is common in patients with inflammatory bowel disease (IBD) in spite of a lack of their robust efficacy in this population. This review provides an overview of the use trends of different classes of antidepressant and anti-anxiety medication and their effects on mood, nervous system function, gastrointestinal physiology and immunity drawing from the literature available in the general population, other medical conditions, and when available, patients with IBD. It also covers the evidence base for the actions, efficacy, and potential complications of antidepressants organized by different classes. We conducted a PubMed search of articles relating the different drug classes probed to the terms above in different populations of interest. All types of articles were accepted including case reports and series, open and randomized trials, reviews, and expert opinion. We also examined the reference lists of the publications found. Selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) are the most commonly prescribed agents for anxiety and depression in patients with IBD, though their efficacy for these conditions in the general population are mild to moderate at best. SSRIs are generally well tolerated, though at higher doses, they, like most antidepressant classes, can be associated with activation, serotonergic syndrome, and increased suicidal ideation. TCAs have many more serious side effects but have some shown efficacy for functional GI symptoms. A newer class, the serotonin noradrenergic reuptake inhibitors (SNRIs), can be effective for refractory depression, anxiety and chronic pain syndromes with a side effect profile similar to both SSRIs and more mild manifestations of TCAs. Mirtazapine has moderate efficacy for depression if sedation and weight gain side effects are tolerated and some small support for use in nausea and vomiting. Bupropion targets dopamine and noradrenaline reuptake and has moderate efficacy for depression, and some small support for use in fatigue and smoking cessation. Buspirone has an indication for generalized anxiety disorder though studies show only a minimal benefit. It has some growing evidence for use in functional dyspepsia. Most of these agents have physiological effects on the brain, immune system, and gastrointestinal tract (with the exception of bupropion) hence their therapeutic and side effects manifested in these systems. Antidepressant medications are frequently prescribed for depression, anxiety disorders, and chronic pain syndromes, but overall support for their efficacy is modest at best. Psychological interventions have growing support for having much more robust effects without the side effects of antidepressants and should be considered first-line treatment or at least an adjunct to psychotropic medications for these conditions.

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Rome IV—Functional GI Disorders: Disorders of Gut-Brain Interaction

Tu1083 Overlap of Functional GI Symptoms Does Not Rule out the Presence of GERD

Tu1083 Overlap of Functional GI Symptoms Does Not Rule out the Presence of GERD

Lower Gastrointestinal Symptoms in Healthy Pre-Adolescents at Risk for Obesity

Purpose: The obesity epidemic affects both pediatric and adult populations. Previous studies have shown obesity to be linked to common functional gastrointestinal disorders in children. However, there has been limited research specifically evaluating the prevalence of functional lower GI symptoms in pre-adolescent children at risk for obesity. Aim: To evaluate the prevalence of lower GI functional symptoms by gender in healthy pre-adolescent children at risk for obesity. Methods: Overweight and obese children (n=305) between the ages of 5 and 11 yrs were recruited to participate in a randomized, controlled obesity prevention study. At the baseline visit, children and their parents completed the several validated questionnaires and questions on abdominal pain and bowel function from the Rome III questionnaire. Univariate and multivariable statistics were used to evaluate the association between MS and pelvic floor dysfunction. The criterion for significance (alpha) was set at 0.050, 2-tailed. Results: Complete data were available for 297 children. As shown in Table 1, female and male children were similar in age, BMI and BMI - Z score. Functional lower GI symptoms were common in healthy, pre-adolescent children of both genders. Females were more likely to report frequent abdominal pain (2 or more days per mos) compared with males. Chronic abdominal pain lasting two months or longer and IBS were relatively rare in both groups.Table 1: No Caption available.Conclusion: Functional lower GI symptoms were found to be common in healthy, pre-adolescent children at risk for obesity. Females reported more frequent abdominal pain, but were otherwise similar to males.

Tricyclic Antidepressants in the Management of IBD Patients with Functional GI Symptoms

Purpose: Irritable bowel syndrome (IBS) is common, affecting 15% of adults, including inflammatory bowel disease (IBD) patients. Antidepressants (ADs), including tricyclic antidepressants (TCAs) are a mainstay of IBS therapy. In IBD in remission or with mild disease activity, functional symptoms may dominate the clinical presentation. Our aim is to assess whether TCA therapy provides benefit by reducing these IBS-type symptoms. Methods: A retrospective study of open-label AD treatment was conducted in two cohorts: 1) IBD patients in clinical remission or with mild inflammation with persistent GI symptoms, and 2) symptomatic IBS patients without IBD. Records from an academic GI practice were reviewed (2000-11). Inclusion required at least one follow-up visit after initiating TCA therapy. Baseline symptom severity was assessed on a 4-point Likert scale (0=no symptoms, 3=severe, disabling symptoms). AD treatment responses were graded using an established 4-point scale (0=no improvement; 3=complete satisfaction). Results: Eighty-one IBD patients (41.3±1.7yrs, 56F/25M; 58 CD/23 UC) without overt evidence of disease activity were started on a TCA. Maintenance IBD regimens included 5-ASAs (22.2%), biologics (16.1%), immunomodulators (28.4%); 22/81(27%) were not on active IBD therapy. 48.1% of the IBD patients had prior surgical resection. 43% were in remission and 57% had mild disease activity. A comparator group of 65 IBS patients (43.9±1.6 yrs, 51F/14M) was identified. Abdominal pain and diarrhea were equally common in both cohorts. Median TCA doses were less in the IBD group (IBD: 25mg; IBS: 50mg, p=0.03). Baseline symptom scores were moderate-severe in both IBD and IBS (2.06±0.03 vs. 2.07±0.05, p=0.73), and both groups experienced slight-moderate improvements with AD therapy (1.37±0.09 and 1.45±0.12, p=0.56). A similar number of IBD and IBS patients achieved at least moderate improvement (Likert ≥2) on AD treatment [40/81 (49.4%) vs.34/65(52.3%);p=0.73]. Among the IBD patients, UC patients had a significantly better response than CD patients (1.78±0.14vs1.17±0.11, p=0.002). A subset of each study group (47/81, 58% IBD and 54/65, 83% IBS) were followed for a second visit; with further symptom improvement (1.38 ±0.13 and 1.57±0.15, respectively, p=0.35). Conclusion: AD therapies are effective in managing moderately-severe functional symptoms among IBD populations without overt disease activity, similar to their IBS counterparts. Symptom responses to ADs occur at modest doses, significantly lower than those for IBS. UC patients respond better than CD patients in our retrospective cohort. While prospective validation is needed, this study suggests that ADs are a viable option in the management of functional symptoms in IBD patients.

The efficacy of antidepressant medications in management of IBD patients with functional GI symptoms

The efficacy of antidepressant medications in management of IBD patients with functional GI symptoms

The association of coeliac disease in childhood with functional gastrointestinal disorders: a prospective study in patients fulfilling Rome III criteria

An association between coeliac disease (CD) and functional gastrointestinal disorders (FGIDs) has at present only been demonstrated in adults. To assess the prevalence of FGIDs at 1 year and the role of psychological aspects on the development of FGIDs in CD children. One-hundred consecutive CD children (36M and 64F) were followed up for 1 year. Fifty-six children (25M and 31F) represented the control group. All children and/or their parents completed validated questionnaires for GI symptoms, depression, and anxiety. GI symptoms at diagnosis and after 1 year of gluten-free diet (GFD) were compared. Twenty-three/82 (28%) CD patients followed up prospectively, on GFD from at least 1 year, fulfilled the Rome III criteria for FGIDs compared with 5/56 (8.9%) controls (P = 0.008; χ² = 6.8; OR: 3.97; 95% CI: 1.40-11.21). Children complaining with GI symptoms alone [21/52 (40.3%)] more likely fulfilled Rome III criteria for FGIDs after 1 year of GFD than children with extra-intestinal symptoms (P = 0.045). CD children with FGDIs presented significantly higher anxiety and depression compared to CD children without FGIDs and controls (P = 0.02). This study demonstrates that children with CD on a GFD for a year have a much higher prevalence of functional GI symptoms than do controls. Whether the risk is due to the residua of a chronic inflammatory process, and/or due to psychological factors remains to be further tested.

Intestinal Fermentation Assessed by Intraluminal pH in Subjects With Abdominal Bloating

Abdominal bloating symptoms are highly prevalent in subjects with functional GI disorders and are associated with increased healthcare utilization and reduced quality of life [APT 2010]. Altered intestinal transit and abnormal intraluminal fermentation have been proposed as possible pathophysiological mechanisms for these symptoms. We have previously demonstrated slower colonic transit in subjects with abdominal bloating compared to subjects without bloating. In this study we investigated the hypothesis that abdominal bloating symptoms are associated with abnormally increased intestinal fermentation.Aim: To investigate and compare the magnitude and site of intestinal fermentation in subjects with functional GI symptoms and bloating (FGI-B) and healthy controls (HC) by measuring pH in the GI lumen. Methods: We studied a total of 47 subjects; FGI-B (n=37) and HC (n=10). Intestinal intraluminal pH was used as a surrogate marker for intestinal fermentation. The intestinal pH levels were measured at different segments of the GI tract using a wireless motility capsule (WMC). Comparisons of transit time and pH variables between the groups were done using t-test; correlation analyses were done using Spearman Correlation Coefficients. Results: Intestinal pH levels were significantly lower at the proximal colon (Q1) of subjects with FGI-B compared to HC (mean pH 6.27 vs. 6.84; p=0.008) suggesting a significantly higher intraluminal intestinal fermentation at this segment of the GI tract in these subjects. The mean intraluminal colonic pH levels in the FGI-B group were also lower than that of HC at other segments of the large intestine; however, statistical differences were noticed only in the proximal and total colon. Mean colonic pH levels at the four (proximal to distal) colonic segments and the total colon are provided in the following Table. There were no noticeable differences between the groups in mean pH levels at any of the segments of the small bowel. The average total colonic pH significantly correlated with the total colonic transit time (r=0.34; p=0.014). However, no correlation was found between the average small bowel pH and small bowel transit time.Conclusions: We provide evidence of abnormal intestinal fermentation in subjects with functional GI symptoms and bloating. We demonstrate that bloating symptoms are associated with increased fermentation in the large rather than the small bowel. WMCmay be helpful in identifying underlying physiological abnormalities and guide treatment in patients with bloating symptoms. Mean intraluminal pH levels in subjects with abdominal bloating and healthy controls

Characterization of the Inflammatory Response in Idiopathic Gastroparesis Reveals a Role for Macrophage Derived Factors

Abdominal bloating symptoms are highly prevalent in subjects with functional GI disorders and are associated with increased healthcare utilization and reduced quality of life [APT 2010]. Altered intestinal transit and abnormal intraluminal fermentation have been proposed as possible pathophysiological mechanisms for these symptoms. We have previously demonstrated slower colonic transit in subjects with abdominal bloating compared to subjects without bloating. In this study we investigated the hypothesis that abdominal bloating symptoms are associated with abnormally increased intestinal fermentation.Aim: To investigate and compare the magnitude and site of intestinal fermentation in subjects with functional GI symptoms and bloating (FGI-B) and healthy controls (HC) by measuring pH in the GI lumen. Methods: We studied a total of 47 subjects; FGI-B (n=37) and HC (n=10). Intestinal intraluminal pH was used as a surrogate marker for intestinal fermentation. The intestinal pH levels were measured at different segments of the GI tract using a wireless motility capsule (WMC). Comparisons of transit time and pH variables between the groups were done using t-test; correlation analyses were done using Spearman Correlation Coefficients. Results: Intestinal pH levels were significantly lower at the proximal colon (Q1) of subjects with FGI-B compared to HC (mean pH 6.27 vs. 6.84; p=0.008) suggesting a significantly higher intraluminal intestinal fermentation at this segment of the GI tract in these subjects. The mean intraluminal colonic pH levels in the FGI-B group were also lower than that of HC at other segments of the large intestine; however, statistical differences were noticed only in the proximal and total colon. Mean colonic pH levels at the four (proximal to distal) colonic segments and the total colon are provided in the following Table. There were no noticeable differences between the groups in mean pH levels at any of the segments of the small bowel. The average total colonic pH significantly correlated with the total colonic transit time (r=0.34; p=0.014). However, no correlation was found between the average small bowel pH and small bowel transit time.Conclusions: We provide evidence of abnormal intestinal fermentation in subjects with functional GI symptoms and bloating. We demonstrate that bloating symptoms are associated with increased fermentation in the large rather than the small bowel. WMCmay be helpful in identifying underlying physiological abnormalities and guide treatment in patients with bloating symptoms. Mean intraluminal pH levels in subjects with abdominal bloating and healthy controls

Objective Assessment of Aerophagia During Meals in Normal Subjects and Patients With Post-Prandial Bloating and Belching

Introduction Many patients attending GI physiology units for assessment of dysphagia and GORD also complain of postprandial bloating and/or belching. Excessive fasting aerophagia has been recently described in patients with severe continuous bloating and belching. Exaggerated air swallowing during meals might be more relevant for postprandial symptoms but, thus far, objective assessment of prandial aerophagia and normal values are lacking. Oesophageal impedance can detect air swallowing. We aimed to quantify aerophagia during meals in asymptomatic subjects and patients with postprandial bloating and belching. Methods We assessed aerophagia during meals using ambulatory impedance-pH monitoring in 39 healthy, asymptomatic controls (from the US-Belgian MII-pH Normal value study, Shay et al . 2004; mean age in original study 39, range 22–62) to establish normal 95% confidence intervals. We identified 38 patients (mean age 43, range 17–74) with postprandial bloating and/or belching who attended the GI physiology unit for assessment of dysphagia or GORD as primary symptoms. Mealtime air swallows were visually identified when swallows were associated with antegrade flow and fast impedance increase (at least 3000 Ω from baseline) in the most distal recording segment. A score of air swallows/10 min mealtime was calculated for each subject. In patients with mealtime exaggerated air swallowing (above 95th percentile of normal values) we examined for evidence of concomitant fasting aerophagia. Results The 95% percentile range of mealtime aerophagia in normal subjects was 6.8 to 9.4 episodes/10 min, mean 8.1. Patients had significantly higher mealtime air swallowing rates than controls (mean 11.8 episodes/10 min, SEM 1.0, p = 0.003 ). There was no significant difference between predominant bloating and belching subgroups. Only 4 of 23 patients with exaggerated mealtime air swallowing had concomitant fasting aerophagia. Conclusion We established normal values of mealtime air swallowing using oesophageal impedance. Patients with postprandial bloating and/or belching exhibit increased aerophagia during meals. Most of these patients do not have fasting aerophagia. Exaggerated air swallowing during meals can now be objectively detected and biofeedback techniques can be attempted to modify such behaviour as a potential therapeutic strategy for these patients with functional GI symptoms.

Epidemiology of FGID symptoms in Japanese general population with reference to life style

Gastrointestinal symptoms are quite common among the general population, but different survey methods show different epidemiology, and the effect of psychosocial and behavioral factors on the symptoms have been studied mainly by the subgroup The aims of this studies are; 1: to clarify the difference of the survey methods on the epidemiology of FGID symptoms, 2: correlation with psycho-behavioral background in symptomatic subjects. Questionnaires focused on GI symptoms and psycho-behavioral background were generated. Questionnaires were sent via e-mail and postal mail to the members of the registered panel. A total of 2125 and 11,020 responses were recovered from electronic survey and postal survey. Significant difference in the prevalence of GI symptoms, 47% in electronic survey and 25% in postal survey, were observed. Despite the difference in the prevalence, the proportions of symptom subtypes and the patterns of the overlaps were similar in the two methods. In the analysis of the effect of psycho-behavioral factors, this study showed that those who have higher level of psycho-behavioral problem had higher prevalence of GERD, FD and IBS symptoms. Those who have impairment in the wellness sensation such as good eating, good bowel movement and good sleep showed higher prevalence of each symptom. Those who prefer unhealthier food have higher prevalence of GI symptoms. These data suggest that psycho-behavioral conditions may affect the development of functional GI symptoms regardless of the subtypes of GI symptoms, and may explain the high proportion of overlap in the subtypes.

PWE-021 Whole gut transit scintigraphy with a liquid-phase meal in patients with chronic gastrointestinal symptoms

<h3>Introduction</h3> Functional gastrointestinal symptoms are common in the general population. Whole gut transit scintigraphy (WGTS) has been available to investigate patients with functional gastrointestinal symptoms for several years but the technique has not been widely utilised. The aim of this study was to review our experience of doing a liquid-phase WGTS in patients with functional gastrointestinal problems and determine its clinical usefulness. <h3>Methods</h3> 56 patients (14 males, mean age 43 years) with functional upper and lower GI symptoms had undergone WGTS using 111In-DTPA in water and a dual-headed gamma camera over a 5-year-period. Gastric emptying (GE) analysis was done using time-activity curves. Small bowel transit (SBT) was determined by the time taken for 10% of total abdominal counts to reach the caecum. Geometric centre (GC) of activity was used to determine colonic transit (CT) time. <h3>Result</h3> Presenting symptoms were constipation (n=27), diarrhoea (n=14) and dyspepsia (n=15). WGTS confirmed the diagnosis in 63% patients with constipation. 26% patients with constipation also had a delayed GE and SBT. 30% patients with constipation and 29% with diarrhoea had normal colonic transit. Only 29% of diarrhoea patients seemed to have a rapid CT. More than 50% patients with dyspepsia had normal GE, SBT and CT whereas 40% of them had a delayed CT and SBT. <h3>Conclusion</h3> WGTS appears to have a useful role in patients with symptoms of chronic constipation. In patients with diarrhoea, WGTS helps to elucidate its true cause. The procedure helps the clinician explain the symptoms and focus on a particular region of the GI tract for further investigation.

T1163 Impact of Hydrogen Breath Testing On Diagnosis, Management, and Clinical Outcome in Children with Chronic Functional GI Symptoms

T1163 Impact of Hydrogen Breath Testing On Diagnosis, Management, and Clinical Outcome in Children with Chronic Functional GI Symptoms

T1406 Probiotic Bacteria Lactobacillus Acidophilus Ncfm and Bifidobacterium Lactis Bi-07 Improve Symptoms of Bloating in Patients with Functional Bowel Disorders (FBD)

FBD are the most common gastrointestinal disorders seen in primary care and GI clinics; however, the etiology still remains unknown. Evidence suggests that intestinal bacteria play a role in the pathophysiology and symptomatology of these disorders and that modulation of intestinal microflora by antibiotics or probiotics may be beneficial in the treatment of patients with these disorders. Aim: To investigate the effect of probiotic bacteria Lactobacillus acidophilus NCFM (L-NCFM) and Bifidobacterium lactis Bi-07 (B-LBi07) in patients with nonconstipation IBS, functional diarrhea, or functional bloating. Methods: Patients with FBD who met the Rome II criteria of non-constipation-IBS, or functional diarrhea, or functional bloating were enrolled in a prospective double-blind, placebo-control clinical trial. Patients were randomized into a placebo arm and an active arm of oral probiotic bacteria containing equivalent amounts of L-NCFM and B-LBi07, 1x1011 cfu total probiotic bacteria in each dose. The placebo and probiotic products were administrated bid in a capsule form over 8-weeks. Patients were evaluated for the following endpoints: global relief of GI symptoms (GSA), specific functional GI symptoms, overall symptoms severity (IBS-Severity Index), satisfaction with treatment, overall well being, and Health Related Quality of Life (IBSQOL). Results: A total of 57 (probiotic n=30; placebo n=27) patients were enrolled. Study population consisted of 72% females, 84% whites, and mean age of 37 years. Baseline demographics were similar among the two groups. Bloating and distention scores (measured on a 10 points scale) improved significantly in the probiotics group compared to the placebo group at 4 weeks (4.10 +3 vs. 6.17+3, p=0.009 respectively) and showed a strong trend of improvement at 8 weeks (4.26 +3 vs. 5.84+3, p=0.06 respectively). Secondary analyses using only the IBS subgroup (n=33) showed similar results with significant improvement in bloating and distention in the probiotics group (n=17) compared to the placebo (n=16) group (4.24 +3 vs. 6.73+3, p=0.03 respectively). Conclusions: Supplement of diet with LNCFM and B-LBi07 BID (2x1011 cfu total probiotic bacteria per day) significantly improved symptoms of bloating and distention in patients with FBD. This data support the role of intestinal bacteria in the pathophysiology of FBD and suggest an important role for these probiotic bacteria in the management of patients with these disorders. (Supported by grants K23 DK075621, RR00046, and Danisco USA Inc.)