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Walter, Susanna
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Publications (10 of 37) Show all publications
Tack, J., Stanghellini, V., Mearin, F., Yiannakou, Y., Layer, P., Coffin, B., . . . Marciniak, A. (2019). Economic burden of moderate to severe irritable bowel syndrome with constipation in six European countries. BMC Gastroenterology, 19(1), Article ID 69.
Open this publication in new window or tab >>Economic burden of moderate to severe irritable bowel syndrome with constipation in six European countries
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2019 (English)In: BMC Gastroenterology, ISSN 1471-230X, E-ISSN 1471-230X, Vol. 19, no 1, article id 69Article in journal (Refereed) Published
Abstract [en]

Background: Irritable bowel syndrome with predominant constipation (IBS-C) is a complex disorder with gastrointestinal and nervous system components. The study aim was to assess the economic burden of moderate to severe IBS-C in six European countries (France, Germany, Italy, Spain, Sweden and the UK). Methods: An observational, one year retrospective-prospective (6 months each) study of patients diagnosed in the last five years with IBS-C (Rome III criteria) and moderate to severe disease at inclusion (IBS Symptom Severity Scale score = 175). The primary objective was to assess the direct cost to European healthcare systems. Results: Five hundred twenty-five patients were included, 60% (range: 43.1-78.8%) suffered from severe IBS-C. During follow-up 11.1-24.0% of patients had a hospitalisation/emergency room (ER) visit, median stay range: 1.5-12.0 days and 41.1-90.4% took prescription drugs for IBS-C. 21.4-50.8% of employed patients took sick leave (mean: 11.6-64.1 days). The mean annual direct cost to the healthcare systems was €937.1- €2108.0. The total direct cost (combined costs to healthcare systems and patient) for IBS-C was €1421.7-€2487.1. Conclusions: IBS-C is not a life-threatening condition; however, it has large impact on healthcare systems and society. Direct and indirect costs for moderate to severe IBS-C were high with the largest direct cost driver being hospitalisations/ER visits. © 2019 The Author(s).

Place, publisher, year, edition, pages
BioMed Central Ltd., 2019
Keywords
Economic analysis; Europe; Healthcare resource utilisation; IBS; IBS-C
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:liu:diva-158060 (URN)10.1186/s12876-019-0985-1 (DOI)000467407000001 ()31064345 (PubMedID)2-s2.0-85065501524 (Scopus ID)
Note

Funding agencies:This study and all data analyses were funded in full by Almirall, S.A. The preparation of this paper was funded by Almirall, S.A and Allergan International.

Available from: 2019-06-24 Created: 2019-06-24 Last updated: 2019-06-24
Hadizadeh, F., Walter, S., Belheouane, M., Bonfiglio, F., Heinsen, F.-A., Andreasson, A., . . . DAmato, M. (2017). Stool frequency is associated with gut microbiota composition [Letter to the editor]. Gut, 66(3), 559-560
Open this publication in new window or tab >>Stool frequency is associated with gut microbiota composition
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2017 (English)In: Gut, ISSN 0017-5749, E-ISSN 1468-3288, Vol. 66, no 3, p. 559-560Article in journal, Letter (Other academic) Published
Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2017
Keywords
GASTROINTESTINAL TRANSIT; INTESTINAL BACTERIA
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:liu:diva-145580 (URN)10.1136/gutjnl-2016-311935 (DOI)000426089000001 ()27196592 (PubMedID)2-s2.0-84966389012 (Scopus ID)
Available from: 2018-03-25 Created: 2018-03-25 Last updated: 2019-02-05Bibliographically approved
Walter, S. A., Forsgren, M., Lundengård, K., Simon, R., Torkildsen Nilsson, M., Söderfeldt, B., . . . Engström, M. (2016). Positive Allosteric Modulator of GABA Lowers BOLD Responses in the Cingulate Cortex. PLoS ONE, 11(3)
Open this publication in new window or tab >>Positive Allosteric Modulator of GABA Lowers BOLD Responses in the Cingulate Cortex
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2016 (English)In: PLoS ONE, ISSN 1932-6203, E-ISSN 1932-6203, Vol. 11, no 3Article in journal (Refereed) Published
Abstract [en]

Knowledge about the neural underpinnings of the negative blood oxygen level dependent (BOLD) responses in functional magnetic resonance imaging (fMRI) is still limited. We hypothesized that pharmacological GABAergic modulation attenuates BOLD responses, and that blood concentrations of a positive allosteric modulator of GABA correlate inversely with BOLD responses in the cingulate cortex. We investigated whether or not pure task-related negative BOLD responses were co-localized with pharmacologically modulated BOLD responses. Twenty healthy adults received either 5 mg diazepam or placebo in a double blind, randomized design. During fMRI the subjects performed a working memory task. Results showed that BOLD responses in the cingulate cortex were inversely correlated with diazepam blood concentrations; that is, the higher the blood diazepam concentration, the lower the BOLD response. This inverse correlation was most pronounced in the pregenual anterior cingulate cortex and the anterior mid-cingulate cortex. For subjects with diazepam plasma concentration > 0.1 mg/L we observed negative BOLD responses with respect to fixation baseline. There was minor overlap between cingulate regions with task-related negative BOLD responses and regions where the BOLD responses were inversely correlated with diazepam concentration. We interpret that the inverse correlation between the BOLD response and diazepam was caused by GABA-related neural inhibition. Thus, this study supports the hypothesis that GABA attenuates BOLD responses in fMRI. The minimal overlap between task-related negative BOLD responses and responses attenuated by diazepam suggests that these responses might be caused by different mechanisms.

Place, publisher, year, edition, pages
San Francisco, CA, United States: Public Library of Science, 2016
Keywords
quantitative magnetic resonance imaging; brain tissue modeling; myelin; edema; T-1 relaxation; T-2 relaxation; proton density
National Category
Neurosciences
Identifiers
urn:nbn:se:liu:diva-126192 (URN)10.1371/journal.pone.0148737 (DOI)000371434500011 ()26930498 (PubMedID)
Note

Funding agencies: Linkoping University; County Council of Ostergotland

Available from: 2016-03-18 Created: 2016-03-18 Last updated: 2018-01-10Bibliographically approved
Sjödahl, J., Walter, S., Johansson, E., Ingemansson, A., Ryn, A.-K. & Hallböök, O. (2015). Combination therapy with biofeedback, loperamide, and stool-bulking agents is effective for the treatment of fecal incontinence in women - a randomized controlled trial. Scandinavian Journal of Gastroenterology, 50(8), 965-974
Open this publication in new window or tab >>Combination therapy with biofeedback, loperamide, and stool-bulking agents is effective for the treatment of fecal incontinence in women - a randomized controlled trial
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2015 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 50, no 8, p. 965-974Article in journal (Refereed) Published
Abstract [en]

Objective. Biofeedback and medical treatments have been extensively used for moderate fecal incontinence (FI). There is limited data comparing and combining these two treatments. The objective of this study was to evaluate the effect of biofeedback and medical treatments, separately and in combination. Material and methods. Sixty-four consecutive female patients, referred to a tertiary centre for FI, were included. The patients were randomized to start with either biofeedback (4-6 months) or medical treatment with loperamide and stool-bulking agents (2 months). Both groups continued with a combination of treatments, i.e. medical treatment was added to biofeedback and vice versa. A two-week prospective bowel symptom diary and anorectal physiology were evaluated at baseline, after single-and combination treatments. Results. Fifty-seven patients completed the study. Median number of leakage episodes during two weeks decreased from 6 to 3 (p less than 0.0001) from baseline to completion. The patients showed a significant (1) decrease in number of leakages without forewarning (p = 0.04); (2) decrease in number of stools with urgency (p = 0.001); (3) decrease in number of loose stool consistency; and (4) an increase in rectal sensory thresholds, both for maximum tolerable rectal pressure and first sensation (less than 0.01). The combination treatment was superior to both single treatments in terms of symptoms and functions. There was no significant difference between the two groups at any time point. Conclusions. The combination therapy with biofeedback and medical treatment is effective for symptom relief in FI. The symptom improvement was associated with improved fecal consistency, reduced urgency, and increased rectal sensory thresholds.

Place, publisher, year, edition, pages
TAYLOR and FRANCIS LTD, 2015
Keywords
anorectal manometry; biofeedback; incontinence; pelvic floor exercises
National Category
Gastroenterology and Hepatology
Identifiers
urn:nbn:se:liu:diva-121926 (URN)10.3109/00365521.2014.999252 (DOI)000361323200005 ()25892434 (PubMedID)
Note

Funding Agencies|County Council of Ostergotland

Available from: 2015-10-13 Created: 2015-10-12 Last updated: 2017-12-01
Lowén, M. B. O., Mayer, E., Tillisch, K., Labus, J., Naliboff, B., Lundberg, P., . . . Walter, S. (2015). Deficient habituation to repeated rectal distensions in irritable bowel syndrome patients with visceral hypersensitivity. Neurogastroenterology and Motility, 27(5), 646-655
Open this publication in new window or tab >>Deficient habituation to repeated rectal distensions in irritable bowel syndrome patients with visceral hypersensitivity
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2015 (English)In: Neurogastroenterology and Motility, ISSN 1350-1925, E-ISSN 1365-2982, Vol. 27, no 5, p. 646-655Article in journal (Refereed) Published
Abstract [en]

Background Irritable bowel syndrome (IBS) patients show evidence of altered central processing of visceral signals. One of the proposed alterations in sensory processing is an altered engagement of endogenous pain modulation mechanisms. The aim was to test the hypothesis that IBS patients with (IBS-S) and without visceral hypersensitivity (IBS-N) differ in their ability to engage endogenous pain modulation mechanism during habituation to repeated visceral stimuli.

Methods Brain blood oxygen level dependent (BOLD) response was measured during repeated rectal distension and its anticipation in 33 IBS patients with and without visceral hypersensitivity and 18 healthy controls (HCs). BOLD response to early and late phase of the distension series was compared within and between groups.

Key Results While BOLD response was similar during the early phase of the experiment, IBS-S showed greater BOLD response than IBS-N and HCs during the late phase of the distension series. IBS-S showed increasing BOLD response both to the anticipation and delivery of low intensity rectal distensions in brain regions including insula, anterior and mid cingulate cortex. IBS-N showed decreasing BOLD response to repeated rectal distensions in brain regions including insula, prefrontal cortex and amygdala.

Conclusions & Inferences These findings are consistent with compromised ability of IBS-S to respond to repeated delivery of rectal stimuli, both in terms of sensitization of sensory pathways and habituation of emotional arousal. The fact that both IBS subgroups met Rome criteria, and did not differ in terms of reported symptom severity demonstrates that similar symptom patterns can result from different underlying neurobiological mechanisms.

Keywords
irritable bowel syndrome, brain-gut interaction, fMRI, visceral sensitivity
National Category
Gastroenterology and Hepatology Neurosciences
Identifiers
urn:nbn:se:liu:diva-122143 (URN)10.1111/nmo.12537 (DOI)000364742000007 ()25777251 (PubMedID)
Note

Funding agencies: County Council of Ostergotland, Sweden; National Institute of Health [DK 64531]

Available from: 2015-10-20 Created: 2015-10-20 Last updated: 2018-01-11Bibliographically approved
Ek, W. E., Reznichenko, A., Ripke, S., Niesler, B., Zucchelli, M., Rivera, N. V., . . . D'Amato, M. (2015). Exploring the genetics of irritable bowel syndrome: a GWA study in the general population and replication in multinational case-control cohorts.. Gut, 64, 1774-1782
Open this publication in new window or tab >>Exploring the genetics of irritable bowel syndrome: a GWA study in the general population and replication in multinational case-control cohorts.
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2015 (English)In: Gut, ISSN 0017-5749, E-ISSN 1468-3288, Vol. 64, p. 1774-1782Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: IBS shows genetic predisposition, but adequately powered gene-hunting efforts have been scarce so far. We sought to identify true IBS genetic risk factors by means of genome-wide association (GWA) and independent replication studies.

DESIGN: We conducted a GWA study (GWAS) of IBS in a general population sample of 11 326 Swedish twins. IBS cases (N=534) and asymptomatic controls (N=4932) were identified based on questionnaire data. Suggestive association signals were followed-up in 3511 individuals from six case-control cohorts. We sought genotype-gene expression correlations through single nucleotide polymorphism (SNP)-expression quantitative trait loci interactions testing, and performed in silico prediction of gene function. We compared candidate gene expression by real-time qPCR in rectal mucosal biopsies of patients with IBS and controls.

RESULTS: One locus at 7p22.1, which includes the genes KDELR2 (KDEL endoplasmic reticulum protein retention receptor 2) and GRID2IP (glutamate receptor, ionotropic, delta 2 (Grid2) interacting protein), showed consistent IBS risk effects in the index GWAS and all replication cohorts and reached p=9.31×10(-6) in a meta-analysis of all datasets. Several SNPs in this region are associated with cis effects on KDELR2 expression, and a trend for increased mucosal KDLER2 mRNA expression was observed in IBS cases compared with controls.

CONCLUSIONS: Our results demonstrate that general population-based studies combined with analyses of patient cohorts provide good opportunities for gene discovery in IBS. The 7p22.1 and other risk signals detected in this study constitute a good starting platform for hypothesis testing in future functional investigations.

National Category
Gastroenterology and Hepatology Medical Genetics
Identifiers
urn:nbn:se:liu:diva-112750 (URN)10.1136/gutjnl-2014-307997 (DOI)000362593700016 ()25248455 (PubMedID)
Available from: 2014-12-12 Created: 2014-12-12 Last updated: 2018-01-11Bibliographically approved
Molinder, H., Agreus, L., Kjellström, L., Walter, S., Talley, N. J., Andreasson, A. & Nyhlin, H. (2015). How individuals with the irritable bowel syndrome describe their own symptoms before formal diagnosis. Upsala Journal of Medical Sciences, 120(4), 276-279
Open this publication in new window or tab >>How individuals with the irritable bowel syndrome describe their own symptoms before formal diagnosis
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2015 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 120, no 4, p. 276-279Article in journal (Refereed) Published
Abstract [en]

Aim: To investigate how individuals fulfilling the Rome II criteria for irritable bowel syndrome (IBS) spontaneously described their symptoms. Method: From a general population, 1,244 randomly sampled adults were asked to describe their gastrointestinal symptoms (if any) verbally, in their own words, at a semi-structured interview. Their own descriptions were sorted into five symptom clusters. The participants independently completed a written questionnaire (the Rome II Modular Questionnaire (RMIIMQ)). Results: A total of 601 participants reported at least one gastrointestinal symptom, and 128 had IBS according to the RMIIMQ. After exclusion of organic causes, previously diagnosed IBS, or additional gastrointestinal diagnosis, 81 participants with IBS according to RMIIMQ remained. Five participants (6%) described symptoms included in the full definition of IBS, but none fulfilled the Rome II criteria completely. Abdominal pain or other IBS-related symptoms were reported by 64 (79%), and 12 (15%) did not report any IBS-like symptom. Conclusion: Previously undiagnosed individuals, who fulfil criteria for Rome II-IBS, often express their complaints in words that do not fit into the current diagnostic criteria.

Place, publisher, year, edition, pages
Taylor & Francis, 2015
Keywords
Diagnosis; digestive symptoms; irritable bowel syndrome (IBS); laymans wording; medical history-taking; questionnaires
National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-123836 (URN)10.3109/03009734.2015.1040529 (DOI)000365684900007 ()25947550 (PubMedID)
Note

Funding Agencies|Swedish Research Council; Ersta Hospital, Stockholm, Sweden; AstraZeneca RD, Sweden; Stockholm County Council; Karolinska Institutet, Stockholm, Sweden

Available from: 2016-01-11 Created: 2016-01-11 Last updated: 2017-12-01Bibliographically approved
Grodzinsky, E., Walter, S., Viktorsson, L., Carlsson, A.-K., Jones, M. P. & Olsen Faresjö, A. (2015). More negative self-esteem and inferior coping strategies among patients diagnosed with IBS compared with patients without IBS - a case-control study in primary care. BMC Family Practice, 16(6)
Open this publication in new window or tab >>More negative self-esteem and inferior coping strategies among patients diagnosed with IBS compared with patients without IBS - a case-control study in primary care
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2015 (English)In: BMC Family Practice, ISSN 1471-2296, E-ISSN 1471-2296, Vol. 16, no 6Article in journal (Refereed) Published
Abstract [en]

Background

Irritable Bowel Syndrome (IBS) is a chronic, relapsing gastrointestinal disorder,that affects approximately 10% of the general population and the majority are diagnosed  in primary care. IBS has been reported to be associated with altered psychological and cognitive functioning such as mood disturbances, somatization, catastrophizing or altered visceral interoception by negative emotions and stress. The aim was to  investigate the psychosocial constructs of self-esteem and sense of coherence among IBS patients compared to non-IBS patients in primary care.     

Methods

A case–control study in primary care setting among IBS patients meeting the ROME III         criteria (n = 140) compared to controls i.e. non-IBS patients (n = 213) without any         present or previous gastrointestinal complaints. The data were collected through self-reportedquestionnaires of psychosocial factors.     

Results

IBS-patients reported significantly more negative self-esteem (p < 0.001), lower scores         for positive self-esteem (p < 0.001), and lower sense of coherence (p < 0.001) than the controls. The IBS-cases were also less likely to report ‘good’ health status (p < 0.001) and less likely to report a positive belief in the future (p < 0.001). After controlling for relevant confounding factors in multiple regressions, the elevation  in negative self-esteem among IBS patients remained statistically significant (p =0.02), as did the lower scores for sense of coherence among IBS cases (p = 0.04).     

Conclusions

The more frequently reported negative self-esteem and inferior coping strategies among         IBS patients found in this study suggest the possibility that psychological therapies         might be helpful for these patients. However these data do not indicate the causal         direction of the observed associations. More research is therefore warranted to determine whether these psychosocial constructs are more frequent in IBS patients.

Place, publisher, year, edition, pages
BioMed Central, 2015
Keywords
Primary care; IBS; Self-esteem; Coping; Psychosocial factors
National Category
Gastroenterology and Hepatology Psychology
Identifiers
urn:nbn:se:liu:diva-114578 (URN)10.1186/s12875-015-0225-x (DOI)000349125500001 ()25626450 (PubMedID)
Note

Funding Agencies|FORSS (Research fund in South of Sweden)

Available from: 2015-02-27 Created: 2015-02-26 Last updated: 2017-12-04
Bednarska, O., Tapper, S., Lundberg, P., Tisell, A., Lowén, M. & Walter, S. (2014). Neurotransmittor Concentration in Pregenual ACC in Stool Consistency Patient Subgroups With IBS. In: : . Paper presented at United European Gastroenterology (UEG), Austria. , 2(Supplement 1)
Open this publication in new window or tab >>Neurotransmittor Concentration in Pregenual ACC in Stool Consistency Patient Subgroups With IBS
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2014 (English)Conference paper, Poster (with or without abstract) (Refereed)
Abstract [en]

Introduction

The Anterior Cingulate Cortex (ACC) is a key region of the central autonomic brain network. Irritable Bowel Syndrome (IBS) is characterized abdominal pain and bowel habit disturbances. Autonomic dysregulation has been reported in IBS as well as altered ACC activation in pregenual ACC during visceral stimulation 1 2. Glutamate is the major excitatory and Gamma-aminobutyric acid (GABA) the major inhibitory neurotransmitter in the brain.

Aim & Methods

We aimed to measure neurotransmitter concentration in the pregenual ACC, in stool consistency subgroups with IBS by using quantitative neurotransmitter Magnetic Resonance Spectroscopy (qMRS)Seven patients with IBS-mixed (6 women) and five patients with IBS -diarrhea (4 women) according to Rome 3 were included. Mean age was 34.2 years (SD 5.3) with no significant difference between subgroups.  Patients completed symptom severity score (IBS-SSS). Quantitative MRS was measured in a 3T MRI scanner. A water-suppressed MEGA-PRESS sequence (TR 2.0 s, TE 68 ms) was used with the editing pulses placed at 1.90 ppm (‘ON-dynamics’) and at 7.46 ppm (‘OFF-dynamics’) with a voxel (3x3x3 cm3) placed in the pACC. Each MEGA-PRESS measurement resulted in a sequence of 40 OFF- and ON-dynamics, where each was computed by 8 phase cycles. Directly after each water-suppressed MEGA-PRESS measurement, a shorter 2-dynamic unsuppressed water MEGA-PRESS measurement was performed within the same voxel, which was used to obtain the concentrations in physically well-defined units of [mM]. The GABA concentrations were computed by averaging the difference spectra obtained by subtracting each OFF-dynamic from subsequent ON-dynamic and using LCModel (Version 6.3) for the final quantification. The Glutamate concentrations were obtained by only averaging the OFF-dynamics, which were not affected by the editing pulses. Additionally, all dynamics were phase and frequency corrected prior to the averaging. For group comparison unpaired T-tests were used.

Results

Patients had moderate to severe symptoms with IBS-SSS of 367 (SD 79.7). There was no significant difference between IBS subgroups in terms of IBS-SSS. Mean pACC GABA concentration was 1.66 (SD 0.17) mM in IBS-M and 1.65 (SD 0.27) mM in IBS-D. There was no significant difference between groups (p=0.9). Mean pACC Glutamate concentration was 4.54 (0.35) mM in IBS-M and 5.13 (SD 0.64) mM in IBS-D. There was no significant difference between groups, although a trend with p=0.06 was observed.

Conclusion

Further qMRS data have to be collected in IBS patients as well as healthy controls to evaluate if IBS subgroups demonstrate alterations in pACC glutamate and GABA concentrations

National Category
Clinical Medicine
Identifiers
urn:nbn:se:liu:diva-114346 (URN)
Conference
United European Gastroenterology (UEG), Austria
Available from: 2015-02-19 Created: 2015-02-19 Last updated: 2017-01-19Bibliographically approved
Walter, S., Jones, M. P., Talley, N. J., Kjellstrom, L., Nyhlin, H., Andreasson, A. N. & Agreus, L. (2013). Abdominal pain is associated with anxiety and depression scores in a sample of the general adult population with no signs of organic gastrointestinal disease. Neurogastroenterology and Motility, 25(9), 741-E576
Open this publication in new window or tab >>Abdominal pain is associated with anxiety and depression scores in a sample of the general adult population with no signs of organic gastrointestinal disease
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2013 (English)In: Neurogastroenterology and Motility, ISSN 1350-1925, E-ISSN 1365-2982, Vol. 25, no 9, p. 741-E576Article in journal (Refereed) Published
Abstract [en]

Background Abdominal pain is common in the community, but only a subset meet diagnostic criteria for irritable bowel syndrome (IBS). Although anxiety and depression have been linked to IBS, the role of mood disturbances in the remainder with symptoms remains unclear. We aimed to study the associations between abdominal pain, anxiety, depression, and quality of life in the general population who were free of organic colonic disease by colonoscopy. Methods Two hundred and seventy-two randomly selected subjects from the general population, mean age 54 years (27-71), were clinically evaluated, had a colonoscopy and laboratory investigations to exclude organic gastrointestinal (GI) disease. All subjects completed GI symptom diaries for 1 week, the Rome II modular questionnaire, the Hospital Anxiety and Depression Scale, and Short Form 36. Key Results Twenty-two subjects were excluded due to organic disease; 1532 daily symptom records were available for analysis in the remainder. Thirty-four percent (n = 83) recorded at least one episode of abdominal pain on the diary. Twelve percent fulfilled Rome II criteria for IBS. Both anxiety and depression scores were higher in subjects who reported abdominal pain vs those who did not (P andlt; 0.0005 and P andlt; 0.0005). Anxiety and depression scores independently from IBS diagnosis (Rome II) predicted pain reporting and also correlated positively with pain burden. Quality of life scores were generally lower in subjects with abdominal pain. Conclusions andamp; Inferences Anxiety and depression are linked to functional abdominal pain, not only in subjects with IBS but also in otherwise healthy people with milder, subtle GI symptoms.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2013
Keywords
Abdominal pain, anxiety, depression, endoscopy, Irritable Bowel Syndrome, quality of life
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-96974 (URN)10.1111/nmo.12155 (DOI)000322594200009 ()
Note

Funding Agencies|Astra Zeneca||County Council of Ostergotland||

Available from: 2013-09-05 Created: 2013-09-02 Last updated: 2017-12-06
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