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Irritable Bowel Syndrome: Diagnostic Symptom Criteria and Impact of Rectal Distensions on Cortisol and Electrodermal Activity
Linköpings universitet, Institutionen för molekylär och klinisk medicin, Gastroenterologi och hepatologi. Linköpings universitet, Hälsouniversitetet. Östergötlands Läns Landsting, Medicincentrum, Endokrin- och magtarmmedicinska kliniken.
2006 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

In a population prevalence questionnaire study we demonstrated that constipation and fecal incontinence are common problems in the general Swedish population with a similar magnitude as in other Western countries. 95.6% of the population had between three bowel movements per day and three per week. Constipation was mostly defined by “hard stools” and “the need of using laxatives”.

Irritable Bowel Syndrome (IBS) is characterized by abdominal pain/discomfort and abnormal bowel habits. The diagnostic criteria of IBS are based on clinical symptoms. Division of IBS patients into symptom subgroups appears important as their bowel symptoms are characterized by heterogeneity. International criteria to subgroup IBS (Rome II) are based on expert consensus and not on evidence. We investigated the variation of stool consistency and defecatory symptoms in 135 IBS patients by symptom diary cards. Most patients had

alternating stool consistency. When subgroups were based on stool consistency, all kinds of defecatory symptoms (straining, urgency, and feeling of incomplete evacuations) were frequently present in all subgroups. Stool frequency was in the normal range in the majority of patients. We propose that IBS subgroups should be based on stool consistency. We suggest that Rome II supportive criteria must be reconsidered as the determination of presence or absence of specific symptoms does not work as an instrument for categorization of IBS patients into diarrhoea- and constipation-predominant. We also propose that abnormal stool frequency should be excluded to define subgroups of IBS. Alternating stool consistency and presence of different defecatory symptoms, regardless of stool consistency should be included as criteria for IBS.

Stress is known to play an important role in the onset and modulation of IBS symptoms. From experimental studies there is evidence for a stress-dependent alteration of visceral sensitivity. The biological mechanisms responsible for the causal link between stress and IBS symptoms are not completely understood, but the hypothalamic-pituitary-adrenocortical axis and the autonomous nervous system seem to play a prominent role in the pathophysiology of IBS. We investigated visceral sensitivity and the effect of repeated maximal tolerable rectal distensions on salivary cortisol levels and skin conductance in patients with IBS, chronic constipation and healthy volunteers.

We found that the expectancy of the experimental situation per se (provocation of bowel symptoms by rectal distensions) compared to non-experimental days at home measured as salivary cortisol had a high impact on the level of arousal in IBS. IBS patients had higher skin conductance values than controls in the beginning of distension series and lower rectal thresholds for first sensation, urge and discomfort than healthy controls and constipation patients. IBS patients demonstrated habituation to repeated subjective maximal tolerable rectal distensions according to sympathetic activity although patients continued to rate their discomfort as maximal. Constipation patients had lower sympathetic activity than IBS patients before and during repeated rectal distensions. None of the groups demonstrated a significant increase in cortisol after repetitive rectal distensions.

We conclude that Rome II supportive criteria for IBS should be reconsidered according to our findings. IBS patients are more sensitive to pre-experimental stress than healthy controls and patients with constipation. This should be considered in the design of experimental IBS studies. IBS patients habituated to subjective maximal tolerable, repetitive rectal distensions with decreasing sympathetic activity. Since responses to repeated stimuli of close-to-pain intensities are resistant to habituation this finding could be caused by psychological influences on perception, that is, perceptual response bias.

sted, utgiver, år, opplag, sider
Institutionen för molekylär och klinisk medicin , 2006.
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 974
Emneord [en]
Irritable Bowel Syndrome (IBS), diarrhoea- and constipation-predominant, stress, nervous, cortisol
HSV kategori
Identifikatorer
URN: urn:nbn:se:liu:diva-7899ISBN: 91-85643-24-6 (tryckt)OAI: oai:DiVA.org:liu-7899DiVA, id: diva2:22812
Disputas
2006-12-15, Eken, Campus US, Linköpings Universitet, Linköping, 13:00 (engelsk)
Opponent
Veileder
Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2012-03-22
Delarbeid
1. A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation
Åpne denne publikasjonen i ny fane eller vindu >>A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation
Vise andre…
2002 (engelsk)Inngår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, Vol. 37, nr 8, s. 911-916Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background: The self-reported bowel habits and the prevalence of faecal incontinence and constipation in men and women between the ages of 31 and 76 are assessed.

Methods: A postal questionnaire was sent to a random sample ( n = 2000) of the total population of persons between the ages of 31 and 76 living in the County of Östergötland, Sweden.

Results: The response rate was 80.5%. Overall, 67.8% reported one bowel movement per day and 4.4% had more than 21 or less than 3 bowel movements per week. This means that 95.6% had between 3 bowel movements a day to 3 bowel movements a week. Among women, 4.3%, and among men, 1.7%, reported less than 3 bowel movements per week. Women and men used the same terms to describe the definition of constipation. Women had a significantly higher self-reported prevalence of constipation than men ( P < 0.0001). About 20% of all women considered themselves constipated. The use of laxatives increased with age and 22% and 10% of elderly women and men, respectively, used laxatives including bulking agents for at least every fourth toilet procedure. About 10% reported leakage of faeces more often than once a month in the case of loose stools. With solid faeces, the rate of leakage was 1.4% and 0.4% for women and men, respectively. Soiling of underclothes more than once a month occurred in 21% of men and in 14.5% of women ( P = 0.006) and involuntary daily leakage of gas in 5.9% of men and 4.9% of women (n.s.).

Conclusions: Constipation and faecal incontinence are common problems in a general Swedish population.

Emneord
Bowel Habits, Constipation, Faecal Incontinence, Population-BASED, Prevalence, Questionnaire
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-14179 (URN)10.1080/003655202760230865 (DOI)
Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2009-08-21
2. Subgroups of irritable bowel syndrome: a new approach
Åpne denne publikasjonen i ny fane eller vindu >>Subgroups of irritable bowel syndrome: a new approach
2004 (engelsk)Inngår i: European Journal of Gastroenterology and Hepatology, ISSN 0954-691X (print) 1473-5687 (online), Vol. 16, nr 10, s. 991-994Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objectives: The newly revised Rome criteria for the definition of irritable bowel syndrome (IBS), derived from the consensus of experts in the field, were developed in order to identify subgroups of IBS patients for research. The criteria have, to our knowledge, never been validated. Both when trying to include IBS patients in studies and in clinical practice we found it difficult to apply the Rome 2 supportive criteria.

Aim: To study the variation of stool consistency and defecatory symptoms in IBS patients prospectively with diary cards and to validate the Rome 2 supportive criteria.

Methods: Sixty IBS patients, included by interview according to the Rome 1 criteria, recorded their bowel symptoms on diary cards over 40 days. Four subgroups were found, characterised by loose-stool-predominant, hard-stool-predominant, alternating stool consistency, and loose stools only. Urgency, straining and feeling of incomplete evacuation occurred in all but seven individuals, irrespective of subgroup.

Results: The Rome 2 criteria could subclassify seven patients into diarrhoea-predominant IBS based on stool consistency and absence of straining and could subclassify no patients into constipation-predominant IBS, as urge was present in nearly all patients. Fifty-three patients could not be classified according to the Rome 2 criteria, as they had defecatory symptoms of all kinds.

Conclusion: As the Rome 2 supportive criteria use the presence or absence of specific defecatory symptoms as an instrument for categorising IBS patients into diarrhoea- and constipation-predominant subgroups, these criteria could not be used for the majority of IBS patients in this study and should be reconsidered.

HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-14180 (URN)10.1097/00042737-200410000-00007 (DOI)
Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2009-10-31
3. New criteria for irritable bowel syndrome based on prospective symptom evaluation
Åpne denne publikasjonen i ny fane eller vindu >>New criteria for irritable bowel syndrome based on prospective symptom evaluation
2005 (engelsk)Annet (Annet vitenskapelig)
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-14181 (URN)10.1111/j.1572-0241.2005.00305_5.x (DOI)
Merknad
Letter to the editor, in American Journal of Gastroenterology vol. 100, no. 11 (2005), pp 2598-2599Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2010-05-24
4. Pre-experimental stress in patients with irritable bowel syndrome: high cortisol values already before symptom provocation with rectal distensions
Åpne denne publikasjonen i ny fane eller vindu >>Pre-experimental stress in patients with irritable bowel syndrome: high cortisol values already before symptom provocation with rectal distensions
Vise andre…
2006 (engelsk)Inngår i: Neurogastroenterology and Motility, ISSN 1350-1925, Vol. 18, nr 12, s. 1069-1077Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Stress is known to affect symptoms of irritable bowel syndrome (IBS) probably by an alteration of visceral sensitivity. We studied the impact of maximal tolerable rectal distensions on cortisol levels in patients with IBS, chronic constipation and controls, and evaluated the effect of the experimental situation per se. In twenty-four IBS patients, eight patients with chronic constipation and 15 controls salivary cortisol was measured before and after repetitive maximal tolerable rectal balloon distensions and at similar times in their usual environment. Rectal sensitivity thresholds were determined. IBS patients but not controls and constipation patients had higher cortisol levels both before and after the experiment compared with similar times on an ordinary day in their usual environment (P = 0.0034 and 0.0002). There was no difference in salivary cortisol level before compared with after rectal distensions. The IBS patients had significantly lower thresholds for first sensation, urge and maximal tolerable distension than controls (P = 0.0247, 0.0001 and <0.0001) and for urge and maximal tolerable distension than patients with constipation (P = 0.006 and 0.013). IBS patients may be more sensitive to expectancy stress than controls and patients with constipation according to salivary cortisol. Rectal distensions were not associated with a further significant increase in cortisol levels.

Emneord
constipation, cortisol, hypersensitivity, IBS, rectaldistensions, stress
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-14182 (URN)10.1111/j.1365-2982.2006.00833.x (DOI)
Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2009-06-08
5. Sympathetic (electrodermal) activity during repeated maximal rectal distensions in patients with irritable bowel syndrome and constipation
Åpne denne publikasjonen i ny fane eller vindu >>Sympathetic (electrodermal) activity during repeated maximal rectal distensions in patients with irritable bowel syndrome and constipation
2008 (engelsk)Inngår i: Neurogastroenterology and Motility, ISSN 1350-1925, E-ISSN 1365-2982, Vol. 20, nr 1, s. 43-52Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Irritable bowel syndrome (IBS) is associated with visceral hypersensitivity, stress and autonomic dysfunction. Sympathetic activity during repeated events indicates excitatory or inhibitory mechanisms such as sensitization or habituation. We investigated skin conductance (SC) during repetitive rectal distensions at maximal tolerable pressure in patients with IBS and chronic constipation. Twenty-seven IBS patients, 13 constipation patients and 18 controls underwent two sets of isobaric rectal distensions. First, maximal tolerable distension was determined and then it was repeated five times. Skin conductance was measured continuously. Subjective symptom assessment remained steady in all groups. The baseline values of SC were higher in IBS patients than in patients with constipation and significantly lower in constipation patients than in controls. The maximal SC response to repetitive maximal distensions was higher in IBS patients compared with constipation patients. The amplitude of the initial SC response decreased successively with increased number of distensions in patients with IBS and constipation but not in controls. Irritable bowel syndrome and constipation patients habituated to maximal repetitive rectal distensions with decreasing sympathetic activity. Irritable bowel syndrome patients had higher sympathetic reactivity and baseline activity than constipation patients. A lower basal SC in constipation patients compared with controls suggests an inhibition of the sympathetic drive in constipation patients.

Emneord
constipation, irritable bowel syndrome, rectal distensions, skin conductance, sympathetic, visceral hypersensitivity
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-14183 (URN)10.1111/j.1365-2982.2007.00998.x (DOI)
Tilgjengelig fra: 2006-12-07 Laget: 2006-12-07 Sist oppdatert: 2017-12-13bibliografisk kontrollert

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