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A Diagnostic Approach to Chronic Abdominal Pain: A Clinical Casebook
Abstract
Chronic abdominal pain is a condition routinely encountered in clinical practice. The differential diagnosis for chronic abdominal pain is broad and can be categorized using a location- and character-based approach. The evaluation begins with a thorough history, comprehensive exam, and thoughtful diagnostic approach. If warning signs are absent and no obvious underlying etiology is identified, patients should be stratified into low-risk versus high-risk categories based on age and associated symptoms. Low-risk patients (age <60 years and without alarm symptoms) may be offered empiric pharmacologic and/or psycho-behavioral treatment directed at the principal underlying symptom without further investigation. High-risk patients (age ≥60 years or with alarm features) may require additional evaluation prior to treatment.
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Patients with functional GI disorders (FGIDs) are commonplace in the gastroenterologist's practice. A number of these patients may be refractory to peripherally acting agents, yet respond to central neuromodulators. There are benefits and potential adverse effects to using TCAs, SSRIs, SNRIs, atypical antipsychotics, and miscellaneous central neuromodulators in these patients. These agents can benefit mood, pain, diarrhea, constipation, nausea, sleep, and depression. The mechanisms by which they work, the differences between classes and individual agents, and the various adverse effects are outlined. Dosing, augmentation strategies, and treatment scenarios specifically for painful FGIDs, FD with PDS, and chronic nausea and vomiting syndrome are outlined.Am J Gastroenterol advance online publication, 28 March 2017; doi:10.1038/ajg.2017.57.
Functional gastrointestinal disorders (FGIDs) are diagnosed and classified using the Rome criteria; the criteria may change over time as new scientific data emerge. The Rome IV was released in May 2016. The aim is to review the main changes in Rome IV. FGIDs are now called disorders of gut-brain interaction (DGBI). Rome IV has a multicultural rather than a Western-culture focus. There are new chapters including multicultural, age-gender-women's health, intestinal microenvironment, biopsychosocial, and centrally mediated disorders. New disorders have been included although not truly FGIDs, but fit the new definition of DGBI including opioid-induced gastrointestinal hyperalgesia, opioid-induced constipation, and cannabinoid hyperemesis. Also, new FGIDs based on available evidence including reflux hypersensitivity and centrally mediatedabdominal pain syndrome. Using a normative survey to determine the frequency of normal bowel symptoms in the general population changes in the time frame for diagnosis were introduced. For irritable bowel syndrome (IBS) only pain is required and discomfort was eliminated because it is non-specific, having different meanings in different languages. Pain is now related to bowel movements rather than just improving with bowel movements (ie, can get worse with bowel movement). Functional bowel disorders (functional diarrhea, functional constipation, IBS with predominant diarrhea [IBS-D], IBS with predominant constipation [IBS-D], and mixed IBS) are considered to be on a continuum rather than as independent entities. Clinical applications such as diagnostic algorithms and the Multidimensional Clinical Profile have been updated. The new Rome IV iteration is evidence-based, multicultural oriented and with clinical applications. As new evidence become available, future updates are expected.
Background
Cognitive biases and personality traits (aversion to risk or ambiguity) may lead to diagnostic inaccuracies and medical errors resulting in mismanagement or inadequate utilization of resources. We conducted a systematic review with four objectives: 1) to identify the most common cognitive biases, 2) to evaluate the influence of cognitive biases on diagnostic accuracy or management errors, 3) to determine their impact on patient outcomes, and 4) to identify literature gaps. Methods
We searched MEDLINE and the Cochrane Library databases for relevant articles on cognitive biases from 1980 to May 2015. We included studies conducted in physicians that evaluated at least one cognitive factor using case-vignettes or real scenarios and reported an associated outcome written in English. Data quality was assessed by the Newcastle-Ottawa scale. Among 114 publications, 20 studies comprising 6810 physicians met the inclusion criteria. Nineteen cognitive biases were identified. ResultsAll studies found at least one cognitive bias or personality trait to affect physicians. Overconfidence, lower tolerance to risk, the anchoring effect, and information and availability biases were associated with diagnostic inaccuracies in 36.5 to 77 % of case-scenarios. Five out of seven (71.4 %) studies showed an association between cognitive biases and therapeutic or management errors. Of two (10 %) studies evaluating the impact of cognitive biases or personality traits on patient outcomes, only one showed that higher tolerance to ambiguity was associated with increased medical complications (9.7 % vs 6.5 %; p = .004). Most studies (60 %) targeted cognitive biases in diagnostic tasks, fewer focused on treatment or management (35 %) and on prognosis (10 %). Literature gaps include potentially relevant biases (e.g. aggregate bias, feedback sanction, hindsight bias) not investigated in the included studies. Moreover, only five (25 %) studies used clinical guidelines as the framework to determine diagnostic or treatment errors. Most studies (n = 12, 60 %) were classified as low quality. Conclusions
Overconfidence, the anchoring effect, information and availability bias, and tolerance to risk may be associated with diagnostic inaccuracies or suboptimal management. More comprehensive studies are needed to determine the prevalence of cognitive biases and personality traits and their potential impact on physicians’ decisions, medical errors, and patient outcomes.
The microbiome has been implicated in the pathogenesis of a number of allergic and inflammatory diseases. The mucosa affected by eosinophilic esophagitis (EoE) is composed of a stratified squamous epithelia and contains intraepithelial eosinophils. To date, no studies have identified the esophageal microbiome in patients with EoE or the impact of treatment on these organisms. The aim of this study was to identify the esophageal microbiome in EoE and determine whether treatments change this profile. We hypothesized that clinically relevant alterations in bacterial populations are present in different forms of esophagitis.
In this prospective study, secretions from the esophageal mucosa were collected from children and adults with EoE, Gastroesophageal Reflux Disease (GERD) and normal mucosa using the Esophageal String Test (EST). Bacterial load was determined using quantitative PCR. Bacterial communities, determined by 16S rRNA gene amplification and 454 pyrosequencing, were compared between health and disease.
Samples from a total of 70 children and adult subjects were examined. Bacterial load was increased in both EoE and GERD relative to normal subjects. In subjects with EoE, load was increased regardless of treatment status or degree of mucosal eosinophilia compared with normal. Haemophilus was significantly increased in untreated EoE subjects as compared with normal subjects. Streptococcus was decreased in GERD subjects on proton pump inhibition as compared with normal subjects.
Diseases associated with mucosal eosinophilia are characterized by a different microbiome from that found in the normal mucosa. Microbiota may contribute to esophageal inflammation in EoE and GERD.
Chronic mesenteric ischemia is a rare condition, generally characterized by postprandial abdominal pain. Although chronic mesenteric ischemia accounts for only a small percentage of all mesenteric ischemic events, it can have significant clinical consequences. There are multiple etiologies; however, the most common cause is atherosclerosis. The diagnosis of chronic mesenteric ischemia requires a high clinical index of suspicion. An imaging study can confirm the presence of a stenosis or occlusion involving the mesenteric vessels in patients who are suspected of having chronic mesenteric ischemia. The diagnosis is usually late in its course due to the slow progression of disease and the abundance of mesenteric collaterals. Because of the extensive collateral network, usually at least two of the three visceral vessels need to be affected before patients develop symptoms. Treatment is necessary to avoid progression to bowel ischemia and infarction. Once a diagnosis of chronic mesenteric ischemia is made, treatment options include open surgical revascularization and endovascular revascularization.
Abdominal wall pain (AWP) is a common yet often overlooked source of abdominal pain. Trigger point injections (TPI) into the abdominal wall have been tried in the past. Few studies have looked at the long-term outcome from these injections.
A retrospective chart review was performed on 110 consecutive patients who received TPI for abdominal pain at the University of Western Ontario, London, Ontario. Outcomes from patients whose pain was due to AWP were determined. AWP was defined as fixed or localized pain and superficial or point tenderness (less than 2.5 cm diameter) or a positive Carnett sign (increased pain with tensing abdomen). The primary outcome was long-term efficacy of TPI. The number of diagnostic tests ordered to exclude AWP and the cost of investigating it were determined. Secondary analyses were done to determine if there were significant predictors of response to TPI.
Eighty-nine of 110 patients who received TPI met the criteria for AWP. In those who met the criteria for AWP, the average age was 42 years, 84% were female, and the average length of follow-up was 25 months. The primary outcome shows that, at follow-up, 77% had some or complete relief and 23% had no relief. An average of 4.3 diagnostic tests per patient were ordered to exclude other causes of abdominal pain. Secondary analyses show that meeting the criteria for AWP (P<0.0005), the absence of gastrointestinal symptoms (P<0.025), and an upper abdominal location of pain (P<0.025) were statistically significant predictors of a positive response to TPI.
This study demonstrates that TPI, in patients who meet criteria for AWP, are effective over the long term.
This document updates the colorectal cancer (CRC) screening recommendations of the U.S. Multi-Society Task Force of Colorectal Cancer (MSTF), which represents the American College of Gastroenterology, the American Gastroenterological Association, and The American Society for Gastrointestinal Endoscopy. CRC screening tests are ranked in 3 tiers based on performance features, costs, and practical considerations. The first-tier tests are colonoscopy every 10 years and annual fecal immunochemical test (FIT). Colonoscopy and FIT are recommended as the cornerstones of screening regardless of how screening is offered. Thus, in a sequential approach based on colonoscopy offered first, FIT should be offered to patients who decline colonoscopy. Colonoscopy and FIT are recommended as tests of choice when multiple options are presented as alternatives. A risk-stratified approach is also appropriate, with FIT screening in populations with an estimated low prevalence of advanced neoplasia and colonoscopy screening in high prevalence populations. The second-tier tests include CT colonography every 5 years, the FIT–fecal DNA test every 3 years, and flexible sigmoidoscopy every 5 to 10 years. These tests are appropriate screening tests, but each has disadvantages relative to the tier 1 tests. Because of limited evidence and current obstacles to use, capsule colonoscopy every 5 years is a third-tier test. We suggest that the Septin9 serum assay (Epigenomics, Seattle, Wash) not be used for screening. Screening should begin at age 50 years in average-risk persons, except in African Americans in whom limited evidence supports screening at 45 years. CRC incidence is rising in persons under age 50, and thorough diagnostic evaluation of young persons with suspected colorectal bleeding is recommended. Discontinuation of screening should be considered when persons up to date with screening, who have prior negative screening (particularly colonoscopy), reach age 75 or have <10 years of life expectancy. Persons without prior screening should be considered for screening up to age 85, depending on age and comorbidities. Persons with a family history of CRC or a documented advanced adenoma in a first-degree relative age <60 years or 2 first-degree relatives with these findings at any age are recommended to undergo screening by colonoscopy every 5 years, beginning 10 years before the age at diagnosis of the youngest affected relative or age 40, whichever is earlier. Persons with a single first-degree relative diagnosed at ≥60 years with CRC or an advanced adenoma can be offered average-risk screening options beginning at age 40 years.
Helicobacter pylori is a common bacterial pathogen responsible for significant gastrointestinal morbidity worldwide. Helicobacter pylori infection can be clinically challenging, given the numerous diagnostic and therapeutic options available. In this article, we provide a systematic review of H pylori epidemiology and pathogenesis. In addition, we provide a simplified approach to the diagnosis and treatment of H pylori infection, suitable for application in the primary care setting. On completion of this article, one should be able to (1) state the indications for H pylori testing; (2) identify noninvasive and invasive tests to diagnose H pylori infection; and (3) describe the advantages and disadvantages of various treatment regimens.
Background
The Bristol Stool Form Scale (BSFS) is a 7-point scale used extensively in clinical practice and research for stool form measurement, which has undergone limited validity and reliability testing. AimTo determine the validity and reliability of the BSFS in measuring stool form in healthy adults and patients with diarrhoea-predominant irritable bowel syndrome (IBS-D). Methods
One hundred and sixty-nine healthy volunteers provided a stool sample and used the BSFS to classify stool form, which was compared with measured stool water content and with values from 19 patients with IBS-D. Eighty-six volunteers used the BSFS to classify 26 stool models to determine accuracy and reliability. ResultsVolunteers' classifications of stool type correlated with stool water (Spearman's rho = 0.491, P < 0.001), which increased in hard (Types 1-2), normal (Types 3-5) and loose stools (Types 6-7) (P < 0.001). The BSFS detected differences in stool form between healthy volunteers (mean 3.7, s.d. 1.5) and IBS-D patients (mean 5.0, s.d. 1.2) (P < 0.001). Overall, 977/1204 (81%) stool models were correctly classified (substantial accuracy, = 0.78), although <80% of Types 2, 3, 5 and 6 were classified correctly. On 852/1118 (76%) occasions, volunteers classified covert duplicate models to the same stool type (substantial reliability, = 0.72), but with only moderate reliability for Types 2 (63%, = 0.57) and 3 (62%, = 0.55). Conclusions
The BSFS demonstrated substantial validity and reliability, although difficulties arose around clinical decision points (Types 2, 3, 5, 6) that warrant investigation in larger clinical populations. Potential for improving validity and reliability through modifications to the BSFS or training in its use should be explored.
Although abdominal pain is a symptom of several structural gastrointestinal disorders (eg, peptic ulcer disease), this comprehensive review will focus on the 4 most common nonstructural, or functional, disorders associated with abdominal pain: functional dyspepsia, constipation-predominant and diarrhea-predominant irritable bowel syndrome, and functional abdominal pain syndrome. Together, these conditions affect approximately 1 in 4 people in the United States. They are associated with comorbid conditions (eg, fibromyalgia and depression), impaired quality of life, and increased health care utilization. Symptoms are explained by disordered gastrointestinal motility and sensation, which are implicated in various peripheral (eg, postinfectious inflammation and luminal irritants) and/or central (eg, stress and anxiety) factors. These disorders are defined and can generally be diagnosed by symptoms alone. Often prompted by alarm features, selected testing is useful to exclude structural disease. Identifying the specific diagnosis (eg, differentiating between functional abdominal pain and irritable bowel syndrome) and establishing an effective patient-physician relationship are the cornerstones of therapy. Many patients with mild symptoms can be effectively managed with limited tests, sensible dietary modifications, and over-the-counter medications tailored to symptoms. If these measures are not sufficient, pharmacotherapy should be considered for bowel symptoms (constipation or diarrhea) and/or abdominal pain; opioids should not be used. Behavioral and psychological approaches (eg, cognitive behavioral therapy) can be helpful, particularly in patients with chronic abdominal pain who require a multidisciplinary pain management program without opioids.
Functional bowel disorders are highly prevalent disorders found worldwide. These disorders have the potential to affect all members of society, regardless of age, gender, race, creed, color or socioeconomic status. Improving our understanding of functional bowel disorders (FBD) is critical as they impose a negative economic impact to the global health care system in addition to reducing quality of life. Research in the basic and clinical sciences during the past decade has produced new information on the epidemiology, etiology, pathophysiology, diagnosis and treatment of FBDs. These important findings created a need to revise the Rome III criteria for FBDs, last published in 2006. This manuscript classifies the FBDs into five distinct categories: irritable bowel syndrome (IBS); functional constipation (FC); functional diarrhea (FDr); functional abdominal bloating/distention (FAB/D); and unspecified FBD (U-FBD). Also included in this article is a new sixth category, opioid induced constipation (OIC) which is distinct from the functional bowel disorders (FBDs). Each disorder will first be defined, followed by sections on epidemiology, rationale for changes from prior criteria, clinical evaluation, physiologic features, psychosocial features and treatment. It is the hope of this committee that this new information will assist both clinicians and researchers in the decade to come.
Chronic abdominal pain is a frequently encountered problem of primary care physicians, gastroenterologists, and pain physicians. Generally it is defined as a continuous or intermittent abdominal discomfort lasting for at least 6 months. This chapter will discuss the epidemiology of a wide variety of etiologies ranging from organic to functional causes of chronic abdominal pain. The chapter will be divided based on three clear delineations of chronic abdominal pain, which include visceral, chronic somatosensory, and primarily functional abdominal pain. The incidence, prevalence, demographics, and environmental associations of these disorders will be discussed in detail.
Alterations in the bidirectional interactions between the intestine and the nervous system have important roles in the pathogenesis of irritable bowel syndrome (IBS). A body of largely preclinical evidence suggests that the gut microbiota can modulate these interactions. A small and poorly defined role for dysbiosis in development of IBS symptoms has been established, through characterization of altered intestinal microbiota in IBS patients and reported improvement of subjective symptoms following its manipulation with prebiotics, probiotics, or antibiotics. It remains to be determined whether IBS symptoms are caused by alterations in brain signaling from the intestine to the microbiota or primary disruption of the microbiota, and whether they are involved in altered interactions between the brain and intestine during development. We review the potential mechanisms involved in the pathogenesis of IBS in different groups of patients. Studies are needed to better characterize alterations to the intestinal microbiome in large cohorts of well-phenotyped patients, and to correlate intestinal metabolites with specific abnormalities in gut-brain interactions.
Acute right upper quadrant pain is a common presenting symptom in patients with acute cholecystitis. When acute cholecystitis is suspected in patients with right upper quadrant pain, in most clinical scenarios, the initial imaging modality of choice is ultrasound. Although cholescintigraphy has been shown to have slightly higher sensitivity and specificity for diagnosis, ultrasound is preferred as the initial study for a variety of reasons, including greater availability, shorter examination time, lack of ionizing radiation, morphologic evaluation, confirmation of the presence or absence of gallstones, evaluation of bile ducts, and identification or exclusion of alternative diagnoses. CT or MRI may be helpful in equivocal cases and may identify complications of acute cholecystitis. When ultrasound findings are inconclusive, MRI is the preferred imaging test in pregnant patients who present with right upper quadrant pain.
The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
Family physicians often must determine the most appropriate diagnostic tests to order for their patients. It is essential to know the types of contrast agents, their risks, contraindications, and common clinical scenarios in which contrast-enhanced computed tomography is appropriate. Many types of contrast agents can be used in computed tomography: oral, intravenous, rectal, and intrathecal. The choice of contrast agent depends on route of administration, desired tissue differentiation, and suspected diagnosis. Possible contraindications for using intravenous contrast agents during computed tomography include a history of reactions to contrast agents, pregnancy, radioactive iodine treatment for thyroid disease, metformin use, and chronic or acutely worsening renal disease. The American College of Radiology Appropriateness Criteria is a useful online resource. Clear communication between the physician and radiologist is essential for obtaining the most appropriate study at the lowest cost and risk to the patient.
The prevalence and impact of abdominal pain, bloating, and diarrhea in the adult US population are largely unknown. We conducted a national, cross-sectional, telephone survey of US households to provide estimates of the frequency, duration, severity, and impact of specific digestive symptoms during the previous month. A total of 2510 subjects completed interviews (70.7% response rate). Among the respondents, 1017 (40.5%) reported one or more digestive symptoms within the month before the interview, including abdominal pain or discomfort 21.8%, bloating or distension 15.9%, and diarrhea or loose stools 26.9%. Women were more likely than men to report abdominal pain or discomfort (24.4% vs 17.5%) and bloating or distension (19.2% vs 10.5%), but not diarrhea or loose stools (27.1% vs 26.7%). Symptoms were less common among those 60 years of age. More than 65% of respondents rated symptoms as moderate or severe in intensity, and the majority reported limitations in daily activities. We conclude that digestive symptoms are more common than previously recognized and have a significant impact.
Unlabelled:
In 2008, according to the Medical Expenditure Panel Survey (MEPS), about 100 million adults in the United States were affected by chronic pain, including joint pain or arthritis. Pain is costly to the nation because it requires medical treatment and complicates treatment for other ailments. Also, pain lowers worker productivity. Using the 2008 MEPS, we estimated 1) the portion of total U.S. health care costs attributable to pain; and 2) the annual costs of pain associated with lower worker productivity. We found that the total costs ranged from 635 billion in 2010 dollars. The additional health care costs due to pain ranged from 300 billion. This represents an increase in annual per person health care costs ranging from 300 compared to a base of about 299 to 309 billion), cancer (188 billion). Our estimates are conservative because they do not include costs associated with pain for nursing home residents, children, military personnel, and persons who are incarcerated.
Perspective:
This study estimates that the national cost of pain ranges from 635 billion, larger than the cost of the nation's priority health conditions. Because of its economic toll on society, the nation should invest in research, education, and training to advocate the successful treatment, management, and prevention of pain.
Small intestinal bacterial overgrowth (SIBO), defined as excessive bacteria in the small intestine, remains a poorly understood disease. Initially thought to occur in only a small number of patients, it is now apparent that this disorder is more prevalent than previously thought. Patients with SIBO vary in presentation, from being only mildly symptomatic to suffering from chronic diarrhea, weight loss, and malabsorption. A number of diagnostic tests are currently available, although the optimal treatment regimen remains elusive. Recently there has been renewed interest in SIBO and its putative association with irritable bowel syndrome. In this comprehensive review, we will discuss the epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of SIBO.
Carnett's test is a simple clinical test in which abdominal tenderness is evaluated while the patient tenses the abdominal muscles. It is useful for differentiating abdominal wall pain from intra-abdominal pain. However, no study has reported its association with psychogenic abdominal pain. We evaluated its diagnostic usefulness in psychogenic abdominal pain.
Two physicians performed Carnett's test on each patient, but only one received the medical history. The other physician only conducted the test. Based on the final diagnosis, patients were categorized into 3 groups: psychogenic pain, abdominal wall pain, or intra-abdominal pain. Each group was analyzed in association with the results of Carnett's test conducted by the blinded physician.
A total of 130 outpatients with the chief complaint of abdominal pain who had abdominal tenderness.
There were 22 patients with psychogenic abdominal pain, 19 with abdominal wall pain and 62 with intra-abdominal pain. In patients with psychogenic pain or abdominal wall pain, Carnett's test was usually positive, whereas the test was usually negative in patients with intra-abdominal pain (p<0.001, respectively). The positive likelihood ratio of Carnett's test for psychogenic abdominal pain was 2.91 (95% confidence interval [CI], 2.71-3.13), while the negative likelihood ratio was 0.19 (95% CI, 0.11-0.34). The corresponding values for abdominal wall pain were 2.62 (95% CI, 2.45-2.81) and 0.23 (95% CI, 0.13-0.41), respectively.
Carnett's test may be useful for ruling in and ruling out psychogenic abdominal pain in addition to distinguishing between abdominal wall pain and intra-abdominal pain.
Chronic abdominal wall pain is frequently misdiagnosed as arising from a visceral source, often resulting in inappropriate diagnostic testing, unsatisfactory treatment, and considerable cost. Its prevalence in general medical practice is unknown, although it may account for about 10% of patients with chronic idiopathic abdominal pain seen in gastroenterological practices. The most common cause appears to be entrapment of an anterior cutaneous branch of one or more thoracic intercostal nerves; myofascial pain and radiculopathy are less frequent. Sharply localized pain and superficial tenderness are suggestive of abdominal wall origin. Carnett's test (accentuated localized tenderness with abdominal wall tensing) is a helpful diagnostic sign, especially when incorporated with other findings. Early exclusion of a parietal source should increase diagnostic accuracy when evaluating patients with chronic abdominal pain. Reassurance of patients by the correct diagnosis and avoidance of precipitating causes is often sufficient treatment. However, accurately placed anesthetic/corticosteroid injections give substantial pain relief to more than 75% of patients, often for prolonged periods, and may be confirmatory for the source of the complaint. The probability of missing visceral disease is small (probably less than 7%) with strict adherence to diagnostic criteria and diligent observation of patients.
The human gut is the natural habitat for a large and dynamic bacterial community, but a substantial part of these bacterial populations are still to be described. However, the relevance and effect of resident bacteria on a host's physiology and pathology has been well documented. Major functions of the gut microflora include metabolic activities that result in salvage of energy and absorbable nutrients, important trophic effects on intestinal epithelia and on immune structure and function, and protection of the colonised host against invasion by alien microbes. Gut flora might also be an essential factor in certain pathological disorders, including multisystem organ failure, colon cancer, and inflammatory bowel diseases. Nevertheless, bacteria are also useful in promotion of human health. Probiotics and prebiotics are known to have a role in prevention or treatment of some diseases.
Functional gastrointestinal disorders (FGID) are common in the community. The natural history of FGID is unknown because of a lack of prospective population-based studies and the indistinct nature of the phenotype. We sought to report the natural history of FGID in a US population.
This prospective cohort study used data from multiple validated surveys of random samples of Olmsted County, MN, residents over a mean of a 12-year period between 1988 and 2003 (n = 1365). The surveys measured gastrointestinal symptoms experienced during the past year. Each subject received a minimum of 2 surveys. Point prevalence, onset, and disappearance rates and transition probabilities were calculated for individual FGIDs.
Between the initial and final surveys, the point prevalences (per 100 residents) were stable for irritable bowel syndrome (8.3% and 11.4%, respectively) and functional dyspepsia (1.9% and 3.3%, respectively). The onset of each of the disorders studied was greater than the disappearance rate, but the transition probabilities varied across the different subgroups. Among people with symptoms at baseline, approximately 20% had the same symptoms, 40% had no symptoms, and 40% had different symptoms at follow-up.
Although the prevalence of the FGID was stable over time, the turnover in symptom status was high. Many episodes of symptom disappearance were due to subjects changing symptoms rather than total symptom resolution. This transition between different FGIDs suggests a common etiopathogenesis.