Gastro-Intestinal

FIGURE 1 Rome III Criteria

First Consultation

In a clinical scenario, the key to diagnosing FGID is careful history taking. The clinic consultation offers a good opportunity to discern not only the main symptoms but also the psychological issues associated with FGIDs. A good consultation using open-ended questionnaires will put patients at ease and allow them to describe their symptoms clearly. Portraying a positive body language and appearing ‘unhurried’ is essential to make patients feel empathized with. It is important to ensure that the consultation allows sufficient time for psychosocial history to come to light as psychological distress has been associated with FGIDs [29,39]. Another reason to discuss this aspect is the fact that it has been proven to reduce return visits to the clinic by making the patient feel that they have been listened to [53]. As well as eliciting the psychological aspects, the clinic appointment should also be used to exclude any red flag symptoms that may warrant further investigations. Dietary precipitants should also be enquired about as should be any infectious precursors to the start of symptoms.

Somatization and Co-Morbidities

One of the most challenging facets of managing functional disorder patients is the high incidence of multiple co-morbidities. These include psychological disorders such as somatization disorder as well as involvement of other bodily systems. Non-cardiac chest pain has been associated with IBS [62] and functional dyspepsia(FD) has been associated with general pain, sleep disorders and osteoarthritis [72]. Due to somatization these patients are subjected to numerous unnecessary investigations and treatments [12,21,57]. Accurate documentation of co-morbidities and previous hospital attendances is vital to identify patients with somatization disorder. These patients have been reported to be more challenging to manage and having a poorer response to conventional treatments [26,52]. The Patient Health Questionnaire 15 (PHQ-15) has been shown to be a useful tool in identifying this group of patients which may warrant specific treatment [35].

Precipitating Events

A relation between FGIDs and precipitating event such as severe adverse life events and chronic stressors, infection and dietary factors, has been reported in several studies. Importance of psychosocial history has already been discussed in the chapter. Recognition of chronic stressors has been shown to be significant in predicting success of treatment [5]. Infectious pathology has been reported to be associated with IBS [60], functional dyspepsia [54] and other functional bowel disorders [67]. A documented history of an infectious episode is quintessential in avoiding needless investigations, in absence of any red flag symptoms. Dietary elements should also be routinely investigated as they are known to be associated with certain FGIDs. For instance, bran seems to worsen symptoms in IBS [22], lactose intolerance can cause IBS-like symptoms [41] and symptoms of functional dyspepsia improve by consuming smaller meals with reduced fat content [55].

Drugs

A complete drug history is important since many drugs, including over the counter medications, can mimic IBS symptoms. Particular attention should be paid to opiates, which cause constipation [49], antibiotics which cause diarrhoea and proton pump inhibitors (PPIs) which can also cause diarrhoea due to microscopic colitis [11,32,50,58,70]. Probiotics are widely used and some have a laxative effect [3] so it is always worth specifically enquiring if they are being taken since many patients do not regard them as drugs. Other rare causes of diarrhoea due to medications are cardiac medications: angiotensin converting enzyme inhibitors [64], beta-blockers, drugs affecting the central nervous system, lithium and carbamazepine [20,24], weight control medication, and lipase inhibitors[1,19].

PRACTICAL IMPLICATIONS

In patients presenting with abdominal and pelvic pain with no alarming symptoms and where no organic cause can be established, FGIDs should be considered as an alternative diagnosis. The clinician should make all efforts to develop an empathetic relationship with their patients. Patient’s trust should be won by discussing the challenging nature of these disorders in a positive manner and by agreeing to the legitimacy of patient’s symptoms. The psychosocial aspect constitutes an important part of these disorders and should be properly explored to manage the patient appropriately. Moreover, patients should be informed of the biopsychosocial model of these disorders, e.g. a stress or vicious-circle model.

Setting up realistic goals for treatment so that the patient aims for improvement rather than cure is essential for success of the treatment. In general, pharmacotherapy and psychotherapy have not been found to be the most effective treatments for functional disorders, yet they do produce impressive results in a few individuals. The therapeutic options should be chosen based on severity of patient’s symptoms, patient’s preferences and psyche, physician’s own expertise, and the availability of different treatment options.

LOOKING AT THE FUTURE

FGIDs are challenging disorders mainly due to the traditional practice of conceptualizing a disease by associating it to identifiable defects. Further research is vital to develop a better understanding of these disorders and their treatment. Increasing awareness amongst clinicians and educating the general public on this rapidly growing knowledge is one of the key areas for development. While the diagnostic modality needs further development, the management of these disorders requiring different specialties needs an even more radical change in order to reduce the socioeconomic burden of these disorders.

The traditional delineation of “functional” versus “organic” is very likely to fade away in the future as the pathophysiology of these diseases is discovered.

TAKE HOME MESSAGES

• Functional bowel disorders are distinct clinical entities having a chronic and benign nature.

• Their development is most likely due to an interaction of somatic and psychosocial disease factors.

• There is a need for creating more awareness of these disorders amongst the primary care physicians in order to reduce their socioeconomic burden on the society

• It is important to communicate the diagnosis to patients in a positive and persuasive communication so as to maintain the legitimacy of the patient’s complaints and uproot their efforts to find an organic cause

• The diagnosis and treatment should be according to current guidelines

FURTHER READING

Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders http://www.romecriteria.org/assets/pdf/19_RomeIII_apA_885–898.pdf

REFERENCES

1. Acharya NV, Wilton LV, Shakir SA. Safety profile of orlistat: results of a prescription-event monitoring study. Int J Obes (Lond) 2006;30(11):1645–1652.

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