Background/objectives Suicidal ideation (SI), a symptom of depression, is known to be associated with irritable bowel syndrome (IBS) but is not known to be associated with other functional gastrointestinal disorders (FGIDs). However, the source of this association is discussed. It could be related to a possible abnormal biochemical pathway implicating neurotransmitters common to both disorders like serotonin or pain and an ill-being associated with a chronic disorder of unknown etiology. The present study aims to search for the FGIDs associated with suicidal ideation. Design Observational study. Methods A total of 1469 patients with FGIDs (71% of women) were included in the present study. They filled the Rome III questionnaire, Beck depression inventory, and state and trait anxiety questionnaires. Data were analyzed using analysis of variance with Bonferroni correction and logistic regression analysis. Results Suicidal ideation was reported by 15% of patients, associated with increased scales of depression (P < 0.001), state (P = 0.006), and trait anxiety (P = 0.021). Clinically, these patients reported a higher prevalence of IBS-diarrhea subtype (P = 0.045), fecal incontinence (P = 0.020), soiling (P = 0.016), and difficult defecation (P = 0.005), and higher perceived severity for constipation, diarrhea, bloating, and abdominal pain (P < 0.001 for all scales). Conclusions This study shows that only functional bowel and functional anorectal disorders are associated with suicidal ideation. This result must be taken into account in the management of these patients.

Stressful events are frequently associated with functional gastrointestinal disorders (FGID). This study aims to determine if the severity of self-perceived stress is associated with specific FGID and personality characteristics in 822 patients with FGID who have filled a Rome III questionnaire, Minnesota Multiphasic Personality Inventory 2 (MMPI-2), and a 10-point Likert scale for self-perceived stress. According to stress severity, the patients were divided into three groups: low (n = 183), moderate (4-6; n = 283), and severe stress (>6; n = 356). Female sex was more frequent in the severe stress group than in the low stress group (p = 0.001). Stress severity was strongly correlated with the two MMPI-2 posttraumatic stress scales. Clinically, chest pain was more frequently reported by severe stress patients than moderate stress patients. MMPI-2 clinical scales vary significantly according to the severity of stress, and "mild stress" patients have increased hysteria and depression scales and showed a higher frequency of irritable bowel syndrome-diarrhea. This study shows that severe stress severity is associated with a higher frequency of noncardiac chest pain and correlated with most personality items.

Background/Aims Although idiopathic fecal incontinence (FI) patients have some psychological characteristics, the personality of FI patients was not described. The present study aims to describe the clinical and personality characteristics of FI patients. Patients and methods This retrospective observational study included 996 outpatients, 72 with fecal incontinence. They filled out the Rome III diagnostic questionnaire, the personality inventory MMPI-2, the questionnaires for urological and sexual disorders, and Likert scales for bowel disorders perceived symptom severity. The main outcome measures were the presence in FI patients of functional gastrointestinal disorders, the self-reported symptom severity, and the personality profile. Results Patients were mainly females (72%). FI patients were characterized by higher age (P= 0.015), and by a higher prevalence of functional diarrhea (P= 0.001), urological (P= 0.001), and sexual disorders (P= 0.005). These patients also report higher diarrhea severity (P< 0.001) and lower abdominal pain severity (P= 0.009). The personality of FI patients is distinguished by a higher score for psychopathic deviate (P= 0.006), social responsibility (P= 0.003), Mac Andrew revised scale (P= 0.005), and antisocial practice (P= 0.007), and a lower score for type A behavior (P= 0.005). Conclusion FI patients are characterized not only by older age, and a high prevalence of diarrhea but also by a specific personality profile characterized by an unfavorable comparison with others.

Background/Aims Abnormal psychological profiles are frequently found in patients with functional gastrointestinal disorders (FGIDs). The present study aimed to evaluate the psychological profiles of FGID patients with irritable bowel syndrome (IBS), and IBS phenotypes. Methods In 608 FGID patients, including 235 with IBS, have filled a Rome III questionnaire and the French version of the Minnesota Multiphasic Personality Inventory 2. Data analysis was performed using univariate analysis and multivariate logistic regression. Results This study shows that IBS patients have abnormal psychological profiles with more significant symptom exaggeration and decreased test defensiveness than non-IBS patients. They have a significantly higher score for all clinical scales. Logistic regression analysis showed in IBS patients a decrease of body mass index (P= 0.002), and test defensiveness score K (P= 0.001) and an increase of Hypochondriasis (P< 0.001) and Masculinity-Femininity scale (P= 0.018). By comparison with non-IBS patients, IBS-constipation, IBS-diarrhea, and mixed IBS patients have increased Hypochondriasis value and Depression score, mixed IBS patients have higher Psychasthenia score and higher Hypomania score. No item was significantly different in the IBS-unspecified group. Conclusions This study shows that IBS patients have different psychological profiles than other FGID patients and that psychological characteristics are associated with IBS phenotypes except for patients with unsubtyped IBS.

Background/Aims: Little is known about the improvement in defecation frequently reported by women around menses. We aimed to describe clinical, physiological, and psychological correlates of this improvement in those with functional bowel disorders. Patients and Methods: We recruited 478 consecutive premenopausal adult females with no indication of gynecologic or psychiatric disease, who were attending an outpatient functional bowel disorders clinic. Patients completed a Rome III questionnaire, psychological evaluation stool form, and a 10-point Likert scale for constipation, diarrhea, bloating, and abdominal pain. These patients underwent physiological tests, anorectal manometry, and colonic transit time and were classified according to the presence or the absence of improvement in defecation during menses. The reverse selection procedure was used for model selection during multivariate logistic regression where statistically significant variables (p < 0.01) remained in the adjusted model. Results: Ninety-seven patients (20%) reported easier defecation during menstruation. These patients were younger (p < 0.001) but had similar body mass indices and psychological profiles as the other patients. Clinically, they only reported more frequent irritable bowel syndrome (IBS) with constipation (p = 0.007), with harder stools (p = 0.005) and delayed left colon transit time (p = 0.002). No anorectal manometric parameter was different between the 2 groups. Conclusion: Improvement of constipation during menses is mainly associated with younger age and constipation-IBS phenotype and not with functional constipation.

Functional gastrointestinal disorders are pathologies of multifactorial origin. A shorter duration of breastfeeding has been found to enhance the prevalence of irritable bowel syndrome (IBS) in adulthood. The present observational study aims mainly to evaluate if breastfeeding is associated with IBS only or with other functional gastrointestinal disorders (FGIDs).

Background/Aims: The aim of the present study is to evaluate if the intensity of the cardinal symptoms of functional bowel disorders could be used to identify homogenous groups of patients defined by the Rome criteria. Method: In this observational study, 1,729 consecutive outpatients (73% females) filled out the Rome III questionnaire and 10-point Likert scales for constipation, diarrhea, bloating (BL)/distension, abdominal pain (AP) during the week before the medical consultation. A Gaussian mixture model was used for clustering the patients according to the intensity of symptoms without a priori information, and a classification tree was constructed from this clustering. Data were analyzed using analysis of variance and logistic regression analysis. Results: According to the intensity of symptoms, the patients are divided into 8 groups named according to their main symptomatology: “painful constipation” (PFC), “mild pain constipation” (MPC), “painful diarrhea” (PFD), “mild pain diarrhea” (MPD), “mixed transit” (MT), “BL,” “AP,” and “nonspecific” (NS). The study of the relationship between the Rome III classification and this new grouping shows that irritable bowel syndrome (IBS)-constipation is associated with PFC, IBS-diarrhea with PFD and MPD, SII-mixed with MT, SII-unspecified with BL, functional constipation with PFC and MPC, functional diarrhea with MPD and NS, BL with “BL” and NS, nonspecific functional bowel disorders (FBD) with NS, and functional AP with “BL” and AP (p < 0.01 for all associations). Conclusion: A symptom intensity-based classification of FBD patients could simplify clinical phenotype, give homogeneous groups of patients, and could eventually be used by nongastroenterologists and in clinical research.

Abdominal pain is not used to characterize constipated patients. This study aimed to compare clinical, psychological, and physiological features in patients with IBS-constipation (IBS-C) with those in patients with functional constipation (FC) according to the intensity of abdominal pain.

Fecal soiling (FS) is the staining of underwear without loss of significant amounts of fecal material. It is frequently associated with defecation disorders in children. The aim of this study was to search for psychological and clinical correlates of adult patients with soiling. Clinically, the complaint of staining is confused with that of fecal incontinence (FI) in the mind of both patients and attending physicians.

Patients affected by gastrointestinal disorders often experience sexual dysfunction (SD). This creates stress and anxiety which impact on patients’ and/or their partners’ quality of life. A multidisciplinary approach to SD is often advisable in these patients. This survey assessed if gastroenterologists routinely discuss SD with their patients and the barriers toward discussing SD in clinical practice.A 29-item questionnaire was sent to members of the Italian Society of Gastroenterology and Digestive Endoscopy (SIGE). A descriptive analysis of responses was performed.Out of 714 eligible gastroenterologists, 426 (59.7%), responded.The majority (>70%) never/infrequently investigated SD with their patients and, similarly, most patients never discussed SD during the visit. The most reported reasons were lack of knowledge (58%), time (44%), and embarrassment (30%). However, more than 70% of respondents indicated that all specialists should be able to manage sexual problems, and more than 80% declared that it would be useful for gastroenterologists to attend courses dedicated to the problem of SD.Despite the high prevalence of SD, counselling was not routinely performed in gastroenterological care. Lack of education/knowledge appeared as the most important factor. Most of responders felt that attending a course on SD might increase the awareness of SD.

Background and aims Food is the most important synchronizer of gastrointestinal motility and secretion. Many patients with functional bowel or anorectal disorders complain of fecal urge and stool output after eating.Patients and methods In this prospective observational study, 408 consecutive outpatients with functional bowel and/or anorectal disorders (74% female, 50.2 +/- 15.6 years, 24.8 +/- 5.0 kg/m(2)) filled Rome III questionnaires. Depression and anxiety scores, a physiological evaluation (total and segmental colonic transit time, colonic transit response to eating using a standard 1000 kcal test meal, and anorectal manometry), were measured. Univariate analysis and multivariate logistic regression were carried out according to the presence or not of stool output after eating.Results Defecation after eating was found in 21% of patients. These patients were not different according to the demographic characteristics of sex ratio (P=0.702), age (P=0.830), and BMI (P=0.314). In contrast, they had lower state anxiety (P=0.032), but similar scores of depression (P=0.240) and trait anxiety (P=0.933). They had similar manometric characteristics (anal pressure and rectal sensitivity), but a greater response to eating in all segments of the colon. There was an increase in the frequency of functional diarrhea (odds ratio=2.576, 95% confidence interval=1.312-5.056; P=0.006) and levator ani syndrome (odds ratio=2.331, 95% confidence interval=1.099-4.944; P=0.017), but no other functional bowel disorder including irritable bowel syndrome and its subtypes was found.Conclusion Stool output after eating is associated with clinical disorders but not physiological parameters. This symptom is not associated with irritable bowel syndrome, but a higher frequency of functional diarrhea. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

We are reporting the case of a 32-year-old female who had suffered from fecal incontinence（FI）. She was born with an imperforate anus and a recto-vaginal fistula; she underwent repair at 6 mo of age. At 29 years of age, she was still fecally incontinent despite extensive pelvic floor reeducation. A magnetic resonance imaging and an anal electromyography were performed. Because her symptoms were considered to be probably due to extra-sphincteric implantation of the neo-anus, a redo was performed of the recto-neo-anal intra-sphincteric anastomosis. A neurostimulator device was subsequently implanted for persistent incontinence. Solid and liquid FI resolved, and her quality of life improved markedly. Combining surgery to correct the position of the neo-anus within the anal sphincter complex and neurostimulation could thus become a new approach in cases of refractory FI for patients with imperforate anus as a newborn. Follow-up into adulthood after pediatric imperforate anus surgery should be recommended for adult patients with persistent FI.

The importance in constipated subjects of having difficult defecation is poorly known. According to the Rome III criteria, constipated patients are classified as having either irritable bowel syndrome with constipation or functional constipation, depending on the presence and characteristics of abdominal pain. But, the Rome III criteria also identify another group of patients, labeled as suffering from functional anorectal disorders. Within this group, two complaints are akin to being constipated, but not labeled so: having dyssynergic defecation or inadequate defecation.

Measuring colonic transit time with radiopaque markers is simple, inexpensive, and very useful in constipated patients. Yet, the algorithm used to identify colonic segments is subjective, rather than founded on prior experimentation. The aim of the present study is to describe a rational way to determine the colonic partition in the measurement of colonic transit time.

BACKGROUND:Functional bowel disorders are recognized as being common, but remain very difficult to diagnose accurately and to differentiate from one another, despite their significant impact on the quality of life of patients.The aim of this study was to evaluate whether the clinical sign of 'floating stools' is associated with psychological disorders, colonic transit time, or other specific bowel disorders as defined by the Rome III diagnostic criteria.MATERIALS AND METHODS:A total of 1252 consecutive patients, referred for and found to have functional gastrointestinal disorders, filled in a standard clinical questionnaire on the basis of the Rome III diagnostic criteria and were asked to provide information on the presence of floating stools. Overall, 344 of these scored positive for functional bowel disorders and underwent psychometric testing and colonic transit time studies.RESULTS:Floating stools were reported by 26% of functional bowel disorder patients and 3% of the other functional gastrointestinal disorder patients (P<0.001). The basic demographic characteristics, psychometric evaluation scores, Bristol stool form scales, and total and segmental colonic transit times were not statistically different according to the presence or not of floating stools in these patients. Logistic regression showed that mixed irritable bowel syndrome was the only functional gastrointestinal disorder associated independently with floating stools (P=0.003).CONCLUSION:Floating stools are a characteristic of patients with mixed irritable bowel syndrome.

Background: Psychosocial factors, such as depression, have been shown to be associated with gastrointestinal disorders like constipation.Methods: We retrospectively compared the depression and anxiety profiles of patients with irritable bowel syndrome with constipation versus those of patients with functional constipation using validated questionnaires. Subjects rated the intensity of digestive symptoms experienced during the previous month using visual analogue scales. Colonic transit time measurements and anorectal manometry were performed.Results: Of the 128 consecutive, constipated patients included (84% females, mean age 49.7 +/- 15.5 years) 66 suffered from irritable bowel syndrome with constipation and 62 from functional constipation. Demographic and physiological traits were similar in the two groups. Patients suffering from irritable bowel syndrome with constipation reported higher depression scores (18.8 +/- 1.4 vs 12.7 +/- 1.3, P = 0.002) and higher symptom intensity scores for constipation (6.2 +/- 0.3 vs 4.3 +/- 0.4, P < 0.001), bloating (6.7 +/- 0.3 vs 3.3 +/- 0.4, P < 0.001) and abdominal pain (6.0 +/- 0.3 vs 2.7 +/- 0.4, P < 0.001) than patients with functional constipation. Multiple linear regression showed positive correlations between symptom intensity and depression and anxiety scores for functionally constipated patients only.Conclusions: Our results support the integration of a psychosocial component to the traditional treatment of constipated patients; however, further research exploring causality between psychosocial factors and specific gastrointestinal disorders would contribute to developing a tailored therapeutic approach. (C) 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:Abdominal pain is common in patients with functional bowel disorders (FBDs). The aim of this study was to characterize the predominant sites of abdominal pain associated with FBD subtypes, as defined by the Rome III criteria.METHODS:A total of 584 consecutive patients attending FBD consultations in a tertiary center participated in the study. Stool form, abdominal pain location (nine abdominal segments), and pain intensity (10-point Likert scale) during the previous week were recorded. Logistic regression analysis was used to characterize the association of abdominal pain sites with specific FBD subtypes.KEY RESULTS:FBDs were associated with predominant pain sites. Irritable bowel syndrome (IBS) with constipation was associated with pain in the left flank and patients were less likely to report pain in the right hypochondrium. Patients with functional constipation reported pain in the right hypochondrium and were less likely to report pain in the left flank and left iliac site. IBS with alternating constipation and diarrhea was associated with pain in the right flank, and unsubtyped IBS with pain in the hypogastrium Patients with functional abdominal pain syndrome reported the lower right flank as predominant pain site. Patients with unspecified FBDs were least likely to report pain in the hypogastrium. Patients with functional diarrhea, IBS with diarrhea, or functional bloating did not report specific pain sites.CONCLUSIONS & INFERENCES:The results from this study provide the basis for developing new criteria allowing for the identification of homogeneous groups of patients with non-diarrheic FBDs based on characteristic sites of pain.

BACKGROUND:Limited data have been published regarding the long-term results of sacral nerve stimulation, or sacral neuromodulation, for severe fecal incontinence.OBJECTIVES:The aim was to assess the outcome of sacral nerve stimulation with the use of precise tools and data collection, focusing on the long-term durability of the therapy. Five-year data were analyzed.DESIGN:Patients entered in a multicenter, prospective study for fecal incontinence were followed at 3, 6, and 12 months and annually after device implantation.PATIENTS:Patients with chronic fecal incontinence in whom conservative treatments had failed or who were not candidates for more conservative treatments were selected.INTERVENTIONS:Patients with ≥ 50% improvement over baseline in fecal incontinence episodes per week during a 14-day test stimulation period received sacral nerve stimulation therapy.MAIN OUTCOME MEASURES:Patients were assessed with a 14-day bowel diary and Fecal Incontinence Quality of Life and Fecal Incontinence Severity Index questionnaires. Therapeutic success was defined as ≥ 50% improvement over baseline in fecal incontinence episodes per week. All adverse events were collected.RESULTS:A total of 120 patients (110 women; mean age, 60.5 years) underwent implantation. Seventy-six of these patients (63%) were followed a minimum of 5 years (maximum, longer than 8 years) and are the basis for this report. Fecal incontinence episodes per week decreased from a mean of 9.1 at baseline to 1.7 at 5 years, with 89% (n = 64/72) having ≥ 50% improvement (p < 0.0001) and 36% (n = 26/72) having complete continence. Fecal Incontinence Quality of Life scores also significantly improved for all 4 scales between baseline and 5 years (n = 70; p < 0.0001). Twenty-seven of the 76 (35.5%) patients required a device revision, replacement, or explant.CONCLUSIONS:The therapeutic effect and improved quality of life for fecal incontinence is maintained 5 years after sacral nerve stimulation implantation and beyond. Device revision, replacement, or explant rate was acceptable, but future efforts should be aimed at improvement.

OBJECTIVES:Past studies confirm that patients with fibromyalgia (FM) and irritable bowel syndrome (IBS) show similar pain processing dysfunctions, such as reduced pain inhibition and aberrant autonomic nervous system (ANS) responses. However, patients with FM and IBS have rarely been investigated in the same study. The aim of the present study, therefore, was to compare descending pain inhibition, pain sensitivity, and ANS reactivity to pain in FM, IBS, and healthy controls (HC).METHODS:Female patients with FM (n=10), IBS (n=13), and HCs (n=10) were exposed to multiple cold water (12°C) immersions to study pain sensitivity and descending pain inhibition. Heart rate variability was also assessed during immersions.RESULTS:Pain intensity scores were highest in FM, intermediate in IBS, and smallest in HCs. In contrast, pain inhibition was absent in FM, intermediate in IBS, and strongest in HCs. Importantly, controlling for differences in pain inhibition abolished group differences in pain sensitivity. Heart rate variability analyses confirmed that, in response to mild levels of pain, patients with FM showed greater sympathetic activity whereas HCs showed greater parasympathetic activity. Patients with IBS showed intermediate ANS responses.DISCUSSION:Our results confirm the presence of graded levels of somatic hyperalgesia across patients with IBS and FM. A similar pattern of result was observed for pain inhibitory dysfunctions. These pain processing changes were accompanied by abnormal autonomic responses, which maintained patients (principally patients with FM) in a state of sympathetic hyperactivity. Results suggest that patients with IBS and FM may present common, but graded, pain processing and autonomic dysfunctions.