# Digest Spring/Summer 2004



## eric (Jul 8, 1999)

Digest A publication of theUniversity of North CarolinaCenter for Functional GI& Motility DisordersTable of ContentsOur mission is toadvance thebiopsychosocialunderstanding and careof patients withfunctional GI & motilitydisorders throughresearch, training andeducation.When is it a burp... and whenis it reflux?2004 Patient SymposiumDrossman Receives 2004AGA Distinguished EducatorAwardWhitehead Receives 2004Janssen Award inGastroenterologyDDW 2004DDW Presentation AbstractsDDW Poster AbstractsCenter Bids Farewell toAlbena Halpert, MDA Tribute to MotoyoriKanazawa, MD, PhD, FJSIMAsk the ExpertsCenter NewsWhen is it just a burp... and when is it reflux?By Nicholas J. Shaheen, MDAssistant Professor of Medicine,School of MedicineUniversity of North Carolina atChapel HillMuch of the publicï¿½s confusionabout gastroesophageal refluxdisease (GERD) stems from thedifficulty recognizing thedisease. Unlike a broken leg ora bloody nose, GERD may be asubtle, yet destructive disease. Since up to 40% of adults experienceat least some GERD symptoms, questions involving the conditionare important. What is GERD, and when and why should you beconcerned about it?What is GERDGERD is an upward displacement of stomach fluids into theesophagus, which leads to certain symptoms or damage to theesophagus. The most common symptom of reflux disease isheartburn. This is the familiar substernal chest burning that oftenradiates from the lower tip of the breastbone upwards into the lowerand then upper chest. This symptom may be accompanied byburping, excessive salivation filling the mouth with water (knownas waterbrash), and dysphagia (difficulty swallowing food). Thesesymptoms may be positional and worse when lying down. Theymay also be worse when eating or drinking, especially certain itemsï¿½ such as alcohol, peppermint, fatty foods, and acidic foods (suchas orange juice).While the symptoms described above have long been associatedwith reflux disease, there is now a growing concern about othercontinued on page 2Nicholas ShaheenUNC Center for Functional GI & Motility Disorders Digestsymptoms that can be caused by reflux. Thesesymptoms are known as the extra-esophagealsymptoms of reflux and include manifestationssuch as asthma, laryngitis, chronic cough,halitosis (bad breath), and even sleepdisorders. These symptoms are much morecommonly caused by GERD than had beenpreviously recognized. For instance, up to 30%of chronic cough patients have GERD as areason for their cough. Furthermore, up to halfof those with an extra-esophageal manifestationof reflux will not have heartburn. This meanstheir physicians will not have a helpful clue thattheir symptom is caused by GERD. Extraesophagealreflux may be more than a nuisanceï¿½ studies have shown that GERD is a strongrisk factor for laryngeal cancer, as well.When should a person with heartburn beconcerned about GERD?Unfortunately, there is no simple answer to thisquestion. It turns out that severity of symptomsis poorly predictive of severity of GERD ï¿½ somesubjects with very high amounts of acid comingup into the chest may have only trivialsymptoms of reflux, whereas others with severesymptoms may have relatively normal acidexposures. On the other hand, frequency ofGERD symptoms is a relatively strong indicatorof GERD severity.What does this mean? If you are a person whogets severe heartburn once every other monthafter a night of beer and pizza, a few TUMS anda little less food and drink next time may be allthat is necessary. On the other hand, if you areexperiencing symptoms weekly or more oftenon a normal diet, even if the symptoms are notsevere, discussion with your doctor isadvisable.How do we treat GERD?Elevating the head of the bed with bricks,avoiding late night and/or large meals,cessation of smoking and drinking alcohol, andavoidance of the foods mentioned above aresome of the measures that we commonlysuggest. For those in whom these measures failto give relief, drug therapy is recommended.Although antacids are fine for infrequent ormild symptoms, they are not a good strategyfor frequent or severe symptoms. Too manypeople we see in our clinic are going througha bottle of TUMS every 2-3 days before theydiscuss the problem with their doctor. Some ofthese patients may do fine with an H2 receptorantagonist, such as Zantac, Tagamet, Pepcid, orAxid. Over-the-counter varieties of thesemedications are at half the strength of theprescription medications, so failure of over-thecountermedications does not necessarily meanyou might not respond well to prescriptiondoses.Your doctor may prescribe a proton pumpinhibitor. This class of medications includesPrilosec, Prevacid, Aciphex, Protonix, orNexium. Proton pump inhibitors are the mostpotent acid suppressive drugs currentlyavailable. Although doctors were initiallyconcerned that long-term usage of these agentsmight be harmful to patients, studies nowindicate these drugs are safe even when takencontinuously for years. This excellent safetyrecord has led the Food and DrugAdministration (FDA) to permit manufacturersto market Prilosec to go over-the-counter.Some patients with relatively severe GERDmight opt to undergo a surgical anti-refluxprocedure. This surgery can now be donelaparoscopically, which is a minimally invasivetechnique. This option might be particularlyattractive for the patient who is unable to getgood control of his or her symptoms even withmaximum medications, or the patient whodislikes or forgets to take his/her medicine.2 When is it just a burp... and when is it reflux?continued on page 3UNC Center for Functional GI & Motility Disorders Digest3GERD can cause problems beyonddiscomfortLong-term exposure of the esophagus to acidcan cause a narrowing of the esophagus, calledstricture formation. This problem is usuallyamenable to endoscopic therapy, in whichballoons or dilators are used to stretch theesophagus to a more normal diameter.Erosive esophagitis is a condition where theesophageal lining is eaten away by the gastriccontents. The inflamed area can bleed or causechest pain.Perhaps the most devastating complication ofGERD is the development of esophageal cancer.Patients with frequent severe GERD are 16 timesmore likely to get esophageal cancer thanpeople who do not experience GERD. Thecancer is thought to occur because the normallining of the esophagus transforms or changesinto a pre-malignant state known as Barrettï¿½sesophagus. Over time, a small portion of peoplewith Barrettï¿½s will progress on to cancer.Use of upper endoscopy to assess thecondition of their esophagusCertain symptoms, known as alarm symptoms,are known to be associated with severeconditions of the esophagus and deserveimmediate investigation. These symptomsinclude dysphagia, odynophagia (pain withswallowing), anemia, throwing up or passingblood in the stools, and weight loss. Bloodpassed from the esophagus into the stool willoften appear jet black, a condition which isknown as melena. It is less clear is when thesubject with GERD ï¿½ but no alarm symptomsï¿½ needs endoscopy. The American College ofGastroenterology suggests that anyone withlong-term symptoms undergo a singlescreening upper endoscopy. The primary goalof this examination is to look for Barrettï¿½sesophagus or early adenocarcinoma. If thepatient is found to have Barrettï¿½s esophagus,most doctors will recommend repeatendoscopies to monitor the Barrettï¿½s and makesure it does not turn into cancer. Upperendoscopy may be especially useful in patientswho are older, Caucasian, and/or male, sinceall of these characteristics are known as riskfactors for esophageal cancer.New endoscopic techniquesNew endoscopic techniques have beendeveloped to treat GERD without medicationsor surgery. For example, endoscopic sewingdevices ï¿½sew tightï¿½ the lower esophagus,allowing less acid to come up into the chest.Another example is the Stretta device, whichuses heat to thicken the lower esophagus,thereby decreasing the amount of fluid that isable to get up into the chest. Third, Enteryx isan injectable polymer that can beendoscopically placed at the lower end of theesophagus to thicken it, decreasing the amountof gastric contents that can reflux. Finally, thePlicator is similar to a giant stapler, designedto tighten the bottom of the esophagus with onebig pacman-like bite, leaving a stitch that goesall the way through the wall of the stomach.Experience with all of these procedures is stillrather preliminary, and it remains to be seenwhether any of them will provide lasting reliefof GERD symptoms. These procedures do holdthe promise, however, that one day GERDsymptoms may be addressed by thegastroenterologist without need of medicationsor surgeries.If you are confused about how much to beconcerned about your GERD symptoms, youhave it right ï¿½ doctors are not always entirelyclear when we need to worry about them either.By following the simple suggestions above, youmay be able to rid yourself of these bothersomesymptoms with over-the-counter remedies. But,if that does not provide the relief you need, doyourself a favor and talk to your doctor.When is it just a burp... and when is it reflux?UNC Center for Functional GI & Motility Disorders Digest4 2004 Patient Symposium - Understanding Functional GI & Motility DisordersOn Saturday, June 12, 2004, theCenter hosted a PatientSymposium on UnderstandingFunctional GI & Motility Disordersat the William and Friday Centerfor Continuing Education inChapel Hill, NC. Participantscame from as far away asEngland, Canada, California,Washington State, the Midwest,New York, Pennsylvania, as wellas North Carolina andneighboring states. The programbegan at 9:15am and wrapped upa little after 5:00pm. The fee was$25.00 and covered all plenaryand breakout sessions, lunch,refreshments throughout the day,and handout materials.UNC faculty members ï¿½ and Dr. Lin Chang from UCLA ï¿½ providedoverviews and supporting materials on the following topics:ï¿½ Douglas Drossman, MD ï¿½ What is a Functional Disorderï¿½ Udi Ringel, MD ï¿½ IBS Diagnosis and Testsï¿½ Douglas Drossman, MD ï¿½ IBS Medications: EffectiveTreatments and New Optionsï¿½ William Whitehead, PhD ï¿½ Behavioral Treatments for IBSï¿½ Marjorie Busby, MPH ï¿½ IBS: Diet and Nutritionï¿½ Lin Chang, MD ï¿½ IBS and Genderï¿½ Udi Ringel, MD ï¿½ The Role of Brain Imaging in Understanding the Pain of IBSï¿½ Christine Dalton, PA ï¿½ Quality of Life in Gastrointestinal Disordersï¿½ Miranda Van Tilburg, PhD ï¿½ IBS and Abdominal Pain in ChildrenFaculty also provided demonstrations on effective treatment techniques:ï¿½ Charles Burnett, PhD, DrPH ï¿½ Cognitive-Behavioral Treatmentï¿½ Steve Heymen, MS ï¿½ Biofeedbackï¿½ Olafur Palsson, PsyD ï¿½ HypnosisFor question and answer interchange, several breakout sessions were led by faculty on the followingtopics:ï¿½ Diarrhea ï¿½ Albena Halpert, MD; Christine Dalton, PAï¿½ Nausea, Vomiting & Dyspepsia ï¿½ Douglas Morgan, MD; Udi Ringel, MDï¿½ Gas & Bloating ï¿½ Olafur Palsson, PsyD; William Whitehead, PhD; Syed Thiwan, MDï¿½ Abdominal Pain ï¿½ Douglas Drossman, MD; Charles Burnett, PhD, DrPHï¿½ Incontinence, Constipation & Rectal Pain ï¿½ Steve Heymen, MSDouglass DrossmanLin ChangWilliam WhiteheadGae CaudillMelanie Walker (volunteer)Kirsten NyropUNC Center for Functional GI & Motility Disorders Digest5Chat with the Expertsï¿½From HomeOn a quarterly basis throughoutthe year, the UNC Center forFunctional GI & MotilityDisorders hosts on on-line chatroom. The next one ï¿½Tuesday,November 9, 2004from 8 ï¿½ 10p.m. ESTEnter the chat roomfrom our Center website:www.med.unc.edu/ibsWe ask that all questions be related tothe topic under discussion for that day,rather than on personal medicalconditions. Check our website for topicsand guest experts or call(919) 966-0144.The School of Medicine of the University of North Carolinaand the UNC Center for Functional GI & Motility DisordersCME Training CourseHypnosis Treatment for Functional GIDisordersNovember 11-14, 2004William Charles Hamner Conference CenterNorth Carolina Biotechnology CenterResearch Triangle Park, North CarolinaThis course teaches health care practitioners to treat IBSand other GI disorders with hypnosis. November 11-12is ï¿½Part A: Basic Hypnosis Training Course.ï¿½ November13-14 is ï¿½Part B: Hypnosis for Functional GI Disorders.ï¿½Fee for the whole course is $545. Fee for Part B only is $285 (withproof of prior hypnosis training). For more information, contact theCourse Director, Olafur Palsson, PsyD, at opalsson###med.unc.edu.Participate in a Research StudyThe UNC Center for Functional GI & Motility Disorders has a number of research studies underwayfor which participants are always welcome and needed. For more detailed information regarding thefollowing studies, please see: http://www.med.unc.edu/medicine/fgidc/research_subjects.htm Research Studies Sponsored by the National Institutes of Health (NIH)Men and Women with IBS and Healthy Controls ï¿½ Lenore Keck (919/966-8329)Men and Women with Fecal Incontinence ï¿½ Steve Heymen (919/966-2515)Men and Women with Constipation ï¿½ Steve Heymen (919/966-2515)Research Studies Involving Mechanisms and OutcomesMen and Women with Bloating ï¿½ Jane Tucker (919/843-4906)Parents of Children Ages 3-14 with Recurrent Abdominal Pain ï¿½ Miranda Van Tilburg (919/843-0688)Men and Women with IBS ï¿½ Jane Hankins (919/966-0147)Research Studies Involving Drugs and TreatmentMen and Women with Functional Diarrhea or Diarrhea-Predominant IBS ï¿½ Alesia Aileo (919/843-4838)Men and Women with Chronic Constipation -- Kim Meyer (919/966-8328)Men and Women with IBS ï¿½ Kim Meyer (919/966-8328)Men and Women with Constipation Predominant IBS -- Kim Meyer (919/966-8328)Women with Diarrhea Predominant IBS ï¿½ Kim Meyer (919/966-8328)News, Events and AnnouncementsUNC Center for Functional GI & Motility Disorders DigestDrossman Receives 2004 AGA Distinguished Educator AwardOn May 17, 2004, Douglas A. Drossman, MD, received the 2004AGA Distinguished Educator Award. Established in 1988, thisaward recognizes an individual for achievements as anoutstanding educator over a lifelong career. Through this award,the American Gastroenterological Association (AGA)recognizes AGA members who have made outstandingcontributions as educators in gastroenterology on both the localand national levels, including longtime efforts dedicated totraining fellows, publishing educational documents, andteaching seminars and classes. The awards presentation tookplace during the Clinical Plenary Session of Digestive DiseasesWeek (DDW) at the Morial Convention Center in New Orleans,with additional recognition at the AGA Presidentï¿½s AwardsDinner.Dr. Drossman is Professor of Medicine and Psychiatry and Co-Director of the UNC Center forFunctional GI and Motility Disorders. His educational and clinical interests relate to thepsychosocial and behavioral aspects of patient care, for which he has produced numerous articlesand videos on aspects of medical care, medical interviewing, and the patient-doctor relationship.As a Charter fellow of the American Academy of Physician and Patient, Dr. Drossman facilitatesworkshops for health care professionals to develop their clinical skills in physician-patientcommunication.Dr. Drossmanï¿½s research interests relate to the clinical, epidemiological, psychosocial, andtreatment aspects of GI disorders, including psychosocial outcomes and the development andvalidation of several assessment measures for clinical research. He has published over 250 articlesand book chapters, two books, a GI procedures manual, and textbook on functional GI disorders.He serves on six editorial or advisory boards in gastroenterology, psychosomatic medicine,behavioral medicine, and patient health.Since 1989, Dr. Drossman has served as Chair of the Executive Committee for the Rome Foundation(Multinational Working Teams to Develop Diagnostic Criteria for Functional GI Disorders). He isalso on the Board of Directors of the International Foundation for Functional GI Disorders (IFFGD)and chairs its Scientific Advisory Board. Dr. Drossman is a fellow of both the American College ofPhysicians (ACP) and the American College of Gastroenterology (ACG). He chairs the Nerve-GutSection of the AGA Council, and is a founder and past chair of the AGAï¿½s Functional Brain-GutResearch Group (FBG). Dr. Drossman is past chair of the Functional GI Disorders campaign of theAmerican Digestive Health Foundationï¿½s Digestive Health Initiative, and past-president of theAmerican Psychosomatic Society.6 Awards and RecognitionDouglass DrossmanUNC Center for Functional GI & Motility Disorders DigestWhitehead Receives 2004 Janssen Award in GastroenterologyOn May 17, 2004, William E. Whitehead, Ph.D., received a 2004Janssen Award in Gastroenterology for ï¿½Basic or ClinicalResearch in Digestive Sciences.ï¿½ This honor is awarded on behalfof Janssen Pharmaceutica Inc. in cooperation with the AmericanGastroenterological Association (AGA). The recognition tookplace during the 10th Annual Master Awards Ceremony andReception at the Orpheum Theatre in New Orleans, as a majorevent of Digestive Diseases Week (DDW).Dr. Whitehead is Professor of Medicine and Co-Director of theUNC Center for Functional GI and Motility Disorders. Prior tocoming to UNC in 1993, Dr. Whitehead was at Johns HopkinsSchool of Medicine for 15 years, where he was chief of the GIPhysiology Laboratory at the Bayview Medical Center.Dr. Whitehead provides research training to postdoctoral fellows as well as clinical training in theconduct and interpretation of diagnostic gastrointestinal motility studies to GI and Urogynecology/Reconstructive Pelvic Surgery fellows. He has taught postgraduate workshops on GI motilityassessment, biofeedback, behavioral modification, and clinical trial design. Dr. Whiteheadï¿½s researchinterests are: (1) understanding the causes of visceral pain in patients with Irritable Bowel Syndrome(IBS), (2) treatment of fecal incontinence and constipation with biofeedback and related behavioraltechniques, and (3) validation of diagnostic criteria for functional GI disorders. He has approximately200 publications in this area.Dr. Whitehead is a member of the Executive Committee for of the Rome Foundation, for which hehas served as chair of the International Resource Committee. He was a co-editor of Rome II: TheFunctional Gastrointestinal Disorders ï¿½ Diagnosis, Pathology and Treatment, A Multinational Consensus.Dr. Whitehead was co-founder and second chairman of the AGAï¿½s Functional Brain-Gut ResearchGroup (FBG), and he has headed the steering committee and chaired two multidisciplinaryconferences on fecal incontinence sponsored by the International Foundation for FunctionalGastrointestinal Disorders (IFFGD).7 Awards and RecognitionWilliam WhiteheadUNC Center for Functional GI & Motility Disorders DigestDigestive Diseases Week (DDW)This yearï¿½s Digestive Diseases Week (DDW) was held May 16 through 19, 2004, at the Morial Convention Center in NewOrleans. DDW is the worldï¿½s largest gathering of clinicians, educators and researchers in gastroenterology and hepatology.More than 17,000 gastroenterologists assembled from throughout the United States and the world to participate in six days ofscientific and educational sessions, presented in various formats such as formal presentations, poster reviews, meet theprofessor and investigator luncheons, and an exhibit hall for products and services.The UNC Center for Functional GI & Motility Disorders was exceptionally well represented among speakers, session chairsand moderators, award recipients (see related Digest articles regarding awards presented to Dr. Douglas Drossman and Dr.William Whitehead), and poster presenters.Shin Fukudo, Jun Tayama, Yasuhiro Sagami, YukoShimada, Michiko Kano, Motoyori Kanazawa,Michio HongoRona Levy, William Whitehead, Lynn Walker,Andrew Feld, Michael Von Korff , DennisChristie, Michelle Garner, Catherine WhiteYehuda Ringel, Douglas Drossman, TaraDyson, Nicholas Shaheen, Carolyn Morris,Yuming Yu, Shrikant Bangdiwala, WilliamWhiteheadChristine Dalton, Nicholas Diamant, CarolynMorris, Albena Halpert, Brenda Toner,William Whitehead, Yuming Hu, JaneLeserman, Shrikant Bangdiwala, DouglasDrossmanDouglas Drossman, Carolyn Morris,Yuming Hu, Carlar Blackman, Brenda Toner,Nicholas Diamant, William Whitehead, JaneLeserman, Shrikant BangdiwalaDouglas Drossman Co-ChairDouglas Drossman Co-ModeratorNimish Vakil, Lin Chang, Sander Veldhuyzen vanZanten, William Whitehead, Jodie Sherman,Mike Fraser, Marielle Cohard-Radice, DavidEarnestDouglas Drossman, ChairWilliam Whitehead, Olafur Pallson, RonaLevy, Andrew Field, Michael Von Korff, MarshaTurnerWilliam Whitehead, Olafur Pallson, RonaLevy, Andrew Field, Michael Von Korff, MarshaTurner, Douglas DrossmanDouglas DrossmanYehuda Ringel Co-ChairDouglas DrossmanDouglas Drossman, ChairYolanda ScarlettEffect of Corticotropin-Releasing Hormone Receptor Antagonist on EEG Power Spectrain Patients with Irritable Bowel Syndrome[Topic Forum ï¿½ ï¿½Corticotropin Releasing Factor:Receptors, Cell Signaling and Modulation of Visceral Sensitivityï¿½]Impact of Learned Illness Behavior on Health Care Costs[AGA Research Forum ï¿½ï¿½Functional GI Disorders: Psychosocialï¿½]Characterization of Physiological and Psychological Factors in Functional EsophagealDisorders (FED)Are Side Effects of Tricyclic Antidepressants (TCAs) Really Side Effects[AGA ResearchForum ï¿½ ï¿½Functional GI Disorders: Psychosocialï¿½]What Factors Predict Improvement in Health Related Quality of Life (HRQOL) AfterTreatment of Functional Bowel Disorders (FBD)[AGA Research Forum ï¿½ ï¿½Functional GIDisorders: Psychosocialï¿½]AGA Distinguished Abstract Plenary SessionAGA Motility and Nerve-Gut Section Business MeetingPatient Comprehension & Awareness of Dyspepsia [New Developments in Dyspepsia ï¿½Patient Comprehension and Awareness of Dyspepsia]State of the Art Lectureï¿½Satisfactory Reliefï¿½ is an Unsatisfactory Method of Defining an Irritable Bowel Syndrome(IBS) Treatment Responder[ï¿½Psychosocial Factors in IBSï¿½]Psychological Symptoms do not Predict Improvement in Standard Medical Care forIrritable Bowel Syndrome (IBS)[ï¿½Psychosocial Factors in IBSï¿½]Secondary Endpoints in Clinical Trials of IBS Including Quality of Life [CME SolvayPharmaceuticals Inc. Satellite Symposium: ï¿½The Future of IBS Management in Men andWomenï¿½]Clinical Symposium: Functional Esophageal DisordersA Treatment Approach to IBS [DDW Meet-the-Professor Luncheon]Clinical Symposium ï¿½ Imaging of Functional GI Disorders: From Gut to Brain and BackClinical Symposium ï¿½ Evaluation and Management of Chronic ConstipationDigestive Diseases Week (DDW) 2004Presentations and Forums8UNC Center for Functional GI & Motility Disorders DigestPoster PresentationsMotoyori Kanazawa, Masatoshi Endo,Keiichiro Yamaguchi, Toyohiro Yamaguchi,William Whitehead, Masatoshi Itoh, ShinFukudoAlbena Halpert, Lenore Keck, DouglasDrossman, William WhiteheadWilliam Whitehead, Olafur Palsson, RonaLevy, Andrew Field, Michael Von Korff, MarshaTurner, Douglas Drossman, Michael CrowellDouglas Drossman, Carolyn Morris,Yuming Hu, Carlar Blackman, Brenda Toner,Nicholas Diamant, William Whitehead, JaneLeserman, Shrikant BandiwalaAlbena Halpert, Carolyn Morris, BrendaToner, Nicholas Diamant, William Drossman,Yuming Hu, Jane Leserman, ShrikantBangdiwala, Douglas DrossmanAlbena Halpert, Carolyn Morris, BrendaToner, Nicholas Diamant, William Whitehead,Yuming Hu, Jane Leserman, ShrikantBangdiwala, Douglas DrossmanSteve Heymen, Yolanda Scarlett, WilliamWhiteheadSteve Heymen, Yolanda Scarlett, WilliamWhiteheadSteve Heymen, Yolanda Scarlett, WilliamWhiteheadSteve Heymen, Yoland Scarlett, WilliamWhiteheadWilliam Whitehead, Olafur Palsson, RonaLevy, Andrew Field, Michael Von Korff, MichaelShetzline, Marsha Turner, DouglasDrossmanYehuda Ringel, William Whitehead, NicholasDiamant, Carolyn Morris, Yuming Yu, BrendaToner, Shrikant Bangdiwala, DouglasDrossmanOlafur S. Palsson, William Whitehead,Victoria Barhout, Marsha TurnerOlafur Palsson, William Whitehead, RonaLevy, Andrew Field, Michael Von Korff, EslieDennis, Victoria Barhout, Marsha TurnerRona Levy, Robert Jeffrey, Jennifer Linde,Catherine White, Michelle Garner, Kayla Feld,William WhiteheadRona Levy, Robert Jeffrey, Jennifer Linde,Catherine White, Michelle Garner, Kayla Feld,William WhiteheadClassical Conditioned Response of Rectosigmoid Motility and Regional Cerebral Activityin Humans[Small Bowel and Colonic Motility]Rectal Contractions are Part of Normal Defecation [Anorectal Motility and Disorders]Identification of Irritable Bowel (IBS) Patients with Alternating Bowel Habits[FunctionalGI Disorders ï¿½ Symptoms, Diagnosis and Epidemiology]What Factors Explain Health Related Quality of Life (HRQOL) in Functional BowelDisorders [Functional GI Disorders/Psychological]The Relationship Between Illness Related Attitudes and Beliefs and Clinical Outcome inFunctional Bowel Disorders (FBD) [Functional GI Disorders/Psychological]Factors Predicting Illness Related Attitudes and Beliefs. Validation of the GI-IMIQ inFunctional Bowel Disorders (FBD) [Functional GI Disorders/Psychological]Severity of Constipation and Anxiety Predict Failure to Improve with Conservative MedicalTreatment for Constipation [Functional GI Disorders/Psychological]Education and Medical Management Resolve Fecal Incontinence in 35%, but Depressionand Greater Symptom Severity Predict a Poor Response [Functional GI Disorders/Psychological]Constipated Subjects Reporting Physical Abuse Are More Likely to Fail an Education/Medical Management Intervention [Functional GI Disorders/Psychological]Anorectal Physiology Predicts Response to Conservative Medical Management of FecalIncontinence[Functional GI Disorders/Psychological]Types of Medications Used for Irritable Bowel Syndrome (IBS): Outcomes, PatientSatisfaction and Side Effects [Pharmacotherapeutics in Functional GI Disorders]Physiological and Psychosocial Effects of Desipramine (DES) Treatment Response inFunctional Bowel Disorders [Pharmacotherapeutics in Functional GI Disorders]Medical Diagnoses in Functional Dyspepsia Patients [Outcomes Research]Constipation is Often Undiagnosed or Misdiagnosed in Outpatient Clinics: Diagnosis ofConstipation is Associated with Better Outcomes [Outcomes Research]Association Between Body Mass Index (BMI) and GI Symptoms and BMI and IBS in ObesePatientsAssociation Between Dieting Practices and GI Symptoms and IBS Among Participants ina Weight Loss programDigestive Diseases Week (DDW) 2004 9UNC Center for Functional GI & Motility Disorders DigestEffect of Corticotropin-Releasing Hormone Receptor Antagonist on EEG Power Spectra in Patients with Irritable BowelSyndromeShin Fukudo, Jun Tayama, Yasuhiro Sagami, Yuko Shimada, Michiko Kano, Motoyori Kanazawa, Michio HongoBackground and Aims: Irritable bowel syndrome (IBS) is believed to be associated with a higher tone of corticotropinreleasinghormone (CRH) in the brain. Our research team previously reported that patients with IBS have abnormal distributionof power spectra on electroencephalograms (EEG). We tested our hypothesis that peripheral administration of CRH antagonistalpha-helical CRH improves abnormal distribution of the power spectra of the EEG in IBS patients.Methods: Ten normal controls and ten IBS patients were enrolled in the study. A barostat bag was inserted into the descendingcolon. EEGs were measured during the baseline period and the colonic distention period through the administration of saline.The same procedure was repeated after the administration of ten microg/Kg of alpha-helical CRH. EEGs were analyzed withpower spectra and topography.Results: IBS patients showed a significantly lower alpha power than controls during the baseline period. IBS patients also hada significantly higher beta power than controls during the baseline period. Colonic distention induced a significant decreasein the alpha power and a significant increase in the beta power in both groups. After the administration of alpha-helical CRH,changes in the EEG power spectra in response to colonic distention were blunted and differences in the EEG power spectraand topogram between IBS patients and controls vanished.Conclusions: Our data strongly suggest that CRH plays an important role in the pathophysiology of IBS and electrophysiologicalproperty of the brain during visceral perception.Fukudo, S., Tayama, J., Sagami, Y., Shimada, Y., Kano, M., Kanazawa, M., Hongo, M., Effect of corticotropin-releasing hormone receptorantagonist on EEG power spectra in patients with Irritable Bowel Syndrome, GASTROENTEROL, 126 (4), SUPPL. 2: A-5, 2004.Characterization of Physiological and Psychological Factors in Functional Esophageal Disorders (FED)Yehuda Ringel, Douglas A. Drossman, Tara Dyson, Nicholas J. Shaheen, Carolyn B. Morris, Yuming Hu, Shrikant Bangdiwala,William E. WhiteheadBackground: Little is known about the effects of physiological and psychological factors in functional esophageal disorders.Aim: (1) To characterize physiological and psychological factors in patients with functional esophageal disorders as comparedto healthy controls. (2) To investigate the association between psychological factors and esophageal physiologic function.Methods: We studied 16 patients who met Rome II criteria for functional esophageal disorders (12 heartburn, 7 chest pain, 6dysphagia) and 18 healthy volunteers with no esophageal complaints. Physiologic assessment included esophageal sensationthresholds by tracking technique, and muscle tone using an electronic barostat (Synectics Medtronics). Psychological assessmentincluded the SCL-90 Global Severity Index (SCL90-GSI), anxiety (SCL-90ANX) and depression (SCL-90-DEP), Sickness ImpactProfile Overall (SIP-O), and the Physical (SIP- PHY), and Psychosocial (SIP-PSY) components of SIP.Results: (1) Compared to healthy controls, patients with functional esophageal disorders had lower pain sensation thresholds,higher muscle tone, higher psychological distress, and poorer daily function. (2) Marked correlations were found betweenlower esophageal sensation thresholds and psychological variables. (3) Greater esophageal muscle tone was associated withhigher anxiety scores.Conclusions: Our study provides physiological and psychosocial characterization of patients with functional esophagealdisorders and evidence for the association between psychological factors (stress and anxiety) and esophageal physiology(muscle tone and sensation thresholds).Ringel,Y., Drossman,D.A., Dyson,T., Shaheen,N.J., Morris,C.B., Hu,Y., Bangdiwala,S.I., Whitehead,W.E. Characterization of physiologicaland psychological factors in functional esophageal disorders (FED), GASTROENTEROL, 126 (4), SUPPL. 2: A-28, 2004.Are Side Effects of Tricyclic Antidepressants (TCAs) Really Side Effects?Christine Dalton, Nicholas E. Diamant, Carolyn B. Morris, Albena Halpert, Brenda B. Toner, William E. Whitehead, Yuming Hu,Jane Leserman, Shrikant Bangdiwala, Douglas A. DrossmanBackground: Tricyclic antidepressants (TCAs) have been shown to be effective in treating IBS and other functional GI disorders.Since patients with IBS may experience non-GI symptoms, the question arises as to whether side effects reported afteradministering TCAs are true side effects or relate to a general tendency to report symptoms.Aim: To determine which, if any, side effects reported by subjects taking a TCA, desipramine (DES), were also reported priorto beginning dosing.Methods: Females in the desipramine arm of a multi-center NIH treatment trial completed a symptom questionnaire (SxQ)which asked if they were currently experiencing any of 15 symptoms. Thirteen of the 15 symptoms were items frequentlyreported as side effects of TCAs. The SxQ was completed by study subjects prior to randomization (Week 0) and after twoweeks on desipramine (Week 2). DES was prescribed as 50mg qhs for Week 1 and 100mg qhs for Week 2. If side effects wereabove moderate intensity, the dose remained at 50 mg.Results: Of the 95 subjects in the desipramine arm of the treatment trial, 57 subjects (60%) completed the SxQ at both Week 0Digestive Diseases Week (DDW) 2004continued on next pageDDW Presentation Abstracts10UNC Center for Functional GI & Motility Disorders Digestand Week 2. This group then comprised the population sample for our study. We found four symptoms reported during treatment(Week 2) were also commonly reported as side effects at Week 0 (before treatment) ï¿½ tired in the morning, nausea, blurredvision, and trouble sleeping. However, other symptoms ï¿½ flushing, jittery, dry mouth, rash and slurred speech ï¿½ were reportedmore during treatment (Week 2) than before treatment (Week 0).Conclusions: Several symptoms often reported as side effects of desipramine were also reported prior to dosing ï¿½ tired,nausea, blurred vision and trouble sleeping. On the other hand, other symptoms ï¿½ flushing, jittery, dry mouth, rash and slurredspeech ï¿½ appear to be true side effects of the drug. These results suggest that, when considering modifying desipraminedosage due to side effects, clinicians should be aware of pre-existing symptoms already present in IBS patients prior to treatment.Supported by NIH RO1 DK 49334.Dalton,C.B., Diamant,N.E., Morris,C.B., Halpert,A., Toner,B.B., Whitehead,W.E., Hu,Y., Leserman, J.L., Bangdiwala,S.I., Drossman,D.A.Are side effects of tricyclic antidepressants (TCAs) really side effects? GASTROENTEROL, 126 (4), SUPPL. 2: A-28, 2004.What Factors Predict Improvement in Health Related Quality of Life (HRQOL) after Treatment of Functional BowelDisorders (FBD)Douglas A. Drossman, Carolyn B. Morris, Yuming Hu, Carlar Blackman, Brenda B. Toner, Nicholas E. Diamant, William E.Whitehead, Jane Leserman, Shrikant BangdiwalaAim. To identify the clinical and psychosocial predictors of improvement in health related quality of life (HRQOL) in femaleswith functional bowel disorders (FBD) in a trial of desipramine (DES) vs. placebo and cognitive behavioral therapy (CBT) vs.education.Methods. Two analyses were done for medical intervention (MED which was DES vs. placebo) and psychological intervention(PSCH which was CBT vs. education). For each analysis, two HRQOL measures were studied: IBS-QOL (condition-specific) andSickness Impact Profile-SIP (generic-daily function). Multiple linear regressions predicted post minus pre-treatment changescores of HRQOL.Results: For the Medical Intervention Group (MED), improvement in HRQOL was explained: (a) for both IBS-QOL and SIP, byimprovement in psychological distress (SCL-90 GSI) and depression (BDI-II) scores and reduction in perceived severity/constancy of symptoms (IMIQ); (







for IBS-QOL alone, by treatment with desipramine, reduced abdominal pain, no diagnosisof psychiatric disorder (DSM-IV), a perceived increased ability to control symptoms (CSQ-control), and an increase in socialsupport satisfaction (SSQ-6), and © for SIP, younger age. For the psychological intervention group (PSCH), improvement inHRQOL was explained: (a) for both IBS-QOL and SIP, by reduced psychological distress (SCL-90 GSI) and reduced depression(BDI-II), and (







for IBS-QOL alone, by being Caucasian, having less stool frequency change, increased control over the illness(IMIQ), increased ability to decrease symptoms (CSQ-decrease), and reduced catastrophizing (CSQ-catastrophizing). Thefour final models strongly predicted improvement in HRQOL.Conclusions: For MED and PSYCH, improvement in HRQOL (IBS-QOL and SIP) is explained primarily by improved psychosocialstate and coping, more than improved symptoms or visceral sensitivity. For MED alone, improvement in IBS-QOL is also explainedby desipramine treatment and reduced pain. Supported by NIH RO1 DK 49334.Drossman,D.A., Morris,C.B., Hu,Y., Blackman,C., Toner,B.B., Diamant,N.E., Whitehead,W.E., Leserman, J.E., Bangdiwala,S.I. What factorspredict improvement in health related quality of life (HRQOL) after treatment of functional bowel disorders (FBD). GASTROENTEROL,126 (4), SUPPL. 2: A-29, 2004.Patient Comprehension and Awareness of DyspepsiaNimish B. Vakil, Lin Chang, Sander J. O. Veldhuyzen van Zanten, William E. Whitehead, Jodie Sherman, Mike Fraser, Marielle Cohard-Radice, David L. EarnestBackground: Dyspepsia is a common disorder, with U.S. prevalence rates ranging between 18-30% of the population. However,recruiting dyspeptic patients for clinical trials has been difficult. This may be due to the lack of physician and patient awarenessof the disorder as well as the overlap of symptoms with other gastrointestinal disorders.Aim: The aim of this study was to determine patient comprehension of symptoms related to dyspepsia.Methods: Patients diagnosed with dyspepsia were referred by gastroenterologists or recruited through advertising using thefollowing symptoms consistent with dyspepsia ï¿½ upper abdominal discomfort/pain, bloating, early satiety, post-prandial fullnessand nausea. Those who agreed to participate in our study did a questionnaire interview, which assessed the diagnosis,characteristics and bothersomeness of their gastrointestinal symptoms and the patientï¿½s understanding of their disorder. Asubset of patients was identified as suffering solely from dyspeptic symptoms without concomitant symptoms of othergastrointestinal disorders, such as GERD or IBS (pure dyspepsia).Results: 70% of the study subjects were not familiar with the term dyspepsia. 43% had predominant heartburn or other GERDrelated symptoms. 17% had a concomitant diagnosis of IBS. 30% had a variety of other gastrointestinal disorders. 10% qualifiedas having pure dyspeptic symptoms; their predominant symptoms included bloating (89%), upper abdominal discomfort/pain (89%), nausea (63%), and fullness (63%). Most patients were not familiar with the terms ï¿½early satietyï¿½ or ï¿½post-prandialDigestive Diseases Week (DDW) 2004DDW Presentation Abstracts, cont.continued on next page11UNC Center for Functional GI & Motility Disorders DigestDigestive Diseases Week (DDW) 2004DDW Presentation Abstracts, cont.fullness.ï¿½ Instead, they recognized these symptoms as early fullness while eating and excessive post-meal fullness.Conclusion: Dyspepsia is not a term familiar to patients diagnosed with the disorder. Dyspepsia occurs most commonly as apoly-symptom complex which overlaps with other gastrointestinal disorders. Only 10% of the patients in our study reporteddyspepsia without concomitant GERD and IBS symptoms. These results suggest that clinical trials evaluating a pure dyspepsiapopulation will require extensive screening and improved physician-patient disorder awareness and communication programs.Vakil, N.B., Chang, L., Van Zanten, S.J.O., Whitehead, W.E.., Sherman, J., Fraser, M., Cohard-Radice, M., Earnest, D.L., Patientcomprehension and awareness of dyspepsia, GASTROENTEROL, 126 (4), SUPPL. 2: A-70, 2004.ï¿½Satisfactory Reliefï¿½ is an Unsatisfactory Method of Defining an Irritable Bowel Syndrome (IBS) Treatment ResponderWilliam E. Whitehead, Olafur S. Palsson, Rona L. Levy, Andrew D. Feld, Michael Von Korff, Marsha J. TurnerBackground: Clinical trials evaluating investigational drugs for IBS often use satisfactory relief as the primary end-point.Aims: (1) Compare a binary satisfactory relief measure to a 7-point rating of improvement, an IBS symptom severity questionnaire(IBSS), and a disease specific quality of life scale (IBS-QOL). (2) Determine whether initial IBS symptom severity influences thesensitivity of these outcome measures.Methods: Prospectively-identified patients at a health maintenance organization who had a medical diagnoses of IBS, abdominalpain, constipation, or diarrhea were sent questionnaires. Those who returned the 1st survey were mailed a 2nd survey 6 monthslater. Type of treatment was chosen by the physician and varied among patients. Analysis was limited to patients meetingRome II criteria for IBS. At follow-up, patients were asked: ï¿½In the past 7 days, have you had satisfactory relief of your bowelsymptoms?ï¿½ They were also asked to rate their improvement on a 7-point scale from ï¿½markedly betterï¿½ to ï¿½markedly worseï¿½,and they completed the IBSS and IBS-QOL at enrollment and follow-up. A responder was defined in 3 ways: (1) ï¿½yesï¿½ responseto satisfactory relief or absence of bowel symptoms; (2) ï¿½somewhatï¿½ or ï¿½markedly betterï¿½ on the rating scale; or (3) at least50% reduction on the IBSS. The IBSS was also used to classify patients as mild, moderate and severe at enrollment.Results: (1) Initially mild patients report the least improvement after 6 months whereas initially severe patients report thegreatest improvement. (2) Using a 50% reduction in symptom severity to define a responder was least confounded by initialsymptom severity.Conclusion: Satisfactory relief is a poor outcome measure, because severe patients are the least likely to report satisfactoryrelief at follow-up despite showing the greatest improvement in symptoms. Supported by NIH RO1 DK 31369.Whitehead, W.E., Palsson, O.S., Levy, R.L., Feld, A.D., Von Korff, M., Turner, M.J., ï¿½Satisfactory Reliefï¿½ is an unsatisfactory method ofdefining an Irritable Bowel Syndrome (IBS) treatment responder, GASTROENTEROL, 126 (4), SUPPL. 2: A-88, 2004.Psychological Symptoms do not Predict Symptom Improvement in Standard Medical Care for Irritable Bowel Syndrome(IBS)William E. Whitehead, Olafur S. Palsson, Rona L. Levy, Andrew D. Feld, Michael Von Korff, Marsha J. Turner, Douglas A. DrossmanBackground: It is not known whether psychological symptoms predict a poor response to standard medical care in patientswith IBS.Aim: To assess the relationship between psychological symptoms and IBS symptom improvement in patients receiving standardmedical care.Methods: Prospectively identified patients visiting primary care (PC) physicians and gastroenterologists in a health maintenanceorganization, with medical diagnoses of IBS, abdominal pain, constipation, or diarrhea, were sent questionnaires. Respondentsto the 1st survey were mailed a 2nd survey 6 months later. Questionnaires included the Brief Symptom Inventory (BSI ï¿½ measuringanxiety, depression, and somatization), Recent Physical Symptoms Questionnaire (RPSQ), IBS Severity Index (IBSS), and IBSQOL.Treatment was chosen by the physician and varied among patients, the most common of which were change in diet(62%), exercise (52%), lifestyle change to reduce stress (42%), antidiarrheals (28%), antispasmodics (26%), and laxatives(24%).Results: Analysis was limited to patients meeting Rome II criteria for IBS. At initial evaluation, psychological symptoms ï¿½especially somatization and anxiety ï¿½ accounted for 12-15% of variance in severity and 15% of variance in IBS-QOL.Psychological symptoms at entry showed negligible correlations with change in symptoms or improvement in quality of lifeduring 6 months of medical care.Conclusion: Psychological status at baseline is associated with IBS severity at baseline, but it does not predict how muchpatients improve with usual medical care. Supported by Novartis Pharmaceuticals Corporation and NIH RO1 DK 31369.Whitehead,W.E., Palsson,O.S., Levy,R.L., Feld,A.D., Von Korff,M., Turner,M.J., Drossman,D.A. Psychological symptoms do not predictsymptom improvement from usual medical care in irritable bowel syndrome (IBS). GASTROENTEROL, 126 (4), SUPPL. 2: A-88, 2004.12UNC Center for Functional GI & Motility Disorders DigestDigestive Diseases Week (DDW) 2004continued on next pageClassical Conditioned Response of Rectosigmoid Motility and Regional Cerebral Activity in HumanMotoyori Kanazawa, Masatoshi Endo, Keiichiro Yamaguchi, Toyohiro Hamaguchi, William E. Whitehead, Masatoshi Itoh, ShinFukudoBackground: Classical conditioning is considered to be a model for understanding anticipatory responses to aversive events,which is an essential aspect of how the brain-gut interaction develops in functional gastrointestinal disorders. The relationshipbetween the central processes of conditioning and conditioned responses of the gastrointestinal function is not completelyunderstood in humans. Our research team tested the hypothesis that rectosigmoid motility is conditioned with anticipatorypainful somatosensory stimulus concomitant with brain activation.Methods: In nine right-handed healthy male subjects, a loud buzzer (the conditioned stimulus, CS) was paired with painfultranscutaneous electrical nerve stimulation to the back of the left hand (the unconditioned stimulus, US). Rectosigmoid muscletone, phasic contractions of the bowel, and regional cerebral blood flow were measured before and after conditioning.Results: Following conditioning trials, the bag volume in the CS alone session did not show significant changes betweenbefore and after two-minute intervals of the stimulus, but the number of phasic contractions of the bowels after two-minuteintervals of the CS alone was significantly greater than before the stimulus. There were no significant changes in the bagvolume or the number of phasic contractions in CS alone prior to conditioning. Regional cerebral blood flow data comparedbetween CS alone sessions before and after conditioning showed that anticipation elicited significant activation of the prefrontal,anterior cingulate, parietal cortices, insula, pons, and cerebellum.Conclusions: Phasic contractions in the rectosigmoid colon were induced by anticipatory but undelivere


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