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• W2619205533 abstract "Abdalla MI, Sandler RS, Kappelman MD, et al. Prevalence and Impact of Inflammatory Bowel Disease–Irritable Bowel Syndrome on Patient-reported Outcomes in CCFA Partners. Inflamm Bowel Dis 2017;23:325-331. Irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD) are traditionally considered distinct chronic disorders affecting the gastrointestinal (GI) tract. The etiology of each is uncertain, but alterations in the intestinal microbiome, disordered intestinal immunity, and increased intestinal permeability are common to both. Activation of the brain–gut axis is central to the propagation and perception of symptoms in IBS, yet its role in IBD remains less certain. A bidirectional association between the onset of GI symptoms and psychological comorbidity in IBS has led to the development of a biopsychosocial model of management in IBS being advocated by some. “Functional” GI symptoms, akin to those observed in patients with IBS, affect as many as 35% of patients with IBD in clinical remission (Am J Gastroenterol 2012;107:1474-1482), suggesting that such an approach to the management of a subgroup of IBD patients may also be worthwhile. This study examined the prevalence and impact of IBS symptoms in a large cohort of IBD patients taken from the Crohn's and Colitis Foundation of America Partners cohort, which is a longitudinal, internet-based cohort of adult patients with IBD that has been in existence since 2011. Participants completed questionnaires at baseline and at 6-monthly intervals during longitudinal follow-up. Questionnaire data included demographics, disease-specific and patient-reported outcome measures regarding psychological well-being and social satisfaction. To identify IBD patients with coexistent IBS (IBD-IBS), patients were asked “After you were diagnosed with IBD, has your doctor ever told you that you had IBS?” Only patients who completed this question were included. Health care use was also assessed, with high use defined as ≥5 visits to the primary care or GI physician in the previous year. A bivariate analysis was conducted to evaluate associations between IBD-IBS and the various demographic and disease-related variables, and logistic regression analysis was conducted to assess for independent associations after adjusting for all other data. The investigators analyzed data from 6309 participants (3947 Crohn disease [CD] and 2362 ulcerative colitis [UC]/IBD-unclassified [IBD-U]). Overall, 1279 participants (20.3%) reported a previous diagnosis of IBS with a similar prevalence in CD and UC/IBD-U (20.0% vs 20.7%; P = .49). In both CD and UC/IBD-U, the proportion of patients who met the criteria for active disease was significantly higher in the IBD-IBS group (48.9% vs 34.8% in CD and 63.7% vs 48.3% in UC/IBD-U). After logistic regression, IBD-IBS was associated with greater health care use (odds ratio for attending primary care, 1.76 [95% CI, 1.45-2.14]; odds ratio for attending GI, 1.36 [95% CI, 1.13-1.64]). After logistic regression, IBD-IBS was a significant independent factor associated with anxiety, depression, fatigue, pain, disturbed sleep, and decreased social satisfaction. These associations remained significant when only those with clinically quiescent disease were included. The authors concluded that appropriate diagnosis, treatment, and counseling may help to improve the functional status of IBD-IBS patients. The results of the study by Abdalla et al support those of previous investigators. Here, the prevalence of IBS-type symptoms was higher than has been demonstrated in the general population (Am J Gastroenterol 2012;107:991-1000), and the presence of IBD-IBS was associated with psychological comorbidity and reduced health-related quality of life. Several studies have reported data on the prevalence of IBS-type symptoms in patients with IBD. Most notably, a systematic review and meta-analysis of observational studies investigated this issue and reported an overall pooled prevalence of 39%, with that figure dropping to 35% in IBD patients in clinical remission (Am J Gastroenterol 2012;107:1474-1482). However, the majority of studies included in this meta-analysis did not use any objective measure of intestinal inflammation as part of their disease activity assessment, thus raising doubt about the robustness of the diagnosis of apparent coexistent IBS, as is the case in the present study. In studies that used an objective assessment to exclude ongoing intestinal inflammation, such as endoscopy or fecal biomarkers of inflammation, the prevalence of such IBS-type symptoms has generally been lower, between 8% to 28% (Inflamm Bowel Dis 2016;22:2630-2640; Clin Gastroenterol Hepatol 2017;15:376-384), but with a higher prevalence in patients with CD, when compared with UC, consistently reported. As a result, although the authors of the present study suggest that IBD-IBS is associated with psychological comorbidity, it is uncertain whether these associations are based on the presence of genuine coexistent IBS, or whether inflammatory disease activity may also have contributed to these findings. In fact, the presence of either ongoing active mucosal inflammation, or genuine IBS-type symptoms in the absence of objectively quantified mucosal inflammation in patients with IBD, have both been shown to be independently associated with psychological comorbidity, including depression, anxiety, somatization, and poor quality of life, when compared with asymptomatic patients without evidence of mucosal inflammation (Inflamm Bowel Dis 2016;22:2630-2640; Clin Gastroenterol Hepatol 2017;15:376-384). Although the findings from Abdalla et al are of interest and strengths of the study, including the large sample size and the presentation of data on the association between IBD-IBS and health care use should be acknowledged, there are important limitations that question the validity of the data presented. First, the diagnosis of IBS used in this study relies on patient recall of a prior diagnosis of IBS, introducing unavoidable bias, which may account for the relatively low prevalence of IBD-IBS seen in this cohort, when compared with previously published data. Second, the incidence rate of new IBD diagnoses being made in patients with an existing diagnosis of IBS is >5-fold that of the general population (PLoS One 2014;9:e106478), suggesting that physicians may mistake symptoms of IBD presenting for the first time with IBS, and thus confounding the study findings further. Third, a primary care physician’s diagnosis of IBS, which was indirectly used to define IBD-IBS in this cohort, is often not based on validated diagnostic criteria (Eur J Gastroenterol Hepatol 2017 doi: 10.1097), thereby reducing the reliability of the authors' use of this to define IBS. These limitations, in conjunction with the absence of any objective assessment of intestinal inflammation, are major flaws in the methodology, and limit the validity of assertions made on the basis of these findings. Rather than defining patients as having IBD-IBS, it may be more appropriate to classify these patients as having symptomatic IBD, regardless of whether these symptoms meet criteria for IBS, as has been suggested previously (Inflamm Bowel Dis 2017;23:E4-E5). It is also important to highlight the lack of relationship between symptom reporting by patients and ongoing mucosal inflammation; the presence of active disease defined using clinical disease activity indices is independently associated with Rome III-diagnosed IBS, but not an abnormal fecal calprotectin (Am J Gastroenterol 2016;111:541-551). In addition, inflammatory disease activity has been identified as an independent risk factor for the development of depression in patients with IBD (Aliment Pharmacol Ther 2014;39:802-810), and failure to account for this undermines the authors' assertions that it is IBD-IBS, rather than symptom reporting per se, that is driving the observed association with psychological comorbidity. In conclusion, this study highlights that IBS-type symptoms affect as many as 1 in 5 patients with IBD. These findings suggest that psychological comorbidity is associated with ongoing symptoms in patients with IBD, and that these patients are greater users of health care resources. However, the relationship between symptom reporting and mucosal inflammation in IBD is complex. The differentiation of symptoms attributable to mucosal inflammation from those occurring secondary to genuine coexistent IBS is of paramount importance before any association between the presence of these symptoms and disease outcomes can be made. There is a growing body of evidence to support the existence of a cohort of IBD patients with persistent symptoms in the absence of objectively quantified mucosal inflammation and, with the increased use of noninvasive biomarkers of intestinal inflammation, such as fecal calprotectin, it is likely that this group of hitherto poorly characterized patients will become more apparent. Whether these patients suffer from genuine IBS or not is uncertain, but the presence of GI symptoms in the absence of mucosal inflammation seems to be associated with psychological comorbidity and a reduced quality of life, regardless of whether these symptoms meet criteria for IBS. Effective management strategies for this difficult-to-treat group of patients are required, but detailed characterization of the relationship between mucosal inflammation and symptom reporting should be mandated before inclusion of such patients into future clinical trials." @default.
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• W2619205533 title "Irritable Bowel Syndrome-Type Symptoms Are Associated With Psychological Comorbidity, Reduced Quality of Life, and Health Care Use in Patients With Inflammatory Bowel Disease" @default.
• W2619205533 doi "https://doi.org/10.1053/j.gastro.2017.05.037" @default.
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