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Notes from Virtual American College Gastroenterology Meeting Oct 23-28, 2020


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Jeffrey Roberts

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October 23, 2020

Utilization of Dietitians in the Management of Irritable Bowel Syndrome by Members of the American College of Gastroenterology

Kate Scarlata, MPH, RD, William D. Chey, MD, FACG, Shanti Eswaran, MD;

This survey of the ACG membership identified a number of gaps in the care of IBS patients. A significant minority of GI providers do not have adequate training, education materials, or time to optimally administer the LFD in IBS patients.Though GI providers strongly feel that a GI dietitian can improve IBS outcomes, increase patient satisfaction, and save time, more than 40% don’t have access to a local GI dietitian. Efforts to provide high quality nutrition training for gastroenterologists and dietitians are needed. High quality education materials on the LFD for IBS patients appear to be another unmet need.

https://www.eventscribe.com/2020/ACG/fsPopup.asp?Mode=posterinfo&PosterID=298900

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Jeffrey Roberts

Randomized, Comparative Effectiveness Trial of Green Kiwifruit, Psyllium, or Prunes in U.S. Patients with Chronic Constipation
Samuel W. Chey, MPH, University of Michigan Health System

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>> View full article: https://www.healio.com/news/gastroenterology/20201027/kiwi-fruit-effective-well-tolerated-in-treating-chronic-constipation

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Jeffrey Roberts

A Novel Method to Classify and Subgroup Patients With IBS Based on Gastrointestinal Symptoms and Psychological Profiles

Black, Christopher J. MBBS (Hons); Yiannakou, Yan MD; Guthrie, Elspeth A. PhD; West, Robert DPhil; Houghton, Lesley A. PhD; Ford, Alexander C. MD

Abstract

INTRODUCTION: 

Conventionally, patients with irritable bowel syndrome (IBS) are subgrouped based on their predominant bowel habit. Given the relevance of psychological comorbidity to IBS symptoms, our aim was to explore an alternative approach to subgrouping by incorporating factors beyond stool form and frequency.

METHODS: 

We collected demographic, symptom, and psychological health data from 1,375 adult subjects in the community who self-identified as having IBS, identifying 2 cohorts meeting either Rome III or Rome IV criteria. In each cohort, we performed latent class analysis, a method of model-based clustering, to identify specific subgroups (clusters). For each cluster, we drew a radar plot and compared these by visual inspection, describing cluster characteristics.

RESULTS: 

In total, 1,080 individuals met the Rome III criteria for IBS, and 811 met the Rome IV criteria. In both cohorts, a 7-cluster model was the optimum solution, and the characteristics of the clusters were almost identical between Rome III and IV. Four clusters were defined by the pattern of gastrointestinal symptoms (loose stools and urgency or hard stools and bloating), further differentiated by the presence of abdominal pain not relieved by defecation, and by the extent of psychological comorbidity. Two clusters had below-average gastrointestinal symptoms, differentiated by the extent of psychological comorbidity. The final cluster had well-above-average gastrointestinal symptoms and high levels of psychological comorbidity. The proportion of subjects with severe IBS symptom scores, high levels of perceived stress, and high levels of gastrointestinal symptom–specific anxiety was significantly higher in clusters with high psychological comorbidity (P < 0.001).

DISCUSSION: 

Latent class analysis identified 7 distinct IBS subgroups characterized by varying degrees of gastrointestinal symptoms, extraintestinal symptoms, and psychological comorbidity. Further research is needed to assess whether they might be used to direct treatment.

>> View full paper: https://journals.lww.com/ajg/Abstract/9000/A_Novel_Method_to_Classify_and_Subgroup_Patients.99045.aspx

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Jeffrey Roberts

The Benefits of Time Spent in Nature on Symptoms and Quality of Life Among Patients With IBS

Katherine Duffey, MD1, Sara Chapin, BS2, Linda Yan, MD1, Stephanie Moleski, MD1;  1Thomas Jefferson University Hospital, Philadelphia, PA; 2Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA

Introduction: Irritable bowel syndrome (IBS) can have significant impact on quality of life and physical and mental health. Time spent in nature has been shown to improve psychosocial well-being. Physical activity and exposure to vitamin D have been shown to positively impact IBS patient symptoms, but there is limited data about the impact of nature on reported symptoms. We aim to better understand the relationship between exposure to nature and IBS symptoms among an urban and suburban patient population.

Methods: Patients with IBS and who follow with our tertiary care hospital’s gastroenterology department were contacted via email for participation in an online survey to assess details of their diagnosis, severity of symptoms, and time spent in nature. The IBS-Symptom Severity System (IBS-SSS) and Bristol Stool Scale were used to assess symptoms and stool type. Simple statistics and chi-squared analyses were used to assess the significance of the symptom variations and relationship to nature exposure.

Results: Of the 1,532 patients who were emailed a link to the survey, 421 patients participated (28%). A total of 293 patients completed the survey in full and were included in our analysis. The majority of patients were female (222, 76%), and Caucasian (252, 86%). The most common age ranges were 25-34 (23%) and 55-64 (22%). Based on IBS-SSS scores, 39% of patients had moderate disease, 22% had severe disease. IBS-Mixed was the most common diagnosis (139 patients, 43%), and those patients had significantly higher IBS-SSS than those with IBS-Constipation (225 vs 187, p=0.034). The majority of patients (66%) reported being in nature 2 or less times over the last 7 days. Patients who were in nature at least 5 times in 7 days reported significantly less symptom interference with life in general compared to those with no exposure (p=0.023). There is a trend towards improved IBS-SSS scores with increasing total time spent in nature, with patients spending more than 150 minutes weekly having significantly better scores than those who spend less than 30 minutes weekly (p=0.008).

Discussion: Among an urban patient population, patients with all subtypes of IBS have a significant symptom burden. Few patients report spending significant time in nature, but for those who do, symptom severity scores indicate improved symptoms compared to patients without the same exposure. In this pilot study, frequency of exposure to, and the total time spent in nature were associated with significantly better self-reported symptoms.

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Jeffrey Roberts

Impact of Chronic Constipation on Economic Status and Work Productivity: A Prospective Case-Control Study

Francisco Alejandro Felix Tellez, MD1, Antonio A. Leon Martinez2, Denisse Alejandra Picazo Mendoza3, Melissa Encarnación Martínez4, Ana Maria Coeto Cano5, Francisco Daniel Lugo Vences6, Daniel Eduardo Sandoval Colin7, Angel Ricardo Flores Rendon8, Ricardo Santiago Ramirez7;  1Hospital Lic. Adolfo Lopez Mateos, Mexicali, NM; 2ISSSTE, Ciudad de Mexico, Distrito Federal, Mexico; 3Universidad Nacional Autonoma de Mexico, Mexico City, Baja California, Mexico; 4UNAM, Ciudad de México, Distrito Federal, Mexico; 5Universidad Nacional Autonoma de Mexico, Mexico City, Distrito Federal, Mexico; 6Universidad La Salle Mexico, Mexico City, Distrito Federal, Mexico; 7Universidad Nacional Autónoma de México, Mexico City, Distrito Federal, Mexico; 8Unidad Regional de Gastroenterologia y Endoscopia Avanzada Gastromedical, Mexicali, Baja California, Mexico

Introduction: Chronic constipation (CC) prevalence is of 15% representing the sixth most common gastrointestinal symptom. Primary constipation can be due functional constipation (FC), constipation predominant irritable bowel syndrome (IBS-C) and defecatory disorders, this last one requiring abnormal anorectal tests. FC prevalence is of 20% affecting predominantly elderly; IBS-C affects younger population with a heterogenic prevalence varying from geographic regions (1.1-45%). Mounting evidence describes an impact of CC on quality of life (QOL) but there is limited data of economic status and work productivity (WP) influence by CC variants.

Methods: This study performed a prospective case-control design to analyze socioeconomic and WP impact of SII-C and FC on productive Mexican population. It took place on Mexico during 2020. Overall, 1000 active workers selected by random sampling completed an internet survey. This study collected social, demographic and WP information; and analyzed psychological and digestive symptoms. Rome IV criteria for SII-C and FC diagnosis, EQ-5D for QOL and Goldberg Scale for depression and anxiety. Comparisons with a regression univariate and multivariate analysis with chi-squared with 95% confidence intervals and a comparative T-test was used to analyze data.

Results: CC prevalence was 33.6% with a predominance of SII-C (61%) and in a less proportion FC (39%). No differences on the mean age being of 29 ± 10 years in SII-C and SII. Both groups affects predominantly female gender, in SII-C representing the 81.5% and 69.5% in FC. Per capita annual health spending was grater in SII-C at compared with FC (MXN 1,485 vs. MXN 905). Negative impact on WP was more frequent in SII-C with higher rates of ausenteeism and presenteeism at compared with FC. Multiple logistic regression indicated that presenteeism OR 1.769 (CI 95% 1.110-2.819, P=0.017) and annual medical attention OR 4.248 (CI 95% 2.555-7.063, P < 0.001) were independently associated with SII-C without statistical association of FC with QOL, economics or work related variables. T-test indicated that there are no differences in per capital annual health spending, but a SII-C frequently sought medical attention at compared with FC (P= 0.002).

Discussion: In Hispanics, CC has the same prevalence reported worldwide, affecting younger population on work productive age. SII-C affects negatively WP being an independent factor for presenteeism. FC do not impact con WP. SII-C seek for medical attention with more frequency than FC.
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Multivariate analysis of associated factors to C-IBS
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T-Student analysis of associated factors to C-IBS

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Jeffrey Roberts

Beware of Nuts and Seeds: A Case of High Oxalate Diet for Irritable Bowel Syndrome Inducing Oxalate Nephropathy

Presenting Author(s)

Victoria Garland

George Washington University
Washington, DC


Introduction: Irritable bowel syndrome (IBS) management often includes dietary intervention. Some individuals consume high oxalate foods to decrease IBS symptoms. High oxalate foods include tea, beans, nuts, spinach, kale, rhubarb, beets and soy. Factors influencing absorption include dose ingested, mineral content of the meal, and fat malabsorption. Oxalate is excreted in urine and excessive filtration can cause oxalate nephropathy. We describe a rare case of a high oxalate diet intended for irritable bowel syndrome (IBS) treatment causing nephropathy.

Case Description/

Methods: 
A 59 year old Caucasian woman with chronic kidney disease (stage 3), IBS, osteoporosis, hypertension and hyperthyroidism presented with worsening renal function during a follow up evaluation. She reported a high oxalate diet for her IBS symptoms, consisting of 6 tablespoons of chia seeds and multiple servings of almonds daily. She denied history of urinary stones. Medications included amlodipine and methimazole. She denied NSAID use, never smoked and drank alcohol occasionally. Her family history was significant for diabetic nephropathy in her father.

Labs revealed an increase in creatinine from 1.3 to 1.8 over six months. Urinalysis was negative for proteinuria and hematuria. A renal ultrasound was normal. A subsequent renal biopsy showed glomerulosclerosis, fibrosis, tubular atrophy, and calcium oxalate deposition. Immunofluorescence was negative. Litholink showed increased oxalate and low citrate in urine. Her acute kidney injury was attributed to diet. She switched to a low oxalate diet with high fluid intake and started calcium carbonate with meals and vitamin D. A two month follow up evaluation revealed that her creatinine improved to 1.57 and urine studies showed decreased oxalate.

Discussion: This case reveals the unintended consequence of a high oxalate diet for IBS symptoms. There is a close relationship between diet, intestinal health, and kidney health, signifying the importance of a thorough dietary history, nutrition counseling, and dietary management of disease. Vulnerable patients include those with chronic kidney disease, calcium and iron deficiencies, fat malabsorption, and those following a plant based or a fad diet. Risk can be mitigated with cooking techniques, hydration, balancing high oxalate diets with foods rich in free calcium, magnesium and iron and by limiting high oxalate foods. The microbiome appears to play an important role in degrading oxalate and in the future may further help stratify risk.

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Correlation Between Irritable Bowel Syndrome and Consumption of High-Fructose Corn Syrup in a Low-Income Community

Nikita R. Paripati, BS1, Lauren Nesi, BS2, Connor Dugan, MD3, John Gaughan, MS, PhD, MBA4, Joshua DeSipio, MD5, Sangita Phadtare, BS, MS, PhD1;  1Cooper Medical School of Rowan University, Camden, NJ; 2Cooper Medical School of Rowan University, Scarsdale, NY; 3Cooper Medical school of Rowan University, Birmingham, AL; 4Cooper University Hospital, Camden, NJ; 5Cooper Digestive Health Institute, Mt. Laurel, NJ

Introduction: 

Irritable bowel syndrome (IBS) is a chronic and debilitating disease. It is predominant in female patients. Due to its complicated treatment, clinical research is focused to improve symptomatology through dietary modifications. Hypersensitivity to certain fructose-containing foods plays a role in the development of IBS. High fructose corn syrup (HFCS) is a widely used, cost-effective sweetener. Our hospital system is committed to service to medically underserved, low-income, and minority populations. More than 37% of our city population lives in poverty. Our city is considered a ‘food desert’ with limited dietary choices due to the lack of access to healthy foods. This may increase consumption of readily available, cheaper, processed HFCS-rich foods. We investigated if HFCS consumption is higher in our IBS patients. Identifying and eliminating these food triggers will aid in the management of this disease.

Methods: 

We completed a retrospective chart review of 969 IBS patients for demographics, social history and psychiatric comorbidities. We also obtained 122 patient and 50 control surveys with additional information on HFCS consumption. USDA database was used to identify foods particularly high in HFCS. HFCS was quantified by Glinsmann’s coefficient. Student’s t-tests were used to compare means of quantitative data. Chi-square was used for categorical proportions. Spearman’s rank-order correlation was used to assess strength of correlation between IBS and psychiatric comorbidities.

Results: 

83% and 78% IBS patients were female and Caucasian, respectively; 39% were obese. Significant number of IBS patients showed one or more psychiatric comorbidities, such as depression (567), anxiety (325), bipolar (93), PTSD (87), and psychosis (21). Notably, IBS patients had significantly higher consumption of HFCS per capita as compared to the control group (p >0.0001) (Table 1 and Figure 1). Specific foods contributing to HFCS consumption are also schematically presented in Figure 2. This will be useful to design a personalized dietary plan to reduce HFCS intake, e.g. HFCS consumption is highest in the IBS-diarrhea patients and majority of that is contributed by beverages.

Discussion: 

Our data shows a strong correlation between IBS and certain psychiatric comorbidities as well as IBS and HFCS consumption. Our data will help to create a personalized management plan for IBS patients in areas where access to healthy food options is difficult.

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Risk Factors for Colorectal Cancer in Patients Diagnosed With Irritable Bowel Syndrome: A Retrospective Cohort Study

Christine Yu, MD1, David Yi, MPH2, Bechien Wu, MD, MPH1;  1Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA; 2Kaiser Permanente, Pasadena, CA

Introduction: Irritable bowel syndrome (IBS) is a chronic disease characterized by abdominal pain, altered bowel habits, bloating and gas. With a rising incidence of colorectal cancer (CRC) among younger age groups, we aimed to evaluate the incidence of CRC in patients with IBS and identify key risk factors for CRC in this patient population.

Methods: Retrospective cohort study using data from 2008-2018 in a diverse, community-based integrated healthcare system in Southern California. We included members over age 18 with an International Classification of Diseases 9 or 10 code for IBS. Exclusions included pregnancy and history of prior gastrointestinal disease (i.e. inflammatory bowel disease, celiac disease, etc). We collected demographic and clinical data (age, sex, race/ethnicity, marital status, body mass index (BMI). Diagnosis of CRC was identified based on internal cancer registry. We calculated the crude incidence rate of CRC. Using Chi-square and Wilcoxon Rank Sum tests, we compared demographic and clinical characteristics between patients who did and did not develop CRC during the study period. We used Cox regression analysis to calculate adjusted hazard ratios including age, sex, race/ethnicity for risk of CRC.

Results: Among 41,775 IBS patients (Mean age 45.8 +/- 17.1, 73.3% female, 49.6% non-Hispanic white, 34.3% Hispanic, 7.1% non-Hispanic black, 9.1% other/unknown), we identified 152 cases of CRC during a combined follow-up period of 282,242 person-years (IR 54 per 100,000 person-years). IBS patients with CRC were predominantly female (104/152, 68.4%) with a mean age of 63.4 +/- 15.2 years as compared to those without CRC, age 45.7 +/- 17.0 (p< 0.0001). Results of univariate and multivariate analyses are presented in Table 1. Although racial/ethnic differences were observed in univariate analysis, age (age >/= 45 HR 1.1, 95% CI 1.0-1.1) and gender (female HR 0.7, 95% CI 0.5-1.0) were the only independent risk factors in multivariable analysis. An age threshold >/= 39 years had a 95% sensitivity for CRC (145/152).

Discussion: CRC in patients with IBS is rare but the risk significantly increases in males and patients over age 45.
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CRC: colorectal cancer; HR: hazard ratio; SD: standard deviation; BMI: body mass index; NS: not significant.
* Multivariate analysis including age, gender, race/ethnicity
**Age of >/= 45 used
***Reference level for multivariate analysis for race/ethnicity is ‘Non-Hispanic White’

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