Aim:
To review the literature on overlapping conditions among patients with DGBI, and based on the available evidence make recommendations for the current diagnostic and therapeutic approach, and for future research regarding…:
a) …overlap among patients with DGBI with non-GI symptoms/syndromes.
b) …overlap among DGBI in different regions in the GI tract
c) …overlap with organic GI diseases.
Rationale
- In patients with DGBI, overlapping non-GI conditions such as fibromyalgia, headaches, gynecological and urologic conditions, sleep disturbances and fatigue are common, as well as overlap among DGBI in different regions of the GI tract. These overlaps strongly influence patient management and outcome. Shared pathophysiology may explain this, but details are not fully understood. This overlap has been shown to be of great relevance for DGBI:
- Presence of overlapping DGBI from different GI regions is strongly associated with e.g. increasing health care consumption, presence of non-GI symptoms, reduced quality of life, reduced work productivity and overall more severe GI symptoms.
- Co-existing non-GI symptoms/syndromes such as fibromyalgia, migraine, dyspareunia, chronic fatigue syndrome, interstitial cystitis in patients with DGBI are associated with e.g. worse outcome in general, and reduced psychological general well-being.
- Furthermore, symptoms considered to be caused by a DGBI may in fact have a detectable organic cause, and in patients with a diagnosed organic GI disease, symptoms not clearly explained by the pathology defining this disease are common. A diagnosis of organic disease, excludes by virtue a diagnosis of DGBI. The Rome Criteria are instrumental to set the boundaries between these two extremes of the spectrum creating a dichotomy between functional and organic gastrointestinal disorders. Nonetheless, there are scenarios in which these boundaries became blurred, including the following:
- The existence of an organic, potentially recognizable cause of DGBI symptoms, which emerge in subgroups of patients upon in depth investigation (e.g., bile acid malabsorption, microscopic colitis, intestinal parasitosis, non-celiac sprue). These investigations are not required in most patients with DGBI and should be confined to selected cases.
- The development of symptoms fulfilling criteria for DGBI (e.g., so called functional dyspepsia-like, irritable bowel syndrome-like symptoms) in patients in remission from an organic disease (e.g., quiescent IBD, celiac disease on a gluten free diet, diverticular disease in the absence of evidence of overt inflammation)
Objective
- Review the literature regarding underlying mechanisms / pathophysiology, including CNS filtering that can explain different types of overlap among different DGBI, with non-GI symptoms/syndromes and with organic GI disease. Particular focus will be on identifying overarching or shared concepts to explain these associations, e.g. central hypersensitivity.
- Describe the prevalence, symptoms patterns and clinical impact of co-existing non-GI symptoms / syndromes, assess potential geographic and demographic differences, and address how the presence of these symptoms relates to GI symptom patterns in specific DGBI. The focus will be on fibromyalgia, chronic fatigue syndrome and interstitial cystitis, but other overlapping non-GI
symptoms/syndromes will also be reviewed. - Provide guidance on how the presence of co-existing non-GI symptoms/syndromes influences burden of the disease, outcome and patient management, including how to prioritize different treatment strategies. Discuss how centrally vs. peripherally acting treatments should be used, including the use of behavioral treatments.
- Describe the prevalence, symptoms and overlap patterns and clinical impact of overlapping DGBI, assess potential geographic and demographic differences, and address how the presence of this overlap relates to other characteristics of patients with DGBI.
- Provide guidance on how overlapping DGBI influences burden of the disease, outcome and patient management. Discuss how centrally vs. peripherally acting treatments should be used, including the use of behavioral treatments.
- Describe the prevalence, symptom patterns and clinical impact (contribution to symptoms implications for therapy) of organic recognizable causes in DGBI, e.g. bile acid malabsorption, microscopic colitis, small intestinal bacterial overgrowth
- Provide guidance on further testing to identify organic causes of symptom development (phenotype, severity, geographic region etc.)
- Describe the prevalence and characteristics of DGBI symptoms in patients with chronic organic disease in remission or overlapping with organic disease (e.g. IBD, celiac disease, diverticular disease)
- Provide guidance on further testing and management of DGBI symptoms in patients with organic disease in remission, including how to prioritize different treatment strategies. Discuss how centrally vs. peripherally acting treatments should be used, including the use of behavioral treatments.
- Provide guidance on how overlapping conditions (overlap among DGBIs, overlap between DGBI and non-GI somatic symptoms/syndromes, DGBI symptoms in patients with organic GI diseases) should be addressed and managed in the context of clinical trials.
- Provide recommendations for future research on these topics.
This working team will serve to support GI region-specific chapter committees in Rome V and incorporate chapter-specific information relating to the different aspects of overlap for the specific disorders. This committee should work in collaboration with the Psychosocial committee to avoid overlap.
Chair
Magnus Simrén, MD, PhD
Department of Internal Medicine
Institute of Medicine
Sahlgrenska Academy
University of Gothenburg,
Gothenburg, Sweden
Co-Chair
Giovanni Barbara, MD
Department of Medical and Surgical Sciences
Center for Applied Biomedical Research
University of Bologna
Bologna, Italy
Working Teams Members:
Imran Aziz, MD, UK
Sarah Ballou, PhD, USA
Lin Chang, MD, USA
Alexander Ford, MD, UK
Shin Fukudo, MD, Japan
Samuel Nurko, MD, USA
Carolina Olano, MD, Uruguay
Gregory Sayuk, MD, USA
Kewin TH Siah, MD, Singapore
Lukas Van Oudenhove, PhD, Belgium