Introduction

Patients with cyclic vomiting syndrome (CVS) experience episodic severe attacks of nausea and vomiting, subsequently limiting food intake during attacks. When the attacks remit, however, patients are mostly asymptomatic. Among adults with CVS in remission, we aimed to examine differences between those with mild versus severe CVS on:
(1) eating-related quality of life (QOL) and
(2) dietary variety.

Aims & Methods

In a prospectively-maintained cohort of adults with CVS, we included all patients in remission (inter-attack phase at assessment time point) from June 2018 up to September 2022. We grouped patients into severe CVS group (4 attacks or more/year) and mild CVS group (less than 4 attacks/year). We assessed eating-related QOL on the Patient Assessment of Upper Gastrointestinal disorders- Quality of life (PAGI-QOL), using the diet and food habits subscale and diet variety on a Food Frequency Questionnaire (FFQ), capturing patient-reported outcomes (PROs) over the prior two weeks, as an approximation of long-term dietary intake.

Results

Of the 49 patients enrolled (30 [61%] females, mean age 33.5 +/- 12.6 years old), 32(65%) patients were included in the severe CVS group (>4 attacks/year), whereas 17 (35%) were enrolled in the mild CVS group. During enrollment, all patients were free of active CVS symptoms. The severe CVS group was significantly younger and experienced significantly more nausea (p<0.001), abdominal pain (p=0.003), early satiety (p=0.002), loss of appetite (p=0.012), discomfort (p=0.022) and bloating (p=0.007) compared to CVS patients with mild symptoms, during the inter-attack phase. Those with more severe CVS attacks had poorer QOL and significantly more concern about eating (p<0.001), avoidance (p=0.005) and restriction behavior, and less enjoyment of food (p=0.002), as displayed by PAGI-QoL. Despite symptom differences, there were no differences neither in food type frequencies, nor in the body mass index (BMI) between the two groups.

Conclusion

Despite the episodic nature of CVS, there are notable decreases in quality of life, specifically food-related QOL, in the inter-attack phase among those with a higher frequency of attacks. Such decrements in QOL and altered eating behaviors suggest that patients with more frequent CVS attacks may have significant inter-attack symptoms that would not typically fall into the typical CVS classification schema.

Disclosure

A.Trikola received the International training grant from American College of Gastroenterology.

Introduction

Avoidant/restrictive eating is common in people with neurogastroenterology disorders including functional dyspepsia (FD). There is debate on whether avoidant/restrictive food intake disorder (ARFID) is an expected response to severe symptoms or simply a common comorbid disorder. To address this, among adults with FD, we aimed to contrast those with and without ARFID on FD symptoms, quality of life, psychosocial factors, nutrient tolerance, and gut transit.

Aims & Methods

Adults with Rome-IV confirmed FD and healthy controls (HC) from an ongoing study participated. ARFID diagnosis was assigned based on a semi-structured DSM-5 diagnostic interview. Surveys: Patient Assessment of GI Disorders Symptom Severity Index (PAGI-SYM), Short Form Nepean Dyspepsia Inventory (SF-NDI), Nine-Item ARFID Screen (NIAS), Fear of Food Questionnaire (FFQ), Visceral Sensitivity Index (VSI), and Hospital Anxiety/Depression Scale (HADS). Nutrient Drink Test (NDT) measured gastric tolerance—liquid nutrient ingestion at 30mL/minute until subject reported unbearable fullness. Wireless Motility Capsule (WMC) measured gut transit. Height/weight was measured for body mass index (BMI).

Results

Sample (80% female, M_age=37.1±14.4y) included 37 FD+ARFID, 14 FD only, and 18 HC. Groups did not significantly differ in sex or age. Adjusted pairwise comparisons showed small (r=.1-.2) non-significant differences between FD and FD+ARFID on FD symptoms by PAGI-SYM and SF-NDI (Table 1). However, FD+ARFID had significantly worse scores compared to FD with medium effects (r=.3-.4) on: FD-related quality of life by SF-NDI, Fear of Food by NIAS-Fear and FFQ, GI-anxiety by VSI, and anxiety by HADS. FD+ARFID vs FD also had small differences (rs=.2) on: feeling more bothered by FD symptoms on SF-NDI, worse depression by HADS, lower BMI, and less NDT consumption. Compared to HC, FD and FD+ARFID had significantly worse survey scores with large effects for FD+ARFID (r=.6-.8) and medium effects for FD vs HC (r=.3-4). For the NDT, FD+ARFID consumed significantly less than HC with large effect (r=.6) but with a trend medium effect for FD consuming less than HC (r=.3). Groups did not significantly differ in WMC transit times.

Conclusion

Our findings suggest ARFID, when present in FD, does not reflect a response to more severe FD symptoms. Thus, ARFID is a legitimate secondary condition in FD. ARFID may reflect more profoundly altered distress around symptoms (e.g., fear of symptoms, anxiety sensitivity) and greater negative impacts (e.g., FD-related quality of life, lower liquid nutrient tolerance).

Introduction

Cyclic vomiting syndrome (CVS) is a disorder of gut-brain interaction defined by episodes of uncontrollable vomiting and retching. CVS has four phases (inter-episodic, prodrome, emetic, recovery) and affects both children and adults. There is a lack of published qualitative research on disease-related and phase-specific symptoms that impact patients with CVS.

Aims & Methods

Two qualitative, cross-sectional, observational interview studies were conducted in adults (18-65 years) and adolescents (12-17 years) with CVS. The studies aimed to explore the patient experience, identify the symptoms and understand their relevance to patients with CVS. The two studies included participants clinically diagnosed with CVS and followed at the tertiary care CVS programs at Froedtert hospital (adults) and Children’s Wisconsin (adolescents). Adolescents participated in a dyad interview with their caregiver or separately. Interviews were conducted remotely using a semi-structured interview guide and analysed with an “open coding” approach using ATLAS.ti 9.0 (adults) or 22.0 (adolescents).

Results

Semi-structured concept elicitation interviews (each up to 90 minutes long) were conducted with 13 adults (mean ± SD age 45.3 ± 13.1 years) and 15 adolescents (mean ± SD age 14.6 ± 1.8 years) by professional qualitative interviewers. Each participant described their symptoms during the prodrome and emetic phases. Most frequently reported symptoms during the prodrome were nausea (92.3%), anxiety (76.9%) and abdominal pain (69.2%) in adults; and nausea (100%), abdominal pain (73.3%), headache (73.3%) and pale skin (73.3%) in adolescents. During the emetic phase, the most frequently reported symptoms were nausea (100%), tiredness (100%), dry heaves (100%), vomiting (92.3%) and retching (92.3%) in adults; and nausea (100%), vomiting (100%), abdominal pain (93.3%), dehydration (86.7%), tiredness (86.7%) and light-headedness (86.7%) in adolescents. The patients most frequently reported nausea (5/13 adults, 6/15 adolescents) and vomiting (5/13 adults, 5/15 adolescents) as the most bothersome CVS symptom. Adults reported anxiety (associated with an impending vomiting episode; 5/13); missing work (2/13); inability to: perform daily tasks (1/13), plan their life (1/13), or parent to their full capacity (1/13); being homebound (1/13); reduced emotional well-being (1/13); and avoiding events (1/13) as the most bothersome impact of CVS symptoms. Adolescents reported impact on school (7/13 with data); missing out on sports (4/13); impacts on: social activities (4/13), sleep (1/13), friendships (1/13), or emotions (1/13); and anxiety (1/13) as the most bothersome impact of CVS symptoms (some provided >1 response). Caregivers reported the emotional impact of seeing their child suffer from CVS (5/11 with data); impact on: their child’s schooling (3/11), social activities (2/11); sports, friends/social activities, effect on their child’s future, work, daily planning, and travel planning (1/11 each) as the factor most difficult for them or their family.

Conclusion

Patients with CVS experience considerable gastrointestinal as well as extra-intestinal symptoms during both the prodrome and emetic phases. The majority suffer from nausea, vomiting and abdominal pain; the associated anxiety in adults is also notable. The study also confirmed major impact of CVS on daily life such as work/school absences, lost time with family/friends and reduced emotional well-being. CVS also markedly affects caregivers to patients with CVS.

Disclosure

Katja Kovacic reports medical advisory board from AbbVie, and is a consultant for Neurogastrx. Yaozhu J. Chen, Melody Wu, Camilla A. Richmond and James Williams are employees of the study sponsor, Takeda, and hold Takeda stock or stock options. Danielle Rodriguez is an employee of Evidera, which were contracted by Takeda for work relating to this study. Karin S. Coyne is an employee of Evidera, which were contracted by Takeda for work relating to this study, and a scientific consultant to Takeda. Thangam Venkatesan reports consultancy fees from Takeda.

Introduction

Dyspeptic patients frequently report nausea and vomiting. However, Rome IV criteria distinguish functional dyspepsia (FD) and chronic nausea and vomiting syndrome (CNVS) as separate disorders.

Aims & Methods

We aimed to assess and compare the characteristics and symptoms of patients with FD alone, with CNVS alone and those fulfilling both FD+CNVS criteria in a population of investigated dyspepsia. The retrospective study included 3,471 consecutive patients with investigated dyspepsia. Functional dyspepsia and CNVS were diagnosed according to Rome IV criteria. The severity of eight digestive symptoms during the 15 days preceding their appointment was assessed prospectively using a 5-point Likert scale. Quality of life (QoL) was quantified by the GastroIntestinal Quality of Life Index (GIQLI). Anxiety and depression were evaluated using the Hospital Anxiety and Depression scale (HADS). Sleep was assessed by the Pittsburgh Sleep Quality Index (PSQI).

Results

Among the 2,317 patients kept for analysis, 651 had FD alone, 144 CNVS alone and 393 FD+CNVS overlap. 73.2% of patients with CNVS fulfilled the criteria for FD, whereas 37.6% of FD patients met the criteria for CNVS. Patients with FD+CNVS overlap had worse quality of life, higher depression levels, and worse sleep quality than both diagnoses alone (p < 0.05). All symptoms were at least as prevalent in patients with FD+CNVS overlap as in patients with FD alone, except early satiation.

Conclusion

Nausea and vomiting are frequently reported by patients investigated for dyspepsia. Nearly three-quarters of patients with CNVS fulfil the criteria for FD, whereas more than one-third of FD patients meet the criteria for CNVS. Patients exhibiting FD+CNVS overlap have more severe disease than those with FD or CNVS alone.

Introduction

The Chicago classification 4.0 (CC4) definition of esophagogastric junction (EGJ) outflow obstruction (EJGOO) was made more stringent than the CC3 iteration to limit overdiagnosis of a disorder of undetermined significance. A clinically relevant EGJOO (Cr-EGJOO) diagnosis in CC4 requires a combination of relevant symptoms, high resolution manometric (HRM) criteria, and adjunctive tests instead of elevated supine median integrated relaxation pressure (IRP) alone in CC3.

Aims & Methods

We aimed to explore the importance of each component (symptoms, HRM, and adjunctive tests) in excluding or establishing Cr-EGJOO.
We included all patients undergoing esophageal HRM since 01/2020-12/2021, (both CC3 and CC4 protocols).
We excluded patients with inadequate tests. Positive symptoms were dysphagia/chest pain.
Adjunctive tests: Barium esophagrams were either timed or with a barium tablet. Functional lumen imaging probe (FLIP) tests were categorized as limited, borderline, or normal EGJ opening.
We also applied the same Cr-EGJOO criteria on the CC3 group (mandating relevant symptoms and adjunctive tests). We examined the proportion of EGJOOs excluded by each component.

Results

We included 486 (CC3, n=198, CC4, n=288) patients, with a median age of 58.7 years, 59% were female patients.
There were 100 (20.6%) with an elevated IRP in at least one position and normal peristalsis. Symptom data were available for all 100 patients and excluded Cr-EGJOO in 24%, barium esophagrams available for 85 and excluded Cr-EGJOO in 78.8%, FLIP was available in 11 patients (all had an esophagram). It rejected Cr-EGJOO in 63.6%, was borderline in 9.1%, and positive in the 27.3%. HRM criteria excluded Cr-EGJOO in 37.1% of the CC4 group. Note, most (93.1%) elevated IRPs were in the supine position.
Consequently, we could apply the Cr-EGJOO criteria on 85 patients with complete data (68 and 17 patients in the CC4 and CC3 groups, respectively). In the CC4 group the EGJOO rate was reduced from 27.3% to 3.1%, and in the CC3 group from 11.1% to 5.3%. Patients with an elevated IRP in at least one position and a positive adjunctive test were invariably symptomatic, but most symptomatic patients did not have Cr-EGJOO.

Conclusion

The updated CC 4.0 criteria considerably reduce the diagnosis rate of EGJOO diagnosis. Barium esophagrams had the highest yield in excluding clinically irrelevant cases, highlighting the importance of utilizing this non-invasive, readily available test to avoid unnecessary worry and invasive treatments.

Introduction

High resolution esophageal manometry (HRM) is commonly used to assess esophageal motility disorders. Data about the effect of age on HRM parameters and diagnoses are contradictory.

Aims & Methods

We aimed to explore the effect of age on HRM parameters and diagnoses in those under and above the age of 65.
We included all patients undergoing HRM within our institution between 2020-2021 (across both Chicago Classification 3 and 4 protocols). Clinically relevant esophagogastric junction outflow obstruction (EJGOO) was defined as having dysphagia or chest pain, elevated integrated relaxation pressure (IRP) in both positions where available, and positive adjunctive tests. Adjunctive tests included timed barium esophagrams, esophagram with a barium tablet, and/or functional lumen imaging probe (FLIP) tests.

Results

Of 486 included patients, 59% were female patients, 81% white, 3% Hispanic. There were 151 (31%) aged 65 and older and 335 (69%) younger than 65. The age≥65 vs. under 65 groups had similar proportions of female patients (61% vs.58%), race and ethnicity distribution, though older patients had lower median (IQR) BMI (26 [23-30] vs. 27 [24-31], p=0.023)
The age≥65 group had a higher IRP and mean lower esophageal sphincter pressure (LES) compared to the age<65 group, p<0.01 for both. Additionally, patients older than 65 had a higher rate of both manometric and clinically relevant EGJOO (p<0.001 for both), and a lower rate of hypomotility diagnoses. See table for details.
Multivariable logistic regression showed that age was independently associated with EGJOO per CC3 (elevated IRP in at least one position [upright or supine] and normal peristalsis): OR= 1.72 (95% CI 1.35-2.19, p<0.001) for each 10-year increase in age and after adjusting for sex, BMI and the study protocol (Chicago 3 or 4). Furthermore, within the group of patients with EGJOO per CC3, the odds of being diagnosed with clinically relevant EGJOO were 4.28 (95% CI 1.34-13.7, p=0.014) for each 10-year increase in age and adjusting for the same variables.

Conclusion

Our data show that HRM results differ in patients referred for manometry and older than 65. Specifically, these patients have a higher rate of clinically relevant EJGOO and greater IRP. This may be related to age related changes in myenteric innervation. Future studies are needed to establish whether patients older than 65 progress to achalasia or will benefit from EGJ directed therapy.