Introduction

Recent guideline from the European Society of Gastrointestinal Endoscopy (ESGE) recommends the use of risk-profiles to determine surveillance colonoscopy after polypectomy.¹ These risk-profiles are potentially a better predictor for the development of colorectal cancer (CRC) incidence after polypectomy. CRC screening programs use advanced neoplasia as primary outcome parameter.² It might be more recognizable for doctors and policy makers to use the same outcome parameter. However, by changing the outcome parameter from advanced neoplasia to high-/low-risk profiles in a FIT-based CRC screening program, the definition of what is considered a relevant lesions will change. Using risk-profiles as outcome parameter may impact both colonoscopy surveillance capacity and the positive predictive value (PPV) of finding a relevant lesions after a positive FIT.

Aims & Methods

Study aim: assessing the impact of applying the ESGE risk-profiles as outcome parameter of a FIT based CRC screening program on colonoscopy surveillance and PPV after a positive FIT.
Methods: We retrospectively analyzed all persons who had a positive FIT (≥ 47µg Hb/g feces) followed by a colonoscopy in the Dutch CRC screening program from 2019-2022. Colonoscopy and pathology reports were used to define the surveillance interval based on the old and new guideline.
The old guideline used a scoring table in which, adenoma count, location, villous type (≥ 75%) or the presence of an adenoma or serrated polyp ≥ 10mm were used to determine a 3 or 5 year surveillance interval.² The new guideline defined a high-risk profile as either a high-risk adenoma or high-risk serrated polyp or ≥ 5 adenomas. A high-risk adenoma is an adenoma ≥ 10mm or with high-grade dysplasia. A high-risk serrated polyp is a serrated polyp ≥ 10mm or with any dysplasia.³ All persons with a high-risk profile receive surveillance in 3 years.
The old definition of the PPV was advanced neoplasia. Advanced neoplasia is defined as CRC or advanced adenoma (adenoma ≥ 10mm or high-grade dysplasia or ≥ 25% villous type).³ The new definition of the PPV was CRC, high-risk adenoma or high-risk serrated polyps. A chi-squared test was used to determine significant differences between the old and new definition.

Results

218,109 persons with a positive FIT underwent a colonoscopy between 2019-2022. Based on the old surveillance guideline, 51.2% of the persons would require colonoscopy surveillance. When applying high-risk profiles only 32.3% persons required surveillance. However, the number of persons referred for a 3-year surveillance interval was now doubled (Table 1). This is a result of 723 persons who first qualified for 10-year return to screening, and 34,451 persons who previously had a 5-year interval. In contrast, only 32 persons who initially had a 3-year interval will be advised to return to screening in 10 years, when risk-profiles are applied. The corresponding PPV for CRC, high-risk adenoma or high-risk serrated polyps was 34.4%, showing an increase of 1.7% (p < 0.05) compared to PPV based on advanced neoplasia.

Conclusion

This study shows that when the new ESGE surveillance guideline risk-profiles are applied as outcome parameter in FIT CRC screening, a total reduction of 18.9% of surveillance colonoscopies can be achieved although the number of persons in the 3-year surveillance interval will be doubled. A minor change in PPV can be expected.

References

1. Hassan C, Antonelli G, Dumonceau JM, Regula J, Bretthauer M, Chaussade S, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2020. Vol. 52, Endoscopy. Georg Thieme Verlag; 2020. p. 687–700.
2. Nederlandse Vereniging van maag-darm-leverartsen (NVMDL) Nederlandse coloscopie surveillance richtlijn 2013 [Internet] cited April 2024, https://www.mdl.nl/files/richlijnen/Richtlijn_Coloscopie_Surveillance_definitief_2013.pdf
3. Federatie Medisch Specialisten (FMS) richtlijn colorectal carcinoom [Internet] cited April 2024, available from https://richtlijnendatabase.nl/richtlijn/coloscopie_surveillance/startpagina.html

Introduction

Studies on the prevalence of gastrointestinal (GI) red flags (RF) in the general population and among individuals with Rome IV disorders of gut-brain interaction (DGBI) in globally representative samples are scarce.

Aims & Methods

We aimed to describe the global prevalence of GI RF in the general population and in individuals meeting Rome IV criteria for DGBI. We analyzed data on participants across 26 countries who completed the Rome Foundation Global Epidemiology Study online survey, which included the Rome IV diagnostic questionnaire along with inquiries about 14 RF (hematemesis, hoarseness of voice, neck/throat pain, chest pain on excertion/related to heart problems, difficulty swallowing, hematochezia, melena, a major change in bowel movements, fever, unintentional weight loss, anemia/iron deficiency, first degree relative with GI cancer/inflammatory bowel disease/celiac disease). We assessed the global prevalence of RF and compared the prevalence in DGBI-positive (any DGBI [all RF] and anatomical DGBI groups [relevant RF for that anatomical region]) vs DGBI-negative participants without a history of organic GI disease using univariate logistic regression models. All analyses were stratified by age with cutoff at 50 years (y).

Results

Of 54,127 participants completing the internet survey, 58.9% reported at least one RF. A major change in bowel movements (frequency or consistency) was the most prevalent RF (16.5%), while hematemesis was the least prevalent (0.6%). Participants <50 y had a higher prevalence of RF compared to participants ≥50 y for any RF (63.1% vs 51.8%) and for all individual RF, except for a family history of GI cancer (more prevalent ≥50 y). Among 20,668 DGBI-positive participants, 72.8% reported any RF, with a higher prevalence in younger participants (Table). The prevalence of RF was highest in the anorectal DGBI group in participants <50 y, and in the esophageal DGBI group in participants ≥50 y (Table). The most prevalent RF was difficulty swallowing (30.1% <50 y; 30.5% ≥50 y) in esophageal DGBI, anemia/iron deficiency (22.8%) in gastroduodenal DGBI <50 y, a family history of GI cancer (17.2%) in gastroduodenal DGBI ≥50 y, and a major change in bowel movements in bowel (27.9% <50 y; 21.5% ≥50 y) and anorectal (38.4% <50 y; 29.5% ≥50 y) DGBI. In DGBI-positive vs DGBI-negative participants without organic GI disease, reporting any RF was positively associated with any DGBI and all anatomical DGBI groups (Table). Hematemesis was the RF most strongly associated with esophageal (OR 13, 95% CI 8.6-18 <50 y; OR 11, 95% CI 4.4-29 ≥50 y) and gastroduodenal (OR 12, 95% CI 8.4-16 <50 y; OR 11, 95% CI 4.5-26 ≥50 y) DGBI, although rare (0.8-3.2% in DGBI-positive participants). A major change in bowel movements was the RF most strongly associated with bowel DGBI (OR 3.3, 95% CI 3.1-3.5 <50 y; OR 3.5, 95% CI 3.1-3.8 ≥50y) and anorectal DGBI <50 y (OR 5.3, 95% CI 4.8-5.8), while hematochezia was the RF most strongly associated with anorectal DGBI ≥50 y (OR 6.1, 95% CI 5.2-7.3).

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Conclusion

GI RF are highly prevalent in the global general population with an even higher prevalence in individuals positive for a Rome IV DGBI. Given the substantial prevalence of RF observed in our study, especially among younger individuals, RF in general may not be as valuable at predicting serious underlying pathology as once thought. Further research is needed to validate the predictive utility of RF in the diagnostic approach to gastrointestinal symptoms and suspected DGBI in unselected population samples.

Introduction

Real-time symptom assessment provides a detailed understanding of the dynamic interplay between gastrointestinal symptoms in irritable bowel syndrome (IBS) and potential triggers, including affect and environmental factors. This study evaluates the association between abdominal pain and potential triggers over time in IBS patients with and without comorbidities, using the Experience Sampling Method (ESM) as a real-time, ecologically valid measurement method.

Aims & Methods

In this prospective, observational multicenter study, as part of the DISCOvERIE project, we included 215 Rome IV IBS patients (80% female; mean age 42.1) from six European countries, categorized into 103 IBS-alone, 67 IBS-mental (anxiety/depression), 16 IBS-somatic (fibromyalgia/chronic fatigue syndrome), and 29 IBS-multicomorbid patient subgroups. Participants scored abdominal pain and affect using an 11-point Numeric Rating Scale and environmental factors using ESM at up to ten random moments each day over seven consecutive days. Linear mixed-effects models analyzed the associations between abdominal pain and these potential triggers, both concurrently and predictively (trigger scores lagged by one time point, maximum of 90 minutes), in each subgroup.

Results

ESM assessment completion rate was 63%. Regarding affect triggers, abdominal pain was significantly correlated with concurrent positive and negative affect in all IBS groups (p<0.02), while significant lagged associations were only found within IBS-mental for positive affect (p=0.02) and within IBS-alone and IBS-multicomorbid for negative affect (p<0.001). Regarding environmental triggers, abdominal pain was significantly associated with concurrent ‘feeling comfortable in situation’ within IBS-alone, IBS-mental and IBS-multicomorbid (p<0.001), concurrent ‘feeling of pleasantness of company’ (p=0.01) and being alone (versus with somebody, p=0.01) within IBS-alone, and eating since the last ESM-assessment within IBS-alone (p=0.04) and IBS-multicomorbid (p=0.002). No significant lagged associations or correlations with location, activity, alcohol consumption, and nicotine use were found.

Conclusion

Our results demonstrate that in IBS patients, real-time abdominal pain is significantly associated with environmental and affect triggers, with both positive and negative affect correlating with abdominal pain irrespective of mental comorbidities. Moreover, fewer triggers predict abdominal pain over time, underscoring the importance of in-the-moment assessments. This study highlights the value of ESM in accurately identifying symptom triggers, thereby enhancing personalized healthcare in IBS.

Disclosure

MB, LV, MH, IM, SM, MRB, and DD declare no conflicts of interests. DJ has received research funding from public-private partnership grants of Top Knowledge Institute (TKI) Agri&Food and Health Holland, by the Carbokinetics program as part of the NWO-CCC Partnership Program, and by Organic A2BV/Mothersfinest BV. DK has received research funding from ZonMw, MLDS, UEG, Rome Foundation, Horizon Europe, Horizon 2020, Grunenthal, Allergan and speaker’s fee from Dr Falk (paid to host institute).

Introduction

Subjectively reported sleep disturbances are common in IBS¹, as are psychological comorbidities². Whilst sleep and psychological disorders are clearly linked, it has been demonstrated that sleep disturbances amongst IBS patients appear to exist independently of psychological factors³, raising the potential for sleep as a novel intervention target in IBS. Developing our understanding of the role and associations of sleep within the disease experience of IBS patients could lead to better treatment.

Aims & Methods

We aimed to compare the characteristics of patients with IBS according to the quality of their sleep. Participants were recruited from the NIHR research register ContactME-IBS. We collected data for demographics, gastrointestinal symptoms^4,5,6, psychological health⁷, quality of life^8,9, and impact on work and daily activities¹⁰using validated questionnaires among adults with Rome IV IBS. We dichotomised the cohort according to whether they were good or poor sleepers, defined by a Pittsburgh sleep index score >5¹¹. We compared the characteristics of the two groups to explore significant associations.

Results

Of 341 respondents with Rome IV IBS, 287 (84.16%) were poor sleepers. A significantly higher proportion of poor sleepers had been diagnosed with IBS for 5 years or more (82.2% vs 66.7% p=0.009). A greater proportion of good sleepers had a university or postgraduate level of education (59.3% vs 41.1% p=0.014), though this did not meet our threshold for statistical significance. Poor sleepers had a significantly higher burden of severe somatisation, nearly fivefold that of good sleepers (60.3% vs 13% p=<0.001). Poor sleepers reported higher levels of anxiety and depression symptoms. Amongst the good sleepers, none had abnormal depression scores. Poor sleepers experienced greater impairment of their work activities, and were more adversely affected in their home and social activities (p=<0.001 across all analyses). Though not statistically significant, poor sleepers reported higher IBS symptom severity. There was no statistically significant difference between poor and good sleepers in relation to their IBS subtype.

Table 1. Characteristics of Individuals with Rome IV IBS according to the quality of their sleep.

Conclusion

Individuals with Rome IV IBS who report poor sleep have significantly higher levels of somatisation and psychological comorbidity and are more adversely affected in both their work and personal lives, compared with those who report good sleep. Our findings could support the potential of sleep as an intervention target in the management of IBS.

References

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3. Koloski NA et al. Alimentary pharmacology & therapeutics. 2021;54(5):627-36.
4. Palsson OS et al. Gastroenterology. 2016:S0016-5085 (16) 00180.
5. Whitehead W et al. Rome III: The functional gastrointestinal disorders, 3rd editionVirginia: Degnon Associates Inc. 2006:835-53.
6. Labus JS et al. Alimentary pharmacology & therapeutics. 2004;20(1):89-97.
7. Spiller R et al. Alimentary pharmacology & therapeutics. 2010;32(6):811-20.
8. Patrick DL et al. Digestive diseases and sciences. 1998;43:400-11.
9. Drossman DA et al. Official journal of the American College of Gastroenterology| ACG. 2000;95(4):999-1007.
10. Reilly M et al. Alimentary pharmacology & therapeutics. 2004;20(4):459-67.
11. Buysse DJ et al. Psychiatry research. 1989;28(2):193-213