Introduction

The biopsychosocial model that underpins our understanding of disorders of gut-brain interaction (DGBI) has childhood trauma as a predisposing factor for adult symptoms¹. The model is supported by empirical data linking childhood emotional, physical and sexual abuse to the severity of adult gastrointestinal (GI) symptoms². However the mechanisms by which childhood trauma affects GI symptom burden later in life are poorly understood. Given the strong association between a number of adverse psychological traits and elevated GI symptom burden, one theory is that childhood adverse experiences (ACEs) induce a widespread negative attitude which might manifest as high levels of neuroticism and anxiety, among other possible traits^3,4, leading to increased allostatic load and amplified perception of bodily sensations⁵. However whether this is actually what happens remains unknown.

Aims & Methods

We aimed to empirically evaluate the hypotheses that:
1. Traits that are negative at high levels, neuroticism, anxiety and depression provide indirect positive paths between ACEs and adult GI symptom burden
2. A trait that may buffer the effect of ACEs, higher dispositional mindfulness, provides a risk-protective path between ACEs and adult GI symptom burden
In contrast to many previous studies, we used a validated measure of ACEs⁶ as well as considering individual traumatic events. GI symptom burden was measured via the gastrointestinal symptom rating scale (GSRS)⁷ and other psychological traits through validated measures. Our primary hypotheses were tested via path models.

Results

A sample of n=241 community individuals was recruited, of whom n=10 reported a physician diagnosis of an organic GI condition and were excluded. Of the remaining sample, 38% (n=88) met Rome IV criteria for irritable bowel syndrome and/or functional dyspepsia and 76% were female. The sample was generally young adults with mean age 19 years (SD=2, min=18, max=36).
GSRS scores correlated positively with overall ACEs score (r=0.16, p=0.02), neuroticism (r=0.35, p<0.001), anxiety (r=0.38, p<0.001), depression (r=0.27, p<0.001), but negatively with dispositional mindfulness (r=-0.39, p<0.001). Conversely, ACEs scores correlated positively with neuroticism (r=0.34, p<0.001), anxiety (r=0.23, p<0.001), depression (r=0.22, p=0.001), but negatively with dispositional mindfulness (r=-0.32, p<0.001).
Of the individual paths between ACEs and GSRS taken separately, the strongest was for mindfulness which explained 74%, followed by neuroticism which explained 70% of the association between ACEs and GSRS. In a model (Figure 1) where all psychological traits are considered jointly, 98% of the association between ACEs and GSRS, 98% is accounted for by indirect paths via psychological traits. Of these paths, the strongest are via mindfulness (44%) and anxiety (23%).

Conclusion

This study provides empirical support for the hypothesis that adverse childhood experiences are associated with later adult GI symptom burden via upregulation of adverse psychological traits and downregulation of positive traits (mindfulness). These findings offer opportunity for early intervention with the buffering effects of positive traits and support previous findings that mindfulness can act as a buffer to negative traits, such as neuroticism⁸.

References

1. Drossman DA. Gastrointestinal illness and the biopsychosocial model. Psychosom Med 1998; 60(3): 258-67.
2. Drossman DA, Leserman J, Nachman G, et al. Sexual and physical abuse in women with functional or organic gastrointestinal disorders. Annals of internal medicine 1990; 113(11): 828-33.
3. Jones MP, Van Oudenhove L, Koloski N, Tack J, Talley NJ. Early life factors initiate a ‘vicious circle’ of affective and gastrointestinal symptoms. A longitudinal study 2013; 1(5): 394-402.
4. Talley NJ, Boyce PM, Jones M. Is the association between irritable bowel syndrome and abuse explained by neuroticism? A population based study. Gut 1998; 42(1): 47-53.
5. Danese A, McEwen BS. Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiol Behav 2012; 106(1): 29-39.
6. Karatekin C, Hill M. Expanding the Original Definition of Adverse Childhood Experiences (ACEs). J Child Adolesc Trauma 2019; 12(3): 289-306.
7. Svedlund J, Sjodin I, Dotevall G. GSRS--a clinical rating scale for gastrointestinal symptoms in patients with irritable bowel syndrome and peptic ulcer disease. Digestive diseases and sciences 1988; 33(2): 129-34.
8. Beath AP, McDonald K, Osborn TC, Jones MP. The Positive Effect of Mindfulness Rivals the Negative Effect of Neuroticism on Gastrointestinal Symptoms. Mindfulness 2019; 10(4): 712-23.

Introduction

Although the peak prevalence of disorders of gut-brain interaction is in the 40-50 year range¹, the biological and psychological processes leading to a diagnosis are thought to start in childhood². Some individuals are diagnosed early in life but for many the diagnosis comes much later. Risk factors for a diagnosis have been well studied and include psychosocial factors³ and demographic factors, particularly female gender⁴. However determinants of how early an individual receives their initial diagnosis is not well studied and is an important question since it has been shown that early intervention in gastrointestinal disorders can lead to long-term resolution of symptoms⁵.

Aims & Methods

This study sought to:
1. Describe the age at first diagnosis of irritable bowel syndrome (IBS) or functional dyspepsia (FD) in general practice
2. Identify clinical determinants of individuals who are diagnosed as children vs adults
3. Among children diagnosed with IBS or FD, identify clinical determinants of those who receive a further diagnosis as adults
The sample was obtained from general practice electronic medical records via The Health Improvement Network (THIN)⁶ which has been shown to be representative of the health care-seeking United Kingdom population. We report on two samples, sample 1 combined patients with record of IBS and/or FD plus a large sample of individuals with no recorded gastrointestinal conditions. Sample 2 included patients on the basis of receiving a clinical diagnosis of IBS or FD at some point in their medical record. To ensure the potential for child and adult diagnoses, patients had to have been with the practice from at least the ages of 12 years to 25 years.

Results

Sample 1 comprised 1.27 million patients. A total of n=16,663 met all inclusion criteria for sample 2, were with their practice, on average, between the ages of 8 and 29 years and 36% were female.
Overall, a childhood DGBI diagnosis was identified in 1.3% (n=16206) and an adult diagnosis in 31% (n=393148) of patients. Across the sample, the mean age of first FGID diagnosis was 45 years (SD=18), being younger for IBS (mean=40, SD=16) than FD (mean=49, SD=18). Childhood diagnoses were first made, on average, at age 14 years (SD=3) and this was similar for IBS (mean=14, SD=3) and FD (mean=13, SD=4).
Among the sample 2 there were relatively few clinical diagnoses that differentiated patients whose first DGBI diagnosis came as a child rather than in adulthood. A lifetime diagnosis of eczema was more common in childhood onset (39% vs 34%) as was a lifetime diagnosis of recurrent abdominal pain (0.6% vs 0.1%) and type I diabetes (1.2% vs 0.7%).
Of patients diagnosed in childhood, 19% (n=542) received a further diagnosis as adults. Prominent factors that differentiated these patients from those who did not included these patients were less likely to be female (27% vs 40%), twice as likely to receive a lifetime diagnosis of anxiety (24% vs 12%) or depression (38% vs 18%) and a lifetime diagnosis of sinusitis (22% vs 11%).

Conclusion

In general practice, patients are more likely to be diagnosed with a DGBI as adults rather than in childhood. The factors that differentiated these groups are known to be risk factors for DGBI, such as eczema, and point to early predispositions to disorders expressed in the GI tract as well as elsewhere. This study suggests that DGBI maybe be lifelong, and a smooth transition from paediatric to adult care should be accomplished.

References

Sani M, Jinsong L, Abdoul Razak M. Functional Bowel Disorders and Functional Abdominal Pain: Prevalence and Symptoms Characteristics in Outpatient Gastroenterology Clinic (Wuhan, China). 2015.
2. Drossman DA. Gastrointestinal illness and the biopsychosocial model. Psychosom Med 1998; 60(3): 258-67.
3. Koloski NA, Jones M, Kalantar J, Weltman M, Zaguirre J, Talley NJ. The brain--gut pathway in functional gastrointestinal disorders is bidirectional: a 12-year prospective population-based study. Gut 2012; 61(9): 1284-90.
4. Koloski NA, Talley NJ, Boyce PM. Epidemiology and health care seeking in the functional GI disorders: a population-based study. The American journal of gastroenterology 2002; 97(9): 2290-9.
5. Trivić I, Hojsak I. Initial Diagnosis of Functional Gastrointestinal Disorders in Children Increases a Chance for Resolution of Symptoms. Pediatr Gastroenterol Hepatol Nutr 2018; 21(4): 264-70.
6. Blak BT, Thompson M, Dattani H, Bourke A. Generalisability of The Health Improvement Network (THIN) database: demographics, chronic disease prevalence and mortality rates. Inform Prim Care 2011; 19(4): 251-5

Introduction

Individuals with Disorders of Gut-Brain Interaction (DGBI) may experience avoidant/restrictive food intake disorders (ARFID). However, these findings have been limited to specialist neurogastroenterology clinics. We assessed the association between ARFID and DGBI within the adult general population.

Aims & Methods

A population-based Internet survey with pre-defined demographic quotas was conducted across the UK and USA in 2023. The survey included the Rome IV diagnostic questionnaire for DGBI, the nine-item ARFID screen (NIAS), and questions regarding demographics, body mass index, non-GI somatic symptoms, anxiety and depression, quality of life, and healthcare utilisation.

Results

4002 adults (mean age 47 [range 18-91] years, 50% females) completed the survey, of whom 1704 (42.6%) had symptoms compatible with at least one DGBI.
The prevalence of ARFID-positive screens was significantly higher among participants with DGBI compared to those without DGBI (34.6% vs. 19.4%, OR 2.2), with similar findings noted in each country. Among participants with DGBI, positive ARFID screens by NIAS subscale were poor appetite (21.5%), picky eating (18.1%) and a fear of aversive consequences (9.9%).
ARFID was present in 42.1% of those with oesophageal DGBI, 49.2% with gastroduodenal DGBI, 33.1% with bowel DGBI, and 41.8% with anorectal DGBI. The presence of ARFID among the two widely investigated DGBI, i.e. functional dyspepsia and IBS, was 56.2% and 50.4%, respectively.
The presence of ARFID increased with the number of DGBI regions, ranging from 19.4% in those with no DGBI, 27.5% with DGBI in one region, 40.0% for DGBI in two regions, 49.7% for DGBI in three regions, and 61.1% for DGBI in four regions (p<0.001). A positive correlation was seen between the number of DGBI regions and the severity of ARFID (r=0.29, p<0.001).
Individuals with DGBI plus ARFID, compared to those with only DGBI, were significantly more likely to be underweight (7.9% vs. 1.5%), have greater non-GI somatic symptoms and mood disturbances, reduced mental and physical quality of life, and increased GI healthcare visits; all p<0.001.

Conclusion

Positive ARFID screens are common in DGBI and associated with increased general health burden. Routine screening for ARFID in DGBI will inform the multi-integrated care plan provided by clinicians, dietitians, and psychologists.

Disclosure

Nil

Introduction

Individuals with disorders of brain gut interaction (DBGI) such as irritable bowel syndrome (IBS) and functional dyspepsia (FD) have symptoms that generally originate either first in the GI tract (e.g. fullness, pain: gut to brain) or brain (e.g. anxiety: brain- to –gut). It is unclear however what risk factors may moderate the order of incidence of either a DBGI or psychological diagnosis.

Aims & Methods

This study aimed to determine the proportion of individuals in general practice with a diagnosis of a DBGI (IBS and/or FD, IBS only, FD only, overlap IBS/FD) prior to a mood or anxiety disorder (gut to brain), and vice versa (brain to gut) and whether specific factors moderate the order of incidence of the diagnosis. Data was collected from a retrospective study of 152,674 patients diagnosed with a DBGI (excluding inflammatory bowel disease, coeliac disease, peptic ulcer disease, colorectal and gastric cancer) and psychological disorder (mood or anxiety disorder) at general practices in the United Kingdom over an average period of 16 years (SD=7 years). Information on which diagnosis appeared first was recorded (January 1994 to end 2022, inclusive). Multiple logistic regression was performed to compare a diagnosis of a DBGI (IBS and/or FD) first versus psychological diagnosis first on a range of sociodemographic factors (age, gender), medical conditions (allergy, eczema, Helicobacter pylori, Type 1 and Type 2 diabetes, autoimmune disease, rheumatoid arthritis, lupus, scleroderma, alcohol related diseases and prior gastrointestinal infection) and medication usage (antibiotics, proton pump inhibitors (PPI) and non-steroidal anti-inflammatory drugs (NSAIDs)) ever and prior to a diagnosis of either a DBGI or psychological disorder. Only individual moderators that reached the criterion of p<0.01 are included in the multivariate model.

Results

Of the 152,674 eligible individuals in the UK GP data set, just over half (56.2% n=85843) were diagnosed with a mood or anxiety disorder first compared with (42.9%, n=64739, 55.43%) a DBGI first. In a multivariate model being female, prior GI infection and prior PPI, antibiotic and NSAID use significantly increased the odds of being diagnosed with a DBGI first, whereas alcohol related diseases, asthma and ever having PPI and NSAID use significantly reduced the odds of having a DBGI diagnosis first (Table 1). Of clinical relevance people diagnosed with a DBGI first were twice as likely to have had prior PPI use compared with those with a psychological diagnosis first (OR=2.0, 95%CI 1.94, 2.06; P=0.000). These results were similar for IBS only, FD only and overlap DBGI.

Table 1. Multivariate model of predictors of a DBGI prior to a mood or anxiety disorder

Conclusion

In a large sample of primary care patients, prior PPI use was associated with an increased probability of a gut to brain pathway. While PPI use may indicate the presence of a upper gut DGBI, the data may equally point towards the possibility that PPI use may cause changes in the gut microbiome including reduced bacterial richness.

Introduction

Functional diarrhea (FDr) is a disorder of gut-brain interaction (DGBI) characterized by chronic or recurrent diarrhea, not explained by structural or biochemical abnormalities. It is distinct from diarrhea predominant irritable bowel syndrome (IBS) with recurrent symptoms and notably the absence of pain. While functional conditions present with complex, likely heterogenous pathophysiology, we aimed to investigate if proxy measures of sociocultural risk factors have any association with the prevalence of FDr in populations across the world.

Aims & Methods

We performed an ecological study utilising peer-reviewed published datasets reporting country prevalence of FDr¹, Helicobacter pylori (H.p) prevalence² as proxy measures for orofecal infections, and the density of quick service restaurants (QSR) per population as proxy measure for processed food exposure. In addition, we used proxy measures of development including household size, median age, gross domestic product (GDP) per capita. The data were retrieved from publicly accessible datasets (United Nations, CIA, World Bank, commercial/financial reports of a global QSR chain). Spearman rank correlations were used to test univariate associations.

Results

The prevalence of FDr in 33 countries was negatively correlated with both the number of people per QSR (r= -0.44, p= 0.02), and household size (r= -0.69, p <0.0001), while positively correlated with median age (r= 0.58, p= 0.004) and GDP/capita (r= 0.56, p= 0.006). Assocaitions with H.Pylori infection did not reach significance (r= -0.27, p= 0.16).

Conclusion

Utilising publicly available data, the prevalence of FDr across diverse countries are linked to various markers of social development and a proxy marker of processed food consumption.

References

1. Sperber AD, Bangdiwala SI, Drossman DA, et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology 2021;160:99-114 e3.
2. Hooi JKY, Lai WY, Ng WK, et al. Global Prevalence of Helicobacter pylori Infection: Systematic Review and Meta-Analysis. Gastroenterology 2017;153:420-429.

Disclosure

Nil