Clinical Case Summary

AAS is an uncommon entity typically linked to systemic inflammatory conditions, particularly inflammatory bowel disease (IBD). This syndrome is characterized by the presence of aseptic lesions, commonly in the liver and spleen. This case report suggests a potential association between AAS and symptomatic diversion colitis.
Case report: A 66-year-old woman was diagnosed with right breast intra-ductal carcinoma. During chemotherapy, she developed perforated diverticulitis and underwent an urgent Hartman’s procedure. Due to rectal fibrosis and local intestinal adhesions, she was left with a permanent colostomy.
Two years later, she complained of rectal excretion, bleeding, tenesmus, and weight loss. Initial laboratory work-up revealed anemia and elevation of cholestatic liver enzymes. Sigmoidoscopy of the rectal stump demonstrated edematous and brittle mucosa, with small ulcers. Histology was consistent with active colitis.
A PET-FDG CT scan showed pathological uptake of the rectum and adjacent lymph nodes, and new hypodense lesions in the liver. Biopsies of the lesions demonstrated foci of acute and chronic inflammation with micro abscess formation. The specimens were negative for malignancy, or infection. Despite lack of evidence for infection, a trial of antibiotics was given with no improvement.
The unique presentation of multiple sterile abscesses in the liver, with unclear ethology, led to a suggested diagnosis of AAS, possibly secondary to her active diversion colitis. Topical treatment with 5-ASA enemas led to clinical and endoscopic resolution of the colitis, as well as normalization of her liver enzymes and complete resolution of the liver abscesses.
Discussion: Our patient’s presentation was consisted with AAS. The complete resolution of her liver disease, following successful treatment of her colonic inflammation, suggest that the two conditions are related. To our knowledge this is the first report of AAS associated with diversion colitis.

References

Image A: PET FDG-CT Pathological uptake of the rectum and mesorecta lymph nodes.
Image B: Abdominal CT showing two hypodense liver lesions, 0.8cm in size, located in segment 7.
Image C: 1^st lesion biopsy sowing mostly neutrophil infiltration and two giant cells, consisted with severe acute inflammation.
Image D: 2^nd lesion biopsy showing with a bile duct infiltrated by neutrophils

Introduction

Somatization is defined as a tendency to experience and communicate psychological distress in the form of somatic symptoms. Literature suggests that there is a link between somatization and irritable bowel syndrome (IBS). Nevertheless, the association between clinical symptoms of IBS and somatization, especially in children, remains unclear.

Aims & Methods

54 children aged 6-12 with a verified diagnosis of IBS according to Rome criteria IV were included in the study. The control group consisted of 50 healthy children of the same age and gender. The level of somatization was assessed by the Somatoform Symptom Screening test (SOMS-2J by Rief, W., & Hiller, W.), which was modified for children. The intensity of abdominal pain and dyspeptic symptoms were estimated using a 4-point Likert scale. Data were processed using Microsoft Excel 2016 and analyzed with GraphPad (Prism 5.0). Pearson test was used to assess the correlation between SOMS rate and the intensity of somatic complaints.

Results

The level of somatization was significantly higher in children with IBS in comparison to the control group (p<0.0001). There was no difference in somatization rate in patients according to the predominant bowel habit. A direct correlation between the intensity of abdominal pain and the level of somatization (r=+0.37; p=0.005) was established in children with IBS (Fig.1). On the contrary, the intensity of dyspeptic symptoms was less influenced by the rate of somatization (r=+0,18; p=0,20).

Conclusion

To conclude, children with IBS who had higher rates of somatization were revealed to have a higher intensity of somatic complaints, especially abdominal pain. We suggest that somatization plays an important role in the occurrence of somatic symptoms of IBS. It may be one of the reasons for the low effectiveness of pharmacological treatment of IBS in children.

Introduction

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction affecting 5 to 10% of the population, combining chronic abdominal pain and altered bowel transit. Its varied and complex mechanisms make management difficult and can be responsible for impaired quality of life. Patient education is recommended for managing chronic diseases. As part of a patient education program, the first step is to assess patients' knowledge and needs by conducting a shared educational assessment. Experiments conducted in various countries have shown that therapeutic patient education (TPE) can be effective, reducing severity, improving quality of life, and reducing care seeking. These studies have also shown that patients often have a lack of knowledge and/or misconceptions about IBS (1).

Aims & Methods

This study aimed to assess the baseline knowledge level of patients enrolled in a patient education program. Patients with IBS were selected for participation in a TPE program following a multidisciplinary day hospital for IBS. All patients had to have seen a general practitioner and/or a gastroenterologist outside the team without sufficient improvement in their condition. The TPE was based on a document developed in collaboration with a patient organisation (APSSII). This program was divided into five 1-hour sessions (training and discussion time) conducted by different professionals (neurogastroenterologists, clinical psychologist, dietitian) covering the following points:
1) understanding my illness (epidemiology, diagnosis, mechanisms),
2) talking about my illness and expressing my needs (interaction with loved ones, work, doctor, school, rights and support);
3) organizing my daily life, improving my quality of life (impact of IBS on QoL, work, exercise, intimate life);
4) taking advantage of different treatments and care options (placebo, adverse effects, symptomatic and long-term treatment, alternative treatments);
5) the role of eating and diets (balanced diet, lactose-free, gluten-free, low-FODMAP, food allergies, risks of diets). Before the start of each session, questionnaires testing participants' knowledge on the session topic were completed.

Results

From November 2023 to September 2024, 135 questionnaires completed by 43 patients with IBS were included. 70% were women, mean age 45 ± 18 years, subtypes based on IBS transit: IBS-C 55%, IBS-D 33%, IBS-M 12%, with a mean severity (IBS-SSS) of 331 ± 72 points, EQ5D health score of 50 ± 21. Among the most common misconceptions, 25% believed that a diagnosis by endoscopy was possible, 48% believed the disease could be complicated by IBD, and 13% by colon cancer. Regarding treatments, 11% of patients believed that the placebo effect only concerned medications, 58% believed that faecal microbiota transplantation could currently be offered in clinical routine for IBS care, 78% believed that hypnotherapy was only effective if you believe in it, and 68% believed that multi-strain probiotics were more effective than single-strain ones.

Conclusion

This study, conducted in France on patients with moderate or severe forms of IBS, shows a highly variable level of knowledge about their disease depending on the questions, with some significant misconceptions that need to be addressed. These results justify the implementation of therapeutic education for these patients. A study is underway to verify the improvement in patients' knowledge and the existence of a positive impact of this strategy on symptom severity and quality of life.

References

(1) Halpert et al. What Patients Know About Irritable Bowel Syndrome (IBS) and What They Would Like to Know. National Survey on Patient Educational Needs in IBS and Development and Validation of the Patient Educational Needs Questionnaire (PEQ). Am J Gastroenterol 2007; 102:1972-82.

Disclosure

Nothing to disclose

Introduction

Psychiatric comorbidity, most commonly measured as severity of anxiety and depression symptoms, has been found to be associated with IBS symptom severity. However, available studies have rarely assessed the importance of formal psychiatric diagnoses on disease burden in IBS. In this analysis from a pan-European project (DISCOvERIE) focusing on the relevance of comorbid mental (anxiety, depression) and/or somatic (fibromyalgia, chronic fatigue syndrome) diagnoses in patients with IBS, we aimed to assess whether presence of psychiatric diagnoses according to the DSM-5 criteria has an impact on overall symptom severity in IBS.

Aims & Methods

We included patients with IBS according to the Rome IV criteria from nine different European centers. Exclusion criteria included the presence of severe psychiatric disease (i.e. bipolar disorder, schizophrenia, autism spectrum disorder, schizoaffective disorder, or organic psychiatric disorder demanding psychopharmacotherapy, psychiatric day-care or inpatient treatment). The patients underwent The Mini International Neuropsychiatric Interview (MINI) to diagnose major psychiatric diagnoses (a total of 17). Fibromyalgia and chronic fatigue were diagnosed by current diagnostic criteria. They also filled in questionnaires assessing Severity of IBS symptoms (IBS-SSS), depression (PHQ-9), anxiety (GAD-7), somatic symptoms (PHQ-15), and fibromyalgia symptoms (FIQ). Severity of symptoms were compared between groups with increasing number of psychiatric diagnoses using One-Way Between-Groups ANOVA with linear trend analysis.

Results

In total, 617 patients with IBS (median age 44 years, 80% females) were included. Among the IBS patients, 269 (44%) had none of the mental (anxiety, depression) or somatic (fibromyalgia, chronic fatigue syndrome) comorbidities (median age 44 y, 75% females), whereas 174 (28%) had comorbid mental disorder only (median age 38 y, 82% females), 49 (8%) had comorbid somatic disorder only (median age 50 y, 86% females) and 124 patients (20%) had mental and somatic comorbidities (median age 47 y, 86% females). The most common psychiatric diagnoses among the IBS patients were depression (n=284), generalized anxiety disorder (n=145) and panic disorder (n=38) followed by agoraphobia (n=23) and social anxiety (n=19). Participants were divided into four groups according to the number of psychiatric diagnoses (0, 1, 2, and ≥3). The severity of IBS, depression, anxiety, somatic, and fibromyalgia symptoms all increased gradually with increasing number of psychiatric diagnoses. The effect sizes (partial eta squared) were small for IBS symptoms, medium for somatic symptoms and large for the other severity measures (Table 1).

Table 1: Symptom severity in groups with increasing number of psychiatric diagnoses

Conclusion

This multicenter pan-European study shows that psychiatric diagnoses are common among IBS patients and that the overall disease burden in IBS is associated with psychiatric comorbidity. These findings highlight the importance of taking psychiatric comorbidity into consideration and to acknowledge the relevance of gut-brain axis interactions when managing patients with IBS.

Disclosure

Hans Törnblom: Consultant or advisory board member for Allergan, Cinclus Pharma, Medifactia, and VIPUN and as a speaker for Tillotts, Takeda, and Shire.
Daisy Jonkers: Part of the work of DJ, outside the submitted work has been financed by 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, by Organic A2BV/Mothersfinest BV.

Introduction

Population-based surveys have demonstrated substantial overlap of DGBI across multiple gastrointestinal (GI) regions and that this overlap is associated with increased health impairment. Comprehensive assessments of this overlap in patients with IBS are lacking, and the link with pathophysiology is not understood. In addition, IBS patients also frequently report overlapping non-GI comorbidities (somatic symptoms disorder , depression and anxiety) .The interaction between overlapping DGBI and non-GI comorbidities in IBS, and the impact of this interaction needs to be further investigated.

Aims & Methods

We included IBS patients with completed ROME II, III or IV questionnaires to assess overlapping DGBI in other anatomical GI regions (esophageal, gastroduodenal, anorectal). Patients completed validated questionnaires to measure the severity of GI (Gastrointestinal Symptom Rating Scale for IBS (GSRS-IBS)) and psychological (Hospital Anxiety and Depression Scale (HADS)) symptoms, IBS-specific quality of life (QOL) (IBS QOL), GI symptom-specific anxiety (Visceral Sensitivity Index (VSI)), and somatic symptoms (Patient Health Questionnaire-15 (PHQ-15) and Symptom Checklist-90 (SCL90)). Overlap of non-GI comorbidites (somatic symptom disorder, depression and anxiety) were assessed using suggested cut-off levels on PHQ, SCL-90 and HADS. Oro-anal transit time (OATT) was measured with radiopaque markers, and rectal sensitivity with balloon distensions using a barostat. GI symptoms following a Lactulose Nutrient Challenge Test (LNCT) were also recorded as a measurement of sensitivity to microbial fermentation and nutrients.

Results

We included 688 patients with IBS (70.5% female, mean age 37.3 ± 12.5 years; IBS-C 29.7 %, IBS-D 34.6 %, IBS-M 24.7%, and IBS-U 11.0%.). Overall, 68.3% of IBS patients had overlapping DGBI in other anatomical GI regions; one region: 39.4%, two regions: 23.3%, three regions: 5.7%. An overlapping esophageal DGBI was seen in 26.2%, a gastroduodenal DGBI in 31.6%, and anorectal DGBI in 38.1%. The prevalence of overlapping somatic symptom disorder in IBS was 53.8%, while depression and anxiety overlap was seen in 32.2% and 50.9% of the IBS patients. A higher number of non-GI comorbidities was associated with a greater number of overlapping DGBI in IBS (p<0.01).
With increasing number of overlapping DGBI diagnoses and non-GI comorbidities in IBS, there was a gradual increase in the severity of GI and psychological symptoms, as well as a gradual decrease in QOL (Table 1). In addition, with increasing number of overlapping diagnoses, a gradual increase in visceral sensitivity (reduction in rectal discomfort threshold and increased discomfort during LNCT) was seen, but no links with abnormal OATT, age or body mass index were noted.

Conclusion

Overlapping DGBI diagnoses and non-GI comorbidities are common among IBS patients. This overlap has an impact on both GI and non-GI symptoms, as well as a link with GI sensitivity. Assessment of overlapping DGBI and non-GI comorbidites seems to be of importance to optimize clinical management in patients with IBS.

Clinical Case Summary

We present the case of a 50-year-old man diagnosed with anti-EJ positive anti-synthetase syndrome in 2020. Two years after the diagnosis, he began experiencing subacute episodes of postprandial abdominal pain, distension, and vomiting. On physical examination, the abdomen was distended, non-tender, and tympanic. Abdominal CT revealed dilatation of small bowel loops without evidence of mechanical obstruction. Endoscopic studies ruled out endoluminal lesions. Given the suspicion of a severe gastrointestinal (GI) motility disorder, a comprehensive motility evaluation was performed. Esophageal manometry revealed absent contractility, gastric emptying scintigraphy was consistent with gastroparesis, and small bowel manometry demonstrated absence of normal migrating motor complexes during fasting and a weak postprandial motor response, findings compatible with a myopathic pattern. A diagnosis of chronic intestinal pseudo-obstruction (CIPO) secondary to autoimmune disease activity was established. The patient’s immunosuppressive therapy was escalated to tofacitinib and supportive treatment with prokinetics (prucalopride), non- absorbable antibiotics for small intestinal bacterial overgrowth and nutritional supplementation, was initiated. The patient showed symptomatic improvement during follow-up, although small bowel dilation persisted on imaging studies. CIPO is the most severe form of GI motility disorder, representing the end stage of various conditions affecting the neuromuscular system of the GI tract (1). Autoimmune diseases are recognized causes of CIPO, with connective tissue disorders being the most frequently documented. The treatment of CIPO involves two main approaches: addressing the underlying disease, in this particular case, through immunosuppression, and providing supportive care to maintain adequate nutrition. A high index of suspicion for severe GI motility disorders is essential to avoid delays in diagnosis and to initiate effective treatment promptly.

References

1. Malagelada C and Alcalá-González LG. Mistakes in chronic intestinal pseudoobstruction and how to avoid them. UEG Education 2024; 24: 12-17.
Pictures from abdominal distention crisis, radiological CT images and manometric tracings, including high-resolution jejunal manometry (small bowel) will be presented.