Introduction

Patients with celiac disease (CD) can present persistence or de-novo occurrence of gastrointestinal (GI) symptoms later in life even following a strict gluten-free diet (GFD). Indeed, GFD can alter the gut microbiota inducing dysbiosis that with time may lead to the development of disorders gut-brain interaction (DGBI).

Aims & Methods

In this prospective study, we evaluated the rate of irritable bowel syndrome (IBS), functional dyspepsia (FD), anxiety, and depression over a follow-up period of more than 10 years in a population of patients with CD following GFD.
Patients with CD diagnosed between 2004 to 2014 at the University Hospital in Modena, Italy were re-evaluated to assess the presence of DGBI. Rome-IV (pediatric modules if patients were younger than 17 years old), gastrointestinal symptoms rating scale (GSRS) and hospital anxiety and depression scale (HADS) questionnaires were administered along with the evaluation of the last blood examinations. The rates of IBS, FD, anxiety, and depression were then assessed. Univariate and multivariate analyses were performed to investigate the presence of factors associated with IBS and FD.

Results

We contacted 197 patients out of 340 from our original pediatric cohort. Patients who were not strictly adhering to GFD (25 patients) and who did not complete the questionnaires (20 patients) were excluded from the study. The median follow-up time was 154 months (inter-quartile range 125-180). The rate of IBS was 14.47% (22/152) which increased to 22.3% (21/94) considering only the adult population (Table 1 panel A). Patients were then subclassified in IBS-C (5/22, 22.7%), IBS-M (6/22, 27.3%) and IBS-D (10/22, 45.5%). The overall rate of FD was 7.24% (11/152) (Table 1 panel B) and up to 11.7% (11/94) in the adult population and none in the pediatric one. We found that postprandial distress syndrome (PDS) was present in 7.89% (12/152) of the population and epigastric pain syndrome (EPS) in 5.26% (8/152). Significantly higher rates of anxiety were found in patients developing IBS and FD (Table 1 and 2). Univariate and multivariate analyses showed that a longer follow-up time was significantly correlated with a higher rate of IBS and that anxiety was correlated with both IBS and FD diagnosis (Table 1).

Conclusion

Over more than 10 years from the initial diagnosis of CD, we found a higher rate of IBS and FD than the one reported for the general population. In our cohort, DGBIs are correlated with higher levels of anxiety and longer follow-up time.

Disclosure

None

Introduction

Salmonella Enteritidis, a Gram-negative bacterium, poses a significant threat to gastro-intestinal health, often leading to widespread outbreaks. Acute gastroenteritis increases the likelihood of developing a disorder of gut brain interaction (DGBI), such as irritable bowel syndrome (IBS) and functional dyspepsia (FD). This study investigates the long-term risk of DGBI development 30 years post-Salmonella exposure and explores additional predictive factors.

Aims & Methods

In 1994 a Salmonella Enteritidis outbreak involved 36 schools in Bologna, 1811 individuals tested positive for this bacterium in stool cultures. Following this event, a prospective cohort study was initiated after 30 years. 300 subjects were randomly selected and assessed for DGBI prevalence using Rome III and Rome IV questionnaires, persistent gastrointestinal symptoms via the Gastrointestinal Symptoms Rating Scale (GSRS), anxiety and depression levels with the Hospital Anxiety and Depression Rating Scale (HADS), and quality of life using the SF12 questionnaire (12 item short form). The exposed group comprised 150 people who contracted S. Enteritis infection in 1994, while the control cohort consisted of individuals, matched for sex, age and geographic origin, who had not experienced a bacterial gastroenteritis. The DGBI course was estimated by comparing our results with a previous follow-up carried out in 2009.

Results

Questionnaires were completed by 175 subjects (58,3%, 88 cases and 87 controls). Among the exposed subjects 39.8% developed IBS and 34.1% FD compared to 6.9% IBS and 4.6% FD in the control group (p=<0.001). Multivariate logistic regression in the study population revealed predictive factors for IBS: S. Enteritidis infection [Odd Ratio (OR) 7.056, 95% CI 2.684-18.554, p=<0.001] and anxiety level evaluated in 2024 (OR 1.244, 95% CI 1.105-1.400, p=<0.001). Similarly, predictors for FD included S. Enteritidis infection (OR 10.218, 95% CI 1.259-82.925, p=0.03), anxiety level assessed in 2009 (OR 1.212; 95% CI 1.058-1.390, p=0.006), and Mental component summary (MCS) score (OR 0.047; 0.002-0.985; p=0.049). Notably, anxiety level evaluated in 2024 was predictive of IBS development in the exposed group, while anxiety level in 2009, along with MCS score, was predictive for FD. We found an increased IBS and decreased FD occurrence in 2024 compared to 2009 follow-up. Exposed individuals exhibited a statistically significative higher rates and severity rates of gastrointestinal symptoms in the following areas: abdominal pain, hunger pains, diarrhea, loose stools, urgency, rumbling bloating, constipation, hard stools and incomplete emptying. Psychiatric comorbidities resulted more common in exposed group than in non-exposed one, in particular anxiety evaluated in 2024 (31.8% vs 10.3%, p=0.002). The exposed group showed lower scores in all SF12 subcategories compared to the control group.

Conclusion

This study, following a 1994 foodborne culture-proven S. Enteritis outbreak, highlights that a bacterial gastroenteritis is a major risk factor for IBS and for FD even after 30 years from the infection.

Introduction

Lower gastrointestinal (GI) disorders of gut-brain interaction (DGBIs) - including irritable bowel syndrome (IBS), chronic constipation, and faecal incontinence - are highly prevalent conditions that significantly affect patients' quality of life. These disorders often present with complex and overlapping symptomatology, necessitating a nuanced understanding of each patient's unique symptom profile to provide the best chance of treatment success. Furthermore, a significant proportion have psychological comorbidities, and a history of psychological trauma is common. Consequently, eliciting a comprehensive clinical history from these patients can be challenging, and requires significant skill and sensitivity. Despite this, formal training in the clinical assessment of these patients is rare in training programs throughout the UK and Europe.

Aims & Methods

This study aimed to investigate the self-reported confidence of gastroenterologists and colorectal surgeons in obtaining comprehensive histories from patients with lower GI DGBIs, identify potential barriers to their confidence and understand their training needs. A cross-sectional survey comprising 12 questions was distributed online using the Qualtrics platform to UK gastroenterologists and colorectal surgeons between March-April 2025. The survey explored clinician demographics, confidence levels in aspects of history taking as well as perceived barriers to confidence and preferred training modalities. Confidence was rated on a 1-10 scale. Participant responses were collected anonymously.

Results

Out of 73 survey responses, 50 were included in the analysis after excluding 23 incomplete submissions. The cohort comprised 29 (58%) colorectal surgeons and 21 (42%) gastroenterologists, primarily consisting of resident doctors (93%) with a minority being post-CCT participants (7%).
Overall, reported confidence in history taking increased with training progression, demonstrating a median self-reported confidence level of 7 during specialty training and 10 at the post-CCT/attending level (T-test, p<0. 0001). Specific confidence ratings for ‘trauma/abuse history’ and ‘psychological co-morbidities’ were notably lower, with medians of 5 and 6, respectively, highlighting significant gaps (ANOVA, p<0. 0001) compared to other areas such as ‘toileting habits’ and ‘pain history’.
The major barriers to confidence included a lack of training (58%) and experience (50%), followed by concerns regarding the management of sensitive information (26%) and difficulties in discussing these topics with patients from different genders/social backgrounds (18%). Less than half (38%) reported receiving any form of training in history taking, and among those, only 47% received training from their institution. Notably, 83% of participants expressed a desire for additional training, with the majority (76%) preferring to receive this from their training providers.

Conclusion

As GI clinicians progress through their medical career, their confidence in conducting histories from patients with lower GI DGBIs increases. However, confidence is lacking when enquiring about psychological factors, in particular a history of trauma or abuse. Enhancing the competence of doctors in this area early is likely to foster confidence and improve patient outcomes in this field.

Introduction

Patients with organic gastrointestinal (GI) diseases and diabetes mellitus (DM) can have concomitant symptoms compatible with a disorder of gut-brain interaction (DGBI). The differentiation of symptoms related more to a DGBI than to the organic disease is important since this influences treatment strategies.

Aims & Methods

This study aimed to compare the global prevalence of symptoms compatible with DGBI in adults with and without self-reported organic GI diseases or DM. Data was collected in a population-based internet survey in 26 countries; the Rome Foundation Global Epidemiology Study (N=54,127). Adult subjects were asked if they had ever been diagnosed by a doctor with any of several organic diseases including gastroesophageal reflux disease (GERD), celiac disease (CeD), peptic ulcer, diverticulitis, inflammatory bowel disease (IBD), and DM. Individuals not reporting each respective organic diagnosis were considered as the reference group. DGBI-compatible symptoms were grouped in regional subgroups based on the diagnostic questions of the Rome IV Adult Diagnostic Questionnaire: esophageal, gastroduodenal, bowel, and anorectal with special focus on five of the most frequently reported DGBI in those groups (functional dyspepsia (FD), irritable bowel syndrome (IBS), functional constipation, functional diarrhea and functional abdominal bloating)¹. Mixed logistic regression, with country as random intercept, was used to calculate the odds ratios (ORs, including [95% confidence interval]) of having DGBI-compatible symptoms, comparing every respective organic disease to their reference group.

Results

The total prevalence rates of a self-reported history of organic disease were 13.2% (n=7,148) for GERD, 3.0% (n=1,613) for peptic ulcer, 0.6% (n=323) for CeD, 1.8% (n=993) for IBD, 1.7% (n=902) for diverticulitis, and 7.1% (n=3,884) for DM. Having any organic GI disease of interest increased the odds of symptoms compatible with a DGBI (prevalence 63.4% vs 43.0% in the reference group, OR 2.76 [2.64-2.90]), which was stronger than for DM (48.5% vs 43.0%, OR 1.26 [1.18-1.35]). Among the individual DGBI, symptoms compatible with IBS and FD were most commonly seen in all organic GI diseases. Increased OR for having symptoms compatible with DGBI were seen across the organic GI diseases. Expected strong links between the organic GI disease and DGBI were seen in the corresponding regions for the disease pathology (e.g. IBD and bowel DGBI, GERD and esophageal DGBI), but also with other regions (e.g. IBD and esophageal DGBI, GERD and anorectal DGBI) (Table 1).

Table 1. Prevalence rates as % (95% confidence intervals) of symptoms compatible with DGBI in self-reported organic GI diseases and DM.

Conclusion

DGBI-compatible symptoms are more common in patients with self-reported organic GI diseases and, to lesser extent, DM compared to the general population. Since this difference is also seen between organic disorders and DGBI-compatible symptoms where not expected, this may influence the focus of treatment strategies.

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(1):99-114.e113.

Introduction

Fructans or fructooligosaccharides are included in the spectrum of FODMAP (fermented) sugars, which are relevant in the induction of symptoms in patients with disorders of gut-brain interaction (DGBI) and in non-coeliac gluten sensitivity (1). Fructans have been shown to induce visceral hypersensitivity, an increase in mucosal mast cells, and changes in the colonic mucosal barrier in mice, and hypersensitivity associated with an altered gut microbiome in humans (2-5). Breath tests are used in the assessment of intolerances to several FODMAPs, but the test is poorly standardised for fructans (6).

Aims & Methods

A standardised breath test with fructans (10g Orafti^®HSI) was performed afer a 24-hour low-FODMAP diet and >8-hour fast. Exhaled hydrogen and methane concentrations were measured every 30 minutes until 5h, and synchronised symptom assessments performed for 24h (composite symptom index score, SI, 7) in 600 successive male (33%) and female patients of average age 41 years referred to our gastroenterology practice with DGBI (irritable bowel syndrome and/or functional dyspepsia, Rome 4 criteria). Breath gas concentration thresholds of >20ppm and >8ppm above baseline were used for hydrogen and methane, respectively.

Results

The SI was positive in 61.2% (n=367) of patients within 24 hours of fructan ingestion. The SI peaked in the first 3 hours in 17.5% (n=105) and in the first 5 hours in 42.5% (n=255) of patients. Suprathreshold increases in hydrogen and methane concentrations within 5 hours were seen in 62.7% and 14.9% of patients, respectively. Discordant SI and breath gas results were obtained in 35.1% (hydrogen) and 57.8% (methane) of patients. A negative SI with a suprathreshold hydrogen or methane result occurred in 18.2% and 5.2%, respectively. A positive SI with a subthreshold hydrogen or methane result occurred in 16.9% and 52.6%, respectively. Suprathreshold concentrations in methane and not in hydrogen were apparent in 4.5%. Main symptoms during tests were excessive flatulence (58.8%), bloating (50.3%), abdominal fullness (49.3%), abdominal cramps (29.0%), nausea (26.7%), GORD (26.7%), diarrhoea (9%) and extra-GI symptoms (16.2%).

Conclusion

Standardised oral provocation with fructans resulted in familiar clinical symptoms in a majority of patients with DGBI, suggesting a high prevalence of fructan intolerance. Due to the slow fermentation of intestinal fructans and the associated delayed symptoms, prolonged data collection over at least 12, preferably 24 hours is recommended. The test duration of 3 hours currently commonly used in test centres is inadequate. Symptom and breath gas concentration results are often divergent, as is known from other FODMAP breath tests, and validation against clinical outcome results is required. Fructans are of interest in DGBI as the current literature suggests they have both protective as well as detrimental effects on intestinal physiology, which may be dependent on the resident microbiota.

References

1. Gry I et al. Gastroenterology 2018;154:529–539
2. Kamphuis JBJ et al. Gastroenterology 2020;158:652-663
3. Chen BR et al. World J Gastroenterol 2017;23:8321-8333
4. Kamphuis JBJ et al. FASEB J. 2022;36:e22297
5. Chumpitazi BP et al. Aliment Pharmacol Ther 2021;53:499-509
6. Fedewa A et al. Curr Gastroenterol Rep 2014;16:370
7. Wilder-Smith CH et al. Aliment Pharmacol Ther 2013;37:1074-83

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