Introduction

IBS is a functional disorder of the gut-brain axis characterized by recurrent abdominal pain related to defecation and/or to a change in bowel habits [1]. According to stool type, 4 IBS-subtypes can be recognized: constipation prevalent (IBS-C), diarrhea prevalent (IBS-D), mixed (IBS-M) and unspecified (IBS-U) [2]. As a majority of IBS patients report symptom exacerbation by food, it is important to find a nutritional approach that could effectively reduce symptoms [3]. The present work is a post hoc analysis of the previously published DOMINO trial [4] conducted in Belgium in primary care. It showed that a FODMAP - lowering diet provided by a smartphone application was more effective than otilonium bromide after an 8-week treatment.

Aims & Methods

For this post hoc analysis, the diet arm population was stratified according to IBS subtype, with the aim of reporting a detailed evaluation of symptoms and psychosocial aspects with this new dietary intervention. 222 primary care IBS patients (85 IBS–M, 62 IBS–D, 44 IBS-C, and 31 IBS–U) followed a FODMAP-lowering diet for 8 weeks with the support of a smartphone application. Two follow up visits were scheduled after 16 and 24 weeks. IBS-Symptoms Severity Score (IBS-SSS), somatisation (PHQ 15), depression (PHQ 9), anxiety (GAD 7) and Quality of Life (QoL) status were evaluated. A One-way ANOVA with Dunnett’s post hoc test was conducted to assess differences between each time and the baseline. Significance was assessed with a p<0.05.

Results

After 8 weeks, IBS-SSS improved in all IBS-subtypes (p<0.0001) and this result was maintained until week 24 (p<0.0001). At week 8 the responder rate was 72% and it remained high (70%) until the end of the study. Evaluating each single subtype at week 8, IBS-C showed a responder rate of 79%, followed by IBS-U (74%), IBS-D (70%) and IBS-M (67%). After 8 weeks, PHQ-15 improved only in the IBS-D subgroup (p<0.05) and this result was maintained until week 24 (p<0.0001). PHQ-9 and GAD-7 did not show any significant differences after 8 weeks but they both significantly improved at the end of the follow up period (p<0.05) in the IBS-D subtype. QoL improved both in the IBS-D and IBS-M (p<0.05) subtypes after 8 weeks while at the end of the follow up the improvement was observed in all subtypes (p<0.05 in IBS-C, IBS–D and IBS-U and p<0.0001 in IBS-M) (Table 1)

Conclusion

Symptom severity improves significantly in all IBS subtypes when using a smartphone app-based FODMAP lowering diet intervention, and improved QoL especially in IBS-D and IBS-M subtypes. The DOMINO app-based dietary intervention should be considered the first-line treatment choice for primary care in IBS.

References

1. Sperber A.D., Bangdiwala S.I., Drossman D.A., Ghoshal U.C., Simren M., Tack J., Whitehead W.E., Dumitrascu D.L., Fang X., Fukudo S et al. Worldwide Prevalence and Burden of Functional Gastrointestinal Disorders, Results of Rome Foundation Global Study. Gastroenterology, 2021; 160:99-114.
2. Lacy BE, Mearin F, Chang L, Chey WD, Lembo AJ, Simren M, et al. Bowel Disorders. Gastroenterology. 2016;150(6):1393-1407.e1395.
3. Melchior C., Algera J., Colomier E., Tornblom H., Simren M. Irritable bowel syndrome with food-related symptoms: Future directions in the clinical management. United European Gastroenterol J. 2022 Jul;10(6):594-600.
4. Carbone F., Van den Houte K., Besard L., Tack C., Arts J., Caenepeel P., Piessevaux H., Vandenberghe A., Matthys C., Biesiekierski J. et al. Diet or medication in primary care patients with IBS: the DOMINO study – a randomised trial supported by the Belgian Health Care Knowledge Centre (KCE Trias Programme) and the Rome Foundation Research Institute. Gut, 2022; 0:1-7

Introduction

COVID-19 infection may increase the risk of developing Disorders of Gut-Brain Interaction (DGBI). However, the extent of this effect on a population level is poorly understood. We performed a two-country survey to address this issue.

Aims & Methods

A population-based Internet survey with pre-defined demographic quotas was conducted across the UK and USA in 2017 (pre-pandemic, n=4050) and repeated in 2023 (post-pandemic, n=4002). The surveys included the Rome IV diagnostic questionnaire, and questions about non-gastrointestinal somatic symptoms, anxiety and depression, quality of life, and healthcare utilization. The 2023 survey also included questions regarding COVID-19 infection and illness history.

Results

The overall DGBI prevalence, i.e., meeting diagnostic criteria for at least one DGBI, has significantly increased from the pre- to post- pandemic era (38.3% vs. 42.6%, OR 1.20, 95% C.I 1.09-1.31), with similar findings independently noted in the UK and USA. The rise in DGBI was observed within the oesophageal (8.8% vs. 10.1%, OR 1.16), gastroduodenal (11.9% vs. 16.4%, OR 1.45), and bowel domains (30.1% vs. 32.5%, OR 1.12). The two most widely investigated DGBI showed large post-pandemic prevalence increases, with functional dyspepsia rising from 8.3% to 11.9% (OR 1.48) and irritable bowel syndrome from 4.7% to 6.0% (OR 1.31).
In multivariable analysis, factors significantly associated with having DGBI in the post-pandemic era included younger age, female sex, anxiety, depression, medium-to-high somatic symptom severity, increasing number of COVID-19 infections, experiencing abdominal pain or diarrhoea during COVID-19 infection, and suffering with long-COVID.
Individuals with DGBI in the post-pandemic era, in particular those with long-COVID, reported reduced quality of life and higher mood disturbances, somatic symptom reporting and healthcare use than individuals with DGBI in the pre-pandemic era.

Conclusion

The population prevalence and burden of DGBI have increased following the COVID-19 pandemic. Healthcare services and research funding bodies need to adapt to this post-COVID surge in DGBI and address how to best manage this patient group.

Clinical Case Summary

Introduction: This case describes a rare complication, triggered by SARS-CoV2 infection in a patient with Crohn’s disease (CD) and a long history of gastrointestinal and extraintestinal manifestations but otherwise stable at the infection onset.
Case Presentation: 25-year old male,non smoker, unvaccinated against COVID-19,with fistulizing and stricturing CD diagnosed at age 12 with multiple extraintestinal complications (articular,ocular, thrombotic, malnutrition). Therapeutic history is marked of various failed attempts over the years, ranging from many courses of steroids, anti-TNFalfa drugs, immunosupresives to holistic approaches until the age of 24 when he presented at our clinic and we initiated treatment with ustekinumab with a good response. During his previous visit,he presented with fever and COVID-19 infection. Radiologic image of the lung was normal but a computed tomography scan was performed to rule out a complication of CD. Both clinical and imaging evaluations confirmed a stable condition with colo-cutaneous fistula in partial remission. Four days later he presented with signs of acute abdomen, extremely distressed, hypotensive,tachycardic.
Tests revealed: leukocytosis, rised inflammatory markers, thrombocytopenia, high D-dimer. The scan suggested a perforation and was taken to surgery where the laparotomy confirmed it, at the level of the transverse colon. He suffered a cardiopulmonary arrest during the surgery and died despite resuscitative efforts.
Discussion: SARS-CoV2 virus binds to the human angiotensin-converting enzyme 2 receptors and triggers direct endothelial lesions and activation of prothrombotic factors resulting in a cascade of microvascular injury and ultimately ischemic tissue damage. Ischemia weakens the bowel wall, increasing risk of ulceration, necrosis,and perforation, especially in Crohn’s patients with fragile mucosa.
Conclusion: The case highlights the potential for fatal outcomes and the importance of close observation in CD patients during SARS CoV2 infection.

References

Images with the colo-cutaneous fistula before and after the treatment with ustekinumab
Ragiologic and computed tomography imaging from his previous visit with the first SARS-CoV2 positive test
Radiologic and computed tomography imaging from his last visit when he presented with acute abdomen