A lengthy report (DA Drossman et al. Gastroenterol 2018; 154: 1140-71) thoroughly reviews the evidence for neuromodulators for functional GI disorders, including Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome.
“Some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship.”
The report makes specific recommendations for several functional conditions (Table 4).
- For dyspepsia, the authors recommend categorizing as either postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) as per Rome IV criteria.
- They state that “Buspirone…may be used for PDS where early satiety, fullness and nausea predominate.”
- “Mirtazapine is a good treatment option for PDS when there is chronic nausea and vomiting, or weight loss, and it may also help coexisting abdominal pain.”
- For EPS, “studies mainly support the use of TCAs, either initially or after an unsuccessful response to a proton pump inhibitor.”
Figure 5 outlines general treatment advice:
- SSRIs -“when anxiety, depression and phobic features are prominent with FGIDs”
- TCAs -“first-line treatment when pain is dominant in FGIDs”
- Tetracyclic antidepressant (mirtazapine, mianserin, trazodone) -“treatment of early satiety, nausea/vomiting, weight loss and disturbed sleep”
- SNRIs (duloxetiine, venlafaxine, desvenlafaxin, milnacipran) -“treatment when pain is dominant in FGIDs or when side effects from TCAs preclude treatment”
- Augmentation therapies are subsequently delineated including atyipical antipsychotics, pyschological treatments (like cognitive behavioral therapy) and hypnosis
Related blog posts:
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
Full Abstract: Low Rates of Gastrointestinal and Non-Gastrointestinal Complicaitons for Screening or Surveillance Colonoscopies in a Population-Based Study
(L Wang, et al. Gastroenterol 2018; 154: 540-555, https://doi.org/10.1053/j.gastro.2017.10.006)
Using California’s Ambulatory Services Databases, the authors identified 1.58 million surveillance/screening colonoscopies (2005-2011) and compared complications to patients who underwent other ambulatory procedures like joint aspiration, arthroscopy and cataract surgery.
- GI complications including perforation and GI bleeding were low but more common with colonoscopy than comparator procedures
- Rates of serious non-GI complications including myocardial infarction, stroke, and serious pulmonary events were no higher than other low-risk comparator procedures.
- Complication rates were higher with advancing age, particularly in those >70 years. see Figure 2 below
A Gini, et al. “Cost Effectiveness of Screening Individuals with Cystic Fibrosis for Colorectal Cancer” Gastroenterol 2018; 154: 556-67.
- Key point: “Colonoscopy every 5 years, starting at age of 40 years was the optimal colonoscopy strategy for patients with cystic fibrosis” without prior organ transplantation.
D Hadjuliais, et al. “Cystic Fibrosis Colorectal Cancer Screening Consensus Recommendations: Gastroenterol 2018; 154: 736-45.
- There are 10 Task Force recommendations. These include “initiation of screening at 40 years” in those without organ transplantation. Among those who have had organ transplantation, CRC screening is recommended at age 30 years and/or within 2 years of transplantation. Link: Abstract
My take: Fortunately, more individuals with cystic fibrosis are living long enough to benefit from CRC screening. Due to increased risk, these guidelines recommend screening at a younger age than the general population.
More pics from Hoover Dam. The figure in this picture is a art piece honoring those who died while working on the construction
A recent prospective study (A M-L Ong et al. Clin Gastroenterol Hepatol 2018; 16: 407-16) of 36 patients (median age 45) showed that diaphragmatic breathing was helpful for PPI-refractory GERD symptoms/belching. Patients enrolled all had “troublesome belching” for 6 months and GERD. Patients underwent high resolution manometry and pH-impedance study.
- 9 of 15 (60%) in the diaphragmatic treatment group reduced their belching visual analog score by ≥50%, whereas none of the control group achieved the primary outcome
- Treatment also resulted in lower GERD symptoms based on reflux disease questionnaire score -decrease of 12.2 vs 3.1 in the control group (P=.01)
- Treatment improved QOL scores, based on Reflux-Qual Short form (15.7 increase for treatment group compared to 2.4 decrease in control group)
- Treatment effects were sustained at 4 months after treatment
My take: Diaphragmatic breathing can be a useful adjunct in GERD, particularly in patients with belching.
Related blog post: Treatment for rumination and belching
Foggy Morning in Sandy Springs
A recent randomized, placebo-controlled cross-over study by A Pauweis et al (Am J Gastroenterol 2018; 113: 97-104) indicated that baclofen improved rumination syndrome in adults (mean age 42 years). Thanks to Ben Gold for this reference.
Baclofen (dosed at 10 mg TID) had the following effects:
- reduced rumination episodes from 13 (8-22) to 8 (3-11) (P=0.004)
- increased lower esophageal sphincter (LES) pressure (17.8 vs. 13.1, P=0.0002) and lowered number of transient LES relaxations (4 vs 7, P=0.17)
- overall treatment evaluation was superior after baclofen compared to placebo (P=0.03)
My take: In this study, baclofen improved symptoms of rumination and regurgitation, but not supragastric belching.
“Escape” stairs in Hoover Dam
Review/excerpt of this study from NEJM Journal Watch: by Daniel J. Pallin, MD, MPH.
In the current trial, 120 adult ED patients with nausea or vomiting who did not require intravenous access were randomized to inhaled isopropyl alcohol plus 4 mg oral ondansetron; inhaled isopropyl alcohol plus oral placebo; or inhaled saline plus 4 mg oral ondansetron. Isopropyl alcohol was provided in the form of a standard alcohol swab. Patients received a single dose of the oral intervention but could sniff alcohol or saline swabs repeatedly. Nausea was measured on a 100-mm visual analog scale at baseline and 30 minutes.
Mean nausea scores decreased by 30 mm in the alcohol/ondansetron group, 32 mm in the alcohol/placebo group, and 9 mm in the saline/ondansetron group. Rescue antiemetic therapy was given to 28%, 25%, and 45% of each group, respectively. Differences between alcohol and saline groups were statistically significant. Patients in the inhaled alcohol groups also had better nausea control at the time of discharge and reported higher satisfaction with nausea treatment. No adverse events occurred. The mechanism of action is currently unknown.
Dr. Pallin’s comments on study:
It is uncommon for us to assign a rating of “Practice Changing” to a small, single-center study, but these results are truly remarkable and are consistent with prior research. For patients not obviously requiring IV therapy, we should treat nausea with repeated inhalations from an isopropyl alcohol swab instead of administering any other drug. And, although this study provides no direct evidence of benefit to patients who do require IV therapy, there would seem to be little downside to trying this simple and safe intervention in that group, too.
My take: Who is doing the pediatric study to try to replicate these results in the pediatric population?
Related blog posts:
Foggy Morning in Sandy Springs
A recent article (P Collin et al. AP&T 2018; 47: 563-72) reviews the presentation of celiac disease in later years (Thanks to Ben Gold for this reference).
- Approximately 25% of celiac diagnoses are made at age ≥60 years
- ~4% of celiac diagnoses are made at age ≥80 years
- About 60% of individuals with celiac disease remain undetected
- Adherence with gluten free diet results in “resolution of symptoms and improvement in laboratory indices…in over 90% of patients”
This review also focuses on specific related problems besides epidemiology: malabsorption, dermatitis herpetifromis, bone mineral density and fractures, autoimmune disease, heart disease, neurological disturbances, and malignancy.
Bright Angel Trail