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A Specialty Clinic for Functional Gastrointestinal Disorders in Tertiary Care: Concept and Patient Population

2017; Elsevier BV; Volume: 15; Issue: 7 Linguagem: Inglês

10.1016/j.cgh.2017.02.039

1542-7714

Sabrina Berens, F Kraus, Annika Gauss, Jonas Tesarz, Wolfgang Herzog, Beate Niesler, Esther Stroe‐Kunold, Rainer Schaefert,

Health, psychology, and well-being

Functional gastrointestinal disorders (FGIDs) are common disorders of the gut-brain interaction classified by gastrointestinal (GI) symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing.1Drossman D.A. Functional gastrointestinal disorders: history, pathophysiology, clinical features and Rome IV.Gastroenterology. 2016; 150: 1262-1279Google Scholar FGIDs are classified according to the Rome criteria, which are primarily based on symptom patterns, related to organ location or overarching dysregulation of symptom control pathways. The most prevalent FGIDs are irritable bowel syndrome (IBS) (abdominal pain, diarrhea/constipation, bloating) and functional dyspepsia (postprandial distress or epigastric pain syndrome). Patients with mild courses can usually be sufficiently managed by general practitioners and/or gastroenterologists.2Almquist E. Törnblom H. Simrén M. Practical management of irritable bowel syndrome: a clinical review.Minerva Gastroenterol Dietol. 2016; 62: 30-48Google Scholar In more severe/complicated courses (25%), psychosocial stressors increase in relevance,3Drossman D.A. Chang L. Bellamy N. et al.Severity in irritable bowel syndrome: a Rome Foundation Working Team report.Am J Gastroenterol. 2011; 106: 1749-1759Google Scholar and standard treatment often remains insufficient.4Palsson O.S. Whitehead W.E. Psychological treatments in functional gastrointestinal disorders: a primer for the gastroenterologist.Clin Gastroenterol Hepatol. 2013; 11: 208-216Google Scholar Accumulating data suggest that FGIDs result from reciprocal interactions between biological, psychological, and social factors.5Van Oudenhove L. Crowell M.D. Drossman D.A. et al.Biopsychosocial aspects of functional gastrointestinal disorders.Gastroenterology. 2016; 150: 1355-1367Google Scholar Therefore, a biopsychosocial framework is critical for their understanding, assessment, and treatment. However, biopsychosocial models of care are lacking or rarely realized. This article aims to present our concept of an interdisciplinary FGID clinic in tertiary care and to characterize its patient population. We conducted a retrospective, observational study of all patients at our clinic between June 2012 and January 2015. The precondition for referral was a suspected FGID diagnosis that is based on laboratory screening, abdominal ultrasonography, endoscopy, and gynecologic examination for women. Basic treatment (eg, communication of the diagnosis or psyllium) should have remained insufficient. Our interdisciplinary model of care implements a simultaneous concept that considers somatic and psychosocial factors of illness:5Van Oudenhove L. Crowell M.D. Drossman D.A. et al.Biopsychosocial aspects of functional gastrointestinal disorders.Gastroenterology. 2016; 150: 1355-1367Google Scholar, 6Häuser W. Layer P. Henningsen P. et al.Functional bowel disorders in adults.Dtsch Arztebl Int. 2012; 109: 83-94Google Scholar, 7Layer P. Andresen V. Pehl C. et al.Irritable bowel syndrome: German consensus guidelines on definition, pathophysiology and management.Z Gastroenterol. 2011; 49: 237-293Google Scholar(1)Simultaneous assessment is based on thorough history taking and a physical (including rectal) examination within a 1-hour clinical consultation.•Physical: Typical symptom patterns are investigated according to the Rome III criteria. Alarm features (red flags) that are based on symptoms (eg, blood in stool or weight loss), patient history (eg, recent antibiotics), and diagnostic findings (eg, high fecal calprotectin) are carefully assessed, and other diagnoses are excluded by stepwise diagnostic assessment. The basic diagnostic evaluation is reviewed and complemented as appropriate. Special diagnostic tests are added depending on the symptom pattern, severity, and patient age.•A psychosocial anamnesis is taken. Psychosocial indicators for a more severe/complicated course (yellow flags: eg, dysfunctional illness perception/behavior) are assessed. If required, additional assessment at our psychosomatic clinic is offered.•All patients keep a diary of their diet, symptoms, and resources during a 2-week period. The diary assesses the patient’s food and fluid intake and symptoms, including their duration and severity, as well as symptom-related daily events and interactions, thoughts, feelings, and behaviors.•The following features are assessed by using general and FGID-specific questionnaires according to pertinent recommendations:8Boeckxstaens G.E. Drug V. Dumitrascu D. et al.Phenotyping of subjects for large scale studies on patients with IBS.Neurogastroenterol Motil. 2016; 28: 1134-1147Google Scholar physical features: stool frequency and consistency (IBS Severity Scoring System [IBS-SSS], Bristol Stool Form Scale), symptom severity (IBS-SSS), somatic symptom severity (Patient Health Questionnaire-15); psychosocial features: abuse, suicidal tendency (Rome III Psychosocial Alarm Questionnaire), quality of life (Functional Digestive Disorders Quality of Life, Short Form-36), depression (Patient Health Questionnaire-9), and anxiety (Generalized Anxiety Disorder 7-item scale).(2)Identified somatic and psychosocial illness factors, triggers, risk factors, and resources are integrated into an individualized biopsychosocial explanatory model together with the patient.(3)Multimodal treatment based on current guidelines and evidence is individually derived from the explanatory model, combining the following measures: general (exercise, warmth, and tea), nutritional (abstention from lactose/fructose as appropriate; nutrition consultation), psychosocial (psychoeducation, relaxation, gut-directed hypnotherapy, and cognitive-behavioral/psychodynamic-interpersonal psychotherapy), and symptom-oriented medication and psychopharmacotherapy. Interventions are partly provided within our FGID clinic and partly by recommended external providers. Assessment and treatment planning are critically reviewed in weekly interdisciplinary meetings between the internal medicine residents, a gastroenterology consultant, a psychosomatic consultant, and a psychologist. Of all 294 patients, 92.2% fulfilled the Rome III criteria for any FGID. Patients with FGID (Table 1) had a median age of 38 years [23.0], and 72.0% were female. The symptoms were chronic (median duration, 4 years), and median symptom severity (IBS-SSS) score was 290 [169]. The most frequent somatic comorbidities were food intolerance (54.2%), gastritis (26.3%), and previous GI operation (22.5%). Moreover, patients exhibited a high psychosocial burden: 65.1% had a somatoform disorder, 41.2% had a depressive disorder, and 18.6% had an anxiety syndrome; accordingly, 53.1% of patients reported current or previous psychotherapy.Table 1Characterization of Patients With FGID in Tertiary Care at Our Interdisciplinary Specialty ClinicEffective nFGID patients (n = 271)Sociodemographic characteristics Age, yaMedian [interquartile range].27138 [23.00] Female gender, n (%)271195 (72.00) German nationality, n (%)265249 (94.00) Marital status, with a partner, n (%)271152 (56.10) Educational level – ISCED ≤ 2, n (%)271126 (46.50) Paid employment, n (%)271144 (53.10) Old-age pension, n (%)27132 (11.81) Disability pension, n (%)2718 (3.00)FGID subtypes IBS271220 (81.20) Functional dyspepsia271153 (56.50) Functional bloating27118 (6.60) Functional constipation2717 (2.60) Functional diarrhea2714 (1.50)GI symptoms Symptom duration, moaMedian [interquartile range].25548.00 [101.00] Symptom severity (IBS-SSS; range, 0–500)aMedian [interquartile range].267290.00 [169.00]Any mental disorder, n (%)250188 (75.20)Somatization (PHQ-15) Any somatoform syndrome, n (%)255166 (65.10) PHQ-15 (range, 0–30)aMedian [interquartile range].25013.00 [7.00] PHQ-12 (range, 0–24)aMedian [interquartile range].2508.00 [5.71] SSS-8 (range, 0–32)aMedian [interquartile range].26113.00 [9.07]Depression (PHQ-9) Any depressive syndrome, n (%)262108 (41.22)Major depressive syndrome, n (%)26366 (25.10)Other depressive syndrome, n (%)26342 (15.97) PHQ-9 (range, 0–27)aMedian [interquartile range].2699.00 [7.37]Anxiety (GAD-7; PHQ panic module) Any anxiety syndrome, n (%)25848 (18.60)Other anxiety syndrome, n (%)25930 (11.58)Panic syndrome, n (%)26327 (10.27) GAD-7 (range, 0–21)aMedian [interquartile range].2677.00 [8.00]Other psychosocial features Illness anxiety (WI-7; range, 0–28)aMedian [interquartile range].26411.00 [10.00] Any eating disorder, n (%)26127 (10.00) Abuse (ROME III), n (%)25348 (18.97) Suicidal tendency (ROME III), n (%)25952 (20.07)Quality of life Functional Digestive Disorders-QoL (range, 0–100)bMean (standard deviation).25848.32 (15.27) Physical QoL (Short Form-36) (range, 0–100)bMean (standard deviation).25040.44 (9.83) Mental QoL (Short Form-36) (range, 0–100)aMedian [interquartile range].25039.29 [21.02]Health care utilization Appointments in FGID clinic, 1 yaMedian [interquartile range].2682.00 [2.00] Appointment in the psychosomatic outpatient clinic Heidelberg, n (%)27182 (30.26) Medical appointments, last 4 wkaMedian [interquartile range].2592.00 [1.00] Psychotherapeutic treatment, n (%)262139 (53.05)Currently, n (%)70 (26.72)Previously, n (%)69 (26.34) Current medication for anxiety, depression, or stress, n (%)25978 (30.12) Previous inpatient stay, n (%)26843 (16.04)Psychiatric acute care hospital, n (%)27 (10.07)Psychiatric rehabilitation hospital, n (%)9 (3.36)Work-related impairment due to GI symptoms in the last year (IBS-SSS) Absenteeism, weeks absent from workaMedian [interquartile range].1552.00 [6.00] Presenteeism, weeks suffering at workaMedian [interquartile range].8325.00 [48.00]GAD-7, Generalized Anxiety Disorder 7-item scale; ISCED, International Standard Classification of Education; PHQ, Patient Health Questionnaire; QoL, Quality of Life.a Median [interquartile range].b Mean (standard deviation). Open table in a new tab GAD-7, Generalized Anxiety Disorder 7-item scale; ISCED, International Standard Classification of Education; PHQ, Patient Health Questionnaire; QoL, Quality of Life. Our biopsychosocial model of care proved highly acceptable for affected patients and is an especially important option for patients with more complicated courses. Psychotherapeutic treatments may not sufficiently relieve FGID problems if GI-specific measures are lacking. Moreover, the core strengths of our clinic are its biopsychosocial approach and the interdisciplinary medical setting. Its limitations are the required specialists and resources. To date, most investigations have focused on various unimodal treatments, and future research should implement interdisciplinary clinics and evaluate their impact against standard medical care.