When I visited MIT, one of the slogans I heard was “Getting an Education from MIT is like taking a drink from a Fire Hose.” While this is a ridiculous notion, it is also true that the amount of information to consume, not just at MIT, but in so many areas is tremendous in quantity. As such, one has to figure out what to read and what to toss. For GI physicians, a recent summary (DA Drossman. Gastroenterol 2016; 1262-80) is worth a read due to the ubiquitous nature of the problems discussed.
Here were some key points:
- “The possibility that passions or emotions could lead to the development of medical disease was first proposed by the Greek physician Claudius Galen.”
- “Rome IV is a compendium of knowledge accumulated since Rome III” –10 years ago.
Some of the Changes:
- New diagnoses: Narcotic bowel syndrome, opioid-induced constipation, cannabinoid hyperemesis syndrome
- Removal of functional terminology when possible…functional abdominal pain syndrome has been changed to centrally mediated abdominal pain syndrome
- Threshold changes for diagnostic criteria
- Addition of reflux hypersensitivity diagnosis.
- Revision of Sphincter of Oddi dysfunction disorder… “driven by evidence that debunks the value of sphincterotomy for type III SOD.”
- Emphasis that functional disorders exist on a spectrum with linked pathogenesis, particularly with regard to irritable bowel syndrome (IBS) subtypes.
- Removal of the term discomfort for IBS criteria and using pain as the key criterion.
Approach to Patients with Functional GI Disorders:
- The author discusses ways to engage patient to create partner-like interaction.
- “Determine the immediate reason for the patient’s visit (eg. What led you to see me at this time?)” Potential reasons: exacerbating factors, concern for serious disease, stressors, emotional comorbidity, impairment in daily functioning or hidden agenda (eg. disability, narcotics, litigation)
- “Determine what the patient understands of the illness…What do you think is causing your symptoms?”
- Provide a thorough explanation of the disorder. “For example: ‘I understand you believe you have an infection that has been missed; as we understand it, the infection is gone but your nerves have even affected by the infection to make you feel like it is still there, similar to phantom limb.”
- “Identify and respond realistically to the patient’s expectations for improvement (e.g. How do you feel I can be helpful to you?)”
- Explain ways that stress can be associated. “I understand you do not see stress as causing your pain, but you have mentioned how severe and disabling your pain is. How much do you think that is causing you emotional distress?”
- “Set consistent limits..narcotic medication is not indicated because it can be harmful.”
- “Involve patient in treatment plan (e.g. Let me suggest some treatments for you to consider).”
- With regard to use of TCAs, the author explains that antidepressants can be used “to turn down the pain, and pain benefit occurs in doses lower than that used for depression.” “Tricyclic antidepressants or the serotonin-norepinephrine reuptake inhibitors help control pain via central analgesia as well as provide relief of associated depressive symptoms. The selective serotonin reuptake inhibitors are less effective for pain but can help reduce anxiety and associated depression.”
- Establish an ongoing relationship. “Whatever the result of this treatment, I am prepared to consider other options, and I will continue to work with you through this.”
My take: This summary provides a succinct update on a 6-year effort of 117 investigators/clinicians from 23 countries. After reading this article, you will probably want to glance at the other articles in the same issue.