Fourth Annual International Symposium on Functional Gastrointestinal Disorders

This was a truly international symposium where the author of this site often found himself at breakfast and meeting breaks sitting next to people from Europe, South America, and the Asian countries.  There were a number of Canadians and many people from the immediate surrounding area of Milwaukee, Wisconsin.  The attendees were mainly physicians and psychologists.  Nurses and occupational therapists were also represented.  Gastroenterology was the most common specialty represented.   But, what impressed me was that the "specialists" were so interdisciplinary and appreciative of one another.  I felt very much at home.  The conference was pricey with physicians and psychologists paying $550 and all others $375.  It would hardly be a venue for laypersons wanting to know more about the functional gastrointestinal disorders, where irritable bowel syndrome (IBS) was the main focus.

The value of this symposium for me, which got very esoteric with many of its topics, was the opportunity for new personal contacts and becoming reacquainted with many of my colleagues.  It was nice to be recognized and have many people comment favorably on my website and the Clean Kid Manual.  One of the symposium's organizers asked permission to put a link to my site on his university's medical school-based site.  I was delighted to meet and talk with people who were on the Rome II committees.  They named and defined the criteria for the basic GI disorders now in use.  There will be a Rome III edition in about another 5 years.  One of these people read my Clean Kid Manual on his airplane ride home and emailed me with a very kind, constructive, and helpful review.

The conference was disappointing to me insofar there was virtually no coverage of my very narrow focus of interest on encopresis in children.  It was only in individual personal encounters that I picked up much wisdom and observations that were relevant to my concerns.  One of the organizers hinted that they were considering the next conference to be more focused on children. 

So stay tuned to this site where I will preview what I can about the next conference in Milwaukee. 

A summary of the conference authored by Douglas A. Drossman, M.D. and Donna D. Swantkowski, M. Ed. follows.  Both authors are associated with the University of North Carolina Medical School at Raleigh, NC. 

The 4^th International Symposium on Functional GI Disorders sponsored by International Foundation for Gastrointestinal Disorders (IFFGD) and Functional Brain Gut Research Group (FBG) was held on March 30^th - April 2^nd, 2001 in Milwaukee, Wisconsin.  The meeting was attended by an international group of experts who came together to share state-of-the-art research and information on diagnosis and treatment of functional gastrointestinal disorders.

The meeting opened with an introduction by Nancy Norton MA, President of IFFGD who welcomed the group and discussed the numerous educational activities of IFFGD and it's role in encouraging federal support for research.  Then, W. Grant Thompson MD, Chair of FBG talked the association with IFFGD from its beginnings in 1992, and endorsed its ongoing association for future meetings with IFFGD.  Following this Frank Hamilton MD, Chief, and Digestive Diseases Programs Branch of NIDDK (NIH) commented on the history of NIH support for FGID's beginning with the 9/92 NIH workshop on IBS.  Next, Victor Raczkowski MD, Deputy Director, Office of Drug Evaluation of FDA identified the members of the FDA GI research team and addressed controversies related to drug approval.  He also identified some of the myths about IBS, and ended with a note that discussions between FDA and GlaxoSmithKline are under way to determine if Lotronex can be returned to the marketplace.

 Following the Introductory Comments, the general (plenary) sessions covered a range of issues and went beyond the basic science understanding of these disorders. Sessions included presentations on Epidemiology and Behavioral Factors, Basic Principles - Brain/Gut, Inflammation, Brain Imaging, Altered Bowel Function, Clinical Application, Functional GI Disorders, General Principles of treatment, Pharmacological treatment, and Psychologic and Psychophysiological Treatment.  Below are some of the highlights of the presentations, which reflect the developing areas of research in IBS and the functional GI disorders.

Epidemiology And Behavioral Factors

q The incidence of IBS is 20 times greater than that for inflammatory bowel disease.  Risk factors include abuse, post-infectious state, genetic/familial factors, and possibly even analgesics. 

q Gender effects seem to appear after puberty.  Also, it is important to consider that gender-related treatments need to be developed and tested. 

q Recent research has shown that children of IBS parents consume greater health care costs and have more clinical visits than children of parents without IBS.

q Early learning factors are quite important is explaining the development of IBS.

Physiology

 q The use of PET and fMRI in humans with GI disorders has become an active area of investigation.  Emotional states, like fear and disgust can activate areas of the limbic system [amygdala, Anterior Cingulate Cortex (ACC)]. This area is associated with emotional arousal, while the prefrontal cortex is associated with pain memory and interpretation.  Disruption of this circuitry may be a factor leading to increased pain in IBS.

q Efforts are being made to move toward non-invasive assessment of bowel motility and more standardized testing methods.

q While normals have greater efficiency in expelling gas, those with IBS/functional bloating have altered gas dynamics with greater retention.  This effect, coupled with visceral hypersensitivity may doubly contribute to symptoms of pain and bloating. Treatments may be directed toward increasing transit rate of accumulated gas (e.g., with neostigmine or prokinetic agents) or increasing compliance of the bowel wall to better accommodate the distension.

q Diarrhea is associated with more rapid transit related to altered MMC (e.g., increased HAPC) activity, an exaggerated contractile response to food, CCK and other physiological stressors, increased visceral hypersensitivity compared to patients with constipation, and possibly altered colonic and rectal tone

q About half of patients reporting constipation have normal transit.  The remaining group have either colonic inertia associated with decreased HAPC's and decreased reactivity to meals and other bowel stimulants, or outlet dysfunction (e.g., pelvic floor dyssynergia) which may be amenable to anorectal biofeedback treatment.

CLINICAL FEATURES

q The clinician needs to be able to elicit and integrate the dietary, lifestyle, gut physiology and psychosocial features unique to the patient, and to use this information through application of a multidisciplinary treatment approach. The importance of good interview skills and an effective physician- patient relationship was emphasized.

q Dietary restriction of poorly absorbed carbohydrates {fructose or sorbitol} may reduce diarrheal symptoms.

q Globus and rumination syndrome are distinctly different from functional chest pain, heartburn and dysphagia. What may be different from previous assumptions is that the latter three diagnoses overlap in pathogenesis, and are not as easily distinguished physiologically.  In one study these complaints were found to be associated with increased wall thickness at the time of symptom presentation

q Rumination is a unique condition, more often affecting males

q Functional biliary disorders and emphasized the importance of excluding other conditions (e.g. GERD, ulcer disease, functional bowel disorder), which may mimic the less common biliary disorders. Newer non-invasive tests are used to assess bile duct emptying, thereby reducing the risks related to ERCP and biliary manometry.

q Functional anorectal disorders including fecal incontinence, pelvic floor dyssynergia and functional anorectal pain (levator ani syndrome and proctalgia fugax).  Unlike most functional GI disorders (though similar to the functional biliary disorders) diagnostic testing using physiological methods is important in confirming the diagnosis and directing treatment, which can include anorectal biofeedback.

q The high health costs and unnecessary procedures (including hysterectomies) may be obviated through physician education about diagnostic criteria. Physicians who address psychosocial factors may further reduce health care costs.

q Good communication skills were emphasized.  Building an effective physician-patient relationship depends on active listening, providing empathy, validating the patient's feelings, educating and reassuring through interactive dialog and mutually negotiating treatments.  This is associated with improved patient satisfaction, adherence to treatment and improved clinical outcome.

Treatment    

 q Newer GI pharmacological agents just coming out, or in the pipeline include the 5HT agents (e.g., Alosetron a 5HT3 antagonist, recently withdrawn from the market, Cilansetron another 5HT3 antagonist, and Tegaserod, a 5HT4 partial agonist soon to be reviewed by the FDA)/

q  Antidepressants are off-label indications for the FGID's based on the association of these conditions with psychiatric co-morbidity, the rich innervation of the gut, which provides a therapeutic target for these drugs, and the fact that antidepressants have an established track record with other chronic painful disorders.

q There are a variety of psychological and psychophysiological treatments available for the FGID's, each with varying benefit depending on the skill of the therapist and motivation of the patient

q Cognitive-behavioral treatment, which focuses on a collaborative interaction where the patient is informed about the techniques of CBT, and efforts are made to demystify the therapeutic process and establish an egalitarian, participatory therapeutic relationship. This is an active form of treatment that requires high patient motivation. Group or individual treatment, tailored to personal needs can be provided.  CBT can be viewed as complementary to other medical treatments and combining CBT with antidepressants was recommended in patients with more chronic or recurrent symptoms.

q  Psychodynamic-interpersonal treatment can help patients with moderate to severe symptoms.  Here a longer initial session focuses on addressing difficult feelings as they emerge in interpersonal relationships, and this information is used in later sessions to help the patient gain insight into these feelings.  Ultimately, this can effect a positive change in feelings and relationship and improvement in GI symptoms

q  Biofeedback targets neuromuscular conditions, autonomic arousal and vascular conditions and can be used in situations like rumination and functional vomiting.  Progressive muscle relaxation and breathing techniques are often used with other treatments, and are ways to reduce anxiety and arousal. Mindfulness stress reduction encourages and supports positive cognitive and behavioral lifestyle, and requires high motivation. 

q  Biofeedback specifically for disorders of defecation (fecal incontinence and constipation), which are not readily amenable to medical or surgical treatments is safe, easily applied and can lead to reduced symptoms via actual changes in physiological functioning, and ultimately improved clinical outcome.

 In addition to the plenary sessions, Meet the Professor Luncheons, and workshop gave participants the opportunity to meet in small groups, role play , and interact with the leaders in the field All aspects of the symposium were equally important as summarized in the following quote by Douglas A. Drossman, MD:

 "What will be remembered is the remarkable energy among the participants, the degree and quality of the scientific and social interactions that occurred in the plenary sessions, during coffee breaks, and in the hallways and lounges, as well as during the wonderful social functions."