Learn diagnostic and therapeutic management strategies for IBS, functional dyspepsia, and cyclic vomiting (aka disorders of gut brain interaction (DGBI))! It’s like three episodes in one as we run through how to individualize evaluation and management for patients with functional dyspepsia, IBS, and cyclic vomiting. Topics: scripts for counseling patients, the pathophysiology of DGBI, which diagnostic tests are necessary, pharmacologic and nonpharmacologic options, and even hypnotherapy?! We’re joined again by the great Dr. Xiao Jing (Iris) Wang, (@IrisWangMD, Mayo Clinic)
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Disorders of the Gut Brain Interaction (DGBI), formerly known as functional GI disorders, are conditions caused by interactions between the nervous systems in the gut and brain. DGBI are characterized by symptom clusters with limited findings or structural abnormalities on diagnostic testing.
The pathophysiology of DGBI involves a combination of altered motility, visceral hypersensitivity, changes in the epithelial barrier of the gut, mucosal immune dysfunction, microbiome disturbance and gut central nervous system neural processing.
Dr. Wang explains DGBI to patients by describing the pathophysiology and focusing on DGBI as a positive diagnosis, not a diagnosis of exclusion. It’s important to talk about DGBI before testing, explaining that negative test results are evidence of DGBI. Reinforce the importance of ruling out potentially threatening structural etiologies and validate the patients’ symptoms and impact on quality of life (Keefer, 2021).
Patients with these disorders are often considered challenging to manage by health care providers because there is a lack of understanding and experience managing DGBI during professional training. Additionally, symptoms commonly overlap with multiple structural abnormalities of the GI system, making the diagnosis more difficult. To address these gaps in comfort, providers should establish a systematic diagnostic approach for DGBI (Keefer, 2021).
Satiation vs. Satiety
Early satiation = a smaller portion of food leads to feeling full
Early satiety = feeling full for a longer period of time
Functional dyspepsia is diagnosed by the Rome-IV criteria:
Functional dyspepsia has two subgroups (Ford, 2020):
The American College of Gastroenterology (ACG) and the Canadian Association of Gastroenterology (CAG) provide guidance for the evaluation of dyspepsia in a consensus statement (Moayyedi, 2017). Younger patients should be evaluated for H pylori by noninvasive testing such as stool antigen or urea breath test. If any alarm features or age >55 years old, upper endoscopy is recommended to evaluate for H pylori and malignancy (Ford, 2020).
Dr. Wang recommends a gastric emptying study in patients with significant vomiting, regurgitation or nausea to evaluate for delayed gastric emptying and gastroparesis. Ford et al describe how up to one quarter of patients with functional dyspepsia present with delayed gastric emptying pointing to potential overlap between these two conditions.
The first step in functional dyspepsia management is explaining the disease pathophysiology to the patient. Next, you should discuss treatments directed toward specific symptoms. Pharmacologic and nonpharmacologic treatments should be considered depending on the patient’s preferences and comorbidities. It is important to reinforce that you believe the patient’s symptoms are real and will target the most bothersome symptoms first with the treatment options available (Keefer, 2021).
Pharmacologic (consider for all patients with functional dyspepsia)
“Next Step” options (Postprandial Distress Syndrome vs. Epigastric Pain Syndrome)
Postprandial Distress Syndrome treatments target early satiation
Epigastric Pain Syndrome treatments target visceral hypersensitivity
New pharmacologic options
Acotiamide is an acetylcholinesterase inhibitor that relaxes the gastric fundus, but the exact mechanism of action is still not completely understood and the medication is not available in the US (Matsueda, 2012). Potassium competitive acid blockers, like Vonoprazan, might be a good choice for patients that do not metabolize PPIs well (Asaoka, 2017).
Irritable Bowel Syndrome (IBS) is diagnosed based on symptoms including recurrent abdominal pain associated with alteration of either stool frequency or consistency at least 1 day per week for > 3 months, with symptom onset >6 months prior. IBS can be classified as IBS with constipation (IBS-C) >¼ bowel movements are types 1 or 2 on the Bristol Stool Scale; IBS with diarrhea (IBS-D) >¼ of stools are types 6 or 7; IBS with mixed pattern, >¼ of stools are type 1 and 2 and >¼ are types 6 or 7. Unclassified meets the criteria for IBS but doesn’t fall in any of those categories (Ford, 2020). Dr. Wang recommends explaining when the diagnosis of IBS is very likely according to symptoms and testing is done to rule out other conditions that could mimic IBS. This will ensure appropriate treatment is started early.
Note: Figures that can help diagnose and workup common GI symptoms from prior episodes: Constipation, Diarrhea Part I and Part II.
Celiac disease, inflammatory Bowel Disease (IBD), Microscopic Colitis and Colorectal Cancer are on the differential diagnosis, and patient factors should guide how far you workup these diagnoses. For PCPs, Dr. Wang recommends celiac serology testing to rule out celiac disease and fecal calprotectin or lactoferrin for IBD (Ford, 2020). Testing for infectious causes is generally not recommended unless there are risk factors (eg, post-infectious IBS-D or possible exposures to Clostridium difficile and/or giardia. If Microscopic Colitis is a consideration, GI specialists will pursue flexible sigmoidoscopy with random biopsy to evaluate. Bile acid diarrhea should be considered for patients with abnormal bile acid circulation, like Crohn’s disease, iliac resection, extensive appendectomy, persistent GI symptoms after cholecystectomy. Bile acid diarrhea is investigated with 48 hour fecal bile acid excretion testing (Ford, 2020). Small intestinal bacterial overgrowth (SIBO) should be considered in patients with risk factors such as previous gastric or intestinal surgery or predisposition to bacteriostasis including Roux-en-Y bypass, small intestine diverticulosis, and dysmotility of the small bowel.
Evalute for pelvic floor dysfunction with a digital rectum exam or anal rectal manometry. If >45 years old, colonoscopy should be performed for screening of colorectal cancer, not as a workup for constipation (Ford, 2020).
IBS management should start with a thorough explanation of the disease, symptoms, pathophysiology and natural history. Treatment aims to decrease the most bothersome symptom and should include a realistic discussion about the limitation of treatments available.
Cyclic vomiting Syndrome (CVS) is a syndrome with episodes of uncontrollable vomiting, separated by periods of relative wellness/absence of vomiting. Episodes are often associated with nausea, abdominal pain, headache, photo- and phonophobia, and autonomic symptoms.
Rome IV criteria: vomiting <1 week occurring at least 1 week apart with at least two acute-onset episodes in the past 6 months. Emesis is absent between episodes, but other symptoms might persist. CVS is associated with a family or personal history of migraines and abdominal migraines (Hasler, 2019; Hayes, 2018).
Cannabinoid Hyperemesis Syndrome (CHS) is characterized by stereotypical episodic vomiting in the setting of chronic, daily cannabis use, and the relief of episodic vomiting with cessation of cannabis use. It is frequently associated with epigastric abdominal pain. There are periods of remission lasting from days to weeks between episodes, and episodes tend to coalesce over time if cannabis use continues (Gajendran, 2020).
Findings in CVS and CHS overlap, requiring a detailed history to differentiate the two, particularly when CVS patients use cannabis for anti-nausea effects. If nausea/emesis was present prior to cannabis use, CVS is more likely (Matheson, 2020; Venkatesan, 2019). Both CVS and CHS can be alleviated by hot showers. Remember to discuss with patients how the effects of cannabis on symptoms can vary with time, so even if cannabis use previously helped nausea/emesis, it can worsen symptoms now.
Dr. Wang reminds us that CVS and CHS have phases.
CVS: Phase 1: feeling fine; Phase 2: prod of nausea/emesis; Phase 3: hyperemesis with intractable nausea/emesis; Phase 4: recovery
CHS: Phase 1: Prod phase – nausea, fear of vomiting, anorexia and abdominal discomfort; Phase 2: Hyperemesis phase – intractable vomiting and sympathetic overactivity; Phase 3: Recovery phase – patient returns to baseline without symptoms (Gajendran, 2020; Hayes, 2018).
Focus on treatment of nausea and emesis during the acute hyperemesis phase. Following resolution of the acute phase, cannabis cessation counseling should be provided while acknowledging cessation can be very difficult (Gajendran, 2020; Venkatesan, 2019; Hayes, 2018). There are no guidelines about how long patients must stop using cannabis to see improvement in symptoms, but it is usually at least several months. Dr. Wang reminds us it is important to ally with patients, making it clear that you are not just blaming cannabis use, but you are trying to treat the symptoms.
For CVS and CHS, action plans are recommended to help patients understand the disease and plan for management according to their current phase. During the wellness phase, the goal is to prevent an episode; treatment is similar to migraine prevention with efficacy for prevention found with amitriptyline, propranolol, and cyproheptadine. In the prodromal phase, the goal is preventing episodes from starting; benzodiazepines, analgesics, or triptans may be used. During the hyperemesis phase, many antiemetics do not have good efficacy, but IV or sublingual ondansetron, lorazepam, chlorpromazine, diphenhydramine can be more helpful. Consider haloperidol as second-line treatment (Gajendran, 2020; Venkatesan, 2019; Hayes, 2018). Medications such as aprepitant, commonly approved for chemotherapy-induced nausea, can be used orally (Venkatesan, 2019). An action plan and therapeutic relationship with outpatient providers can help patients manage crises and ask for treatments that work for them during hyperemesis episodes in the ED.
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Listeners will develop a framework to diagnose and manage DGBI, and learn to make an action plan that will treat patients based on their most bothersome symptoms.
After listening to this episode listeners will…
Dr. Xiao Jing (Iris) Wang reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Gibson E, Perdigão AG, Wang XJ, Williams PN, Watto MF. “#333 IBS, Functional Dyspepsia and, Cyclic Vomiting: Disorders of Gut Brain Interaction (DGBI)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date, 2021.
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