Functional gastrointestinal disorders: advances in understanding and management, 2020, Black, Ford et al

[Andy]

Gastrointestinal symptoms are highly prevalent, but many people who have them will have no organic explanation for their symptoms. Most of these people will be labelled as having a functional gastrointestinal disorder, such as irritable bowel syndrome, functional dyspepsia, or functional constipation. These conditions affect up to 40% of people at any one point in time, and two-thirds of these people will have chronic, fluctuating symptoms.

The pathophysiology of functional gastrointestinal disorders is complex, but involves bidirectional dysregulation of gut–brain interaction (via the gut–brain axis), as well as microbial dysbiosis within the gut, altered mucosal immune function, visceral hypersensitivity, and abnormal gastrointestinal motility. Hence, nomenclature refers to the conditions as disorders of gut–brain interaction.

Psychological comorbidity is common; however, whether or not this predates, or is driven by, symptoms is not clear. Patients with functional gastrointestinal disorders can feel stigmatised, and often this diagnosis is not communicated effectively by physicians, nor is education provided. Prompt identification and treatment of these conditions is crucial as they have a considerable impact on health-care systems and society as a whole because of repeated consultations, unnecessary investigations and surgeries, prescriptions and over-the-counter medicine use, and impaired health-related quality of life and ability to work.

Symptom-based criteria are used to make a diagnosis, with judicious use of limited investigations in some patients. The general principles of treatment are based on a biopsychosocial understanding and involve management of physical symptoms and, if present, psychological comorbidity. In the future, treatment approaches to functional gastrointestinal disorders are likely to become more personalised, based not only on symptoms but also underlying pathophysiology and psychology.

Paywall, https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32115-2/fulltext
Sci hub, https://sci-hub.se/10.1016/S0140-6736(20)32115-2

 

[duncan]

Oh, FFS. What's next, functional death?

 

[chrisb]

It's already known as CFS.

Cessation of Function Syndrome.

 

[Invisible Woman]

This is all about the self serving business of keeping people sick, keeping other specialities that might be able to help away and themselves on the gravy train.

The whole gastric ulcer/heliobacter business all over again. At least in those days they came from a starting point of ignorance where as this shower don't have that excuse.

 

[rvallee]

It's really amazing that the TL;DR of all those "advances in" and systematic reviews boasting of unquantifiable benefits never actually have any substance and are limited entirely to "if we could figure this thing out we may help, eventually, maybe". It's fan fiction.

It's basically click bait, "here is the answer to this question" where the answer is nowhere to be found and people just marvel at how wonderful it would be if the explanation they favor were true and how they're (still, a FULL CENTURY LATER) working towards that.

And 100% that without Marshall's team taking away peptic ulcers from these fanatics, ulcers would absolutely be a quintessential functional GI syndrome. The only progress that happens with these people is when patients are taken out of their reach by actual scientists.

I mean seriously it says it right here:

In the future, treatment approaches to functional gastrointestinal disorders are likely to become more personalised, based not only on symptoms but also underlying pathophysiology and psychology.

In some undefined future people may somehow formulate treatments that could be useful. That's not "advances", it's just imagining how things would work if this stuff were real. What are the advances here? Still not a hint of understanding, let alone management. And anyway most of their version of "management" is to have the patient self-manage without anyone knowing what's actually wrong, which is absurd.

A full century of this and even in op-eds talking about imaginary "advances" they are still wishing and imagining how wonderful it will be if they actually came up with something but meanwhile people should continue to be "treated" despite there being no such thing. Zero respect for the human lives affected. Self-serving narcissists.

 

[Kalliope]

Lancet's full series on Functional Gastrointestinal Disorders is here:
https://www.thelancet.com/series/functional-gastrointestinal-disorders

In the first article of a Series of three papers in The Lancet, Christopher Black, Douglas Drossman, and colleagues elucidate advances in our understanding of the epidemiology, pathophysiology, investigation, and management of these conditions overall. The other two papers expand on the two most common of these conditions, as Alexander Ford, Ami Sperber, and colleagues discuss irritable bowel syndrome, and Ford, Sanjiv Mahadeva, and colleagues discuss functional dyspepsia.

 

[Arnie Pye]

This is absolutely absurd.

One of the commonest effects of hypothyroidism is that sufferers develop severe indigestion and acid reflux. It is known amongst many patients on the thyroid forum I read that this is caused by reduced secretion of stomach acid. But before most of them find out the underlying cause of their gut problems they are told by GPs to take antacids, or they are prescribed PPIs (which switch off stomach acid secretion).

Those who actually increase their stomach acid with vinegar or lemon juice in water, or betaine hydrochloride capsules, actually find out their indigestion and acid reflux actually go away.

I once mentioned the low stomach acid problem to a GP and they denied it completely, and said indigestion and acid reflux was caused by excess stomach acid.

One of the absurdities of PPIs is that they are more likely to be prescribed the older the patient is, despite the fact that the older someone is the less stomach acid they produce.

Some people have found that improving the acidity of their stomach has had a beneficial effect on their IBS as well as their indigestion.

I know that there are some circumstances where PPIs can't be avoided - for instance in the case of people being on NSAIDs. And some people with hiatus hernias have to stay on them too.

In my own case, I had IBS for about 25 years. It was mostly cured by surgery that dealt with the adhesions I had that were sticking my bowel to the left side of my abdomen. I know that adhesions recur. But if the bowel is better positioned when it does get stuck down again it can reduce or eliminate IBS pain. So the surgery I had was worth it.

None of the things I've described have any connection to psychology or depression or anxiety or "being all in your head" or "being functional" - and they can all be helped or even cured in many cases.

 

[Hutan]

The clever/awful thing about this paper and the BPS approach in general is that it doesn't say that the biomedical issues don't contribute. So if a biomedical cause is identified in someone, the BPS clinician can never be wrong. It's just that they see the biomedical issue as such a small part of the problem - and the biomedical issue itself as probably the result of psychological/family issues.



See there, top left, infection for example, it's there, in amongst everything else. And I'm sure that we all could agree that some behaviours, such as those around diet, can affect gastrointestinal function. It's hard to disagree with the literal idea of 'biopsychosocial'. It's the implementation of it, the automatic assumption that your medical condition is a product of your traumatic childhood and your moral weakness; the inability to believe the patient when they say that obvious things like a good diet, good sleep and exercise don't help the condition; the lazy lack of curiosity, where things go so dreadfully wrong.

This paper allows for biomedical causes of 'functional gastrointestinal disorders' much more than most BPS papers. That should feel like a positive thing, a move in the right direction.

By definition, no structural abnormalities explain FGIDs and, on the basis of the biopsychosocial model developed by Engel34 and adapted by Drossman,35,36 they are char acterised as complex bidirectional dysregulations of gut–brain interaction, via the gut–brain axis, rather than diseases (figure 1). Visceral hypersensitivity, abnormal gastrointestinal motility, and psychological disturbances have been recognised to contribute to the pathogenesis of FGIDs for decades, but more recently lowgrade intestinal inflammation, increased intestinal permeability, immune activation, and disturbances in the microbiome have been identified, challenging the idea that structural changes are absent entirely.

Emerging data challenge the concept that gut– brain pathways act similarly in all patients with FGIDs. Independent epidemiological studies43–45 suggest that in 50% of cases, FGIDs begin with psychological distress, followed later by gastrointestinal symptoms, whereas in the other 50% of cases gut dysfunction occurs first, and psychological distress follows later.

However, cause and effect cannot be disentangled from these studies, and is not relevant when pathophysiology is understood in terms of interacting systems.

Maybe I've read too many BPS papers, but to me the paper reads of a hedging of the bets.

The value of identifying other diagnoses, such as coeliac disease or inflammatory bowel disease, which could present with similar symptoms, is that they benefit from entirely different treatments.

Well, yes.

Yet, the process of doing so requires good clinical judgment given the risk associated with overinvestigating.13 Experienced clinicians can discern which patients need further evaluation.

Hmm.

So yeah, perhaps this paper is a sign of a welcome move to more caution before slapping a psychosomatic label on someone and offering them help to think about their symptoms differently. But I'm not getting too excited.

 

[Mithriel]

I would have more confidence in the concept of MUS or FNDs if I was sure they were actually looking at all possible biological causes before deciding there were none.

Surely it needs more investigating before you can say there is nothing biological going on rather than doing less after a quick glance.