Background & Aims Pain is a prominent symptom in chronic pancreatitis (CP), but the underlying mechanisms are incompletely understood. We investigated the role of descending pain modulation from ...supraspinal structures as well as central nervous system sensitization in patients with pain from CP. Methods Twenty-five patients with CP and 15 healthy volunteers were included. Descending pain modulation was investigated by diffuse noxious inhibitory control (a descending inhibitory response after conditioning stimulation). Central pain processing was investigated as the perceptual responses to multimodal (electrical, thermal, and mechanical) stimulations of the rectosigmoid and evoked brain potentials after electrical stimulation of the rectosigmoid. Results Compared with healthy volunteers, the efficacy of diffuse noxious inhibitory control was reduced in patients with CP (13% ± 21% vs 39% ± 22%, respectively; F = 3.8; P = .01); central sensitization was indicated by remote hyperalgesia in the rectosigmoid to electrical stimulation (21 ± 15 mA vs 27 ± 15 mA; F = 6.2; P = .02) and heat stimulation (51°C ± 5°C vs 53°C ± 4°C; F = 5.9; P = .02). Compared with controls, patients with CP had increased latency of the early P1 peak to rectosigmoid stimulation (85 ± 21 ms vs 108 ± 28 ms, respectively; P = .02), possibly reflecting reorganization of central pain pathways. Conclusions Patients with CP have impairments in inhibitory pain modulation and evidence of central sensitization. Treatment of their pain therefore should focus not only on the pancreas, but also on descending pain modulation from supraspinal structures and central nervous system sensitization.
Abstract
Objective. Painful symptoms are prevalent in patients with eosinophilic oesophagitis but experimental data are sparse. The aim of this study was to compare the pain response to experimental ...oesophageal stimulation in 14 patients with eosinophilic oesophagitis and 15 healthy volunteers. Material and methods. A multimodal probe was placed in the oesophagus. The participants were subjected to mechanical, thermal and electrical pain stimuli followed by perfusion with 0.1 M HCl. Pain scores, referred pain areas and evoked brain potentials to electrical stimulation of the oesophagus were recorded. Results. Patients tolerated significantly less acid perfused in the oesophagus (median 123 versus 200 ml; P = 0.02) and felt the burning sensation evoked by the acid earlier (median 2.0 versus 5.0 min; P = 0.01). Eight patients had coexisting gastro-oesophageal reflux disease. Six patients had pure eosinophilic oesophagitis, and this group felt the acid earlier than those with concomitant reflux or the healthy volunteers (median 0.8 versus 2.0 and 5.0 min; P = 0.03). There were no differences between patients and controls in the responses to mechanical or thermal stimulation (P > 0.4). Furthermore, no differences were found for the proxies of central nervous system sensitization (response to electrical stimulations, referred pain areas or evoked brain potentials; P > 0.1). Conclusions. Patients with eosinophilic oesophagitis are hypersensitive to acid perfused in the oesophagus, and pathophysiologic findings are likely confined to the peripheral tissue. Reflux from physiological acid may play a role in the symptoms of eosinophilic oesophagitis.
•Anticoagulation in liver disease and atrial fibrillation may reduce thromboembolic risk.•Anticoagulation in liver disease and atrial fibrillation is not associated with increased bleeding.•Only a ...minority of patients with liver disease and atrial fibrillation receive anticoagulation.
Balancing the risk of thromboembolism and bleeding in patients with liver disease and atrial fibrillation/flutter is particularly challenging.
To examine the risks of thromboembolism and bleeding with use/non-use of oral anticoagulation (including vitamin K-antagonists and direct oral anticoagulants) in patients with liver disease and AF.
Danish nationwide register-based cohort study of anticoagulant naive individuals with liver disease, incident atrial fibrillation/flutter, and a CHA2DS2-VASc-score≥1 (men) or ≥2 (women), alive 30 days after atrial fibrillation/flutter diagnosis. Thromboembolism was a composite of ischaemic stroke, transient ischaemic attack, or venous thromboembolism. Bleeding was a composite of gastrointestinal, intracerebral, or urogenital bleeding requiring hospitalisation, or epistaxis requiring emergency department visit or hospital admission. Cause-specific Cox-regression was used to estimate absolute risks and average risk ratios standardised to covariate distributions. Because of significant interactions with anticoagulants, results for thromboembolism were stratified for CHA2DS2-VASc-score, and results for bleeding were stratified for cirrhotic/non-cirrhotic liver disease.
Four hundred and nine of 1,238 patients with liver disease and new atrial fibrillation/flutter initiated anticoagulants. Amongst patients with a CHA2DS2-VASc-score of 1–2 (2–3 for women), five-year thromboembolism incidence rates were low and similar in the anticoagulant (6.5%) versus no anticoagulant (5.5%) groups (average risk ratio 1.19 95%CI, 0.22–2.16). In patients with a CHA2DS2-VASc-score>2 (>3 for women), incidence rates were 16% versus 24% (average risk ratio 0.66 95%CI, 0.45–0.87). Bleeding risks appeared higher amongst patients with cirrhotic versus non-cirrhotic disease but were not significantly affected by anticoagulant status.
Oral anticoagulant initiation in patients with liver disease, incident new atrial fibrillation/flutter, and a high CHA2DS2-VASc-score was associated with a reduced thromboembolism risk. Bleeding risk was not increased with anticoagulation, irrespective of the type of liver disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Balancing the risk of thromboembolism and bleeding in patients with liver disease and atrial fibrillation/flutter is particularly challenging.
To examine the risks of thromboembolism and bleeding ...with use/non-use of oral anticoagulation (including vitamin K-antagonists and direct oral anticoagulants) in patients with liver disease and AF.
Danish nationwide register-based cohort study of anticoagulant naive individuals with liver disease, incident atrial fibrillation/flutter, and a CHA
DS
-VASc-score≥1 (men) or ≥2 (women), alive 30 days after atrial fibrillation/flutter diagnosis. Thromboembolism was a composite of ischaemic stroke, transient ischaemic attack, or venous thromboembolism. Bleeding was a composite of gastrointestinal, intracerebral, or urogenital bleeding requiring hospitalisation, or epistaxis requiring emergency department visit or hospital admission. Cause-specific Cox-regression was used to estimate absolute risks and average risk ratios standardised to covariate distributions. Because of significant interactions with anticoagulants, results for thromboembolism were stratified for CHA2DS2-VASc-score, and results for bleeding were stratified for cirrhotic/non-cirrhotic liver disease.
Four hundred and nine of 1,238 patients with liver disease and new atrial fibrillation/flutter initiated anticoagulants. Amongst patients with a CHA2DS2-VASc-score of 1-2 (2-3 for women), five-year thromboembolism incidence rates were low and similar in the anticoagulant (6.5%) versus no anticoagulant (5.5%) groups (average risk ratio 1.19 95%CI, 0.22-2.16). In patients with a CHA2DS2-VASc-score>2 (>3 for women), incidence rates were 16% versus 24% (average risk ratio 0.66 95%CI, 0.45-0.87). Bleeding risks appeared higher amongst patients with cirrhotic versus non-cirrhotic disease but were not significantly affected by anticoagulant status.
Oral anticoagulant initiation in patients with liver disease, incident new atrial fibrillation/flutter, and a high CHA2DS2-VASc-score was associated with a reduced thromboembolism risk. Bleeding risk was not increased with anticoagulation, irrespective of the type of liver disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
This study compared short-term effectiveness of proton pump inhibitors (PPI), swallowed topical corticosteroids (STC), and dietary therapies in reversing clinical and histological features in ...pediatric patients with eosinophilic esophagitits (EoE). Determinants for treatment choice and PPI therapy effectiveness were also assessed. A cross-sectional study analysis of patients under 18 years old recruited onto the multicenter EoE CONNECT registry was performed. Clinico-histological response was defined as symptomatic improvement plus a peak eosinophil count below 15 per high-power field after treatment. Effectiveness of first-line options used in monotherapy was compared. Overall, 393 patients (64% adolescents) receiving PPI, STC, or dietary monotherapy to induce EoE remission were identified. PPI was the preferred option (71.5%), despite STC providing the highest clinico-histological response rates (66%) compared to PPI (44%) and diet (42%). Logistic regression identified fibrotic features and recruitment at Italian sites independently associated to first-line STC treatment; age under 12 associated to dietary therapy over other options. Analysis of 262 patients in whom PPI effectiveness was evaluated after median (IQR) 96 (70-145) days showed that this effectiveness was significantly associated with management at pediatric facilities and use of high PPI doses. Among PPI responders, decrease in rings and structures in endoscopy from baseline was documented, with EREFS fibrotic subscore for rings also decreasing among responders (0.27 ± 0.63 vs. 0.05 ± 0.22, p < 0.001). Conclusion: Initial therapy choice for EoE depends on endoscopic phenotype, patient's age, and patients' origin. High PPI doses and treatment in pediatric facilities significantly determined effectiveness, and reversed fibrotic endoscopic features among responders. What is Known: • Proton pump inhibitors are widely used to induce and maintain remission in EoE in real practice, despite other first-line alternative therapies possibly providing higher effectiveness. What is New: • Proton pump inhibitors represent up to two-thirds of first-line monotherapies used to induce EoE remission in pediatric and adolescent patients with EoE. The choice of STC as first-line treatment for EoE was significantly associated with fibrotic features at baseline endoscopy and recruitment in Italian centers; age less than 12 years was associated with dietary therapy. • PPI effectiveness was found to be determined by use of high doses, attendance at pediatric facilities, presenting inflammatory instead of fibrotic or mixed phenotypes, and younger age. Among responders, PPI therapy reversed both inflammatory and fibrotic features of EoE after short-term treatment.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Eosinophilic oesophagitis (EoE) is a chronic, immune‐mediated disease of the oesophagus. Eosinophilic oesophagitis is associated with a substantial disease burden affecting the quality of ...life and affecting mental health. There are limited data describing the incidence of psychiatric disorders and the use of psychotropic drugs (PDs) in EoE patients.
Objectives
The aim was to investigate whether EoE patients in Denmark have higher use of PDs, contacts with the department of psychiatry, and attempts of suicide or intentional self‐harm compared with the general population after being diagnosed with EoE.
Methods
This study was a nationwide, population‐based register study including 3367 EoE patients and 16,835 age‐ and sex‐matched comparators. A register‐based EoE definition was used to identify cases. Incident PD use was extracted from the prescription register and information regarding psychiatric contacts was retrieved from the Danish Psychiatric Central Research Register.
Results
The 5‐year incidence of PD use in EoE patients was 13.8% compared to 7.1% of the matched comparators (Hazard ratio 1.83; confidence interval 1.6–2.0; p ≤ 0.001). Antidepressants were the most frequently prescribed PD, whereas antipsychotics were the least prescribed PD. Increasing age, lower educational level, and comorbidity (Charlson Comorbidity Index score ≥1) were associated with the prescription of PDs. The risk of PD use was lower in men than in women with EoE.
Conclusion
Treatment with PDs were more common in EoE patients after they were diagnosed than in the general Danish population, indicating that EoE patients have an increased risk of psychiatric disorders.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Several studies have suggested that patients with irritable bowel syndrome (IBS) frequently have symptoms of sexual dysfunction.
The current study aims to map the current knowledge about the burden ...of sexual dysfunction in patients with IBS.
A literature review was conducted on PubMed and EMBASE using the following search terms or combinations thereof: irritable bowel syndrome; functional colonic disease; sexual function; sexual health; sexual behavior; sexual dysfunction; dyspareunia; erectile dysfunction; quality of life; and questionnaire.
Sexual dysfunction.
1,273 texts were found, 331 duplicates were removed, and 844 texts were excluded because they did not meet the inclusion criteria, leaving 98 full text articles. These were examined and it was found that 41 fulfilled the criteria. 4 questionnaires were found; Irritable Bowel Syndrome Quality of Life (IBS-QOL) questionnaire, the Irritable Bowel Syndrome – Quality of Life (IBSQOL) questionnaire, the Irritable Bowel Syndrome-36 question (IBS-36) questionnaire, and the Arizona Sexual Experience Scale. Subscores for sexual relations in IBS-QOL ranged from 37.7−100 (11.9) for patients with IBS and 82.2−100 (6.6) for controls. The IBSQOL and IBS-36 subscores for sexual relations ranged from 49.7−90.5 (9) to 3.9−5.4 (0.8) with no healthy controls for comparison. After interventions were implemented, there was an improvement in subscores (the IBS-QOL mean changed to 10.5%, IBSQOL mean changed to 3.8%, and the IBS-36 mean changed to 40%). The study using Arizona Sexual Experience Scale showed that 51% of patients with IBS had sexual dysfunction and also scored lower on the IBSQOL questionnaire.
The information about sexual dysfunction in patients with IBS is sparse and emerges primarily from quality of life questionnaires. It seems as though patients with IBS have more sexual problems compared to controls, but further investigation regarding the extent and type of sexual dysfunction is needed.
Sørensen J, Schantz Laursen B, Drewes AM, et al. The Incidence of Sexual Dysfunction in Patients With Irritable Bowel Syndrome. Sex Med 2019;7:371–383.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
National Danish guidelines for the diagnosis and treatment of irritable bowel syndrome (IBS) in adult patients in secondary and tertiary care have been approved by the Danish Society for ...Gastroenterology and Hepatology. IBS can be a positive diagnosis in patients fulfilling the Rome III criteria for IBS with no alarm signals, a normal physical examination and a normal CRP and hemoglobin. In patients < 40 years with IBS and diarrhea, a normal fecal calprotectin excludes inflammatory bowel disease with a high probability. Patients with IBS and diarrhea should be tested for celiac disease. Endoscopy is not routinely recommended. The therapeutic gain of various treatment modalities is small and most likely overestimated in older studies. However, side effects are usually mild which may justify empirical treatment. The choice of therapy based on IBS subtyping is pragmatic and there are only few trials as guidance. The significance of previous failure with another treatment modality is unclear. There is a lack of long-term treatment trials. The generalizability of the trials is poor, mainly due to selection bias.
Irritable bowel treatment Fassov, Janne; Fynne, Lotte; Krarup, Anne Lund
Ugeskrift for læger,
2016-Aug-29, Volume:
178, Issue:
35
Journal Article
More than every tenth Dane have irritable bowel syndrome. The condition is diagnosed by a positive strategy including fulfilment of the Rome III criteria, absence of alarm symptoms, and if needed a ...few paraclinical tests. Currently, there is no cure of the disorder. Treatment is recommended on a symptom-based approach targeting the dominating symptom/symptoms. If symptoms are reduced, the quality of life is considerably improved.
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