Functional gastrointestinal disorders, development of symptoms over time, and self-care

Abstract

Background: Adults with Gastrointestinal (GI) symptoms such as abdominal pain, acid regurgitation, flatulence, diarrhea, constipation and nausea constitute a large part of the patient population in both primary and specialist care. Today, up to half of patients with gastrointestinal symptoms seen by gastroenterologists go through a standard diagnostic work-up usually including endoscopy, laboratory testing, and possibly radiological evaluation but do not show any signs explaining their symptoms. This group of patients is said to have Functional Gastrointestinal Disorders (FGIDs), as it is assumed that abnormalities in gastrointestinal function underlie the generation of their symptoms. Functional dyspepsia and Irritable Bowel Syndrome (IBS) are both examples of FGIDs. The pathogenesis and mechanisms underlying FGIDs are largely unknown, and many principles such as neutralizing gastric acid, inhibiting gastric acid production and eliminating triggering factors have been tested in medical treatment of FGIDs, but the benefits have been limited. People with FGIDs face many challenges in their everyday lives, and each individual has his/her own way of dealing with this illness. The patient’s experiences of illness and the lack of effective therapies for managing FGIDs may lead to an interest in applying complementary and alternative medicine (CAM) as a viable healthcare choice. CAM can be defined as “self-initiated healthcare measures taken to achieve symptom relief” and offers alternative or complementary treatments to those provided by the medical service. Although dealing with daily life with FGIDs is primarily the task of the patients themselves, close contact with the healthcare system is still important. If the healthcare system is to provide care and support appropriate to patients’ needs, healthcare personnel must have knowledge of available forms of care and treatment conventional as well as nonconventional. In this context, nurses have a unique opportunity to develop their nursing work.

Aim and Method: The aim of Study I was to elucidate CAM methods and their perceived effects in a middle-sized community in Sweden. Group interviews were conducted and manifest content analysis was used to analyze the data. The results of Study I would come to form the basis of the self-care survey used in Study IV. The aim of Study II was to conduct a descriptive analysis of GI symptoms, lifestyle factors and demographics in a cohort of patients suffering from abdominal or other symptoms assumed to be related to the digestive system and diagnosed as FGIDs in 1990. These data were then used as baseline data for an 18-year follow-up (Study III). Study II included a subset of patients enrolled in the Swedish Dyspepsia Study, which commenced in 1990. The study included a basic physical examination, measuring such things as weight and height, blood pressure, and waist and seat circumference, as well as a computer-based questionnaire (the Glasgow Diagnostic System for Dyspepsia; GLADYS) to collect data on symptoms and lifestyle. GLADYS is a computer-based questionnaire for medical history taking and symptom assessment; it contains 162 two- to six-grade response levels, the GI symptom-related items including: Somatic symptoms: pain, nausea, dysphagia, vomiting, heartburn, flatulence, acid regurgitation, diarrhea and constipation; Lifestyle factors: tobacco, alcohol, food, coffee consumption, exercise and BMI; and finally demographic data such as age, gender and marital status. The aim of Study III was to conduct a longitudinal follow-up on subjects initially seeking healthcare for FGIDs and to assess the possible impact of lifestyle factors over time on initial symptoms. The study population comprised a sub-set of subjects enrolled in the Swedish Dyspepsia Study, which commenced in 1990. Each subject in that study underwent a physical assessment and completed a computer-based questionnaire on nine GI symptoms and lifestyle factors in 1990, using the same methods as in Study II. The aim of Study IV was to describe the CAM methods most commonly used to alleviate symptom distress in persons with FGIDs and to develop a study-specific CAM questionnaire, including questions about the CAM methods used and the perceived effects of each method. The results were presented using descriptive statistics.

Results: Study I included a total of 25 persons (median age 58 years, range 18-82 years), 13 women and 12 men, who were assigned to five different groups. Twenty-six CAM methods associated with various effects were identified, and all persons had used at least one method. The CAM methods used by participants were categorized as follows: nutritional, drug/biological, spiritual/psychological and physical activity. The effects were described using the categories labeled: prevention, partial symptom relief or total symptom relief. Study II included 161 women and 106 men (mean age 42 years, range 18- 81 years). The most frequent symptoms were abdominal pain (92%) and acid regurgitation (63%), and 69% of patients reported 4 or more symptoms. Acid regurgitation (p=0.034) and heartburn (p=0.016) were more common in men, while constipation (p=0.004) and nausea (p=0.028) were more common in women. Patients with constipation had a more regular fiber intake (p=0.006), while patients with flatulence were more likely to be milk drinkers (p=0.002) than non-milk drinkers. More non- smokers suffered from abdominal pain (p=0.023), and patients who vomited had a low intake of alcohol (p=0.000). Patients with dysphagia had dinner more often than 3 days/week (p=0.006) and patients with heartburn reported no or little exercise (p=0.039). Study III included 137 subjects, 85 women and 52 men. None of the symptoms increased in frequency. Four of the symptoms decreased in frequency: abdominal pain (OR 2. 70), flatulence (OR 4. 09), nausea (OR 3. 05) and acid regurgitation (OR 1. 59). Significant lifestyle changes were increased BMI (p <, 0001), decreased tobacco smoking (p = <, 0001) and milk drinking (p= 0, 008). Increased exercise correlated with a decrease in acid regurgitation (OR 3. 05) and vomiting (OR 7. 38), but an increase in diarrhea (OR 0. 23) and nausea (OR 0. 33). Decreased smoking correlated with a decrease in acid regurgitation (OR 3. 45) and heartburn (OR 2. 91). A decrease in BMI was associated with decreased dysphagia (OR 7. 48). Study IV included 137 persons with FGIDs, and the gender distribution was 85 women and 52 men (mean 58 years, range 37-93 years). A total of 28 different CAM methods were identified and grouped into four categories: Nutritional, Drug/biological, Psychological activity, and Physical activity. Efficacy assessments for each method were preventive effect, partial symptom relief, total symptom relief or no effect. All persons had tried at least one method and most methods provided partial symptom relief. The most commonly used CAM method was Nutritional. Antacids and Proton pump inhibitors were used by the majority, and drugs used that were purchased from the healthcare store were dominated by Aloe Vera. There were no gender differences.

Conclusion: In conclusion, the present doctoral thesis has shown that persons with FGIDs have a high frequency of GI complaints. Some symptoms decreased significantly over time, while others remained at the same level. To our knowledge, the follow-up time used here – 18 years – is the longest of its kind to date. There was no difference in symptom frequency between men and women. A small number of significant relationships between symptoms and lifestyle factors were revealed. All participants had used at least one self-care method on their own initiative in an attempt to alleviate symptoms. Of the 28 self-care methods that emerged, most of which consisted of household remedies, the effects were preventive, partial symptom relief, or total symptom relief. Larger population-based studies are needed to elucidate the various self-care methods and their effects on GI complaints. Also of importance are studies that can shed light on healthcare personnel’s knowledge and treatment of patients’ use of self-care. The present results should be seen as a point of departure for further research in this area. In the end, this is a question of people’s long-term trust in the healthcare system and of societal resources, but most importantly it is a question of people’s health, well-being and feeling of security.