Kevin W. Olden | PubMed Health

PubMed2003

Approach to the Patient with Severe, Refractory Irritable Bowel Syndrome.

Defining which patients with irritable bowel syndrome (IBS) are "refractory" is a highly subjective undertaking. Duration of symptoms, severity of symptoms, type of symptoms, and a host of other medical, epidemiologic, and psychosocial variables all play a role in this determination. It is safe to say that a long duration of disease per se does not constitute a refractory patient. A number of studies have given us some suggestion of what constitutes refractoriness in IBS. Patients who have a predominant pain complaint as opposed to those who are mainly concerned about their bowel habit (either diarrhea or constipation) are more likely to be disabled by their IBS. However, at a clinical level, patients who are considered refractory are usually seen as individuals who fail to improve on a variety of drug therapies or who have high healthcare utilization despite aggressive treatment of their IBS. Finally, patients who are unhappy about their care and/or are assertive in their request to "be cured" can also be seen as refractory because of unrealistic expectations they set for both themselves and the physician. The key to effectively dealing with patients with "refractory" IBS is to understand that their behaviors most often have correlates and underlying issues that need to be dealt with in order to effectively address the patient's concerns. Unfortunately, most patients who fall into this category are quickly identified as "difficult," "unpleasant," or even "crazy" and are not infrequently dismissed by their treating physician. This leads to an ever-enlarging circle of healthcare utilization, with patients seeking out physicians and other practitioners looking for the elusive cure. A key component of this process is an increasing frustration and cynicism regarding the healthcare system and physicians in particular, which does no good for anyone involved. It is clearly critical for the physician dealing with a patient with IBS and a history of poor response to treatment to understand these correlates. Failure to do so creates a continuation of the cycle of treatment failure and frustration that so often characterizes these patients' care.

Journal Article↗

PubMed2001

Rumination.

Rumination is an unusual gastrointestinal symptom that is characterized by the repetitive regurgitation of gastric contents into the oropharynx. The regurgitation occurs very soon after a meal and tends to persist for 1 to 2 hours. Rumination is defined by the setting in which it occurs. It is seen in three distinct populations: infants; individuals with psychiatric and neurologic disorders, particularly developmental disabilities; and adults who do not have overt psychiatric or neurologic disorders. The hallmark of rumination, which separates it from other disorders of the upper gastrointestinal tract (such as gastroesophageal reflux disease or cyclic vomiting syndrome), is the fact that in patients with rumination, the gastric contents appear in the oropharynx without retching or nausea. Rather, the patient makes a conscious decision on how to handle the regurgitated material after it presents into the oropharynx. The regurgitated meal usually consists of undigested or partially digested food. The regurgitation is effortless or at most is preceded by a sensation of belching immediately prior to the regurgitation itself. The management of patients with rumination needs to be accomplished in a highly individualized manner. Children with infant rumination syndrome often have symptoms related to significant defects in bonding with their mother. Thus, problems of mother-child bonding in pediatric patients with rumination syndrome should be identified and appropriately addressed. The management of adult patients with developmental disabilities or neurologic impairments who ruminate focuses mainly on behavioral modalities, including adversive conditioning and contingency management. The healthy adult who ruminates and has no evidence of neurologic or developmental disability is best seen as someone with a habit. Management in these patients is directed towards adjunctive therapies (ie, the use of proton pump inhibitors or H(2 )receptor antagonists to decrease acid injury to the esophagus) as well as identifying situations and emotions that trigger the patient's symptoms. Randomized controlled trials of various treatment modalities need to be undertaken; likewise, the evaluation strategy needed to best diagnose rumination is yet to be well defined. At this time, the challenge for gastroenterologists is to understand the nature of rumination, to identify individuals at high risk, and to use the management strategies most associated with good outcomes in patients with rumination in various clinical settings.

Journal Article↗