Management Of Functional Gastrointestinal DisordersⅠ

Functional gastrointestinal (GI) disorders (eg irritable bowel syndrome and functional dyspepsia) are very common conditions which are associated with very poor quality of life and high healthcare utilisation. They are caused by disorders of GI functioning, namely altered gut sensitivity, motility, microbiota, immune functioning and central nervous system processing. They cause chronic symptoms throughout the gut (eg pain, dyspepsia and altered bowel habit), all of which are made worse by maladaptive patient behaviours, stress and psychological comorbidity. Management involves a biopsychosocial approach involving changes in lifestyle and diet, addressing coexisting psychological comorbidity and using medication to treat underlying pathophysiology. Pharmacological treatment with antispasmodics, neuromodulators, motility agents and antidepressants is effective. Psychotherapy in motivated individuals is equally effective. The success of treatment is increased by a good doctor–patient relationship and so this needs to be taken into account during the consultation.

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Functional gastrointestinal disorders (FGID) are a group of disorders characterised by chronic gastrointestinal (GI) symptoms (eg abdominal pain, dysphagia, dyspepsia, diarrhoea, constipation and bloating) in the absence of demonstrable pathology on conventional testing. Historically, they were defined as conditions which had no organic basis, but this definition has evolved with an increasing understanding of these conditions and we now know that they arise due to alterations in brain–gut communication. The current classification system (ROME IV) divides them into 33 adult disorders and 20 paediatric disorders, the most common subtypes being irritable bowel syndrome (IBS) which causes abdominal discomfort, altered bowel habits and bloating; and functional dyspepsia (FD) which causes epigastric pain or discomfort, often related to eating which can be associated with fullness and satiety.1

Epidemiology 

FGID are very common with a worldwide prevalence of 40%, more common in women than men and this decreases with age.2 They account for 12% of the workload in primary care and 30% of gastroenterology outpatient consultations.3,4 More than two-thirds of patients with FGID will have seen a doctor in the last 12 months and 40% will use regular medication.5 FGID poses a huge economic burden and treating them cost the NHS at least £ 72.3 million in the year 2014/2015, of which, two-thirds were on prescriptions, community care and hospital treatment.6 

The presence of FGID is often associated with chronic pain (eg fibromyalgia) and other functional syndromes (eg chronic fatigue syndrome), and two-thirds will have psychopathology including anxiety and depression.7 It is therefore not surprising that these patients have a very poor quality of life, worse than other chronic medical conditions (eg grade III congestive cardiac failure and rheumatoid arthritis).8 Due to the very low quality of life (QOL) of patients with FGID and the fact that they incur a lot of healthcare costs, it is important that they are recognised and managed promptly.

Pathophysiology 

It is now clear that there is abnormal physiological functioning in patients with FGID, thought to be due to underlying alterations in GI motility (either too fast or too slow), visceral hypersensitivity, altered microbiota, increased intestinal permeability, low-grade immune infiltration and altered central nervous system processing of sensory input.9 However, symptoms and healthcare seeking arise for complex reasons involving an interplay between early life events and coping styles, learned behaviour, alterations in GI physiology, and associated psychological morbidity as seen in the biopsychosocial model in Fig 1.9 Management is therefore not simply directed at the abnormal physiology or symptoms but has to address behaviours, cognitions and beliefs.

Clinical approach 

Assessment 

The optimal approach involves a holistic assessment starting with a detailed history, taking care to exclude the presence of red flags (weight loss, family history of cancer, nocturnal symptoms, anaemia or GI bleeding) and organic differentials. It is important to ask about diet, lifestyle and psychological status, as this will enable you to target these as part of the management plan. Integral to all this is the doctor–patient relationship and the quality of the consultation (Box 1). This involves being empathic, avoiding jargon, being honest and admitting when you do not have the answers, which takes a lot longer than organising yet another futile test. In our opinion, 10 minutes is not sufficient for this kind of consultation, however, spending time addressing all these factors on the first visit and breaking the diagnosis of a functional disorder will save time (and money) on future visits. Examination should include an assessment for abdominal masses, and quality of pain as well as a rectal examination. The latter is essential to rule out rectal masses and haemorrhoids and to assess for anal tone and function. The latter can be assessed at baseline and by asking the patient to squeeze as if they are preventing themselves from emptying their bowels. Anal hypotonia is associated with faecal incontinence and hypertonia can be associated with dyssynergia defecation, itself a cause of constipation.

Investigations 

With the current ROME classification, it is possible to make a positive diagnosis of FGID based on the pattern of symptoms, so the exclusion of all organic diseases is not necessary. However, serious differentials that seem feasible after taking a good history (Box 2) should be ruled out.

All patients should get a basic blood and stool panel including: 

> Full blood count to look for anaemia 

> urea and electrolytes to look for dehydration and evidence of electrolyte derangements with diarrhoea 

> C-reactive protein or erythrocyte sedimentation rate to look for underlying inflammation, this should be normal in IBS 

> coeliac serology 

> Thyroid function tests 

> faecal calprotectin, if diarrhoea is present, to rule out inflammatory causes of this > Helicobacter pylori testing (stool antigen test or urea breath test) for patients with dyspeptic symptoms.

Endoscopy: 

If a patient has typical IBS symptoms with a normal faecal calprotectin and there are no red flags to suggest colorectal cancer (see earlier) then a lower GI endoscopy is not needed. There is little yield in performing a gastroscopy for H pylori negative dyspepsia in the absence of alarm symptoms (such as continuous pain, vomiting, anaemia and weight loss in patients under the age of 60), so this should not routinely be organised.10

Abdominal ultrasound: 

Abdominal ultrasound can be useful in IBS to screen for abdominal causes of pain and, in particular, for ovarian cancer which can cause pain, visible abdominal bloating and altered bowel habits. In dyspepsia, it can be useful to look for gallstones if the history is suggestive (ie colicky pain with fatty meals).

SeHCAT scan. 

If available, SeHCAT scans should be used to assess for bile salt malabsorption in up to a third of patients with IBS-D.11 Typical symptoms include watery diarrhoea, often yellow, with or without nocturnal symptoms and faecal incontinence.

GI physiology. 

GI physiology is rarely indicated in IBS. One situation where it can be helpful is in patients who have severe constipation and are not responding to multiple laxatives. Lower GI physiology testing, particularly a colonic transit study and proctography can be useful at differentiating slow transit from a rectal evacuatory problem and can therefore help in fine-tuning the management of constipation. In patients with functional dyspepsia, a gastric emptying study can be useful to look for severely delayed gastric emptying if there is persistent vomiting which is impacting on nutritional status, as this can help with feeding decisions. For all physiological tests, it is important to be aware that medications, particularly opiates and anticholinergics, will alter GI motility and transit.

Natural Herbal Medicine For Relieving Constipation-Cistanche 

Cistanche is a genus of parasitic plants that belongs to the family Orobanchaceae. These plants are known for their medicinal properties and have been used in Traditional Chinese Medicine (TCM) for centuries. Cistanche species are predominantly found in arid and desert regions of China, Mongolia, and other parts of Central Asia. Cistanche plants are characterized by their fleshy, yellowish stems and are highly valued for their potential health benefits. In TCM, Cistanche is believed to have tonic properties and is commonly used to nourish the kidney, enhance vitality, and support sexual function. It is also used to address issues related to ageing, fatigue, and overall well-being. While Cistanche has a long history of use in traditional medicine, scientific research on its efficacy and safety is ongoing and limited. However, it contains various bioactive compounds such as phenylethanoid glycosides, iridoids, lignans, and polysaccharides, which may contribute to its medicinal effects.

Wecistanche's cistanche powder, cistanche tablets, cistanche capsules, and other products are developed using desert cistanche as raw materials, all of which have a good effect on relieving constipation. The specific mechanism is as follows: Cistanche is believed to have potential benefits for relieving constipation based on its traditional use and certain compounds it contains. While scientific research specifically on Cistanche's effect on constipation is limited, it is thought to have multiple mechanisms that may contribute to its potential to relieve constipation. Laxative Effect: Cistanche has long been used in Traditional Chinese Medicine as a remedy for constipation. It is believed to have a mild laxative effect, which can help promote bowel movements and induce constipation. This effect may be attributed to various compounds found in Cistanche, such as phenylethanoid glycosides and polysaccharides. Moistening the Intestines: Based on traditional use, Cistanche is considered to have moisturizing properties, specifically targeting the Intestines. Promoting hydration and lubrication of the Intestines may help soften tools and facilitate easier passage, thereby relieving constipation. Anti-inflammatory Effect: Constipation can sometimes be associated with inflammation in the digestive tract. Cistanche contains certain compounds, including phenylethanoid glycosides and lignans, that are believed to have anti-inflammatory properties. By reducing inflammation in the intestines, it may help improve bowel movement regularity and relieve constipation.