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9/21/2017 Disclosures Gastrointestinal Motility Disorders & Irritable Bowel Syndrome None Jasmine Zia, MD Acting Assistant Professor Division of Gastroenterology, University of Washington 6 th Asian Health Symposium October 6, 2017

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9/21/2017 1

Gastrointestinal Motility Disorders & Irritable Bowel Syndrome

Jasmine Zia, MD

Acting Assistant Professor Division of Gastroenterology, University of Washington 6th Asian Health Symposium October 6, 2017

Disclosures

  • None

GI Motility Disorders

Organ GI Motility Disorders Esophagus

  • GERD
  • Achalasia
  • Esophageal Spasms: DES, Nutcracker,

Jackhammer

  • Ineffective Esophageal Motility

Stomach

  • Gastroparesis

Small Bowel

  • Small Bowel Dysmotility

Colon

  • Slow Transit Constipation

GI Motility Disorders: Highlighting Differences in Asians

Organ GI Motility Disorders Any Differences in Asians Esophagus GERD Yes Achalasia No Esophageal Spasms ??? Ineffective Esophageal Motility ??? Stomach Gastroparesis ??? Small Bowel Small Bowel Dysmotility ??? Colon Slow Transit Constipation Possibly

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Gastroesophageal Reflux Disease

Lower Prevalence of GERD in Asians

Ethnic Background GERD Prevalence (Weekly)

Caucasians 28% Asians 8%

Chinese 3% Taiwan 7% Hong Kong 3% Japanese 5% Malaysians 6% Koreans 8% Indians 8% Iranians 8% Turkish 20%

J Clin Gastroenterol 2015;50(1):e1‐e7. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824.

GERD‐Related Complications in Asians Compared to Caucasians

Dig Dis Sci. 2009;54(5): 964‐71.

5 10 15 20 25 30 35 40 Esophagitis Barrett's Esophagus Hiatal Hernia Stricture White Asian % Prevalence

Barrett’s Esophagus in Asians

Ethnic Background Barrett’s Esophagus Prevalence

Asians 0.06% to 6%

Indians 6 to 23.6%% Japanese 19.9% Chinese 1% Taiwan 0.8% Koreans 0.22%

Journal of Gastroenterology and Hepatology, 2011;26: 816‐824.

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Esophageal Adenocarcinoma in Asians

Ethnic Background Prevalence Death Rate Japanese Increasing 3.7 to 6.9 per 100,000 population from 1960 to 1995 Singapore Increasing 0.03 to 0.13 per 100,000 population from 1968 to 2002 Chinese Hong Kong Decreasing 11.7% to 6.4% from 1988 to 2003 Taiwan Unchanged Korea Unchanged

Journal of Gastroenterology and Hepatology, 2011;26: 816‐824.

Why are Asians less likely to get GERD?

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. Dig Dis Sci. 2009;54(5): 964‐71. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824.

  • Lower rates of hiatal hernias
  • Lower rates of transient LES relaxations
  • Smaller gastric parietal cell mass
  • Lower gastric acid output

Why else is GERD less prevalent in Asians?

  • “Heartburn” has no direct translation
  • Lower awareness of “GERD” in Asian countries

where peptic ulcer and gastric cancer are highly prevalent

  • Less likely to seek medical attention for GERD

– 70‐96% of survey participants with GERD do not consult their medical practitioner

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793. J Clin Gastroenterol 2015;50(1):e1‐e7. Diseases of the Esophagus, 2011;24(1):18‐24.

Prevalence of GERD is rising in Asians

Ethnic Background Change in Weekly GERD Prevalence Asians 5.2% (2005) 8.5% (2010) Koreans 7.1% (2002) 7.9% (2007) Singapore 5.5% (1994) 10.5% (1999)

J Clin Gastroenterol 2015;50(1):e1‐e7. Journal of Gastroenterology and Hepatology, 2011;26: 816‐824.

Ethnic Background Change in Esophagitis Prevalence Taiwan 5% (1995) 12.6% (2002) Koreans 1.8% (1995) 9.1% (2005) Malaysians 2.7% (1992) 9.0% (2001) Singapore 3.9% (1992) 9.8% (2001) Philippines 2.9% (1992) 6.3% (2002)

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9/21/2017 4 Why is GERD increasing amongst Asians?

  • Increased awareness
  • Increasing age
  • Rapid urbanization
  • Adoption of Western lifestyle

– Dietary habits – Resultant obesity

  • Decline in H pylori

– H pylori colonization decreases gastric acid output

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

GERD symptoms present differently in Asians than Caucasians

Caucasians

  • Heartburn
  • Acid regurgitation

Asians

  • Non‐cardiac chest pain
  • Dyspepsia/epigastric pain
  • Feeling of stomach acidity
  • Extra‐esophageal
  • Typical acid reflux

symptoms are uncommon (8 – 15%)

Diseases of the Esophagus, 2011;24(1):18‐24. J Clin Gastroenterol 2015;50(1):e1‐e7. Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

Treatment Approach of GERD for Asians

  • Start with:

– Upper endoscopy – H pylori test and treat

  • More cost effective than empirical PPI test as

the initial diagnostic strategy for patients with reflux symptoms.

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

Asians response to PPIs

  • More profound gastric acid suppression
  • Higher rate of healing of esophagitis
  • Required lower maintenance dose of PPI
  • Why???

– Smaller parietal cell mass – Higher prevalence of poor metabolizers due to cP450 2C19 polymorphism ‐> higher plasma PPI levels – Higher prevalence of H pylori: enhances acid suppressing effects of PPI through increased intensity

  • f corpus gastritis, which further suppresses the acid

secretory function

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

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9/21/2017 5

Asians are less likely to respond to PPIs

PPI Response Rates Asians Non‐Asians P value Week 4 44.3% 60.7% < 0.001 Week 8 63.6% 72.2% 0.010

  • Similar to Caucasians:

– Higher response rates for ERD (71.3%) versus NERD (48.5%) – ERD and less severe GI symptoms predicted symptomatic response to PPIs.

  • Unlike Caucasians:

– Lower BMI did not predict response to PPI therapy

BMC Gastroenterology 2014;14:156.

H Pylori Eradication and GERD

Caucasians

  • Little effect on GERD

severity (in terms of symptom relapse after withdrawal of acid suppressive therapy) Asians

  • Higher failure rates of step‐

down therapy compared to patients with persistent infection

– 43% vs 21%, P = 0.04

  • Increase in esophageal acid

exposure

  • Attributed to higher

prevalence of CagA+ strain

  • f H pylori and more severe

corpus gastritis

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

Recommendations for H pylori

  • Current consensus: eradicate H pylori before

long‐term PPI in Asian patients with GERD.

  • H pylori eradication prevents progression of

atrophic gastritis (premalignant condition).

  • This is a big deal where the incidence of

gastric cancer is high.

Journal of Gastroenterology and Hepatology, 2008;23:1785‐1793.

Achalasia

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9/21/2017 6

Prevalence of Achalasia in Asians

  • Equivalent to Non‐Asians
  • In a Singapore Study, within Asians:

Chinese Indian Malay

Dig Dis Sci 1993;38(10):1920‐5 Journal of Gastroenterology and Hepatology 1999;14:791‐795.

Esophageal Manometry: Differences in Normal Values in Asians

Journal of Gastroenterology and Hepatology 2013;28:1611‐1615.

EMAN Value Caucasians Asians Integrated Relaxation Pressure < 15 mmHg < 20.5 mmHg

Constipation

Bowel transit times may be faster in Asians

Ethnic Background Colon Transit Times (h) Caucasians Americans 56.2 Canadians 93 French 67 Asians Hong Kong 62 Japanese 33.9

Journal of Gastroenterology and Hepatology 2004;19:1270‐1275. Lancet 1977;2(8029):110‐1.

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9/21/2017 7 Asian Factors Affecting Colon Transit Times

Eur J of Clin Investigation 2006;737‐742.

Factor Effect on Colon Transit Times Lactose intolerance Reduction H pylori Reduction

Prevalence of Constipation by Country

Best Practice & Research Clinical Gastroenterology 2011;25:3‐18.

Sex Differences in Constipation in Asians versus Non‐Asians

Caucasians Asians

Aliment Pharmacol Ther. 2010;31(2):274‐84.

> =

China Indonesia South Korea % using laxatives 20 40 60 80 100

Laxative Use Amongst Asians with Constipation

Aliment Pharmacol Ther. 2010;31(2):274‐84.

Women Men

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9/21/2017 8

Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS)

ROME IV Criteria: Recurrent abdominal pain at least 1 day/week in last 3 months associated with two or more of the following:

1. Related to defecation 2. Onset associated with change in stool frequency 3. Onset associated with a change in form (appearance

  • f stool)

*In absence of selected alarm features

Rome IV Diagnostic Criteria for FGIDs Neurogastroenterol Motil 2005;17:317‐324.

Lower Prevalence of IBS in Asians?

2005

Prevalence of IBS is similar between Caucasians and Asians

J Gastroenterol Hepatol. 2017; ahead of print.

2016

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Prevalence of IBS in Asians

Ethnic Background Prevalence of IBS Japanese 19 – 21% Chinese 5 – 20% Malaysians 16% Pakistan 13% Bangladesh 13% Singapore 9 – 11% Koreans 10% Indians 4 – 7% Iran 1%

J Gastroenterol Hepatol. 2017; ahead of print.

Cultural Differences in Symptom Interpretations

  • Constipation, bloating, & fullness are difficult

to define and differentiate from each other.

  • Bloating is an English term.
  • Post‐prandial fullness, bloating, and relative

severity of abdominal pain may not be interpreted in the same way in different countries.

Gender Distribution of IBS in Asians versus Non‐Asians

Non‐Asians Asians

> =

J Gastroenterol Hepatol. 2017; ahead of print.

Frequency of IBS Symptoms in Asians and Non‐Asians

J Gastroenterol Hepatol. 2017; ahead of print. J Gastroenterol Hepatol 2007;22(8):1168‐9.

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Neurogastroenterol Motil 2005;17:317‐324.

Location of Abdominal Pain in Asian versus Non‐Asian IBS Patients Diet Highlights for Asian IBS Patients

  • Rice

– Complete small bowel absorption, low gas production, low fiber

  • Chili (Capsaicin)

– Can aggravate abdominal pain and burning – May desensitize capsaicin receptors that play a role in gut irritability associated with FGIDs

  • Vegetarians

– Vegetarianism is a risk factor for IBS in Northern India – May make low FODMAP diet challenging

Doctors in Asia are less likely to prescribe psychotropic agents.

Non‐Asian Providers

  • USA: 45 ‐ 55%

Asian Providers

  • Asia: 20%
  • 70% of Asian

gastroenterologists would

  • nly use a psychotropic

agent as second‐line therapy.

Traditional Chinese Medicines for IBS

  • Padma Lax
  • Tumeric
  • Tong Xie Yao Fang
  • Xiaoyao San (MXS)
  • Xinwei decoction
  • Chang’an I recipe
  • Shugan Jianpi Zhixie
  • Moxibustion

Grundmann O et al. World J Gastroenterol 2014;20(2):346‐362. Portincasa P et al. J Gastrointestin Liver Dis 2016;25(2):151‐157. Bundy R et al. J of Alternative and Complementary Med 2004;10(6):1015‐1018. Brinkhause B et al. Scandinavian J of Gastroenterology 2005;40:936‐943. Qin F et al. J of Gastroenterol Hepatol 2009;24(8):1320‐5. Dabos KJ et al. J of Ethanopharmacology 2010;127:205‐209. Zhao L et al. Amer J of Chinese Medicine 2005;33(2):249‐257.

Efficacy: ???

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Acupuncture for IBS

  • Efficacy: Unlikely
  • At least 4 double blind, sham controlled trials
  • No differences in responder rates between

acupuncture & sham acupuncture

– Adequate relief of IBS, IBS‐QOL, IBS‐SSS

  • Real benefit: interaction between CAM

provider and patient?

Chey WD et al. Gut and Liver. 2011;5(3):253‐266.

Questions?

  • JZia@medicine.washington.edu