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Gerry Gajadharsingh writes:
“Many clinicians now accept that a fair proportion of abdominal symptoms are not related to any defined organic pathology/disease and these are often described as functional abdominal or gastrointestinal tract (GIT) symptoms, which simply means that something is not working properly, but there’s no evidence of an actual disease process.
In fact, functional problems occur in many different systems in the body, with patients often reluctant to accept that there may be no obvious medical/pathological cause for their symptoms (I suspect because the patient thinks often incorrectly that the clinician thinks that it’s all in the patient’s mind).
Functional abdominal symptoms are extremely common. Historically, for example, changes in mood were also focused on the abdomen. In fact, the term melancholia, literally black bile, the predecessor of depression was thought to emanate from abnormality of gastrointestinal function.
Sigmund Freud also recognised importance of the GIT symptoms as a mirror of the mind and emotion.
Irritable bowel syndrome (IBS), as opposed to inflammatory bowel disease (IBD), is probably the most common of all the functional gastrointestinal disorders and usually include the symptoms of distension/bloating, abdominal pain and alteration in defecation (constipation and or loose bowel movements/diarrhoea).
It’s estimated that up to 20% of adults in the industrialised world have functional gastrointestinal symptoms. Although only a minority of individuals with symptoms present doctors.
IBS accounts for between 20 and 50% of referrals to Gastroenterologists.
Functional constipation occurs in up to 20% of the population and is more common in women whereas functional diarrhoea is less common only occurring in 4% of healthy subjects.
The challenge is that functional GIT symptoms can present in a similar way as organic disorders. Which is probably why many people who do present to clinicians are initially investigated and when results turn out to be negative then the label of a functional GIT condition such as IBS is often given.
One of the most commonly recognised functional symptoms affecting the oesophagus is that of globus, used to be called globus hystericus. Patients suffer a sensation of a lump in their throat sometimes combined with difficulty swallowing. An ENT consultant would usually visualise the oesophagus via an endoscope with the majority of cases again no obvious medical cause found.
Functional or non-cardiac chest pain is also very common and may resemble the pain of myocardial ischaemia (MI) or oesophageal spasm.
Functional heartburn/dyspepsia is also one of the more common syndromes. Dyspepsia comes from the Greek dys meaning bad and peptein meaning to digest.
Dyspepsia affects the epigastric/upper abdominal area and may or may not be related to eating meals.
Functional abdominal pain and sometimes anal/rectal pain, as an isolated symptom is one of the more difficult functional bowel symptoms to manage. Usually, patients will have extensive investigations and multiple doctors and a majority of patients with functional abdominal pain syndrome will eventually have some form of psychiatric disorder diagnosed, such as depression and anxiety being the most common diagnosis. Again, patients find us hard to accept, they generally say “but I physically feel it” as they do with many other pain syndromes.
In one of the earliest systemic clinical studies published by Bockus et al in 1929, they explored psychological factors related to colitis (pain in the colon). In the 50 patients they looked at they concluded from observations, that nervousness of some type was present in practically every case, with 46% considered to be depressed. However, the patients were for the most reluctant to being described as nervous minimising the considerable emotional suffering to avoid the stigma of neurosis.
Repeatedly investigating patients for functional symptoms is not sustainable on an economic level and is often to the detriment of the patient. The problem for clinicians is that nobody wants to miss anything, and patients are often dismissive when told that nothing medically can be found to account for the symptoms and will keep on seeking other clinicians willing to carry on investigating.
One of the useful tests I carry out in clinic is an assessment of a patient’s autonomic nervous system via heart rate variability (HRV) in particular breathing heart wave or respiratory sinus arrhythmia which is the HRV which correlates with a person’s breathing pattern. I have assessed over 4 ½ thousand patients using capnometry and HRV and there is no doubt in my mind that autonomic dysregulation plays quite a significant part in many patient symptom presentations, especially functional symptom presentations.”