Stating the obvious about ABUSE and its repercussions

ACG: GI Docs Should Ask About Abuse

By Kristina Fiore, Staff Writer, MedPage Today Published: October 20, 2010

SAN ANTONIO -- Gastroenterologists may want to be attuned to signs of possible abuse or trauma among their patients, a researcher suggested here. Subtle signs -- a rectal exam that provokes tearfulness in a patient, for instance -- may indicate psychological issues that could complicate treatment for GI problems, said Douglas Drossman, MD, of the University of North Carolina Chapel Hill. Drossman has been studying the link between abuse and GI disease for the last 20 years and summarized his work at the annual meeting of the American College of Gastroenterology. Delivering the American Journal of Gastroenterology lecture at the meeting, Drossman also offered advice on how fellow clinicians can address the issue of prior abuse and trauma to get patients the help they need to improve outcomes. "Being a gastroenterologist, it's not our responsibility to ask about abuse history in someone coming in with GERD, a GI bleed, or liver disease," he commented. "We're asking about it when we think that information would make a meaningful difference in outcome by identifying and treating it." Researchers have long known of an association between stress and gastrointestinal symptoms, but have only recently begun to understand the mechanisms at work between stressful life events like abuse or trauma and more serious GI problems. Drossman said the first line of evidence linking the two came from epidemiologic studies that found a higher-than-expected association of abuse history in patients with GI symptoms. Other epidemiological data have found an association between a history of abuse and poor health status in general, and that patients with prior trauma had more pain and a higher number of doctor visits. Over the past 10 years, researchers have been able to get a more profound understanding of this association with the help of brain imaging, Drossman said. He and his colleagues have been able to show that irritable bowel syndrome (IBS) patients who had a history of abuse had greater activation of the cingulate cortex, an area associated with pain processing. These IBS patients indeed reported greater pain, Drossman said. Other data from an Institute of Medicine report on Gulf War veterans also found an association between war trauma and the development of IBS, he added. "IBS may be facilitated by psychological stress," he commented. The question, Drossman said, is how to translate knowledge of this link into clinical practice -- acknowledging that asking patients about past abuse and trauma is not easy. However, he has identified factors that may reveal abuse, making it easier for clinicians to broach the subject. One clue, he said, may be a GI patient who presents with trust issues or feelings of vulnerability, shame, or loss of control during a visit. "Those kinds of feelings, the more you see of them, the more you think about it," he said, referring to a potential history or abuse. Other hints of past abuse or trauma may manifest themselves in physical problems, including chronic abdominal pain, morbid obesity, or eating disorders. Patients troubled by past traumas may also have a record of multiple procedures and hospitalizations for their symptoms, he added. But one of the biggest clues to past abuse may come from patient reactions to procedures like rectal exams or colonoscopy. "If we see an unusual response like tearfulness or agitation, we really should think about the link," he said. He cautioned that the greatest problem is figuring out how to break the ice and ask the tough questions. "It's easy to do that if you're doing a colonoscopy and the patient has an emotional and dramatic response," he said. "Then it's easy to say, 'I see you don't feel comfortable, has something like this happened before?'" Physicians can emphasize that evidence has shown that these issues can affect the way they manage their conditions. "It's about being gentle, and giving them the opportunity to tell you what they want to tell you," he said. "If they don't want to talk, you can register that information and say, 'If you want to talk about it, I'll be available.'" Physicians should have a psychiatrist colleague for patient referrals. Walter Coyle, MD, of the Scripps Clinic in La Jolla, Calif., said many gastroenterologists aren't doing a good job of asking about past abuse and trauma. "If you do, you have to deal with the consequences of opening that door," he said. "It's not easy to ask, but I think you've got to, because there is so much abuse out there."