To Örebro University

INTRODUCTION: Irritable bowel syndrome (IBS) is a common condition that should be diagnosed using the Rome criteria and limited laboratory testing. The aim of this retrospective, medical record-based study was to evaluate the adherence of Swedish primary health care practitioners to diagnostic guidelines for IBS.

METHODS: Using the electronic patient register in primary care, we identified 1943 new IBS cases in patients aged 18-65 between January 2015 and December 2019 in Region Örebro County. A random sample of 400 patients was selected and their medical records were scrutinized to evaluate diagnostic methods.

RESULTS: Of the 309 eligible medical records, only 36.2% of patients met the Rome III or IV criteria. The criteria were explicitly documented in 4.9% of cases, and subclassification was noted in 5.5%. There were no significant differences in diagnostic practices between GPs and other physicians. Only 9.4% were diagnosed without laboratory testing, although 69.9% did not undergo all recommended tests according to local guidelines. Rectoscopy was performed in 14.2%, while 9.7% and 5.8% of patients were referred for colonoscopy or CT, respectively, with significantly higher referral rates in patients over 40 years. Men were more frequently referred for colonoscopy while other diagnostic procedures showed no significant sex differences.

CONCLUSIONS: Adherence to IBS diagnostic guidelines in Swedish primary care seems to be limited among both GPs and non-GPs. The documented use of Rome criteria is minimal, and guideline-compliant laboratory testing is insufficient. Increased awareness and structured implementation of IBS diagnostic criteria are warranted.

BACKGROUND: The standardised course of care colorectal cancer pathway (SCC-CRC) is a symptom-based fast-track diagnostic pathway. Age-related differences in outcomes and referral-factor associations within different age groups are incompletely described.

OBJECTIVE: To describe colonoscopy outcomes across age groups in SCC-CRC and evaluate unadjusted and adjusted associations between referral factors and CRC and advanced colorectal lesions.

DESIGN: A retrospective cohort study. METHODS: A cohort of 3258 patients referred through SCC-CRC and investigated with colonoscopy during 2016-2023 was grouped by age (18-40, 41-50, 51-60, 61-70, 71-80, >80 years). Referral factors were analysed using positive predictive value (PPVs), sensitivity, specificity, likelihood ratios and logistic regression adjusted for age, sex and coexisting referral factors; a second model included faecal immunochemical test (FIT) among patients with available FIT data.™.

RESULTS: CRC was detected in 0% of patients aged 18-40, 6.5% aged 41-50, 11.2% aged 51-60, 18.3% aged 61-70, 18.1% aged 71-80 and 21.2% aged >80. The frequency of referral factors varied across age groups, while the PPV for CRC increased with age. Rectal and radiological findings were associated with CRC across age groups. In adjusted analysis without FIT, radiological findings, rectal findings, anaemia and visible blood were independently associated with CRC. Among patients with FIT data, positive FIT was strongly associated with CRC and negative FIT had a high negative predictive value.

CONCLUSION: CRC detection increased with age in this symptomatic cohort. Several referral factors were independently associated with CRC, but PPV increased with age, partly because CRC prevalence increased with age. Routine FIT testing in SCC-CRC referrals and complete FIT data capture should be assessed in future studies.

Objectives: Colonoscopy in elderly, frail patients requires weighing diagnostic yield against procedure-related risk, but real-world data are limited. We describe outcomes from two Swedish cohorts undergoing non-screening colonoscopy in two regions.

Methods: We combined aggregated results from two retrospective cohort studies. The Ersta cohort included all patients aged >= 75 years undergoing colonoscopy in 2022 and compared inpatient versus outpatient examinations. The Örebro cohort included all colonoscopies in patients aged >= 80 years during 2016-2018. We extracted data on indications, pre-referral investigations, findings, quality indicators, and short-term mortality. For Örebro, we used previously calculated odds ratios and positive predictive values for significant findings.

Results: At Ersta, 1,066 patients aged >= 75 years underwent 1,144 colonoscopies; 40% were performed in inpatients admitted for bowel preparation. Colorectal cancer was diagnosed in 5%, inflammatory bowel disease in 6%, microscopic colitis in 3%, and other colitis in 4%, with similar proportions in inpatients and outpatients. One-year mortality was 6% after inpatient and 1% after outpatient colonoscopy. In Örebro, 565 colonoscopies in patients aged >= 80 years were analyzed. Significant findings occurred in 26.2% (colorectal cancer 18.8%, high-grade dysplasia 4.6%, any colitis 5.0%, with some overlap). Abnormal rectal examination, abnormal abdominal imaging, low ferritin, and positive f-Hb predicted significant disease. Altered bowel habits was the most common indication but had an odds ratio below 1 for significant disease.

Conclusions: In elderly Swedish patients, colonoscopy detects colorectal cancer or colitis, but many examinations show benign or no findings. Selection using simple pre-referral tests and life expectancy may reduce low-yield examinations.

BACKGROUND: Fast-track colonoscopy pathways detect colorectal cancer (CRC) but strain endoscopy capacity. We developed and externally validated multivariable risk models combining faecal immunochemical test (FIT) with clinical data to triage Swedish fast-track referrals.

METHODS: We analysed 2,539 fast-track colonoscopies (2016-2020) and 723 as a validation cohort (2021-2022). Predictors were age, sex, eight symptoms, binary FIT, haemoglobin, and suspicious imaging. In development, missing predictors were imputed within training/test splits; validation used complete cases. Class imbalance was handled with oversampling to balance classes. Logistic regression and CatBoost models were built. External validation assessed AUC, calibration, and calibration slope. Variable influence was examined with feature contribution analysis. Decision-curve analysis (DCA) used the entry rule as a treat-all baseline.

RESULTS: CRC prevalence was 16% in both cohorts. Development AUCs were 0.81 (95% CI 0.78-0.83) for CatBoost and 0.77 (0.74-0.80) for logistic regression. In external validation, AUCs were 0.67 (0.61-0.74) and 0.66 (0.58-0.75), respectively. FIT status, suspicious imaging, and age were the main predictors. Calibration drift was observed. The entry rule functions as treat-all (specificity 0%). CatBoost DCA curves were near or above treat-all at common thresholds, but 95% bands overlapped; advantage over treat-all was not confirmed.

CONCLUSIONS: A multivariable approach using FIT, simple laboratory data, and clinical findings can support triage in a fast-track pathway. In validation, discrimination was modest, and superiority over the entry rule could not be shown because all referred patients underwent colonoscopy. External testing across regions, recording quantitative FIT, and routine recalibration are needed before implementation.

AIMS: Low-energy diet (LED) plus cognitive-behavioural therapy (CBT) produces substantial short-term weight loss in obesity, but long-term maintenance remains difficult. We evaluated whether adding intragastric balloon (IGB) treatment to group-based CBT improves weight maintenance after initial weight loss using LED.

MATERIALS AND METHODS: In this open-label randomized controlled trial, adults aged 30-65 years with BMI 32.5-45 kg/m2 underwent a 6-month run-in period combining LED and group-based CBT and were subsequently randomized to CBT and 1-year IGB or CBT alone. The primary endpoint was weight change in percent between randomization (6 months from enrollment) and 18 months (from enrollment), compared to total body weight (TBW) at enrollment. Secondary outcomes included the proportion of participants achieving weight loss thresholds, metabolic parameters and health-related quality of life (HRQoL).

RESULTS: Of 126 enrolled (mean 43.7 years; BMI 38.0 kg/m2), 107 were randomized 6 months after enrollment (IGB n = 51; CBT n = 56) and lost -18.7% (SE: 0.64) of TBW. At 18 months, the mean weight change from randomization was 5.2% with IGB versus 10.1% with CBT (p < 0.001). A significantly greater proportion of IGB recipients achieved ≥ 5% (84.3% vs. 63.6%; p = 0.021) and ≥ 10% (70.6% vs. 45.5%; p = 0.013) weight loss after 18 months, compared to the CBT group. Improvements in metabolic parameters and HRQoL showed no between-group differences.

CONCLUSIONS: As an adjunct to group-based CBT and after LED-induced weight loss, IGB treatment provided a modest advantage in weight maintenance for up to 18 months, although safety concerns remain and long-term studies are warranted.

Selective cyclooxygenase-2 (COX-2) inhibitors are often considered when anti-inflammatory analgesia is needed for musculoskeletal pain in patients with inflammatory bowel disease (IBD), but concerns remain about intestinal safety. The clinical evidence on short-term selective COX-2 inhibitor use in IBD, with focus on disease activity outcomes, was reviewed. A prespecified literature search was performed in PubMed and the Cochrane Library supplemented by reference list screening. Clinical trials and clinical studies evaluating celecoxib, etoricoxib or rofecoxib in patients with IBD and musculoskeletal/rheumatological symptoms were considered when gastrointestinal (GI) outcomes were reported. Two placebo-controlled randomised trials did not show higher rates of IBD relapse or symptom aggravation vs placebo during short-term treatment in selected patients, including ulcerative colitis in remission and IBD with rheumatic manifestations. Open-label studies and retrospective series reported variable GI adverse events and occasional symptom worsening, but study populations, baseline disease activity, relapse definitions and follow-up duration differed widely. Overall, the strongest available evidence supports cautious short-term use of selective COX-2 inhibitors in selected patients with IBD in remission when anti-inflammatory analgesia is required. Given the small evidence base and limited follow-up, treatment should be time-limited, use the lowest effective dose and include clinical monitoring.

BACKGROUND: In 2021, a nation-wide screening program for colorectal cancer (CRC) was step-wise implemented in Region Örebro County (RÖC) for patients aged 60 to 74 years, utilizing the fecal immunochemical test (FIT) to refer patients for colonoscopy. Concurrently, the standardized care course for colorectal cancer (SCC-CRC), initiated in 2016, employs a fast-track pathway for patients with alarm symptoms to undergo colonoscopy. This study compares CRC screening colonoscopies with SCC-CRC colonoscopies in RÖC among patients aged 60 to 67 years.

METHODS: An initial analysis of the Swedish colorectal screening cohort was combined with a retrospective cohort study, analyzing data from 307 CRC screening patients and 441 age-matched SCC-CRC patients in RÖC. Data included demographics, colonoscopy participation rates, and pathology findings. Statistical analyses compared outcomes between the 2 groups.

RESULTS: Among the screening group, 2% tested positive for FIT, with an 86% colonoscopy participation rate (N=9296). In RÖC, 266 screening patients underwent colonoscopy, with 10% diagnosed with CRC, compared with 20% in the SCC-CRC group. In addition, 39% of the screening group in RÖC were diagnosed with advanced adenomas, versus 15% in the SCC-CRC group.

CONCLUSIONS: Screening participation was high, with effectiveness aligning with international counterparts. The SCC-CRC pathway excels in diagnosing CRC among symptomatic patients, while the nationwide screening program is effective in early detection of CRC and advanced adenomas. underscoring the importance of integrating and optimizing both approaches within the Swedish health care system to optimize CRC prevention and management.

Objectives: Irritable bowel syndrome (IBS) is a common functional gastrointestinal condition. A respectful patient-doctor relationship with good communication is crucial for optimal treatment. Q-methodology is a combination of qualitative and quantitative methods used to study subjectivity. The aim of this study was to compare viewpoints on IBS between patients with IBS and general practitioners (GPs).

Methods: We conducted a Q-methodology study by including 30 patients and 30 GPs. All participants were asked to complete Q- sorting of 66 statements on IBS using an online software program. Data were processed using factor analysis. In addition, 3 patients and 3 GPs were interviewed.

Results: Three factors were extracted from both groups: Patient Factor 1 'Question the diagnosis of IBS', Patient Factor 2 'Lifestyle changes for a physical disorder', Patient Factor 3 'Importance of a diagnosis', GP Factor 1 'Unknown causes of great suffering', GP Factor 2 'Lifestyle changes are important, stress makes IBS worse', GP Factor 3 'Recognized the way IBS affects patients'. There was a strong and statistically significant correlation between patient Factor 1 and GP Factor 1, with a Pearson's r of 0.81 (p < 0.001). Correlations between other factors varied.

Conclusions: There was consensus between patients and GPs that IBS is a physical and not a psychiatric disorder of unknown etiology. They also seemed to agree that IBS has a great negative impact on patients' lives and that lifestyle changes are beneficial. There were conflicting opinions regarding gender, cultural factors and the use of antidepressants.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is the gold standard method for diagnosing upper gastrointestinal (GI) pathology. Swedish guidelines recommend patients over 50 years with new-onset dyspeptic symptoms undergo direct gastroscopy to rule out malignancy. However, the incidence of dysplasia or cancer in patients aged 61-70 years remains unclear.

OBJECTIVES: To investigate the referral factors and endoscopic findings in patients aged 61-70 years and compare the result with age groups 51-60 and 41-50 years from our previous studies to establish whether there is an age cutoff for upper GI cancer risk.

DESIGN: A retrospective observational study was conducted to evaluate EGD referrals and outcomes in patients aged 61-70 years.

METHODS: We analyzed EGD referrals for patients aged 61-70 years within Region Örebro County from January 2019-April 2020 to January 2022-2023. Clinical data, including symptoms, medications, and laboratory results, were collected from medical records. Statistical analysis, including odds ratios (OR) and positive predictive values (PPV), was conducted to evaluate pathological outcomes based on referral factors.

RESULTS: A total of 1003 referrals were analyzed. Statistically significant differences in pathological findings were observed between the 41-50 years reference group and the older groups (51-60 years: OR 2.08, p < 0.001; 61-70 years: OR 3.05, p < 0.001). However, no statistically significant difference in cancer incidence was found between the age groups.

CONCLUSION: The most common pathological findings were benign, including hiatal hernia, gastroesophageal reflux disease/esophagitis, or gastritis. The incidence of cancer was low in all three groups. These results suggest that the "test-and-treat" strategy, currently recommended for patients under 50 years, may be appropriate for patients aged 51-70 years as well.

TRIAL REGISTRATION: NCT04585516.

Abnormal visceral perception and motor function are often observed in patients with fecal incontinence, evacuation disorders and irritable bowel syndrome. The international anorectal physiology working group has proposed a standardization for anorectal function assessment, where rectal sensitivity testing is performed using an elastic balloon attached to a high-resolution anorectal manometry (HRAM) catheter. Rectal compliance, another component of rectal function evaluation, is a pressure-volume relationship that refers to the rectum's ability to stretch and expand as it receives and holds fecal matter. There are no data available regarding the possibility of compliance testing using HRAM, although this is theoretically possible by correcting for the elastic balloon's intrinsic properties. The gold standard for measurement of visceral sensitivity and compliance is the rectal barostat, according to the procedure described by the European COST action GENIEUR group. Data on the agreement between the two different procedures are scarce. Hence, we performed a comparative study of the HRAM and barostat investigations in 26 healthy individuals. We hypothesized that by inflating the balloon before the examination, rectal compliance can be measured with HRAM investigations, and we examined correlations and levels of agreement between the methods. Our results demonstrate that assessing rectal compliance with HRAM is technically possible; however, a strong correlation with the rectal barostat was only observed at the maximum tolerable volume (Spearman's rho = 0.7, p = 0.02). We only found moderate correlations (Spearman's rho = 0.562, p = 0.019) for compliance according to the barostat methodology and for rectal sensibility testing (Spearman's rho = 0.57, p = 0.03 for maximum tolerable volume). Bland-Altman plots showed poor levels of agreement between the methods. We conclude that HRAM and the rectal barostat cannot be used interchangeably for compliance or sensitivity assessments. We suggest the development of a non-elastic balloon with a fixed size and shape to assess rectal sensory function and compliance in HRAM testing.