As of 2012, 233,000 Canadians were reported to be living with inflammatory bowel disease (IBD), 2.5% of which were <18 years of age. In Ontario, the incidence of pediatric IBD is ~11.8 per 100,000 population, which is one of the highest rates in the world. Youth with IBD experience numerous health problems secondary to their diagnosis, including poor fitness and lower lean mass. The extent to which youth with IBD can respond to an exercise training program designed to improve fitness remains unknown. The aim of this thesis was to assess the safety, feasibility and physiological efficacy of an exercise training program for youth in remission from IBD. Additionally, we attempted to understand the barriers and facilitators to physical activity in this population. A total of 104 patients were approached to participate in this study, 18 demonstrated interest and 11 consented to participate. Ten youth (nine males, age: 15.4±1.2 years) with IBD completed the study. Participants trained three times per week (2d in lab, 1d at home) for 16 weeks. Training sessions lasted 30 to 60 minutes, and consisted of a customized combination of aerobic and resistance exercises. Fat mass and lean mass were measured via Dual Energy X-ray Absorptiometry. Isometric and isokinetic torque of elbow flexion and knee extension were evaluated using an isokinetic dynamometer system. Peak oxygen consumption (VO2peak) and peak mechanical power (Wpeak) were determined using the McMaster All-Out Continuous cycling test. Barriers and facilitators to physical activity were measured via qualitative interviews pre-training. Body composition, muscle strength and aerobic fitness variables were measured at baseline, after 8 weeks, and after 16 weeks of training. Participants completed 89.1±5.2% of lab training sessions and 55.0±26.5% of home training sessions. There were significant increases in whole body lean mass (p<0.001), isokinetic knee extension strength (p<0.05) and Wpeak (p<0.001) over the course of the training program with small, moderate and large effect sizes respectively. All participants were in remission post-training, demonstrated small deviations in features of disease activity and reported no adverse events with training. Participants described similar barriers and facilitators to physical activity, to those of the general public, such as lack of access to facilities and peer support, respectively. Additionally barriers and facilitators unique to individuals with this condition were identified including the physical burden of disease (e.g., episodic abdominal pain) and creating modifications to activities to facilitate accessibility. Our results demonstrate that exercise training in youth in remission from IBD is safe, feasible and has the capacity to counteract a broad range of secondary symptoms such as deficits in lean mass, muscle weakness and aerobic deconditioning. Youth with IBD should be encouraged to exercise on a regular basis. Results from this study will inform the design of a larger, randomized controlled trial. / Thesis / Master of Science in Kinesiology

Detta är en kvalitativ studie med fenomenologisk ansats, som beskriver kvinnor med Irritable Bowel Syndrome (IBS) och deras upplevelser av sjukdomen. Vårt syfte med studien är att öka kunskapen och förståelsen hos sjuksköterskor och övrig vårdpersonal, genom att låta kvinnor med diagnosen IBS beskriva sina upplevelser av att leva med syndromet samt hur de blivit bemötta vid kontakter med sjukvården. Målsättningen är att det holistiska omhändertagandet av patienten skall förbättras. Studien baseras på semistrukturerade intervjuer med sju diagnostiserade kvinnor. Materialet har sedan bearbetats utifrån Philip Burnards modell för textanalys. Resultaten presenteras i följande kategorier sociala aktiviteter, sociala relationer, okunskap, bemötande och utredning, vilka kan relateras till de aktuella frågeställningarna (1) Hur upplever kvinnor med IBS att sjukdomen påverkar deras dagliga liv? Och (2) Hur upplever kvinnor med IBS att de blivit bemötta vid kontakter med sjukvården. Våra resultat ger en uppfattning av hur kvinnorna upplever att deras IBS påverkar det dagliga livet. Utmärkande för studiepopulationen är upplevelser av att sociala relationer och sociala aktiviteter förändrats till följd av sjukdomen. Gällande bemötande vid kontakter med sjukvården upplever kvinnorna att de bemötts med okunskap från sjuksköterskor och annan vårdpersonal. De upplever sig dessutom ofta åsidosatta och lågprioriterade av sjukvårdssystemet. / This is a qualitative study with a phenomenological approach, about females with Irritable Bowel Syndrome (IBS). The purpose of the study is to increase the knowledge and understanding among nurses and other caring personnel, by letting females diagnosed with IBS describe their experiences of living with the syndrome, and how they have been treated in contacts with the Swedish healthcare system. The intention of the study is that the holistic care should be improved. The study is based on seven semi-structured interviews of IBS-diagnosed females. The data has been analysed with Burnard´s method for transcripts. The results are presented in the following categories social activities, social relations, ignorance, treatment, analysis, which can be related to the actual questions of the study: (1) How do females with IBS experience that the illness affects their daily life? and (2) How do females with IBS experience the treatment in contacts with the Swedish care-system? The results have been presented in categories that can be related to the empiric questions in the study. The results of the study give us a conception of how IBS influences the daily life. Distinguishing for the study population is their experiences of changes in their social activities and relations due to their illness. About treatment in contacts with the Swedish healthcare system the females experience that they have been treated with ignorance from nurses and other health care personnel. They also experience themselves as disregarded and low prioritised by the healthcare system.

Irritable bowel syndrome (IBS) is a functional bowel disorder with 6.5% worldwide prevalence that causes gas production, abdominal distension, and abdominal pain or discomfort. This systematic review describes efficacy of the Low-Fermentable Oligosaccharides, Disaccharides, Monosaccharides And Polyols (FODMAP) diet (Low-FODMAP diet or LFD) to alleviate IBS symptoms using the PRISMA guidelines. Nine randomized controlled trials (RCT) and one non-RCT consecutive controlled study published between 2015 to 2019 were identified using PubMed and CENTRAL. Included studies involved adult IBS participants with symptoms of abdominal pain, constipation, and/or diarrhea. A total of 530 participants completed the interventions from the 10 studies included in the final systematic review with participants ranging from mean ages of 40.31±12.83 years. The LFD can be recommended to patients for its use with alleviating abdominal pain severity and quality of life; however, more research is needed to verify the efficacy of the LFD concerning stool frequency and consistency.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24476号 / 医博第4918号 / 新制||医||1062(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 羽賀 博典, 教授 小濱 和貴, 教授 川口 義弥 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Background: It has been hypothesized that dysbiosis plays a significant role in the pathogenesis of intestinal failure–associated liver disease (IFALD). Therefore, we aimed to investigate the effect of probiotics on IFALD in patients receiving parenteral support, namely home parenteral nutrition (HPN) and home intravenous fluids (HIVFs). Methods: We retrospectively reviewed charts of patients with intestinal failure who received HPN or HIVF for >2 weeks at our tertiary center between January 2005 and August 2016. We excluded patients <18 years of age, patients with other causes of liver disease, patients who used probiotics for <30 days, patients with <6 months' follow-up, and those who had long-term antibiotic use (>30 days). Bivariable and multivariable logistic regression analyses were used in this study. Results: A total of 282 patients who received parenteral support were included. Eighty-five percent of our sample received PN. A total of 78 (27.7%) patients used probiotics. The prevalence of IFALD in patients who used probiotics was 35.9% vs 54.4% in patients who did not use probiotics, P =.005. In multivariable analysis, only small-bowel length of 10-90 cm and HPN use showed a significant impact on IFALD, odds ratio (OR) = 4.394 (95% confidence interval [CI], 1.635-11.814; P =.003) and OR = 4.502 (95% CI 1.412-14.351; P =.011), respectively. Conclusion: Our study revealed that the prevalence of IFALD was comparable among the probiotic users and nonusers. Only small bowel length of 1090 cm and HPN use showed a significant impact on IFALD.

Despite advancements in the treatment of individuals with Inflammatory Bowel Disease (IBD), many patients will require the need to utilize biological therapies during their disease course. Moreover, some patients with IBD develop disease manifestations outside of the GI (gastrointestinal) tract termed extraintestinal manifestations (EIM). We sought to establish an association between prior EIM exposure and the sequential use of biological therapies in patients with IBD. A retrospective analysis of 555 patients with confirmed IBD and relevant EIM data was performed. EIM exposure was treated as both a dichotomized (ever, never) variable and a categorical (0, 1, 2 or more) variable in our analysis. Crude ratios were established using logistic regression and multinomial regression models. Bivariate analysis was used to test for significant confounding variables and significant confounders were included in the final multivariate regression model. We found female sex (p < 0.001), a disease duration of 13 years or longer (p = 0.001), and an ileocolonic disease location (p = 0.036) to be significantly associated with EIM exposure. We found that a disease duration of 13 years or longer (p = 0.037), diagnosis of Crohn’s Disease (CD) (p < 0.001), corticosteroid use (p < 0.001), and an ileocolonic disease location (p = 0.021) to be significantly associated with use of biologics. Our final adjusted model did not show statistical significance, but did notably indicate that individuals exposed to 2 or more EIM had 1.51 times the odds of progressing to biological therapy (95%CI: 0.67, 3.41; p = 0.32) compared to those patients with no EIM history. As a result, EIM exposure may be an indicator for high-risk IBD patients likely to require biological therapy, especially among particular groups. Our data emphasizes the need for further studies to characterize the association between EIM exposure and specific EIM with the utilization of biologics.

Bakgrund: Inflammatorisk tarmsjukdom är en grupp av autoimmuna sjukdomar som idag är ett globalt folkhälsoproblem och ökar i hela världen. Ulcerös kolit och Crohns sjukdom är de två huvudsakliga typerna. Symtomsbördan är stor och kan begränsa det sociala livet samtidigt som stigmatisering och känslor av skam är förekommande. Syfte: Syftet var att belysa unga vuxnas erfarenheter av att leva med inflammatorisk tarmsjukdom. Metod: Studien var en allmän litteraturstudie som omfattade nio vetenskapliga artiklar som bearbetades i en induktiv ansats. Resultat: De unga vuxnas erfarenheter av att leva med IBD sammanställdes i tre huvudkategorier; ”Erfarenheter av psykosocial påverkan”, ”Erfarenheter av behandlingen för inflammatorisk tarmsjukdom” och ”Erfarenheter av stöttning från vård- och omsorgspersonal”. Konklusion: Unga vuxna med inflammatorisk tarmsjukdom upplevde symtombesvär som gav upphov till känslor av kontrollöshet, skam och begränsningar i vardagen. Erfarenheter av läkemedelsbehandlingarna innehöll upplevelser av otillräcklig effekt, information och efterföljdsamhet. Behandlingen med stomi upplevdes vara symtomlindrande men hade en psykisk påverkan initialt. Informationsgivning och stöttning från hälso- och sjukvården var bristande. Litteraturstudien bidrar till en ökad förståelse för dessa erfarenheter och behov hos de unga vuxna med inflammatorisk tarmsjukdom. / Background: Inflammatory bowel disease is a group of autoimmune diseases and is today a public health problem that is increasing worldwide. The primary types: Ulcerative colitis and Crohn's disease both affect the gastrointestinal tract. The symptoms can limit social life, stigmatization and feelings of shame are also common. Aim: The aim of this study is to describe young adults experiences of living with inflammatory bowel disease. Method: This study was a general literature study which includes nine scientific articles that were processed with an inductive approach. Results: The young adults experiences of living with inflammatory bowel disease were compiled into three categories; “Experiences of psychosocial influence”, “Experiences of the treatment for inflammatory bowel disease” and “Experiences of support from health care professionals”. Conclusion: Young adults with inflammatory bowel disease experienced symptom distress that gave rise to feelings of lack of control, shame and limitations in everyday life. Experiences of the drug treatments included feelings of insufficient effect, information and compliance. Stoma as a non-pharmacological treatment relieved symptoms but had a psychological impact. Experiences from the healthcare system included lack of information and support. This literature study contributes to the increased understanding of needs to young adults with inflammatory bowel disease.

Complete or partial obstruction of the duodenum by the superior mesenteric artery (SMA) is a rare cause of bowel obstruction. SMA syndrome results from the compression of the 3rd part of the duodenum between the superior mesenteric artery and the abdominal aorta. Causes include anatomical variation in the superior mesenteric artery, trauma, burns, surgeries, malignancy, and rapid weight loss. Diagnosis of SMA syndrome in patients may be difficult, as the clinical findings often resemble other forms of small bowel obstructions. This syndrome was first described in the literature by Carl Freiherr von Rokitansky in 1861. Subsequently, David Wilke provided a comprehensive description of the disease in a series of 75 patients. There has been skepticism about the existence of SMA syndrome due to scant literature reports and non-specific symptomatology. However, modern cross-sectional imaging has confirmed the existence of this rare syndrome. Here we present the case of a 50-year-old female with longstanding symptoms of gastrointestinal discomfort, weight loss, nausea, and vomiting. She underwent an exhaustive gastrointestinal workup until a diagnosis of SMA syndrome was made. We elected to proceed with a minimally invasive three-port laparoscopic, trans-mesenteric side-to-side duodenojejunostomy. The patient was discharged on postoperative day one after tolerating a regular diet. On one month follow-up, our patient reported improvement in symptoms with no postprandial pain or nausea and normal bowel movements. In conclusion, we report a case of superior mesenteric artery syndrome in a patient with recurrent abdominal pain and nausea. CT scan has the highest sensitivity for the diagnosis of SMA syndrome, findings suggestive of the diagnosis include an abnormal aortomesenteric angle and distance. While supplemental tube feeds and gastric drainage may resolve the condition without the need for surgery, this often takes many weeks to months to be effective. Minimally invasive surgical bypass is an attractive option because of the rapidity of symptom resolution, lack of need for long-term invasive tubes, short inpatient length of stay, and high success rate.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24131号 / 医博第4871号 / 新制||医||1059(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 阪上 優, 教授 佐藤 俊哉, 教授 小杉 眞司 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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