TECHNICAL EVALUATION
unavoidable A section of the evaluation is the study of biological determinants of the response problem, which involves the prior execution of a thorough examination by a gastroenterologist in also the analysis of the symptoms there will be a physical examination, biochemical and radiological and other diagnostic investigations aimed at determining the existence of specific injuries.
Although sometimes might be feasible to make valid generalizations about the entire gastrointestinal tract, the fact is that spectrum of dysfunctions of it and its clinical manifestations depend largely on the affected regions. For example, esophageal disorders are manifested especially its relationship to swallowing, while the predominant features of gastric acid secretion in the small intestine and large bowel anomalies and defects of nutrition.
addition to the intrinsic processes, gastrointestinal disorders may be affected by systemic, vascular, inflammatory, infectious or neoplastic. There are also metabolic and endocrine dysfunctions, as well as certain pharmacological agents used for therapeutic purposes, which affect the normal motility of the gastrointestinal tract.
In general, the evaluation involves the pursuit and establishment of a possible correlation between precipitating / exacerbating symptoms and exposure to certain types of environmental conditions or presence of subjective distress. Also during the assessment should consider getting information on all the behavioral habits that affect the functioning of the gastrointestinal system and the determination of the nature and characteristics of the environmental response to the behavior of the individual. We will only presentation
Schematic of some of the most useful assessment techniques. Noted that these techniques presented have greater validity in chronic gastrointestinal disorders.
The interview
The interview is the predominant method of evaluation of gastrointestinal disorders. The clinical information obtained during the initial interview guides you towards finding specific findings, and the accumulation of these data determined the studies and examinations are to be made later. Therefore, a lot that data collection occurs during a patient evaluation cumulative process.
Therefore, the interview is primarily an instrument around which other methods should be organized. Its main function is to decompose the problems of the subject in "behavioral units" defined topographically and functionally, taking the information as a first approximation. In the clinic to carry out a proper assessment of gastrointestinal problems, often used a combination of subjective criteria (preoccupation with the rate of deposition) and goals (weekly frequency of incontinence episodes).
The interview can also help establish a first, hypothetical association between certain types of situations and the presence or worsening of symptoms, which can be explored more specifically making use of other assessment tools such as self-reports.
AutoReport
At the moment there are few self-report designed specifically to assess gastrointestinal disorders, although they are a useful tool to supplement the clinical interview. His interest lies in the possibility of isolating both the presence of various gastrointestinal symptoms, such as to obtain a quantitative measure of the severity of symptoms in specific problems allowing a better quantification of treatment results and facilitate comparison of the various clinical research studies. A good example is the Gastrointestinal Symptom Inventory, which provides a measure of symptom severity in patients with irritable bowel syndrome.
Despite the usefulness of these instruments, the most common in this area has been the use of general instruments, aimed at assessing possible alterations emotional and personal characteristics that are supposed to provide data relevant to understanding and delimitation the problem.
Self-reports
The self-reports are a simple assessment procedure, practical and useful in the field of gastrointestinal disorders. The clinician can more consistently provide a possible link between certain types of events and the presence of symptoms, and to obtain a more direct and meaningful measure of the frequency, duration and severity of symptoms presented by the subject, since the data collected in the proper context in which they occur, aggravating or mitigating.
One of the main problems involved in this method is own cooperation and patient adherence. Therefore, The clinician must pay close attention and care to the way it presents the subject technique, it must be clear about what they should do, how and why to do it.
Regardless of the self-registration form is used, it should be usable in a simple and unobtrusive and should consider both the quality and quantity of information that is requested from the patient. A small amount of properly collected data on specific well-defined, is of more value than many inconsistent data collection
psychophysiological
Among
psychophysiological recording procedures most commonly used measures include gastric acid secretion, manometric techniques, electromyography (EMG) and electrograstrograma (EGG).
Measurement of gastric acid secretion involves detecting and recording changes in stomach pH, \u200b\u200bwhich can be both externally and in the interior of the stomach itself. The external determination of pH involves the aspiration of stomach contents through a tube. For its part, the main measures include telemetry intragastric pH and evidence of "titration." PH telemetry has the advantage to be a little intrusive procedure. Finally, tests of "titration" require the neutralization of stomach contents by the administration, usually sodium bicarbonate.
manometric techniques, can be defined as a set of procedures used to determine the pressure in hollow organs. Techniques used for evaluation of motility in various segments of the gastrointestinal tract. These techniques use balloons or balls of varying size. The techniques currently available for use in the clinic are esophageal manometry, colonic and anorectal.
anorectal manometry is the procedure evaluation of responses rectoesfintéricas more useful in clinical practice. In parallel, the manometry not only provides great information on the physiological mechanisms of the anorectal area, but also from the point of view is likely to use therapeutic effective as biofeedback procedure for the treatment of problems such as fecal incontinence and chronic constipation due to contraction or paradoxical puborectalis dyssynergia rectoesfinteriana.
Electromyography (EMG) is also potentially useful in gastroenterology as assessment procedure Bioelectric activity in patients with anal dysfunction. As anorectal manometry procedures, this technique is starting to be used as an intervention procedure in the context of biofeedback techniques.
Finally, note that the electrogastrogram (EGG) is a noninvasive technique. However, unfortunately it is still difficult to interpret, there are serious doubts about the meaning psychophysiological some of the events recorded.
Other evaluation techniques
psychophysiological recording procedures most commonly used measures include gastric acid secretion, manometric techniques, electromyography (EMG) and electrograstrograma (EGG).
Measurement of gastric acid secretion involves detecting and recording changes in stomach pH, \u200b\u200bwhich can be both externally and in the interior of the stomach itself. The external determination of pH involves the aspiration of stomach contents through a tube. For its part, the main measures include telemetry intragastric pH and evidence of "titration." PH telemetry has the advantage to be a little intrusive procedure. Finally, tests of "titration" require the neutralization of stomach contents by the administration, usually sodium bicarbonate.
manometric techniques, can be defined as a set of procedures used to determine the pressure in hollow organs. Techniques used for evaluation of motility in various segments of the gastrointestinal tract. These techniques use balloons or balls of varying size. The techniques currently available for use in the clinic are esophageal manometry, colonic and anorectal.
anorectal manometry is the procedure evaluation of responses rectoesfintéricas more useful in clinical practice. In parallel, the manometry not only provides great information on the physiological mechanisms of the anorectal area, but also from the point of view is likely to use therapeutic effective as biofeedback procedure for the treatment of problems such as fecal incontinence and chronic constipation due to contraction or paradoxical puborectalis dyssynergia rectoesfinteriana.
Electromyography (EMG) is also potentially useful in gastroenterology as assessment procedure Bioelectric activity in patients with anal dysfunction. As anorectal manometry procedures, this technique is starting to be used as an intervention procedure in the context of biofeedback techniques.
Finally, note that the electrogastrogram (EGG) is a noninvasive technique. However, unfortunately it is still difficult to interpret, there are serious doubts about the meaning psychophysiological some of the events recorded.
Other evaluation techniques
Along with psychophysiological recordings, there are a number of objective techniques whose primary purpose is to evaluate very different aspects the functioning of the gastrointestinal system. Defecography stand and measures of colonic transit time.
BEHAVIORAL TREATMENT TECHNIQUES
Depending on the psychological mechanisms involved in gastrointestinal disorders we have described, it is clear that the behavioral intervention in this area focuses primarily on following:
- Teach the patient a technique to control their own reactions to stressful events.
- Expand the repertoire of skills and abilities of the subject of such so that you can actively address stress-producing situations. Exposing the patient
- repeated and extended to situations that elicit or exacerbate their symptoms. Decrease
- reinforcement to the somatic complaints and encourage the patient to engage in conduct incompatible with the anomalous behavior of the disease.
- Instruct the patient to specifically modify their own physiological responses.
Relaxation
As in other areas of the behavioral intervention on stress-related disorders, relaxation techniques have been and are widely used in order to give individuals a strategy adequate coping with stressful events. Have been applied either alone or as part of a treatment package along with other cognitive-behavioral techniques to reduce anxiety and stress management.
The Relaxation training is a behavioral procedures so far has shown great utility in psychophysiological disorders of the esophagus. Jacobson was the first to use this procedure in gastrointestinal disorders.
But the fact is that one of the areas most relevant to the application of relaxation techniques is the control of conditioned nausea and vomiting in cancer patients undergoing chemotherapy.
While Progressive Neuromuscular Relaxation training is the dominant relaxation process in this area, some studies have been used other techniques, especially autogenic training, applied with some success in patients with ulcerative colitis.
As noted, relaxation training is also part of some useful therapeutic programs in the field of gastrointestinal disorders, as is the case of Multicomponent Behavioral Treatment Program of Albany for the treatment of irritable bowel syndrome, consisting of 4 components: information and education about normal bowel function, progressive muscle relaxation training, temperature biofeedback and cognitive coping techniques. 60% of patients showed a reduction of at least 50% on symptoms earnings unchanged Clinical follow-up periods after 4 years.
coping techniques
In general, coping techniques are cognitive-behavioral intervention extensively investigated and appear to be more valid and useful in the treatment of particular disorders such as peptic ulcers and irritable bowel syndrome. However, under the rubric of coping techniques have been used multicomponent programs have very different characteristics. We will comment briefly on only a few studies that have been implemented procedures for coping better structured and best known in behavior modification, such as Management Training Anxiety and Stress Inoculation.
As regards Anxiety Management Training has been used towards the treatment of peptic ulcers. In this vein, the work done by Brooks and Richardson is a marked decrease in epigastric pain (which is the main symptom that defines peptic ulcer), a lower consumption of antacids and a decrease in the frequency of visits to the hospital.
For its part, Stress Inoculation is a procedure that typically is often part of programs for the treatment of gastrointestinal disorders based on the behavior modification procedures. Several studies have shown clinical utility in problems such as irritable bowel syndrome.
exposure techniques
As noted, some gastrointestinal symptoms may be classically conditioned. The main modality of treatment for such symptoms are exposure techniques, and more specifically the systematic desensitization. It is useful that this exhibition takes place under circumstances that counteract or acting contrary to the fears of the subject (counter-conditioning). For this reason, usually begins by teaching the patient an arousal-reduction technique such as progressive neuromuscular relaxation. Subsequently, once built the hierarchy of anxiety situations (which is usually carried out simultaneously to relaxation training), begins the desensitization itself, consisting of an exhibition in the imagination of each of the situations in the hierarchy, while the subject is in a state of relaxation.
They can be used other exposure techniques, such as DS live or flooding techniques, although most work in this area are opting for the standard DS.
Several studies support the clinical effectiveness of the DS for the treatment of some gastrointestinal disorders, especially to the control of symptoms in irritable bowel syndrome. Also, its application is very useful towards the processing of conditioned nausea and vomiting in patients undergoing chemotherapy.
operant techniques
In general, operant techniques are indicated in cases in which gastrointestinal symptoms presented by subjects are maintained by social reinforcers of different kinds. In fact, since the conditioning operant theories have been proposed to explain the etiology and maintenance of various gastrointestinal problems according to specific reinforcement contingencies, with emphasis on the operant theory of rumination syndrome. Similarly, these techniques are useful in view of the modification of the disease called anomalous behavior, which has a high consistency of presentation in many patients with gastrointestinal disorders.
The rumination syndrome known techniques have been used as positive punishment, negative punishment (time out) and differential reinforcement of incompatible behaviors. The most effective seems be the time-out, although the positive punishment with electric shock quickly deleted regurgitation and therefore may be more suitable in medical emergencies. On the contrary, the punishment with flavors and food satiation is not recommended unless other procedures fail.
operant techniques can be used effectively both in isolation and as part of classical training programs in defecation habits.
Finally, as regards the anomalous behavior modification of disease, we used different techniques, emphasizing the contingency contract. Looking to the proper implementation contracts, patient behaviors and their associated consequences should be clearly defined and specified, and that the contract should not be imposed on the patient, but it has to be designed with the collaboration of all parties.
biofeedback techniques
In the area of \u200b\u200bgastrointestinal disorders, biofeedback techniques have been used primarily towards the treatment of peptic ulcers, irritable bowel syndrome, some disorders of esophageal motility and defecation disorders.
biofeedback techniques have been applied under two different approaches. On the one hand those that might be called specific. For other applications that call non-specific, which is not itself altered response to feedback, but other psychophysiological response (usually electrodermal activity or frontal EMG) under the assumption that this control will decrease the subject psychophysiological activation level., which will result in significant improvements in those stress-related gastrointestinal problems. Some authors have used frontal EMG biofeedback combined with relaxation training or with some cognitive-behavioral stress management, obtaining some results positive. Therefore, it seems that in those cases in which evidence an exacerbation of symptoms with certain stressful environmental events, biofeedback training in a non-specific response program combined with cognitive-behavioral stress management, could be of more value than direct training in the control of specific pathophysiological responses. However, so far only studies have been conducted that clearly demonstrate the validity and effectiveness of these applications. Furthermore, most studies have not included control groups.
In general, currently the most suitable applications of biofeedback techniques are based in the use of specific procedures. This approach seems more consistent with the results of both basic research and clinical research.
Finally, a promising area of \u200b\u200bapplication of biofeedback techniques is focused on control of gastrointestinal symptoms as common as aerofagia, becoming clear that a specific biofeedback procedure based on the record and feedback on the frequency of occurrence swallowing response is more effective to the control of this problem that a non-specific biofeedback procedures such as biofeedback Electrodermal activity.
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