Quality of life in irritable bowel syndrome: Authors’ reply

We thank dr Yuanjun Dong for his interest in our publication.1 Dr Dong points out that previous and current stressful life events mod‐ ulate gastrointestinal (GI) symptom severity and quality of life (QoL) in patients with irritable bowel syndrome (IBS),2 which is indeed based on recent findings.3 In addition, we would like to note that abdominal pain is the predominant symptom in IBS, as per Rome IV definition. The primary treatment outcome for IBS in clinical tri‐ als, in accordance with FDA and EMA requirements, is reduction in daily abdominal pain.4 Whether a successful treatment, based on these criteria, improves patients’ life satisfaction and QoL remains an item of debate. In the current study, we performed an extensive prospective evaluation of the natural course of IBS which included demographics, gastrointestinal symptoms, symptoms of anxiety and depression, GI‐specific anxiety, satisfaction with life, and QoL. With regard to QoL, we showed among others that general anxiety and depression levels at follow‐up were independently associated with mental quality of life scores at the same time point. Furthermore, no associations were found between GI symptom severity, including abdominal pain, and the change in QoL scores over time.1 With regard to a possible interaction between GI symptoms and stress, in Table 1 we provide data on specific questions and answers from the database of Maastricht IBS cohort regarding the patients’ perspective on this matter. No statistically significant differences were found between Rome‐positive and Rome‐negative IBS patients at follow‐up. However, the current understanding on the relationship between abdominal pain and stress, whether current or related to life events, may be limited by the methods used to assess these factors. Traditionally, data from retrospective reports have been used to de‐ scribe this relationship, but it is known that these questionnaires are limited by recall and ecological bias.4 We therefore believe that the best available method to study the relationship between GI symp‐ toms, comorbid psychological complaints, and daily life stress is re‐ peated momentary symptom assessment.5 Such methodology has been used recently to assess the temporal relationship between ab‐ dominal pain and (preceding) daily life stress.6 We have developed and are currently validating specific questionnaires based on experience sampling method (ESM) which may provide additional leads in this matter.7 In a recently completed study, we demonstrate that real‐time stress scores are positively associated with concurrent abdominal pain scores in IBS, but not in healthy subjects, whereas abdominal pain could not be predicted by preceding stress levels, and vice versa, suggesting an in‐the‐moment rather than a longitudinal association.8 Taken together, we postulate that reduction in abdominal pain is not necessarily accompanied by long‐term improvement in quality of life in patients with IBS. This may indicate that the primary treat‐ ment focus in IBS should shift from solely abdominal pain reduction and improvement of bowel habits, toward a holistic approach, which includes quality of life, comorbid psychological symptoms, and im‐ provement of coping strategies with regard to GI symptoms as well as daily life stress. However, the evidence to support a change in the approach of IBS management is still inconclusive, and further research is needed.