Challenges in functional bowel disease

Society, the workplace and the family are changing. Despite increasing weal th, these changes appear to be accompanied by increasing anxiety and depres sion. Functional bowel disorders are associated with increased psychologica l morbidity, and the treatment of functional disorders needs to take these social and psychological factors into account. In the medical setting, ther efore, the "therapeutic team" needs to be restructured to encompass a broad er spectrum of skills and resources than currently exists in most units. An increase in understanding of pathophysiological mechanisms is likely to be helpful for patients who are not amenable to, or have failed, first line p sychologically based, or simple drug, therapies. For example, in reflux dis ease, the elucidation of the mechanism underlying spontaneous sphincter rel axations may lead to precise end organ targeting-this can be at efferent or afferent ends of the pathways. Recent elucidation of involvement of GABA a nd NO have highlighted possible neurochemical targets. In constipation 5-HT 4 agonists have lead to specific activation of motor events responsible for gut transport. For diarrhoea, multiple targets are available, e.g. opioid agonists, somatostatin analogues. Modulation of pain represents a more diff icult task. Decreasing visceral sensitivity, and alteration of cerebral or spinal mediation of pain, remain unproven strategies. Greater understanding of the mechanisms by which chronic stress influence gut function and sympt oms is likely to lead to new therapeutic approaches. This should include an understanding of the link between psychological morbidity and altered auto nomic effector function. It should help in understanding why symptoms local ise to different body systems, such as the gut or gynaecological viscera. O ther priorities in this area are to improve clinical trial design, and to i mprove symptom and quality of life measures of the efficacy of treatments.