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Introduction Background Central autonomic dysfunction may result in a unilateral dissociation of temperature sensation, and is increasingly being investigated in FGIDs. The autonomic function score (AFS) and sleep disturbance score (SDS) are accepted measures in aiding the diagnosis of autonomic dysfunction. Aims To assess and compare the AFS and SDS of consecutive FGID patients attending a specialist clinic, with and without upper limb temperature dissociation. Methods Clinic attenders with a FGID diagnosis were sequentially invited to undertake the temperature sensation test. This comprised holding a bag of ice in both hands for 30 seconds and stating if they perceived the temperature to be either unilaterally colder or bilaterally equally cold. Unilaterally colder was considered to be evidence of upper limb temperature sensory dissociation. Patients had their total AFS calculated as follows: headaches, dizziness, sweating and sleep disturbance were severity scored using a Likert scale of 0–3, the sum of which is the AFS. The mean total AFS and mean sleep disturbance score were compared between patients with and without temperature dissociation. Results 173 patients completed the AFS and 7 were excluded from the analysis for incomplete data leaving 166. 115 patients (69%) had upper limb temperature dissociation (group 1) compared to 51 (31%) with normal temperature sensation bilaterally (group 2). The mean total AFS in group 1 was 6.35 [SD 3.17] compared with 5.01 [SD 2.87] in group 2 [P = 0.009]. Mean sleep disturbance scores were not significantly different between the groups. Conclusion FGID patients with upper limb temperature dissociation appear to have a significantly higher autonomic function score than those without temperature dissociation. This seems to suggest that the cause of the temperature dissociation may well be due to autonomic dysfunction acting at a central nervous system level. These results are an interesting observation from our clinic but are likely to be limited by inherent methodological biases in the data collection. Further investigation of autonomic function scores and temperature dissociation are required in formal and appropriately powered clinical research studies to validate these findings. Disclosure of Interest None Declared

Introduction Temperature sensations from the upper limbs are transmitted through the contralateral spinothalamic tract in the cord to the ventral posterior lateral nucleus of the thalamus and then the primary somatic sensory cortex. Autonomic dysfunction arising in the central nervous system is known to affect the sympathetic function of skin which can result in a unilateral dissociation of temperature sensation. Autonomic dysfunction is also increasingly being hypothesised as a component of the functional gastrointestinal disorders (FGIDs). Aims To assess the bilateral upper limb temperature sensation of a consecutive cohort of FGID patients and compare the incidence of temperature dissociation with controls. Method Clinic attenders with a FGID diagnosis were sequentially invited to undertake the temperature sensation test. This comprised holding a bag of ice in both hands for 5 s and stating if they perceived the temperature to be either unilaterally colder or bilaterally equally cold. Unilaterally colder was considered to be evidence of upper limb temperature sensory dissociation. If a relative, spouse or friend was present they were also invited to participate as either a blood relative or un-related control. Results 58 FGID patients and 58 controls undertook the temperature sensation test. 42 patients (72.4%) had upper limb temperature dissociation compared with 20 controls (34.4%) [P = 0.005]. 18/22 (81.8%) patients had dissociation compared to 8/22 (36.3%) blood relative controls [P = 0.049], and 24/36 (66.6%) patients had dissociation compared to 12/36 (33.3%) unrelated controls [P = 0.045]. There was no significant difference in the incidence of dissociation between blood relatives and unrelated controls, 36.3% and 33.3% respectively [P = 0.84]. Conclusion Upper limb temperature dissociation seems to be more prevalent in patients with FGIDs than their blood relatives or unrelated controls. It may be associated with autonomic dysfunction as a result of a central nervous process. These findings are an interesting observation in our clinic, but do not constitute formal research and are limited by possible biases (selection and assessment) and a relatively small sample size. The observed proportions of temperature dissociation in these groups could be used to calculate an adequate sample size to detect whether this may be true in a formal research study of autonomic dysfunction in FGIDs. Disclosure of interest None Declared.

Introduction Upper limb temperature dissociation has been demonstrated to exist in a prevalence of approximately 72% of FGID patients in our clinic, and in approximately 34% of controls. The prevalence of temperature dissociation in the subgroups of FGIDs are unknown. Aims To assess the prevalence of upper limb temperature dissociation in FGID subgroups and compare against an expected prevalence previously demonstrated in controls. Method Clinic attenders with a FGID diagnosis from a specialist tertiary clinic were sequentially invited to undertake the temperature sensation test. This comprised holding a bag of ice in both hands for 5 s and stating if they perceived the temperature to be either unilaterally colder or bilaterally equally cold. Unilaterally colder was considered to be evidence of upper limb temperature sensory dissociation. The actual percentage prevalence in each FGID subgroup was tested against an expected prevalence of 34.5% using a CHI-squared test with Fisher’s correction where applicable. Results Temperature sensory dissociation in the upper limbs was prevalent in most patients with FGIDs: 120/173 in the overall cohort (69%) [P Conclusion Upper limb temperature sensory dissociation appears to be significantly more prevalent in most subgroups of the FGIDs. This may imply a connexion with a central autonomic aetiology for these conditions. These results are an interesting observation from our clinic but are likely to be limited by inherent methodological biases in the data collection. Further investigation of the prevalence of temperature dissociation is required in both patients and controls in order to validate these findings. Disclosure of interest None Declared.

Introduction This is the first study to assess the burden of IBS-C in 6 European countries (France, Germany, Italy, Spain, Sweden, UK). Here we present the results for the UK. Method Observational, retrospective-prospective (6 months each) study in patients (pts) diagnosed with IBS-C in the last five years (Rome-III criteria) and moderate-to-severe symptoms at baseline: IBS-Symptom Severity Score (IBS-SSS) ≥175. Health resource utilisation was retrospectively and prospectively assessed. Symptom evolution was assessed in the prospective period, and quality-of-life (QoL) was assessed at baseline with EuroQoL-5D (EQ-5D) and IBS-QoL. Work productivity was prospectively assessed using the Work Productivity and Activity Impairment (WPAI): IBS-C questionnaire. Results 104 pts were included (79% severe, mean age [± SD] 45.5 ± 14.6 yrs, 93% female). At baseline, symptom severity (IBS-SSS; severe >300) was 373.1 ± 82.5; presenteeism (WPAI:IBS-C; mean ± SD): 47.9% ± 28.7%; absenteeism: 8.4% ± 24.2%; work productivity loss: 51.5% ± 27.2%; daily activity impairment: 56.8% ± 29.6%. Mean IBS-QoL was 57.2 ± 24.2, (scale: 0–100 [best-to-worst]) and mean EQ-5D was 54.0 ± 23.3 (scale: 0–100 [worst-to-best]. 87.5% and 64.4% of pts reported moderate-to-severe problems in pain/discomfort, anxiety/depression respectively. Most prevalent symptoms were abdominal pain (92%) and bloating (91%). 70% pts consulted a GP, and 100% a gastroenterologist; mean: 6.2 and 2.7 visits, respectively. 24% pts required emergency department visits or hospitalisation (mean stay [95% CI]: 12 [2.5–21.1] days). 52% had a diagnostic test (mean [95% CI]: 3.6 [2.9–4.4]). 90% pts took prescription drugs for IBS-C. Mean (95% CI) annual direct cost for the NHS: £ 1753 (1251–2308); the mean pt cost: £ 315 (184–482). 51% of pts took sick leave (mean: 5.2 times; mean duration: 26 days) and 82% had productivity losses (mean: 162 h). Mean indirect costs were £ 3407 (2078–4977). Total costs amounted to £ 5443 (3970–7252)/year. Conclusion Moderate-to-severe IBS-C has a major impact on patient QoL, productivity, and healthcare resource utilisation. Disclosure of interest Y. Yiannakou Conflict with: Grants: Shire; Medtronic. Speaker fees: Almirall; Shire; Sucampo, M. Eugenicos Conflict with: Consultant/Advisory Board Member: Almirall; Astellas; Dr Falk Pharma; NAPP; and Shire, D. Sanders Consultant for: Almirall, A. Emmanuel Conflict with: Advisory Board and Educational Talk honoraria: Almirall., P. Whorwell Conflict with: Consultant/research grant support: Almirall; Chr. Hansen; Danone Research; Ironwood; Salix; Shire; Sucampo, F. Butt: None Declared, S. Bridger: None Declared, N. Arebi: None Declared, A. Millar Conflict with: The hospital received payment from Almirall for the conduct of the study, V. Kaushik Conflict with: Advisory Board and Educational Talk honoraria: Almirall. Meeting support: Cooks; Tillotts; AbbVie., M. Rance Employee of: Almirall, J. Mackinnon Employee of: TFS Develop S. L., contracted by Almirall S. A to conduct the study, J. Bertsch Employee of: TFS Develop S. L, contracted by Almirall S. A. to conduct the study, J. Fortea Employee of: Almirall, J. Tack Conflict with: Grants/research support: Abbott; Novartis; Shire. Honoraria/consultancy fees: Almirall; AstraZeneca; Danone; GI Dyamics; GlaxoSmithKline; Ironwood; Janssen; Menarini; Novartis; Rhythm; Shire; Takeda; Theravance; Tsumura; Will Pharma; Zeria. Speaker fees: Abbott; Almirall; AstraZeneca; Janssen; Menarini; Novartis; Shire; Takeda; Zeria.

Introduction Sacral nerve stimulation (SNS) can be an effective treatment for some patients with functional bowel disorders. The highly variable nerve stimulation waveforms generated by the re-usable “brown box” (model 3625, Medtronic US) SNS test stimulator have previously been reported. 1 Since 2013, the single-use digital test stimulator “Verify” (model 3531, Medtronic US) has been used in our trust. Within the UK most clinicians continue to use the brown box; Medtronic no longer manufacture model 3625 and it requires recalibration between patient use. We aimed to assess the Verify stimulator’s output waveform to quantify if this was as variable as the analogue precursor. Method A prospective output waveform assessment of 15 used Verify SNS test stimulators using a cross-calibrated oscilloscope (Tektronix model 2230) and a counter-timer (Black Star Apollo 100). Devices were successively loaded with the same AAAA batteries and connected to a constant simulated tissue load (993Ω) circuit with two output electrodes attached to the oscilloscope (Figure 1). The output waveform amplitude and pulse width were measured at clinically used settings and compared with the expected output values (amplitude by V = IR). Devices passed the calibration test if within tolerances of 10% and 20%. Results At clinical settings (14 Hz/210 µSec) the measured amplitude and pulse width did not vary significantly from expected at a programmed current of 0.2, 0.5, 1.0, 2.0 and 3.0 mAmp, and 100% of devices passed the calibration test (Table 1). 6 devices failed at 0.1milliAmps due to more variation at low energy settings. The variations in device frequency were too small to be measured with the counter-timer and therefore in the order of magnitude of × 10 –4 Hertz. Similarly, the pulse width times were just as accurate at 100, 210 and 400 µSec with the standard deviations 0.48, 0.93 and 0.69 µSec respectively. Conclusion At all clinically relevant settings 100% of the devices passed the calibration test. The failures at 0.1 mAmps are irrelevant (below therapeutic thresholds). Given these results, the lack of manufacturer support for the 3625 model, and its reported variability, we conclude that only the Verify testing device is fit for purpose in clinical practice. Disclosure of interest None Declared. Reference Etherson KJ, Davidson A, Yiannakou Y, Mason JM. Surgeons don’t forget to calibrate: Findings from SNS test stimulators. Gut 2013; 62 :A27-A8

Introduction The IBIS-C study assessed the burden of IBS-C in 6 European countries (France, Germany, Italy, Spain, Sweden, and UK). Here we present the diagnosis and management results for the UK. Method Observational study in patients (pts) diagnosed with moderate-to-severe IBS-C in the last five years (Rome-III criteria) with a 12-month follow-up (6 months retrospective and 6 months prospective, in order to assess health resource utilisation [HRU] prior to and after an active phase of the disease). Moderate-to-severe IBS-C was defined as an IBS-Symptom Severity Score (IBS-SSS) ≥175. Results 104 pts were included (79% severe, mean age [±SD] 45.5 ± 14.6 years old, 93% female). Mean time since diagnosis: 2.6 ± 4.0 years; mean symptom duration: 15.3 ± 14.9 yrs. Diagnostic procedures were highly variable; the most common were blood tests (72%), colonoscopy (69%), and abdominal ultrasound (55%). At inclusion the most prevalent symptoms were abdominal pain (92%) and bloating (91%). Main ongoing comorbidities were anxiety (50%), chronic pain (44%), headache (40%), insomnia (33%), or dyspepsia (31%). 52% of pts had an average of 3.6 ± 2.7 diagnostic tests during follow-up, the most common were haematology (29%) and clinical chemistry (29%) blood tests, and colonoscopy (13%). 93% of pts took prescription drugs (90% took prescription drugs for their IBS-C). The most common medication groups were: laxatives (81%), prokinetics (32%), antispasmodics (20%), and analgesics (18%) alone or in combination. Overall, 63% of pts took OTC medication for their IBS-C; the most common were laxatives (37%), prebiotics/probiotics (14%), and peppermint oil (14%). In addition, 36% of pts received complementary therapies. Overall, marginal improvement was noted in symptom severity (IBS-SSS total score) between baseline (373 ± 83) and the 6-month visit (324 ± 113). Conclusion Moderate-to-severe IBS-C symptoms often remain undiagnosed for many years and degree of control does not improve over time even though there is a high degree of prescription medication use. Consequently, moderate-to-severe IBS-C continues to be a burden despite the availability of therapeutic interventions. Disclosure of interest Y. Yiannakou Conflict with: Grants: Shire; Medtronic. Speaker fees: Almirall; Shire; Sucampo, M. Eugenicos Conflict with: Consultant/Advisory Board Member: Almirall; Astellas; Dr Falk Pharma; NAPP; and Shire., D. Sanders Consultant for: Almirall, A. Emmanuel Conflict with: Advisory Board and Educational Talk honoraria: Almirall., P. Whorwell Conflict with: Consultant/research grant support: Almirall; Chr. Hansen; Danone Research; Ironwood; Salix; Shire; Sucampo., F. Butt: None Declared, S. Bridger: None Declared, N. Arebi: None Declared, A. Millar Conflict with: The hospital received payment from Almirall for the conduct of the study, V. Kaushik Conflict with: Advisory Board and Educational Talk honoraria: Almirall. Meeting support: Cooks; Tillotts; AbbVie, M. Rance Employee of: Almirall, J. Mackinnon Employee of: TFS Develop S. L, contracted by Almirall S. A to conduct the study, J. Bertsch Employee of: TFS Develop S. L, contracted by Almirall S. A to conduct the study, J. Fortea Employee of: Almirall, J. Tack Conflict with: Grants/research support: Abbott; Novartis; Shire. Honoraria/consultancy fees: Almirall; AstraZeneca; Danone; GI Dyamics; GlaxoSmithKline; Ironwood; Janssen; Menarini; Novartis; Rhythm; Shire; Takeda; Theravance; Tsumura; Will Pharma; Zeria. Speaker fees: Abbott; Almirall; AstraZeneca; Janssen; Menarini; Novartis; Shire; Takeda; Zeria.

Introduction The prevalence of constipation is between 43% and 58% in patients with either MS or spinal cord injury (SCI). Neuro-constipation is a very difficult to treat because of poor mobility, poor diet and side effects of long-term medication. Surgical options for intractable neuroconstipation involve prolonged operations with significant complications, and are unacceptable to many patients. In contrast sacral nerve stimulation (SNS) offers a potential minimally invasive and effective alternative. Methods Patients with refractory neuropathic constipation were offered temporary SNS (TSNS).Bilateral TSNS was performed under sedation and electrodes placed in the sacral foramen that produced the best peripheral response. The electrodes were removed after a 3 week evaluation period (week 7, 8 and 9 of the study) during which patients completed diaries and questionnaires. Patients with more than 50% improvement of baseline symptoms and recurrence of pre-stimulation symptoms were offered bilateral permanent SNS (PSNS). Paired student t test was used to calculate the changes in outcome measures before and during treatment. Results 22 patients recruited in the trial over 2 years. There were 8 men and 14 women with an average age of 51.5 years (range 38–69 years.). 4 patients dropped out and 18 completed the trial. 12 patients (67 %) received a permanent implant. The Global Assessment Score for constipation, PAC-SYM and PAC-QOL scores for these patients improved during treatment (p value Conclusion Patients with neuropathic constipation have a better response after TSNS than patients with idiopathic constipation. However TSNS has only a 50% positive predictive value for a long-term response. SNS offers a reasonable alternative to invasive surgical procedures in these patients but method of predicting long term response need to be improved.

Introduction Within the UK, there is anecdotal evidence of disparity in the training, practice, supervision, and perception of efficacy amongst practitioners of biofeedback therapy for chronic constipation. Methods Between October 2012 and October 2013, a prospective service evaluation was distributed to biofeedback practitioners in the UK through academic conferences or by invitation to complete an online assessment form. Results 76 practitioners responded, consisting of nurses (47%), physiotherapists (35%), physiologists (12%) and others (7%). Only 45% described ‘biofeedback’ consistent with an accepted definition. 86% use equipment to provide sensory feedback. Methods of biofeedback varied: balloon catheter (54%), brace pump technique (78%), urge resistance (83%), irrigation (16%), and relaxation (12%). Only 65% of practitioners had attended formal training courses, and 52% considered themselves to be self-tau, UKght. 36% receive formal supervision and only 38% of those by a senior. Regular audit of outcomes is undertaken by 67%. UK-wide perception of treatment response for chronic constipation is markedly variable (mean response = 57% [IQR: 50–75%, SD 23%]); there were no differences in perception of treatment response between nurses or physiotherapists. Practitioners’ free responses demonstrated strong positive themes of a holistic approach and an overall perception of effectiveness. Negative themes included service restrictions. Conclusion There is marked variation in practice, training, and supervision of biofeedback therapists throughout the UK. Perceptions of efficacy vary greatly. Development of training and supervision standards is a priority as well as consensus to standardise therapy. Disclosure of Interest None Declared.

Introduction Chronic constipation in the UK is prevalent in less than 10% of the population but can affect up to 25% of adults above 70 years of age.1 Women are affected more by constipation with a female to male ratio of 2.2.2 There are limited published UK data regarding patient satisfaction with traditional therapies for constipation. We have looked at patient satisfaction in two patient populations with chronic constipation: (1) an online survey among a random sample and (2) patients attending a tertiary referral centre in the northeast of England. Methods (1) An internet survey was conducted in 2009 in 7 European countries. Subjects were recruited by targeted advertising on Google and patient health websites. Data reported are for the UK sub-group. (2) The case notes of 195 consecutive follow-up patients attending the Durham Constipation Clinic were surveyed. Participants satisfying ROME III criteria for functional constipation were included. Results (1) The UK subgroup included 122 patients; 85% women; average age of 43 years. 65% had a duration of symptoms >3 years. 83% were taking medication for constipation which included both OTC and prescription treatments. Only 25% of subjects were satisfied with their current treatment(s), while 46% were neutral and 29% extremely dissatisfied or dissatisfied. 43% used alternative relief therapies, such as acupuncture and homeopathy. (2) There were 195 patients in the tertiary group (13 M, 182 F) with an average age of 43 years (17–86 years). The average duration of symptoms was 16 years. 78% of patients received specialist treatments not available in primary care. 27% (53/195) patients were extremely or quite satisfied with their treatment, 47% (91/195) were little or moderately satisfied and 26% (51/195) were not satisfied at all with treatment. Conclusion Traditional treatment options for chronic constipation are not adequately addressing patient needs and expectations in the UK. In both the online survey, and the survey of patients attending a tertiary clinic, only around a quarter of patients were satisfied with treatment. Improved therapeutic options need to be developed for this condition.

Introduction It is a common practice to subclassify patients with chronic constipation (CC) as having slow or normal transit using radio-opaque marker studies. However, the procedure has never been validated for construct validity and shows poor responsiveness. Recent reports have shown no correlation with symptoms or quality of life1; there is no correlation between transit and faecal loading2; and little value in assessing segmental transit3. Even so, perhaps it would be valuable in predicting outcome. The aim of this study was to assess outcome in patients with CC who had undergone a transit study. Methods The case notes of consecutive follow-up patients attending a specialist constipation clinic were surveyed. Patients for the study group were selected on the basis of fulfilling the Rome III criteria for chronic constipation (FC or IBS-C) and having colonic transit measured at the first clinic assessment. This was done using a validated radio-opaque marker technique. Details of treatments were recorded together with demographic details. Patients were divided into two groups depending on the type of treatment required to stabilise symptoms (conservative=laxatives, biofeedback, rectal irrigation; surgical=SNS, rectocoele repair, ACE, stoma, colectomy). Paired student t-test was used to calculate the difference between the colonic transit times of the two groups. Subject were divided into patients with slow transit constipation (STC) (>45 markers retained) and normal transit constipation (NTC). The significance of treatments provided in each group was calculated using Fisher9s exact test. Results 148 patients were included, aged 18–72 years (mean 42.2 years). There were 22 men and 126 women. 79(53%) patients were satisfactorily managed with conservative treatment and 69 (46%) required surgical treatment. The mean transit time for conservative group was 56.13 h (SD 18.10) vs 55.14 h (SD18.32) for the surgical group. Paired t test did not demonstrate any differences between the transit times of the two groups (two-tailed p value 0.4761). There were 108 patients with STC and 40 with NTC. 53/108 (49%) had biofeedback in STC group whereas 16/40 (40%) in NTC group underwent biofeedback. There were no differences between STC and NTC groups (p value 0.3581). Conclusion There is no evidence from these data that transit times influence outcome. The use of slow transit to determine therapy has never been proven and further work is required to justify the validity of subclassification based on transit.