American Journal of Gastroenterology ISSN 0002-9270 C  2006 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00592.x Published by Blackwell Publishing REFLECTIONS ON MEDICAL PRACTICE Functional versus Organic: An Inappropriate Dichotomy for Clinical Care Douglas A. Drossman, M.D. Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (Am J Gastroenterol 2006;101:1172-1175) One of the exciting challenges within gastroenterology relates to the proper diagnosis and care of patients with functional GI disorders. These patients have symptoms that are com- plex and multifaceted. The pathophysiological determinants of these conditions are only beginning to be understood, and relate to enteric dysfunction (abnormal motility and visceral hypersensitivity), mucosal immune alterations, and brain-gut dysregulation (altered CNS pain control and stress regulatory systems). These relatively new concepts in the health-care field need to be properly communicated to clinicians and in- vestigators. Despite a growing scientific understanding of the patho- physiology of these disorders, there is a lag in its dissemina- tion. This adversely affects the opportunity to provide ben- efits to patients, and is further complicated by the current emphasis on rapid “throughput” in both the outpatient and inpatient settings (1). The latter approach, while presumed to be rewarding economically, can lead to “testing before thinking,” and it diminishes motivation to obtain a careful history, perform a directed physical examination and apply this information in clinical decision making. Importantly, certain attitudes and beliefs imbedded in our health-care system may impede the recognition and accep- tance of this new knowledge (2). For example, physicians may set different standards for evaluation and treatment de- pending on whether they perceive the patient to have a “func- tional” or “organic” diagnosis. In fact, recent studies suggest that physicians interpret the health-care impact and disabil- ity of patients with functional GI disorders as considerably less than the patients, and tend to make negative value judg- ments more than patients with organic diagnoses (3, 4). Inter- estingly, the distinction between organic and functional has become blurred, and thus is not beneficial in modern health care (5). The consequences of such attitudes and behaviors may actually lead to a less efficient process of care, greater costs, and patient dissatisfaction (1). The purpose of this ar- ticle is to highlight errors that may occur in the diagnosis and treatment of patients where fixed beliefs as to whether a patient is functional or organic can lead to faulty judgments and ineffective care. It is hoped that awareness and avoidance of making this inappropriate dichotomy will improve patient care. Consider the following two cases that presented to the functional GI clinic at the University of North Carolina. CASE 1 A 22-yr-old woman was referred for left-sided abdominal pain, bloating, and diarrhea, which became much worse over the previous 2 yr. Her illness began at the age of 17 after a cesarean section. At age 18, because of the pain, she un- derwent a pelvic laparoscopy and one endometrial implant was found. Based on this finding, she was diagnosed to have endometriosis. Because of continued symptoms she had an- other laparoscopy that was negative, and a third showed a few small implants which were treated but without resolution of pain. At age 19, after having a normal pelvic ultrasound she underwent a hysterectomy for endometriosis, “to fix this problem once and for all.” The symptoms continued after surgery. At age 21, a CT scan was done without contrast. The findings were thought to be consistent with Crohn’s disease, and she was started on prednisone, which was increased up to 60 mg/day. Six months later, after gaining 60 lbs, there was no change in the symptoms. She was then referred to a gas- troenterologist for a second opinion. He did a colonoscopy and small bowel barium study, which were normal with no evidence for inflammatory bowel disease (IBD). The patient was then referred to the functional GI clinic and additional information was elicited. The pain was cramp- like and frequently occurred after meals, leading to loose and frequent bowel movements. The pain was also relieved by defecation and worsened during menses and when under stress. She frequently had nausea and vomiting early in the day (“like morning sickness”). When the diarrhea was severe, she experienced fecal incontinence. There was no history of blood in the stool or a family history of IBD. The psychoso- cial history was notable for becoming pregnant at age 16, and she stated “This was the first time I wanted to have sex.” She married her partner soon after the child’s birth. Within a few months, the husband became physically and emotionally abusive to her and the symptoms became more severe. She divorced the husband and within several months remarried, and she is now reporting a good marital relationship. 1172