Gut-focused hypnotherapy normalizes disordered rectal sensitivity in patients with irritable bowel syndrome

BACKGROUND

We have previously shown that hypnotherapy alters rectal sensitivity in some patients with irritable bowel syndrome. However, this previous study used incremental volume distension of a latex balloon, which might be susceptible to subject response bias and might compromise the assessment of compliance. In addition, the study group was symptomatically rather than physiologically defined.

AIM

To assess the effect of hypnotherapy on rectal sensitivity in hypersensitive, hyposensitive and normally sensitive irritable bowel syndrome patients using a distension technique (barostat) that addresses these technical issues.

METHODS

Twenty-three irritable bowel syndrome (Rome I) patients (aged 24-72 years) were assessed before and after 12 weeks of hypnotherapy in terms of rectal sensitivity, symptomatology, anxiety and depression. Normal values for sensitivity were established in 17 healthy volunteers (aged 20-55 years).

RESULTS

Compared with controls, 10 patients were hypersensitive, seven hyposensitive and six normally sensitive before treatment. Following hypnotherapy, the mean pain sensory threshold increased in the hypersensitive group (P = 0.04) and decreased in the hyposensitive group, although the latter failed to reach statistical significance (P = 0.19). Normal sensory perception was unchanged. Sensory improvement in the hypersensitive patients tended to correlate with a reduction in abdominal pain (r = 0.714, P = 0.07).

CONCLUSION

Hypnotherapy improves abnormal sensory perception in irritable bowel syndrome, leaving normal sensation unchanged.

The rectum: a window to irritable bowel syndrome?

This report summarizes current concepts and information gathered to date about the rectum in the irritable bowel syndrome (IBS) that were presented at the 10th meeting of IBiS Club held in Leuven, Belgium. A working group of experts in the field of IBS discussed whether the rectum or the whole colon is the better site to test in IBS patients and provided suggestions for a number of areas where further advances are required.

Interleukin 10 genotypes in irritable bowel syndrome: evidence for an inflammatory component?

BACKGROUND AND AIMS

Inflammation may play a role in the pathogenesis of irritable bowel syndrome in some individuals, such as in those who develop symptoms following a dysenteric illness. Persisting inflammation, resulting from an imbalance of cytokines regulating the inflammatory response, is one possible mechanism. As the elaboration of cytokines is under genetic control, this study was designed to establish whether there might be a genetic predisposition to an altered pattern of anti-inflammatory cytokine production in patients with irritable bowel syndrome.

SUBJECTS

A total of 230 unselected patients with irritable bowel syndrome and 450 healthy, ethnically matched controls were studied.

METHODS

DNA was extracted from peripheral blood leucocytes of subjects. Allele and genotype frequencies were determined for the anti-inflammatory cytokine interleukin 10 at the site (-1082) concerned with production in lymphocytes. Transforming growth factor beta(1) (codons 10 and 25) genotypes were also examined in a smaller group of subjects.

RESULTS

Patients with irritable bowel syndrome had significantly reduced frequencies of the high producer genotype for interleukin 10 than controls (21% v 32%; p=0.003). There was no apparent relationship with any particular bowel habit subtype. Genotypes for transforming growth factor beta(1) were not altered.

CONCLUSIONS

These preliminary results suggest that at least some patients with irritable bowel syndrome may be genetically predisposed to produce lower amounts of the anti-inflammatory cytokine interleukin 10. This lends some support to the hypothesis that there may be an inflammatory or genetic component in some cases of this condition and that further studies in specific irritable bowel syndrome subgroups are justified.

A device for 24 hour ambulatory monitoring of abdominal girth using inductive plethysmography

Inductive plethysmography (IP) sensors and oscillator modules were assessed for their potential use in the ambulatory monitoring of abdominal girth in subjects with irritable bowel syndrome (IBS) in order to objectively quantify their bloating symptoms. A dedicated microprocessordata logger was designed to record over 24 h the frequency output of IP oscillators connected to a belt around the subject's lower abdomen. Posture was also recorded via tilt switches (standing, sitting and lying). The system was separately calibrated by placing the belts around a variable rectangular phantom and measuring the frequency of oscillation. A theoretical geometric model was devised to convert measured frequency into circumference and account for changes caused by variations in shape. Using the calibration factors, it was found that the circumference of a circular phantom could be measured accurately (mean difference 1.27 cm and SD 0.25 cm). The system has been tested over 24 h with 20 volunteers. Movement introduced variations in measured girth larger than those found during periods of non-movement during sleep. We conclude that IP promises to be a useful and quantitative tool suitable for ambulatory monitoring of abdominal girth, a hitherto relatively unexplored symptom of IBS.

Visceral sensation and emotion: a study using hypnosis

BACKGROUND AND OBJECTIVES

We have previously shown that hypnosis can be used to study the effect of different emotions on the motility of the gastrointestinal tract. These studies demonstrated that both anger and excitement increased colonic motility while happiness led to a reduction. The purpose of this study was to investigate the effect of hypnotically induced emotion on the visceral sensitivity of the gut.

METHODS

Sensory responses to balloon distension of the rectum and compliance were assessed in 20 patients with irritable bowel syndrome (IBS) (aged 17-64 years; 17 female) diagnosed by the Rome I criteria. Patients were studied on four separate occasions in random order either awake (control) or in hypnosis, during which anger, happiness, or relaxation (neutral emotion) were induced.

RESULTS

Hypnotic relaxation increased the distension volume required to induce discomfort (p=0.05) while anger reduced this threshold compared with relaxation (p<0.05), happiness (p<0.01), and awake conditions (p<0.001). Happiness did not further alter sensitivity from that observed during relaxation. There were no associated changes in rectal compliance or wall tension.

CONCLUSIONS

Further to our previous observations on motility, this study shows that emotion can also affect an IBS patient's perception of rectal distension and demonstrates the critical role of the mind in modulating gastrointestinal physiology. These results emphasise how awareness of the emotional state of the patient is important when either measuring visceral sensitivity or treating IBS.

Serotonergic Agents in the Treatment of Functional Gastrointestinal Disorders

Functional gastrointestinal disorders are exceptionally common, cause a great deal of suffering, and are extremely challenging to treat. Current therapies, usually targeted at possible abnormalities of gut contractility, are often disappointing and there is a real need for a new approach to treatment. Over the last decade, there has been an increase in our understanding of potential pathophysiologic processes involved in these conditions resulting in novel therapeutic agents based on this information. Serotonin receptor modulators are one such example of this approach, but their development has met with a number of difficulties mainly centered around issues of safety and trial design. It is becoming increasingly apparent that a drug universally effective in all forms of functional gastrointestinal disorders is unlikely to emerge unless some centrally acting compound can achieve this goal. Thus, the current approach of targeting specific subgroups is probably the best strategy. Many patients with functional gastrointestinal disorders do not even bother to consult the medical profession because of the lack of benefit from any currently available treatments. Thus, if a new effective drug is developed, even for a subgroup, demand is likely to be substantial, leading to an even greater burden on already stretched drug budgets.

What do patients with irritable bowel syndrome dream about? A comparison with inflammatory bowel disease

BACKGROUND

It is a common experience for people to dream of events about which they are either anxious or concerned. We therefore hypothesised that the dreams of patients with irritable bowel syndrome may reflect their worries about their problem especially as hospital out-patients with this disorder tend to exhibit some anxiety. In addition, dreaming about, for instance bowels, in patients with irritable bowel syndrome in excess of that observed in other gastrointestinal disorders may be of importance.

AIM

To establish whether patients with irritable bowel syndrome dream about bowel-related issues more than controls or patients with inflammatory bowel disease.

PATIENTS AND METHODS

A total of 57 patients with irritable bowel syndrome and 57 patients with inflammatory bowel disease were compared with 60 healthy controls. All subjects completed a structured questionnaire concerning sleeping habits and dream characteristics as well as an assessment of anxiety and depression.

RESULTS

There were no differences in the sleeping habits between any of the groups. However, significantly more patients with irritable bowel syndrome and inflammatory bowel disease dreamt about their bowels (22% inflammatory bowel disease patients, 18% irritable bowel syndrome patients vs 3% of controls, p < 0.05 inflammatory bowel disease and irritable bowel syndrome vs controls) and soiling themselves (16% of inflammatory bowel disease patients, 14% of irritable bowel syndrome patients vs 2% of controls; p < 0.05 inflammatory bowel disease and irritable bowel syndrome vs controls) than controls.

CONCLUSION

Chronic gastrointestinal disorders, of both a functional and organic nature, may influence the nature of dreams. In those patients who dream about their symptoms, it would be interesting to know whether this affects the course of their disease, either positively or negatively, in any way.

The menstrual cycle affects rectal sensitivity in patients with irritable bowel syndrome but not healthy volunteers

BACKGROUND

We have previously shown that the menstrual cycle has no effect on rectal sensitivity of normal healthy women, despite them having looser stools at the time of menses. Patients with irritable bowel syndrome (IBS) often report significant exacerbation of their IBS symptoms with menses, raising the possibility that IBS patients may respond differently to the menstrual cycle.

AIM AND METHODS

Rectal responses to balloon distension during days 1-4 (menses), 8-10 (follicular phase), 18-20 (luteal phase), and 24-28 (premenstrual phase) of the menstrual cycle were assessed in 29 female IBS patients (aged 21-44 years), diagnosed by the Rome I criteria. During the course of the study patients completed symptom diaries to assess abdominal pain and bloating (visual analogue scale), and frequency and consistency of bowel habits. In addition, levels of anxiety and depression were assessed using the hospital anxiety and depression questionnaire.

RESULTS

Menses was associated with a worsening of abdominal pain and bloating compared with most other phases of the menstrual cycle (p<0.05). Bowel habits also became more frequent (p<0.05) and patients tended to have a lower general well being. Rectal sensitivity increased at menses compared with all other phases of the cycle (p<0.05). There was no associated change in rectal compliance, wall tension, or motility index. Neither was there any difference in resting anal pressure or the distension volumes required to relax the internal anal sphincter during the menstrual cycle.

CONCLUSION

These data (1) confirm that IBS symptomatology is exacerbated at menses and (2) show for the first time that in contrast with healthy women, rectal sensitivity changes with the menstrual cycle. These cyclical changes in sensitivity suggest that women with IBS respond differently to fluctuations in their sex hormonal environment or its consequences compared with healthy females.

Hypnotherapy in irritable bowel syndrome: a large-scale audit of a clinical service with examination of factors influencing responsiveness

OBJECTIVES

Hypnotherapy has been shown to be effective in the treatment of irritable bowel syndrome in a number of previous research studies. This has led to the establishment of the first unit in the United Kingdom staffed by six therapists that provides this treatment as a clinical service. This study presents an audit on the first 250 unselected patients treated, and these large numbers have also allowed analysis of data in terms of a variety of other factors, such as gender and bowel habit type, that might affect outcome.

METHODS

Patients underwent 12 sessions of hypnotherapy over a 3-month period and were required to practice techniques in between sessions. At the beginning and end of the course of treatment, patients completed questionnaires to score bowel and extracolonic symptoms, quality of life, and anxiety and depression, allowing comparisons to be made.

RESULTS

Marked improvement was seen in all symptom measures, quality of life, and anxiety and depression (all ps < 0.001), in keeping with previous studies. All subgroups of patients appeared to do equally well, with the notable exception of males with diarrhea, who improved far less than other patients (p < 0.001). No factors, such as anxiety and depression or other prehypnotherapy variables, could explain this lack of improvement.

CONCLUSIONS

This study clearly demonstrates that hypnotherapy remains an extremely effective treatment for irritable bowel syndrome and should prove more cost-effective as new, more expensive drugs come on to the market. It may be less useful in males with diarrhea-predominant bowel habit, a finding that may have pathophysiological implications.

Bleeding angiodysplasia: should we concentrate more on the aortic valve than on the bowel?

A case of bleeding from angiodysplasia in association with aortic stenosis is presented. The particular interest in this patient is that the bleeding ceased immediately after the insertion of a bioprosthetic valve and recurred when the valve restenosed. Furthermore, the bleeding again promptly resolved when the valve was exchanged for a metallic prosthesis despite long-term anticoagulation. The implications of these observations are discussed.

Diarrhea- and Constipation-predominant Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) has a reputation for being hard to treat, trivial, and often psychologic in origin. Furthermore, there currently appears to be almost more of a stigma attached to being diagnosed as having IBS than a depressive illness. Thus, it is not surprising that patients with this syndrome become distressed by the attitudes they encounter, particularly as we now know that this condition can substantially impair one's quality of life. The problem with effective management is that there is no "standard treatment" and therapy has to be targeted to the symptoms of the individual patient. This frequently proves to be time consuming and also may involve some degree of trial and error. However, when all the issues surrounding IBS are addressed in a sympathetic and positive manner, these patients can be surprisingly rewarding to treat.

Ambulatory abdominal inductance plethysmography: towards objective assessment of abdominal distension in irritable bowel syndrome

BACKGROUND

Abdominal distension is one of the cardinal features of irritable bowel syndrome (IBS) with patients often ranking it as more intrusive than their pain or bowel dysfunction. If this symptom could be quantified accurately and reliably it would provide, for the first time, an objective way of assessing this disorder. Using the principle of inductance plethysmography we have developed a microprocessor based system capable of recording even minimal changes in girth over 24 hours and we describe its validation and establish normal ranges.

METHODS

Twenty four hour recordings were made in 20 healthy female volunteers (aged 23-58 years) to assess changes in abdominal girth with respect to time, posture, meals, and sleep. Normal daily activity was encouraged and meals were standardised. The feeling of abdominal distension was also assessed using a visual analogue scale.

FINDINGS

Measurement of abdominal girth using abdominal inductance plethysmography (AIP) at a static point in time showed a close relationship with that measured using a tape measure (rho=0.8910, p<0.001). Furthermore, girth was significantly greater both in the sitting and standing postures compared with lying (p<0.01). Measurement over a 24 hour period showed that girth was significantly greater at the end compared with the beginning of the day, and ingestion of a standard meal also increased its value (p<0.05). Sleep was associated with a reduction in girth (p<0.05).

CONCLUSIONS

AIP promises to add an objective dimension to the assessment of IBS which could prove invaluable in clinical trials. Furthermore, it should aid research into the pathogenesis of this symptom for which no satisfactory explanation has yet emerged.

Quality of life in irritable bowel syndrome

Quality-of-life (QOL) assessment is becoming increasingly important in the evaluation of the impact of disease and the effect of therapy. This is particularly so forirritable bowel syndrome (IBS) where there is often a tendency for a chronic clinical course, but with no associated mortality. Instruments used to study quality of life may be generic or disease specific, and care needs to be taken to ensure that the instrument used has been adequately validated for the purpose intended. Several disease-specific instruments [Irritable Bowel Syndrome Quality of Life (IBS-QOL, IBSQOL) and Functional Digestive Disorders Quality of Life (FDDQL)], in addition to generic measures, are now available for use in IBS. Quality of life in patients with IBS is surprisingly poor, particularly in the population seeking healthcare, where it can be compared with conditions which carry a high mortality, such as ischaemic heart disease, heart failure and diabetes mellitus. Pain severity appears to be an important factor in determining quality of life in IBS, although bowel disturbance and psychological difficulties are also likely to be important. There is limited data on the effect of treatment of IBS on quality of life. Improvement has been reported with dietry modification, drug treatments and hypnotherapy. It is likely that, in the future, QOL measures will become increasingly used as secondary end-points in therapeutic trials in IBS.

Chlamydia trachomatis infection: is it relevant in irritable bowel syndrome?

BACKGROUND

Irritable bowel syndrome can present with gynaecological symptoms similar to those of chronic pelvic inflammatory disease, which is commonly caused by Chlamydia trachomatis. Infection with this organism might therefore lead to diagnostic and management difficulties in patients, not only as a result of symptom overlap between the two disorders but also because chlamydial infection might exacerbate the symptoms of irritable bowel syndrome. This study was designed to investigate any possible link between chlamydial infection and irritable bowel syndrome.

PATIENTS/METHODS

The prevalence of antibodies to C. trachomatis and abdominal symptomatology was assessed in a group of 100 female patients with irritable bowel syndrome and 100 matched female controls.

RESULTS

25% of patients and 17% of controls were found to have evidence of previous chlamydial infection. This difference was not statistically significant. Within the patient group, no association was found between chlamydial infection and any particular pattern of symptomatology.

CONCLUSIONS

The results of this study indicate that occult chlamydial infection is not a major problem in irritable bowel syndrome and that routine investigation for this organism is unnecessary. They also provide some reassurance that pelvic inflammatory disease and all its potentially serious consequences is not being significantly overlooked in gastroenterological practice.

Do male sex hormones protect from irritable bowel syndrome?

OBJECTIVE

Irritable bowel syndrome (IBS) is more common in women and it is frequently assumed that being female may predispose to the development of this disorder. Alternatively, being male could offer some degree of protection and if so, this might be mediated by testosterone. The aim of this study was to assess whether male patients with IBS have lower levels of testosterone and related gonadotrophins than their unaffected counterparts and if this relates to rectal sensitivity.

METHODS

Fifty secondary care, male outpatients with IBS (aged 19-71 yr) were compared with 25 controls (aged 22-67 yr). Each subject had serum testosterone, free testosterone, sex hormone-binding globulin, follicle stimulating hormone, and luteinizing hormone (LH) measured, together with rectal sensitivity to balloon distension. Anxiety and depression were also assessed.

RESULTS

The only difference in the hormone levels between patients and controls that reached statistical significance was the lower value for LH in the IBS patients (p = 0.014). Although patients were more anxious and depressed than the controls (p < 0.001), this could not solely account for the reduced level of LH, as adjusting for these (analysis of variance) still tended to show that LH values were lower in men with rather than without IBS [F(1,70) = 2.74; p = 0.10]. Men with IBS were more sensitive to balloon distension of the rectum, with the distension volumes required for "urgency" (p < 0.001) and "discomfort" (p = 0.001) significantly lower than controls. Paradoxically, the patient's sensory thresholds negatively correlated with levels of testosterone (p < 0.05) and free testosterone (p < 0.002), and positively with levels of sex hormone-binding globulin (p < 0.05). Finally, there was a tendency for IBS symptomatology to be inversely related to testosterone levels (p = 0.15).

CONCLUSIONS

These results support the need for further exploration of the role of male sex hormones in the pathophysiology of IBS.

Alosetron, a 5-HT3 receptor antagonist, delays colonic transit in patients with irritable bowel syndrome and healthy volunteers

BACKGROUND

Alosetron is a potent and selective 5-HT3 receptor antagonist, which has been shown to be beneficial in the treatment of female patients with non-constipated irritable bowel syndrome.

AIMS

To investigate the effect of alosetron on whole gut, small bowel and colonic transit in patients with irritable bowel syndrome (Study 1) and healthy volunteers (Study 2).

SUBJECTS

Thirteen patients with irritable bowel syndrome and 12 healthy volunteers.

METHODS

Both studies were randomized, double-blind, placebo-controlled with a two-way crossover design, in which each subject received alosetron (2 mg b.d. administered orally) or placebo for 8 days. Mean whole gut transit was determined from the excretion of radio-opaque markers; small bowel transit was determined from rise in breath hydrogen after a meal; and colonic transit and segmental transit were evaluated from abdominal X-ray. In addition, colonic transit was calculated by subtracting small bowel transit time from whole gut transit time.

RESULTS

Alosetron increased colonic transit time by prolonging left colonic transit in both patients with irritable bowel syndrome and controls. This resulted in a tendency for the whole gut transit to be delayed in irritable bowel syndrome patients (P=0.128), which was confirmed in controls (P=0.047).

CONCLUSION

Alosetron delays colonic transit by prolonging left colonic transit. These results add to the body of evidence suggesting that alosetron should have a therapeutic role in patients with non-constipated irritable bowel syndrome.

5-HT4 receptor antagonism in irritable bowel syndrome: effect of SB-207266-A on rectal sensitivity and small bowel transit

BACKGROUND

Pre-clinical studies indicate that the 5-hydroxytryptamine (5-HT)4 receptor may be involved in the pathophysiology of irritable bowel syndrome and that antagonism of this receptor may be an effective therapeutic strategy.

AIM

To investigate the effects of SB-207266-A, a selective 5-HT4 receptor antagonist on rectal sensitivity and small bowel transit in patients with irritable bowel syndrome.

METHODS

Eighteen patients with diarrhoea-predominant irritable bowel syndrome and a history of increased rectal sensitivity were randomized to receive either SB-207266-A (20 mg) or placebo for 10 days. Following a washout period, patients were then crossed over to receive the alternative therapy for 10 days. Rectal sensitivity and orocaecal transit time were assessed on day 10 of each treatment period. In addition, patients were asked whether they had experienced any changes in their symptoms.

RESULTS

Fifteen patients completed the study. SB-207266-A significantly increased orocaecal transit time towards normal (placebo: 5.3 h (4.0-7.2 h), mean (IQR) vs. SB-207266-A: 6.5 h (4.8-8.0 h); P=0.027) and tended to decrease rectal sensitivity (volume to discomfort 89 mL (60-150 mL), geometric mean (IQR) vs. 107 mL (75-150 mL); P=0.134). Eleven out of 15 patients reported symptomatic improvements with SB-207266-A but none with placebo. SB-207266-A was well tolerated.

CONCLUSION

Our results support a role for the 5-HT4 receptor in the pathophysiology of irritable bowel syndrome and suggest that the selective 5-HT4 antagonist, SB-207266-A, is worthy of further evaluation in this disorder.

Interleukin-10 (IL-10) genotypes in inflammatory bowel disease

Interleukin-10 (IL-10) is an anti-inflammatory cytokine. Its production in humans is under genetic control, and genotype defines high or low producers of this cytokine. This study addresses the hypothesis that idiopathic inflammatory bowel disease (IBD) patients are more likely to have the low IL-10 producer genotype and phenotype. DNA was extracted from blood cells of patients with Crohn's disease (CD) or with ulcerative colitis (UC) for IL-10 genotyping. The frequency of the high IL-10 producer allele (-1082*G) was decreased in the whole IBD group (41% vs. 51%, P = 0.03) and in the UC patients compared with normal controls (37% vs. 51%; P = 0.04). Hence, there appears to be an association between the IL-10 genotypes and IBD. This suggests that individuals genetically predisposed to produce less IL-10 are at a higher risk of developing IBD, in particular, UC.

Design of treatment trials for functional gastrointestinal disorders

Until recently many clinical trials of functional gastrointestinal disorders (FGIDs) suffered from important weaknesses in trial design, study execution, and data analysis. This makes it difficult to determine whether truly efficacious therapies exist for these disorders. One of the important methodologic problems is the absence of validated outcome measures and lack of consensus among stakeholders on how to measure outcome. Currently much of the effort is being put into the development of validated outcome measures for several of the FGIDs. The randomized, controlled trial with parallel groups is the design of choice. In this report, guidelines are given for the basic architecture of intervention studies of FGIDs. Further studies on design issues are required to ensure the recommendations will become evidence based in the future.

Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome

OBJECTIVE

As many as 70% of patients with fibromyalgia complain of the symptoms of irritable bowel syndrome (IBS), but there is a clinical impression that IBS patients do not suffer from fibromyalgia as frequently. The sicca complex (dry eyes and mouth) is also commonly observed in fibromyalgia, but its prevalence in IBS has not been evaluated. Our objective was to assess the frequency of fibromyalgia and sicca complex in secondary care patients with IBS.

METHODS

Forty-six secondary care patients with IBS and 46 healthy controls were assessed by a rheumatologist for the presence of fibromyalgia and objective evidence of sicca complex (Schirmer and Rose-Bengal tests). Psychological status was also assessed (HAD questionnaire).

RESULTS

Thirteen (28%) IBS patients suffered from fibromyalgia, compared with five (11%) controls, a difference of 17% (95% confidence intervals [CI], 2-33%). Fifteen (33%) IBS patients versus three (6%) controls had sicca complex, a difference of 27% (95% CI, 11-45%).

CONCLUSIONS

These results suggest that the prevalence of fibromyalgia in IBS is approximately half that of IBS in fibromyalgia. Furthermore, sicca complex seems to be another complaint that should be added to the list of extracolonic manifestations of IBS. Study of the overlap between functional disorders presenting to different specialties may give new insights into the pathophysiology of these puzzling conditions.