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Goodoory VC, Khasawneh M, Thakur ER, Everitt HA, Gudleski GD, Lackner JM, Moss-Morris R, Simren M, Vasant DH, Moayyedi P, Black CJ, Ford AC. Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis. Gastroenterology 2024:S0016-5085(24)04932-1. [PMID: 38777133 DOI: 10.1053/j.gastro.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 05/08/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND & AIMS Some brain-gut behavioral treatments (BGBTs) are beneficial for global symptoms in irritable bowel syndrome (IBS). United States management guidelines suggest their use in patients with persistent abdominal pain, but their specific effect on this symptom has not been assessed systematically. METHODS We searched the literature through December 16, 2023, for randomized controlled trials (RCTs) assessing efficacy of BGBTs for adults with IBS, compared with each other or a control intervention. Trials provided an assessment of abdominal pain resolution or improvement at treatment completion. We extracted data as intention-to-treat analyses, assuming dropouts to be treatment failures and reporting pooled relative risks (RRs) of abdominal pain not improving with 95% confidence intervals (CIs), ranking therapies according to the P score. RESULTS We identified 42 eligible randomized controlled trials comprising 5220 participants. After treatment completion, the BGBTs with the largest numbers of trials and patients recruited demonstrating efficacy for abdominal pain, specifically, included self-guided/minimal contact cognitive behavioral therapy (CBT) (RR, 0.71; 95% CI, 0.54-0.95; P score, 0.58), face-to-face multicomponent behavioral therapy (RR, 0.72; 95% CI, 0.54-0.97; P score, 0.56), and face-to-face gut-directed hypnotherapy (RR, 0.77; 95% CI, 0.61-0.96; P score, 0.49). Among trials recruiting only patients with refractory global IBS symptoms, group CBT was more efficacious than routine care for abdominal pain, but no other significant differences were detected. No trials were low risk of bias across all domains, and there was evidence of funnel plot asymmetry. CONCLUSIONS Several BGBTs, including self-guided/minimal contact CBT, face-to-face multicomponent behavioral therapy, and face-to-face gut-directed hypnotherapy may be efficacious for abdominal pain in IBS, although none was superior to another.
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Affiliation(s)
- Vivek C Goodoory
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Mais Khasawneh
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Elyse R Thakur
- Department of Psychiatry & Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Hazel A Everitt
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Gregory D Gudleski
- Division of Behavioral Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Jeffrey M Lackner
- Division of Behavioral Medicine, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Rona Moss-Morris
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Magnus Simren
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester, United Kingdom; Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, United Kingdom
| | - Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Christopher J Black
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals National Health Service Trust, Leeds, United Kingdom; Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, United Kingdom.
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Meyerson J, Konichezky A. Applying hypnotic associative - dissociative techniques in psychotherapy for psychosomatic symptoms. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2024:1-10. [PMID: 38687908 DOI: 10.1080/00029157.2024.2337625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Patients experiencing psychosomatic symptoms frequently have difficulty obtaining correct treatment. They are often reluctant to partially attribute their symptoms to psychological factors and, as a result, delay referrals to mental health professionals. Furthermore, the dropout rate from therapy is high and relapses are common. Hypnosis is a complex psycho-physiological phenomenon. Hence, hypnotic psychotherapy may play an important role in managing and treating psychosomatic symptoms and disorders that involve both the mind and body. In the current study, we propose a clinically oriented, four-phase, hypnotic approach, the hypnotic associative-dissociative approach (HADA), which may be useful in encouraging more patients with psychosomatic problems to engage in psychotherapy, thereby achieving effective long-term effects.
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Benson S, Labrenz F, Kotulla S, Brotte L, Rödder P, Tebbe B, Theysohn N, Engler H, Elsenbruch S. Amplified gut feelings under inflammation and depressed mood: A randomized fMRI trial on interoceptive pain in healthy volunteers. Brain Behav Immun 2023:S0889-1591(23)00147-2. [PMID: 37302437 DOI: 10.1016/j.bbi.2023.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/26/2023] [Accepted: 06/04/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Inflammation and depressed mood constitute clinically relevant vulnerability factors for enhanced interoceptive sensitivity and chronic visceral pain, but their putative interaction remains untested in human mechanistic studies. We tested interaction effects of acute systemic inflammation and sad mood on the expectation and experience of visceral pain by combining experimental endotoxemia with a mood induction paradigm. METHODS The double-blind, placebo-controlled, balanced crossover fMRI-trial in N=39 healthy male and female volunteers involved 2 study days with either intravenous administration of low-dose lipopolysaccharide (LPS, 0.4ng/kg body weight; inflammation condition) or saline (placebo condition). On each study, day two scanning sessions were conducted in an experimentally induced negative (i.e., sad) and in a neutral mood state, accomplished in balanced order. As a model of visceral pain, rectal distensions were implemented, which were initially calibrated to be moderately painful. In all sessions, an identical series of visceral pain stimuli was accomplished, signaled by predictive visual conditioning cues to assess pain anticipation. We assessed neural activation during the expectation and experience of visceral pain, along with unpleasantness ratings in a condition combining an inflammatory state with sad mood and in control conditions. All statistical analyses were accomplished using sex as covariate. RESULTS LPS administration led to an acute systemic inflammatory response (inflammation X time interaction effects for TNF-α, IL-6, and sickness symptoms, all p<.001). The mood paradigm effectively induced distinct mood states (mood X time interaction, p<.001), with greater sadness in the negative mood conditions (both p<.001) but no difference between LPS and saline conditions. Significant main and interaction effects of inflammation and negative mood were observed for pain unpleasantness (all p<.05). During cued pain anticipation, a significant inflammation X mood interaction emerged for activation of the bilateral caudate nucleus and right hippocampus (all pFWE<.05). Main effects of both inflammation and mood were observed in multiple regions, including insula, midcingulate cortex, prefrontal gyri, and hippocampus for inflammation, and midcingulate, caudate, and thalamus for mood (all pFWE<0.05). CONCLUSIONS Results support an interplay of inflammation and sad mood on striatal and hippocampal circuitry engaged during visceral pain anticipation as well as on pain experience. This may reflect a nocebo mechanism, which may contribute to altered perception and interpretation of bodily signals. At the interface of affective neuroscience and the gut-brain axis, concurrent inflammation and negative mood may be vulnerability factors for chronic visceral pain.
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Affiliation(s)
- Sven Benson
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational and Behavioral Neuroscience, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Institute for Medical Education, University Hospital Essen, Center for Translational and Behavioral Neuroscience, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.
| | - Franziska Labrenz
- Department of Medical Psychology and Medical Sociology, Ruhr University Bochum
| | - Simone Kotulla
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational and Behavioral Neuroscience, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Lisa Brotte
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational and Behavioral Neuroscience, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Philipp Rödder
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Bastian Tebbe
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Nina Theysohn
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Harald Engler
- Institute of Medical Psychology and Behavioral Immunobiology, Center for Translational and Behavioral Neuroscience, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Sigrid Elsenbruch
- Department of Medical Psychology and Medical Sociology, Ruhr University Bochum; Department of Neurology, Center for Translational Neuro- and Behavioral Sciences, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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Hasan SS, Ballou S, Keefer L, Vasant DH. Improving access to gut-directed hypnotherapy for irritable bowel syndrome in the digital therapeutics' era: Are mobile applications a "smart" solution? Neurogastroenterol Motil 2023; 35:e14554. [PMID: 36847206 DOI: 10.1111/nmo.14554] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 02/11/2023] [Accepted: 02/14/2023] [Indexed: 03/01/2023]
Abstract
Gut-directed hypnotherapy (GDH) is a highly effective brain-gut behavioral therapy which is recommended in international guidelines for the treatment of irritable bowel syndrome (IBS). There is increasing recognition of the value of GDH as part of integrated care alongside medical and dietary approaches. This has led to recent innovations to widen access to GDH to meet the increasing demand. Recent advances include streamlined courses of individualized GDH, group therapy, and remote delivery. In this issue of Neurogastroenterology and Motility, Peters et al. retrospectively report outcomes of smartphone app-delivered GDH in a population with self-reported IBS. While adherence was low, those that completed smart phone-delivered GDH-achieved symptom benefit. This mini-review summarizes the current evidence-base for available modalities of GDH and discusses the current and future utility and development of mobile health applications in the digital therapeutics' era.
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Affiliation(s)
- Syed S Hasan
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
| | - Sarah Ballou
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laurie Keefer
- The Henry D. Janowitz Division of Gastroenterology, The Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dipesh H Vasant
- Neurogastroenterology Unit, Manchester University NHS Foundation Trust, Wythenshawe Hospital, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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Shiha MG, Aziz I. Review article: Physical and psychological comorbidities associated with irritable bowel syndrome. Aliment Pharmacol Ther 2021; 54 Suppl 1:S12-S23. [PMID: 34927759 DOI: 10.1111/apt.16589] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/10/2021] [Accepted: 08/17/2021] [Indexed: 12/11/2022]
Abstract
Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders encountered by physicians in primary and secondary care. Patients with IBS commonly present with various extraintestinal complaints, which account for a substantial clinical and economic burden. The common extraintestinal comorbidities associated with IBS include anxiety, depression, somatisation, fibromyalgia, chronic fatigue syndrome, chronic pelvic pain, interstitial cystitis, sexual dysfunction and sleep disturbance. The presence of comorbidity in IBS poses a diagnostic and therapeutic challenge with patients frequently undergoing unnecessary investigations and interventions, including surgery. This review discusses the different physical and psychological comorbidities associated with IBS, the shared pathophysiological mechanisms and potential management strategies.
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Affiliation(s)
- Mohamed G Shiha
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Imran Aziz
- Academic Unit of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Black CJ, Thakur ER, Houghton LA, Quigley EMM, Moayyedi P, Ford AC. Efficacy of psychological therapies for irritable bowel syndrome: systematic review and network meta-analysis. Gut 2020; 69:1441-1451. [PMID: 32276950 DOI: 10.1136/gutjnl-2020-321191] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES National guidelines for the management of irritable bowel syndrome (IBS) recommend that psychological therapies should be considered, but their relative efficacy is unknown, because there have been few head-to-head trials. We performed a systematic review and network meta-analysis to try to resolve this uncertainty. DESIGN We searched the medical literature through January 2020 for randomised controlled trials (RCTs) assessing efficacy of psychological therapies for adults with IBS, compared with each other, or a control intervention. Trials reported a dichotomous assessment of symptom status after completion of therapy. We pooled data using a random effects model. Efficacy was reported as a pooled relative risk (RR) of remaining symptomatic, with a 95% CI to summarise efficacy of each comparison tested, and ranked by therapy according to P score. RESULTS We identified 41 eligible RCTs, containing 4072 participants. After completion of therapy, the psychological interventions with the largest numbers of trials, and patients recruited, demonstrating efficacy included self-administered or minimal contact cognitive behavioural therapy (CBT) (RR 0.61; 95% CI 0.45 to 0.83, P score 0.66), face-to-face CBT (RR 0.62; 95% CI 0.48 to 0.80, P score 0.65) and gut-directed hypnotherapy (RR 0.67; 95% CI 0.49 to 0.91, P score 0.57). After completion of therapy, among trials recruiting only patients with refractory symptoms, group CBT and gut-directed hypnotherapy were more efficacious than either education and/or support or routine care, and CBT via the telephone, contingency management, CBT via the internet and dynamic psychotherapy were all superior to routine care. Risk of bias of trials was high, with evidence of funnel plot asymmetry; the efficacy of psychological therapies is therefore likely to have been overestimated. CONCLUSIONS Several psychological therapies are efficacious for IBS, although none were superior to another. CBT-based interventions and gut-directed hypnotherapy had the largest evidence base and were the most efficacious long term. TRIAL REGISTRATION NUMBER The study protocol was published on the PROSPERO international prospective register of systematic reviews (registration number CRD 42020163246).
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Affiliation(s)
- Christopher J Black
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK.,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
| | - Elyse R Thakur
- Department of Psychiatry and Behavioural Sciences, Baylor College of Medicine, Houston, Texas, USA.,Division of Gastroenterology and Hepatology, Atrium Health, Charlotte, North Carolina, USA
| | - Lesley A Houghton
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
| | - Eamonn M M Quigley
- Lynda K and David M Underwood Center for Digestive Disorders, Houston Methodist Hospital and Weill Cornell Medical College, Houston, Texas, USA
| | - Paul Moayyedi
- Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Alexander C Ford
- Leeds Gastroenterology Institute, St. James's University Hospital, Leeds, West Yorkshire, UK .,Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, West Yorkshire, UK
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7
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Vasant DH, Whorwell PJ. Gut-focused hypnotherapy for Functional Gastrointestinal Disorders: Evidence-base, practical aspects, and the Manchester Protocol. Neurogastroenterol Motil 2019; 31:e13573. [PMID: 30815936 PMCID: PMC6850508 DOI: 10.1111/nmo.13573] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/20/2019] [Accepted: 01/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Despite their high prevalence and advances in the field of neurogastroenterology, there remain few effective treatment options for functional gastrointestinal disorders (FGIDs). It is recognized that approximately 25% of sufferers will have symptoms refractory to existing therapies, causing significant adverse effects on quality of life and increased healthcare utilization and morbidity. Gut-focused hypnotherapy, when delivered by trained therapists, has been shown to be highly effective in severe refractory FGIDs. However, hypnotherapy continues to be surrounded by much misunderstanding and skepticism. PURPOSE The purpose of this review is to provide a contemporary overview of the principles of gut-focused hypnotherapy, its effects on gut-brain interactions, and the evidence-base for its efficacy in severe FGIDs. As supplementary material, we have included a hypnotherapy protocol, providing the reader with an insight into the practical aspects of delivery, and as a guide, an example of a script of a gut-focused hypnotherapy session.
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Affiliation(s)
- Dipesh H. Vasant
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
- Division of Diabetes, Endocrinology & Gastroenterology, Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
| | - Peter J. Whorwell
- Neurogastroenterology Unit, Gastroenterology, Wythenshawe HospitalManchester University NHS Foundation TrustManchesterUK
- Division of Diabetes, Endocrinology & Gastroenterology, Manchester Academic Health Sciences CentreUniversity of ManchesterManchesterUK
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Kolacz J, Kovacic KK, Porges SW. Traumatic stress and the autonomic brain-gut connection in development: Polyvagal Theory as an integrative framework for psychosocial and gastrointestinal pathology. Dev Psychobiol 2019; 61:796-809. [PMID: 30953358 DOI: 10.1002/dev.21852] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 02/12/2019] [Accepted: 02/23/2019] [Indexed: 12/14/2022]
Abstract
A range of psychiatric disorders such as anxiety, depression, and post-traumatic stress disorder frequently co-occur with functional gastrointestinal (GI) disorders. Risk of these pathologies is particularly high in those with a history of trauma, abuse, and chronic stress. These scientific findings and rising awareness within the healthcare profession give rise to a need for an integrative framework to understand the developmental mechanisms that give rise to these observations. In this paper, we introduce a plausible explanatory framework, based on the Polyvagal Theory (Porges, Psychophysiology, 32, 301-318, 1995; Porges, International Journal of Psychophysiology, 42, 123-146, 2001; Porges, Biological Psychology, 74, 116-143, 2007), which describes how evolution impacted the structure and function of the autonomic nervous system (ANS). The Polyvagal Theory provides organizing principles for understanding the development of adaptive diversity in homeostatic, threat-response, and psychosocial functions that contribute to pathology. Using these principles, we outline possible mechanisms that promote and maintain socioemotional and GI dysfunction and review their implications for therapeutic targets.
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Affiliation(s)
- Jacek Kolacz
- Traumatic Stress Research Consortium at the Kinsey Institute, Indiana University, Bloomington, Indiana
| | - Katja K Kovacic
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen W Porges
- Traumatic Stress Research Consortium at the Kinsey Institute, Indiana University, Bloomington, Indiana.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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9
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Hasan SS, Pearson JS, morris J, Whorwell PJ. SKYPE HYPNOTHERAPY FOR IRRITABLE BOWEL SYNDROME: Effectiveness and Comparison with Face-to-Face Treatment. Int J Clin Exp Hypn 2019; 67:69-80. [PMID: 30702396 PMCID: PMC6538308 DOI: 10.1080/00207144.2019.1553766] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/03/2018] [Indexed: 12/14/2022]
Abstract
Gut-focused hypnotherapy is an effective treatment for irritable bowel syndrome but is not widely available. This study assessed whether providing hypnotherapy by Skype might partially overcome this problem. Using a 50-point or more reduction in the IBS Symptom Severity Score as the primary outcome measure, 65% of subjects responded to Skype hypnotherapy with all other outcomes significantly improving. The primary outcome figure for face-to-face hypnotherapy was 76%. When other outcome scores for Skype and face-to-face treatment were compared, the mean changes were these: symptom severity (-94.1 vs. -129.2), noncolonic score (-52.3 vs. -64.8), quality of life (+56.4 vs. +66.2), anxiety (-3.3 vs. -3.0), depression (-1.7 vs. -2.5), and a 30% or more pain reduction (44% vs. 62%). Skype hypnotherapy is effective but slightly less so than face-to-face treatment. However, many patients would have been unable to access treatment without the Skype option.
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Affiliation(s)
- Shariq S. Hasan
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester, UK
| | - James S. Pearson
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester, UK
| | - Julie morris
- Neurogastroenterology Unit, Wythenshawe Hospital, Manchester, UK
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Krouwel M, Greenfield S, Farley A, Ismail T, Jolly K. Factors which affect the efficacy of hypnotherapy for IBS: Protocol for a systematic review and meta-regression. Eur J Integr Med 2018. [DOI: 10.1016/j.eujim.2018.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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Carrington EV, Scott SM, Bharucha A, Mion F, Remes-Troche JM, Malcolm A, Heinrich H, Fox M, Rao SS. Expert consensus document: Advances in the evaluation of anorectal function. Nat Rev Gastroenterol Hepatol 2018; 15:309-323. [PMID: 29636555 PMCID: PMC6028941 DOI: 10.1038/nrgastro.2018.27] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Faecal incontinence and evacuation disorders are common, impair quality of life and incur substantial economic costs worldwide. As symptoms alone are poor predictors of underlying pathophysiology and aetiology, diagnostic tests of anorectal function could facilitate patient management in those cases that are refractory to conservative therapies. In the past decade, several major technological advances have improved our understanding of anorectal structure, coordination and sensorimotor function. This Consensus Statement provides the reader with an appraisal of the current indications, study performance characteristics, clinical utility, strengths and limitations of the most widely available tests of anorectal structure (ultrasonography and MRI) and function (anorectal manometry, neurophysiological investigations, rectal distension techniques and tests of evacuation, including defecography). Additionally, this article provides our consensus on the clinical relevance of these tests.
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Affiliation(s)
- Emma V. Carrington
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - S. Mark Scott
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Adil Bharucha
- Department of Gastroenterology and Hepatology, Mayo College of Medicine, Rochester, MN, USA
| | - François Mion
- Exploration Fonctionnelle Digestive, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon I University and Inserm 1032 LabTAU, Lyon, France
| | - Jose M. Remes-Troche
- Laboratorio de Fisiología Digestiva y Motilidad Gastrointestinal, Instituto de Investigaciones Médico Biológicas, Universidad Veracruzana, Veracruz, México
| | - Allison Malcolm
- Division of Gastroenterology, Royal North Shore Hospital, and University of Sydney, Sydney, Australia
| | - Henriette Heinrich
- National Bowel Research Centre, Blizard Institute, Queen Mary University of London, London, UK
| | - Mark Fox
- Abdominal Center: Gastroenterology, St. Claraspital, Basel, Switzerland
- Clinic for Gastroenterology & Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Satish S. Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia
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12
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Farhadi A, Banton D, Keefer L. Connecting Our Gut Feeling and How Our Gut Feels: The Role of Well-being Attributes in Irritable Bowel Syndrome. J Neurogastroenterol Motil 2018; 24:289-298. [PMID: 29605984 PMCID: PMC5885728 DOI: 10.5056/jnm17117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/23/2017] [Accepted: 01/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background/Aims There is a close relationship between the mind and gut in the pathogenesis of functional bowel disorders. Common psychological disturbances such as depression and anxiety are not uncommon in those with irritable bowel syndrome (IBS). There is little research investigating the role of positive psychology and gastrointestinal (GI) conditions. In this pilot study we investigated the well-being attributes in those with and without IBS. Methods We used an anonymous online survey and recruited 416 study subjects using social media as the main method of recruitment. We gathered demographic information, GI symptoms, history of mental health issues such as anxiety and depression, assessed several well-being attributes, and finally assessed subjective well-being. We hypothesized that those with GI symptoms and IBS have lower scores in their well-being attributes compared to healthy controls. Results We observed that a history of anxiety and depression is significantly associated with GI symptoms and IBS. In addition, sense of subjective well-being and several well-being attributes are negatively associated with GI symptoms and/or IBS. Of interest, the household income showed a negative correlation with the prevalence of GI symptoms and IBS. Conclusions Subjective well-being, and several well-being attributes that contribute to the sense of overall contentment, are negatively associated with GI symptoms and IBS. The link between subjective well-being, and GI symptoms and IBS are independent of anxiety and depression. Well-being attributes and sense of subjective well-being may be a contributory factor in clinical expression of GI symptoms or IBS consistent with the biopsychosocial model of the disease.
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Affiliation(s)
- Ashkan Farhadi
- Section of Gastroenterology and Nutrition, University of California, Irvine, CA, USA
| | - Dwaine Banton
- Janssen Research and Development, Spring House, PA, USA
| | - Laurie Keefer
- Icahn School of Medicine at Mount Sinai, Division of Gastroenterology, New York, NY, USA
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Abstract
Bloating is one of the most common and troublesome problems in a large proportion of patients with gastrointestinal disorders but the mechanism is not completely understood. Several factors, including gas-producing intestinal microbiota, disturbed handling of intestinal gas, visceral hypersensitivity, abnormal viscero-somatic responses, fermentable diet, and psychological factors, have been suggested as mechanisms. For an assessment, thorough medical history-taking and physical examination are the first steps. On the other hand, organic disorders should always be considered first for a differential diagnosis. The therapeutic options available are considered challenging and still limited in clinical practice. The treatment strategy may include diet modification, pharmacologic approach, psychiatric approach, biofeedback, etc. Further studies will be needed to explore the variable mechanism of bloating and develop an efficient treatment.
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Affiliation(s)
- Hyun Jik Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Malagelada JR, Accarino A, Azpiroz F. Bloating and Abdominal Distension: Old Misconceptions and Current Knowledge. Am J Gastroenterol 2017; 112:1221-1231. [PMID: 28508867 DOI: 10.1038/ajg.2017.129] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 03/07/2017] [Indexed: 02/08/2023]
Abstract
Bloating, as a symptom and abdominal distension, as a sign, are both common functional-type complaints and challenging to manage effectively. Individual patients may weight differently the impact of bloating and distension on their well-being. Complaints may range from chronic highly distressing pain to simply annoying and unfashionable protrusion of the abdomen. To avoid mishaps, organic bloating, and distension should always be considered first and appropriated assessed. Functional bloating and distension often present in association with other manifestations of irritable bowel syndrome or functional dyspepsia and in that context patients tend to regard them as most troublesome. A mechanism-based management bloating and distension should be ideal but elucidating key operational mechanisms in individual patients is not always feasible. Some clues may be gathered through a detailed dietary history, by assessing bowel movement frequency and stool consistency and special imaging technique to measure abdominal shape during episodes of distension. In severe, protracted cases it may be appropriate to refer the patient to a specialized center where motility, visceral sensitivity, and abdominal muscle activity in response to intraluminal stimuli may be measured. Therapeutic resources focussed upon presumed or demonstrated pathogenetic mechanism include dietary modification, microbiome modulation, promoting gas evacuation, attenuating visceral perception, and controlling abdominal wall muscle activity via biofeedback.
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Affiliation(s)
- Juan R Malagelada
- Digestive System Research Unit, University Hospital Vall d'Hebron; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Anna Accarino
- Digestive System Research Unit, University Hospital Vall d'Hebron; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
| | - Fernando Azpiroz
- Digestive System Research Unit, University Hospital Vall d'Hebron; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Universitat Autònoma de Barcelona, 08193 Cerdanyola del Vallès, Spain
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Lee C, Doo E, Choi JM, Jang SH, Ryu HS, Lee JY, Oh JH, Park JH, Kim YS. The Increased Level of Depression and Anxiety in Irritable Bowel Syndrome Patients Compared with Healthy Controls: Systematic Review and Meta-analysis. J Neurogastroenterol Motil 2017; 23:349-362. [PMID: 28672433 PMCID: PMC5503284 DOI: 10.5056/jnm16220] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 06/08/2017] [Accepted: 06/10/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIMS Irritable bowel syndrome (IBS) patients commonly experience psychiatric disorders, such as depression and anxiety. This meta-analysis sought to compare depression and anxiety levels between IBS patients and healthy controls. METHODS We searched major electronic databases (PubMed, EMBASE, MEDLINE, and Cochrane library) to find comparative studies on IBS patients and healthy controls. The primary outcome was a standardized mean difference (SMD) of anxiety and depression levels; sub-group analyses were conducted according to IBS-subtypes. RESULTS In total, 2293 IBS patients and 4951 healthy controls from 27 studies were included. In random effect analysis, depression and anxiety levels were significantly higher in IBS patients (pooled SMD = 0.76; 95% CI, 0.62-0.90; P < 0.001; I2 = 77.2% and pooled SMD = 0.84; 95% CI, 0.67-1.01; P < 0.001; I2 = 85.6%, respectively). Both analyses' funnel plots showed symmetry. In meta-regression analysis, heterogeneity was due to the studied region and questionnaire type for both depression and anxiety. In sub-group analyses of IBS-subtype, the pooled SMDs of depression and anxiety levels (IBS with predominant constipation: 0.83 and 0.81, IBS with predominant diarrhea: 0.73 and 0.65, and IBS with mixed bowel habits: 0.62 and 0.75; P < 0.001, respectively) were significantly higher in all IBS-subtypes. CONCLUSIONS The present meta-analysis showed depression and anxiety levels to be higher in IBS patients than in healthy controls, regardless of IBS-subtype. However, the gender effect on psychological factors among IBS patients could not be determined and should be evaluated in prospective studies.
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Affiliation(s)
- Changhyun Lee
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul,
Korea
| | - Eunyoung Doo
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul,
Korea
| | - Ji Min Choi
- Department of Internal Medicine and Healthcare Research Institute, Healthcare System Gangnam Center, Seoul National University Hospital, Seoul,
Korea
| | - Seung-ho Jang
- Department of Psychiatry, School of Medicine, Wonkwang University, Iksan, Jeollabuk-do,
Korea
| | - Han-Seung Ryu
- Department of Gastroenterology and Digestive Disease Research Institute, Wonkwang University School of Medicine, Iksan, Jeollabuk-do,
Korea
| | - Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu,
Korea
| | - Jung Hwan Oh
- Division of Gastroenterology, Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jung Ho Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul,
Korea
| | - Yong Sung Kim
- Division of Gastroenterology, Department of Internal Medicine, Wonkwang University Sanbon Hospital, Gunpo, Gyeonggi-do,
Korea
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Prokinetic effects of LD02GIFRO on functional gastrointestinal disorder in rats. Exp Ther Med 2017; 13:2043-2049. [PMID: 28565806 DOI: 10.3892/etm.2017.4185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/18/2016] [Indexed: 12/24/2022] Open
Abstract
LD02GIFRO is a novel prokinetic agent formulated with Poncirus fructus and Zanthoxylum sp. fruits. The aim of the present study was to evaluate the effect of LD02GIFRO on delayed gastrointestinal transit (GIT) and colorectal hypersensitivity. To investigate the effect of LD02GIFRO, a rat model of delayed GIT was induced via three mechanisms; postoperative ileus (POI), morphine, and POI plus morphine. Visceromotor responses (VMR) to colorectal distension (CRD) were also evaluated. POI was induced by laparotomy surgery and manipulation of the small intestine under anesthesia, and GIT was calculated by measuring the length that Evans Blue travelled through the gastrointestinal tract in a given time. Oral administration of 260 mg/kg LD02GIFRO caused Evans Blue to migrate significantly further in the delayed GIT models induced by POI, morphine and POI plus morphine compared with the control (P<0.05). This effect was inhibited by atropine, a muscarinic receptor antagonist, and completely abolished by GR125487, a 5-HT4-receptor antagonist. Furthermore, intraperitoneal administration of 600 and 900 mg/kg LD02GIFRO significantly reduced VMR to CRD in acute and chronic colorectal hypersensitive rat models, induced by acetic acid and trinitrobenzenesulfonic acid, to almost normal levels (P<0.01). In the present study, LD02GIFRO successfully ameliorated delayed GIT models and colorectal hypersensitivity models, suggesting that LD02GIFRO may be an effective therapeutic treatment for patients with functional gastrointestinal disorders and abnormalities in GIT.
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Elsenbruch S, Enck P. Psychobiologische Mechanismen bei der Pathophysiologie chronischer viszeraler Schmerzen. Schmerz 2016; 30:407-411. [DOI: 10.1007/s00482-016-0130-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Palsson OS. Hypnosis Treatment of Gastrointestinal Disorders: A Comprehensive Review of the Empirical Evidence. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2015; 58:134-58. [PMID: 26264539 DOI: 10.1080/00029157.2015.1039114] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hypnotherapy has been investigated for 30 years as a treatment for gastrointestinal (GI) disorders. There are presently 35 studies in the published empirical literature, including 17 randomized controlled trials (RCTs) that have assessed clinical outcomes of such treatment. This body of research is reviewed comprehensively in this article. Twenty-four of the studies have tested hypnotherapy for adult irritable bowel syndrome (IBS) and 5 have focused on IBS or abdominal pain in children. All IBS hypnotherapy studies have reported significant improvement in gastrointestinal symptoms, and 7 out of 10 RCTs in adults and all 3 RCTs in pediatric patient samples found superior outcomes for hypnosis compared to control groups. Collectively this body of research shows unequivocally that for both adults and children with IBS, hypnosis treatment is highly efficacious in reducing bowel symptoms and can offer lasting and substantial symptom relief for a large proportion of patients who do not respond adequately to usual medical treatment approaches. For other GI disorders the evidence is more limited, but preliminary indications of therapeutic potential can be seen in the single randomized controlled trials published to date on hypnotherapy for functional dyspepsia, functional chest pain, and ulcerative colitis. Further controlled hypnotherapy trials in those three disorders should be a high priority. The mechanisms underlying the impact of hypnosis on GI problems are still unclear, but findings from a number of studies suggest that they involve both modulation of gut functioning and changes in the brain's handling of sensory signals from the GI tract.
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Szigethy E. Hypnotherapy for Inflammatory Bowel Disease Across the Lifespan. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2015; 58:81-99. [PMID: 26046718 DOI: 10.1080/00029157.2015.1040112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inflammatory bowel disease (IBD) is an autoimmune disorder characterized by lifelong relapsing gastrointestinal symptoms and associated with high rates of chronic pain, depression, and anxiety. In this review the author covers the existing literature including randomized controlled studies, open trials, and case reports as well as expert opinion in evaluating how hypnotherapy can be most beneficial in adolescents and adults with IBD. Hypnotherapy evidence for functional gastrointestinal disorders (FGIDs) is also reviewed as many of the gut-focused hypnotherapy (GHT) approaches used in IBD trials were developed for this latter population. Collectively, the strongest evidence of use of hypnotherapy is its association with reduced IBD-related inflammation and improved health-related quality of life with mixed results in terms of its effects on psychological and pain outcomes in adults with IBD. Studies of hypnotherapy for FGID symptoms show consistently more positive results. Post-operative hypnotherapy may also be helpful based on findings in other surgical samples. Adolescents with IBD have not been as systematically studied but small case series support the use of hypnotherapy to improve inflammation and pain. Future studies are needed to better delineate the specific brain-gut pathways which are most influenced by hypnotherapy in the IBD population and to investigate the longer-term course of the positive short-term findings.
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Wong RK, Van Oudenhove L, Li X, Cao Y, Ho KY, Wilder-Smith CH. Visceral pain perception in patients with irritable bowel syndrome and healthy volunteers is affected by the MRI scanner environment. United European Gastroenterol J 2015; 4:132-41. [PMID: 26966533 DOI: 10.1177/2050640615580888] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/16/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The MRI scanner environment induces marked psychological effects, but specific effects on pain perception and processing are unknown and relevant to all brain imaging studies. OBJECTIVES AND METHODS We performed visceral and somatic quantitative sensory and pain testing and studied endogenous pain modulation by heterotopic stimulation outside and inside the functional MRI scanner in 11 healthy controls and 13 patients with irritable bowel syndrome. RESULTS Rectal pain intensity (VAS 0-100) during identical distension pressures increased from 39 (95% confidence interval: 35-42) outside the scanner to 53 (43-63) inside the scanner in irritable bowel syndrome, and from 42 (31-52) to 49 (39-58), respectively, in controls (ANOVA for scanner effect: p = 0.006, group effect: p = 0.92). The difference in rectal pain outside versus inside correlated significantly with stress (r = -0.76, p = 0.006), anxiety (r = -0.68, p = 0.02) and depression scores (r = -0.67, p = 0.02) in controls, but not in irritable bowel syndrome patients, who a priori had significantly higher stress and anxiety scores. ANOVA analysis showed trends for effect of the scanner environment and subject group on endogenous pain modulation (p = 0.09 and p = 0.1, respectively), but not on somatic pain (p > 0.3). CONCLUSION The scanner environment significantly increased visceral, but not somatic, pain perception in irritable bowel syndrome patients and healthy controls in a protocol specifically aimed at investigating visceral pain. Psychological factors, including anxiety and stress, are the likely underlying causes, whereas classic endogenous pain modulation pathways activated by heterotopic stimulation play a lesser role. These results are highly relevant to a wide range of imaging applications and need to be taken into account in future pain research. Further controlled studies are indicated to clarify these findings.
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Affiliation(s)
- Reuben K Wong
- Neurogastroenterology Unit, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Medicine, University Medical Cluster, National University Health System, Singapore
| | - Lukas Van Oudenhove
- Translational Research Centre for Gastrointestinal Disorders, University of Leuven, Leuven, Belgium
| | - Xinhua Li
- Neurogastroenterology Unit, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yang Cao
- Neurogastroenterology Unit, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Khek Yu Ho
- Neurogastroenterology Unit, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Medicine, University Medical Cluster, National University Health System, Singapore
| | - Clive H Wilder-Smith
- Neurogastroenterology Unit, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Brain-Gut Research Group, Gastroenterology Group Practice, Bern, Switzerland
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Foley A, Burgell R, Barrett JS, Gibson PR. Management Strategies for Abdominal Bloating and Distension. Gastroenterol Hepatol (N Y) 2014; 10:561-571. [PMID: 27551250 PMCID: PMC4991532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Bloating and distension are among the most common gastrointestinal complaints reported by patients with functional gut disorders and by the general population. These 2 complaints are also among the most prevalent of the severe symptoms reported by patients with irritable bowel syndrome. Nonetheless, only a limited number of published studies have specifically addressed bloating; it is infrequently studied as a primary endpoint, and what little systematic information exists has often been garnered from the assessment of secondary endpoints or the dissection of composite endpoints. This lack of data, and our consequent limited understanding of the pathophysiology of bloating, had hampered the quest for effective and targeted therapies until recently. Advances in the knowledge of underlying mechanisms, particularly with regard to the roles of diet, poorly absorbed fermentable carbohydrates, dysbiosis of the gut bacteria, alterations in visceral hypersensitivity, and abnormal viscerosomatic reflexes, have enabled the development of improved treatment options. The most significant recent advance has been a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which significantly reduces patients' symptoms and improves quality of life. Given the prevalence of bloating and its perceived severity, it is clear that further studies regarding the pathogenesis and treatment of this problem are needed.
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Affiliation(s)
- Anna Foley
- Dr Foley and Dr Burgell are gastroenterologists, Dr Barrett is a dietitian, and Dr Gibson is a professor and the director of the Department of Gastroenterology at Monash University and Alfred Hospital in Melbourne, Victoria, Australia
| | - Rebecca Burgell
- Dr Foley and Dr Burgell are gastroenterologists, Dr Barrett is a dietitian, and Dr Gibson is a professor and the director of the Department of Gastroenterology at Monash University and Alfred Hospital in Melbourne, Victoria, Australia
| | - Jacqueline S Barrett
- Dr Foley and Dr Burgell are gastroenterologists, Dr Barrett is a dietitian, and Dr Gibson is a professor and the director of the Department of Gastroenterology at Monash University and Alfred Hospital in Melbourne, Victoria, Australia
| | - Peter R Gibson
- Dr Foley and Dr Burgell are gastroenterologists, Dr Barrett is a dietitian, and Dr Gibson is a professor and the director of the Department of Gastroenterology at Monash University and Alfred Hospital in Melbourne, Victoria, Australia
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22
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Stasi C, Rosselli M, Bellini M, Laffi G, Milani S. Altered neuro-endocrine-immune pathways in the irritable bowel syndrome: the top-down and the bottom-up model. J Gastroenterol 2012; 47:1177-85. [PMID: 22766747 DOI: 10.1007/s00535-012-0627-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 06/04/2012] [Indexed: 02/06/2023]
Abstract
The interaction between the brain and the gut as a pathological mechanism of functional gastrointestinal disorders has been recently recognized in the pathophysiology of the irritable bowel syndrome. Communication between central nervous system and enteric nervous system is two-directional: the brain can influence the function of the enteric nervous system and the gut can influence the brain via vagal and sympathetic afferents. In patients with irritable bowel syndrome, symptoms may be caused by alterations either primarily in the central nervous system (top-down model), or in the gut (bottom-up model), or in a combination of both. The brain-gut axis may be stimulated by various stressors either directed to the central nervous system (exteroreceptive stress) or to the gut (interoceptive stress). Particularly, clinical evidence suggest that in complex and multifactorial diseases such as irritable bowel syndrome, psychological disorders represent significant factors in the pathogenesis and course of the syndrome. Neuroimaging techniques have shown functional differences between central process in healthy subjects and patients with irritable bowel syndrome. Moreover, a high prevalence of psychological/psychiatric disorders have been reported in IBS patients compared to controls. Several data also suggest an alteration of neuro-endocrine and autonomic output to the periphery in these patients. This review will examine and discuss the complex interplay of neuro-endocrine-immune pathways, closely associated with neuropsychiatric disorders.
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Affiliation(s)
- Cristina Stasi
- Dipartimento di Medicina Interna, University of Florence, Viale GB Morgagni, 85, 50134 Florence, Italy.
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Kraft D. Comment on Zimmerman's use of the river metaphor in irritable bowel syndrome treatment. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2012. [PMID: 23189520 DOI: 10.1080/00029157.2012.658531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The river approach has been used effectively in the treatment of irritable bowel syndrome within the U.K. National Health Service (Gonsalkorale, Houghton, & Whorwell, 2002; Whorwell, 2006) and in single case studies (Galovski & Blanchard, 2002; Zimmerman, 2003; Kraft & Kraft, 2007). Zimmerman (2003) pointed out that this metaphor was extremely powerful in that it linked the altered motility of the digestive system to an emotional disturbance: by encouraging his patient to imagine a smooth flowing river, he helped her to come to terms with her emotional conflict and, in turn, to experience normal gut activity. The author reviews this approach to treatment and offers an alternative which utilizes process suggestions, accessing questions and truisms while providing clients with the space to imagine their own tailor-made scene.
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Verdejo-Garcia A, Clark L, Dunn BD. The role of interoception in addiction: A critical review. Neurosci Biobehav Rev 2012; 36:1857-69. [DOI: 10.1016/j.neubiorev.2012.05.007] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 05/13/2012] [Accepted: 05/21/2012] [Indexed: 10/28/2022]
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Hattori T, Watanabe S, Kano M, Kanazawa M, Fukudo S. Differential responding of autonomic function to histamine H₁ antagonism in irritable bowel syndrome. Neurogastroenterol Motil 2010; 22:1284-91, e335. [PMID: 20667004 DOI: 10.1111/j.1365-2982.2010.01568.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of histamine in the pathophysiology of irritable bowel syndrome (IBS) is largely unknown. Dysfunction of the autonomic nervous system (ANS) in IBS patients is also not fully confirmed. We hypothesized that blockade of histamine H₁ receptors affects ANS responses differently between IBS subjects and controls. METHODS Subjects were 12 IBS subjects and 12 age- and sex-matched controls. Either 100 μg kg⁻¹ chlorphenamine or the same amount of saline was administered on different days. The rectum was stimulated with electrical currents of 0 mA (sham) or 30 mA. Autonomic nervous system function was measured using mean arterial pressure (MAP), heart rate (HR), high frequency (HF) component of HR variability, low frequency/high frequency ratio (LF/HF ratio) and plasma catecholamines and histamine. Subjective perceived stress during the examination was evaluated on an ordinate scale. KEY RESULTS Mean arterial pressure showed significant effects of diagnosis (P < 0.05) and drug × diagnosis interaction (P < 0.05). The MAP significantly increased after chlorphenamine administration in IBS subjects, but not in controls. Heart rate revealed a significant drug effect (P < 0.001), which decreased after chlorphenamine administration in controls, but not in IBS subjects. Perceived stress significantly increased by rectal stimulation (P < 0.001) and a significant stimulus × diagnosis interaction (P < 0.05) was revealed, indicating greater reduction in IBS subjects by chlorphenamine. CONCLUSION & INFERENCES Sympathetic vasomotor tone in IBS subjects differentially responded on administration of a histamine H₁ antagonist to that of controls. These findings suggest an increased histaminergic activity in IBS subjects.
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Affiliation(s)
- T Hattori
- Department of Behavioral Medicine, Tohoku University Graduate School of Medicine, Aoba, Sendai, Japan
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Elsenbruch S, Rosenberger C, Bingel U, Forsting M, Schedlowski M, Gizewski ER. Patients with irritable bowel syndrome have altered emotional modulation of neural responses to visceral stimuli. Gastroenterology 2010; 139:1310-9. [PMID: 20600024 DOI: 10.1053/j.gastro.2010.06.054] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 05/18/2010] [Accepted: 06/16/2010] [Indexed: 12/29/2022]
Abstract
BACKGROUND & AIMS In patients with irritable bowel syndrome (IBS), pain amplification and hypervigilance might result from altered affective-motivational modulation of the pain response. We investigated the effects of emotional context on the behavioral and neural response to visceral stimuli in IBS patients. METHODS We used functional magnetic resonance imaging (fMRI) to assess the blood oxygen level-dependent response to nonpainful and painful rectal distensions in 15 female IBS patients and 12 healthy women. Distensions were delivered during psychologic stress or relaxation; data were compared with those in a neutral condition (control). Group and context-dependent differences in the processing of visceral stimulation were assessed at behavioral and the neuronal levels. Secondary analyses of group differences were performed using anxiety scores as a covariate because of higher anxiety symptoms among patients with IBS. RESULTS During rectal stimulation, IBS patients demonstrated more pronounced stress-induced modulation of neural activation in multiple brain regions, including the insula, midcingulate cortex, and ventrolateral prefrontal cortex. In response to relaxation, IBS patients demonstrated reduced modulation of distension-induced activation in the insula. During relaxation, the difference observed between groups could be accounted for by higher anxiety symptoms in patients with IBS; differential effects of stress in the insula and prefrontal regions were not attributable to anxiety. CONCLUSIONS IBS patients appear to have disrupted emotional modulation of neural responses to visceral stimuli, possibly reflecting the neural basis for altered visceral interoception by stress and negative emotions.
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Affiliation(s)
- Sigrid Elsenbruch
- Institute of Medical Psychology and Behavioral Immunobiology, University Clinic of Essen, University of Duisburg-Essen, Essen, Germany.
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Rectal visceral sensitivity in women with irritable bowel syndrome without psychiatric comorbidity compared with healthy volunteers. Gastroenterol Res Pract 2009; 2009:130684. [PMID: 19789637 PMCID: PMC2748192 DOI: 10.1155/2009/130684] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 06/16/2009] [Accepted: 06/24/2009] [Indexed: 12/31/2022] Open
Abstract
Background. Psychiatric comorbidity and visceral hypersensitivity are common in patients with irritable bowel syndrome (IBS), but little is known about visceral sensitivity in IBS patients without psychiatric disorders.
Aim. We wanted to examine rectal visceral sensitivity in IBS patients without comorbid psychiatric disorders, IBS patients with phobic anxiety and healthy volunteers.
Methods. A total of thirty-eight female, non-constipated IBS patients without psychiatric disorders and eleven female IBS patients with phobic anxiety were compared to nine healthy women using a barostat double random staircase method. The non-psychiatric patients were divided into those with diarrhoea predominant symptoms and those with alternating stool habits.
Results. The IBS patients without psychiatric disorders had normal visceral pressure thresholds. However, in the diarrhoea predominant subgroup, the volume discomfort threshold was reduced while it was unchanged in those with alternating stool habits. The phobic IBS patients had similar thresholds to the healthy volunteers. The rectal tone was increased in the non-psychiatric IBS patients with diarrhoea predominant symptoms and in the IBS patients with phobic anxiety.
Conclusions. Non-constipated IBS patients without psychiatric disorders had increased visceral sensitivity regarding volume thresholds but normal pressure thresholds. Our study suggests that the lowered volume threshold was due to increased rectal tone.
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Heitkemper MM, Jarrett ME. Update on irritable bowel syndrome and gender differences. Nutr Clin Pract 2008; 23:275-83. [PMID: 18595860 DOI: 10.1177/0884533608318672] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Irritable bowel syndrome (IBS) is a chronic functional GI disorder characterized by abdominal pain associated with alterations in defecation or stool frequency and consistency. In Western industrialized countries, women seek health care services for their symptoms more frequently than men. The cause of IBS is likely multifactorial involving altered motility, visceral hypersensitivity, and dysregulation of the autonomic nervous system. Many patients note that their symptoms are exacerbated by diet and stress, and women frequently report menstrual cycle fluctuations in symptoms. Current approaches to IBS management include behavioral management therapies such as dietary intake changes and stress reduction cognitive restructuring. Drug therapies are targeted at altering pain sensitivity, motility, and secretion. This review provides an overview of the pathogenesis of IBS, factors that contribute to gender differences, and current therapeutic approaches for symptom management.
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Affiliation(s)
- Margaret M Heitkemper
- Department of Biobehavioral Nursing, University of Washington, Seattle, WA 98195, USA.
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Flammer E, Alladin A. The efficacy of hypnotherapy in the treatment of psychosomatic disorders: meta-analytical evidence. Int J Clin Exp Hypn 2007; 55:251-74. [PMID: 17558717 DOI: 10.1080/00207140701338696] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hypnotherapy is claimed to be effective in treatment of psychosomatic disorders. A meta-analysis was conducted with 21 randomized, controlled clinical studies to evaluate efficacy of hypnosis in psychosomatic disorders. Studies compared patients exclusively treated with hypnotherapy to untreated controls. Studies providing adjunctive standard medical care in either treatment condition were also admitted. Hypnotherapy was categorized into classic (n = 9), mixed form (n = 5), and modern (n = 3). Results showed the weighted mean effect size for 21 studies was d(+) = .61 (p = .0000). ANOVA revealed significant differences between classic, mixed, and modern hypnosis. Regression of outcome on treatment dose failed to show a significant relationship. Numerical values for correlation between suggestibility and outcome were only reported in three studies (mean r = .31). The meta-analysis clearly indicates hypnotherapy is highly effective in treatment of psychosomatic disorders.
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Affiliation(s)
- Erich Flammer
- Constance University, Department of Psychology, Konstanz, Germany.
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Paré P, Bridges R, Champion MC, Ganguli SC, Gray JR, Irvine EJ, Plourde V, Poitras P, Turnbull GK, Moayyedi P, Flook N, Collins SM. Recommendations on chronic constipation (including constipation associated with irritable bowel syndrome) treatment. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21 Suppl B:3B-22B. [PMID: 17464377 PMCID: PMC2794454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Accepted: 03/05/2007] [Indexed: 05/15/2023]
Abstract
While chronic constipation (CC) has a high prevalence in primary care, there are no existing treatment recommendations to guide health care professionals. To address this, a consensus group of 10 gastroenterologists was formed to develop treatment recommendations. Although constipation may occur as a result of organic disease, the present paper addresses only the management of primary CC or constipation associated with irritable bowel syndrome. The final consensus group was assembled and the recommendations were created following the exact process outlined by the Canadian Association of Gastroenterology for the following areas: epidemiology, quality of life and threshold for treatment; definitions and diagnostic criteria; lifestyle changes; bulking agents and stool softeners; osmotic agents; prokinetics; stimulant laxatives; suppositories; enemas; other drugs; biofeedback and behavioural approaches; surgery; and probiotics. A treatment algorithm was developed by the group for CC and constipation associated with irritable bowel syndrome. Where possible, an evidence-based approach and expert opinions were used to develop the statements in areas with insufficient evidence. The nature of the underlying pathophysiology for constipation is often unclear, and it can be tricky for physicians to decide on an appropriate treatment strategy for the individual patient. The myriad of treatment options available to Canadian physicians can be confusing; thus, the main aim of the recommendations and treatment algorithm is to optimize the approach in clinical care based on available evidence.
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Affiliation(s)
- P Paré
- Université Laval and CHAUQ-Hôpital St-Sacrement, Quebec City, Canada.
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31
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Howell RT, Kern ML, Lyubomirsky S. Health benefits: Meta-analytically determining the impact of well-being on objective health outcomes. Health Psychol Rev 2007. [DOI: 10.1080/17437190701492486] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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32
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Ohman L, Simrén M. New insights into the pathogenesis and pathophysiology of irritable bowel syndrome. Dig Liver Dis 2007; 39:201-15. [PMID: 17267314 DOI: 10.1016/j.dld.2006.10.014] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2006] [Revised: 10/20/2006] [Accepted: 10/25/2006] [Indexed: 02/08/2023]
Abstract
The pathogenesis and pathophysiology of irritable bowel syndrome is complex and still incompletely known. Potential pathogenetic factors include genes, infectious events, psychological symptoms and other loosely defined environmental factors. Both alterations at the central and peripheral level are thought to contribute to the symptoms of irritable bowel syndrome, including psychosocial factors, abnormal gastrointestinal motility and secretion, and visceral hypersensitivity. Today irritable bowel syndrome is viewed upon as a disorder of dysregulation of the so-called brain-gut axis, involving abnormal function in the enteric, autonomic and/or central nervous systems, with peripheral abnormalities probably dominating in some patients and disturbed central processing of signals from the periphery in others. Lines of evidence also suggest that inflammation within the gastrointestinal tract may be of great importance in at least subgroups of irritable bowel syndrome patients. To conclude, a complex picture of the pathogenesis and pathophysiology of irritable bowel syndrome is emerging, with interactions between several different alterations resulting in the divergent symptom pattern in these patients.
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Affiliation(s)
- L Ohman
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Elsenbruch S, Lucas A, Holtmann G, Haag S, Gerken G, Riemenschneider N, Langhorst J, Kavelaars A, Heijnen CJ, Schedlowski M. Public speaking stress-induced neuroendocrine responses and circulating immune cell redistribution in irritable bowel syndrome. Am J Gastroenterol 2006; 101:2300-7. [PMID: 16952284 DOI: 10.1111/j.1572-0241.2006.00837.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Augmented neuroendocrine stress responses and altered immune functions may play a role in the manifestation of functional gastrointestinal (GI) disorders. We tested the hypothesis that IBS patients would demonstrate enhanced psychological and endocrine responses, as well as altered stress-induced redistribution of circulating leukocytes and lymphocytes, in response to an acute psychosocial stressor when compared with healthy controls. METHODS Responses to public speaking stress were analyzed in N = 17 IBS patients without concurrent psychiatric conditions and N = 12 healthy controls. At baseline, immediately following public speaking, and after a recovery period, state anxiety, acute GI symptoms, cardiovascular responses, serum cortisol and plasma adrenocorticotropic hormone (ACTH) were measured, and numbers of circulating leukocytes and lymphocyte subpopulations were analyzed by flow cytometry. RESULTS Public speaking led to significant cardiovascular activation, a significant increase in ACTH, and a redistribution of circulating leukocytes and lymphocyte subpopulations, including significant increases in natural killer cells and cytotoxic/suppressor T cells. IBS patients demonstrated significantly greater state anxiety both at baseline and following public speaking. However, cardiovascular and endocrine responses, as well as the redistribution of circulating leukocytes and lymphocyte subpopulations after public speaking stress, did not differ for IBS patients compared with controls. CONCLUSIONS In IBS patients without psychiatric comorbidity, the endocrine response as well as the circulation pattern of leukocyte subpopulations to acute psychosocial stress do not differ from healthy controls in spite of enhanced emotional responses. Future studies should discern the role of psychopathology in psychological and biological stress responses in IBS.
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Affiliation(s)
- Sigrid Elsenbruch
- Department of Medical Psychology, University Hospital of Essen Medical School, Essen, Germany
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34
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Miranda A, Sood M. Treatment options for chronic abdominal pain in children and adolescents. ACTA ACUST UNITED AC 2006; 9:409-15. [PMID: 16942666 DOI: 10.1007/bf02738530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic abdominal pain is a common feature of most functional gastrointestinal disorders in children, including functional abdominal pain (FAP) and irritable bowel syndrome (IBS). FAP can impair a child's life and often leads to significant school absences. Although the underlying mechanism is likely multifactorial, early pain experiences during a vulnerable period in the developing nervous system can cause long-term changes in the brain-gut axis and ultimately may result in altered pain pathways and visceral hyperalgesia. Care providers often feel uncomfortable managing patients with chronic abdominal pain, as the pathophysiology is poorly understood, and limited data exist regarding safety and efficacy of therapeutic options in children. The primary goal of therapy in FAP is to alleviate pain symptoms and to help the child return to normal daily activities. Treatment should be individualized and chosen based on the severity of symptoms, the existence of comorbid psychological disorders, and the impact the disorder has on the child's school attendance and normal functioning. Various psychological interventions, such as cognitive-behavioral therapy, hypnosis, and guided imagery, have been successfully used in children with chronic abdominal pain. Pharmacologic therapies such as H(2) blockers, proton-pump inhibitors, tricyclic antidepressants, and various serotonergic drugs have been used, but good controlled trials are lacking. More studies are clearly needed to investigate the benefits and safety of pharmacologic therapy in children. Newer pharmacologic agents that target specific receptors involved in nociception, stress, and neurogenic inflammation currently are being developed. Future targets for visceral hyperalgesia should not only be aimed at alleviating symptoms but also should include prevention, particularly in cases with a suspected sensitizing event such as neonatal pain and postinfectious IBS.
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Affiliation(s)
- Adrian Miranda
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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35
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Abstract
This review highlights consistent patterns in the literature associating positive affect (PA) and physical health. However, it also raises serious conceptual and methodological reservations. Evidence suggests an association of trait PA and lower morbidity and of state and trait PA and decreased symptoms and pain. Trait PA is also associated with increased longevity among older community-dwelling individuals. The literature on PA and surviving serious illness is inconsistent. Experimentally inducing intense bouts of activated state PA triggers short-term rises in physiological arousal and associated (potentially harmful) effects on immune, cardiovascular, and pulmonary function. However, arousing effects of state PA are not generally found in naturalistic ambulatory studies in which bouts of PA are typically less intense and often associated with health protective responses. A theoretical framework to guide further study is proposed.
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Affiliation(s)
| | - Sheldon Cohen
- Department of Psychology, Carnegie Mellon University
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Abstract
BACKGROUND No data are available on the effect of hypnosis on gastric emptying. AIM To determine the effect of a hypnosis session on gastric emptying and dyspeptic symptoms. METHODS We studied emptying by ultrasonography and epigastric sensations in 11 healthy subjects and in 15 patients affected by functional dyspepsia under three conditions according to a fixed schedule: (a) basal, (b) after cisapride and (c) during a 90 min hypnotic trance. Eight healthy subjects repeated an emptying study listening to relaxing music. Statistical analysis was performed using the Friedman test or RM-ANOVA. RESULTS In dyspeptics, the postprandial increase in the antral area was significantly smaller during the hypnosis trance than under the basal and the cisapride conditions. For the patients gastric emptying was significantly shortened by cisapride, and even more by hypnosis (basal 274 +/- 16.8 min; cisapride 227 +/- 13.2; hypnosis 150 +/- 9.7) whereas for healthy subjects it was shortened only by hypnosis. The repeated study in healthy subjects listening to relaxing music showed no significant difference compared with the basal. Epigastric sensations were improved in dyspeptics by hypnosis, but not by cisapride. CONCLUSIONS Gut-oriented hypnosis is effective in shortening gastric emptying both in dyspeptic and in healthy subjects.
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Affiliation(s)
- G Chiarioni
- Department of Gastroenterology, Rehabilitation Hospital of Valeggio s/M, University of Verona, Verona, Italy.
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37
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Abstract
Many future investigations into FGIDs are needed. These should focus on refining and validating the Rome diagnostic criteria, investigating possible biologic markers of these disorders, elucidating the role of the visceral afferent dysfunction or reflex motor responses that lead to symptoms, searching for new pathogenic factors (eg, corticotrophin-releasing factor), and evaluating therapies in prospective controlled trials. To tackle this challenging group of disorders successfully, there must be a broad collaboration among basic scientists, clinical investigators, physicians, psychologists, and practitioners of alternative and complementary medicine to develop and evaluate improved therapies. In the meantime, it is our duty as practitioners to keep updated and receptive to the needs of patients and families to reduce patient suffering, improve functioning, and control the costs to society.
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Affiliation(s)
- Miguel Saps
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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38
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Chang L, Mayer EA, Labus JS, Schmulson M, Lee OY, Olivas TI, Stains J, Naliboff BD. Effect of sex on perception of rectosigmoid stimuli in irritable bowel syndrome. Am J Physiol Regul Integr Comp Physiol 2006; 291:R277-84. [PMID: 16574882 DOI: 10.1152/ajpregu.00729.2005] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In irritable bowel syndrome (IBS) patients, the relationship between sex and sensitivity to visceral stimuli is incompletely understood. Our aim was to evaluate the effect of sex on perceptual responses to visceral stimulation in IBS. Fifty-eight IBS patients (mean age 42+/-1 yr; 34 men, 24 women) and 26 healthy controls (mean age 38+/-3 yr; 9 men, 17 women) underwent barostat-assisted distensions of the rectum and sigmoid colon. Rectal discomfort thresholds were measured using a randomized, phasic distension paradigm before and after repeated noxious sigmoid stimulation (SIG, 60-mmHg pulses). Sex had a significant effect on rectal discomfort thresholds. Women with IBS were the most sensitive (lower thresholds [27+/-2.7 mmHg] and higher ratings), with significantly lower rectal discomfort thresholds compared with men with IBS (38+/-2.3 mmHg) and healthy women who were the least sensitive (41.9+/-3.2 mmHg; both P<0.01). There were no significant differences in rectal discomfort thresholds between healthy men (34+/-4.3 mmHg) and men with IBS. Across both IBS and control groups, women demonstrated a significant lowering of discomfort thresholds after noxious sigmoid stimulation (P<0.01), while men did not. Sex significantly influences perceptual sensitivity to rectosigmoid distension. Women show greater perceptual responses to this paradigm.
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Affiliation(s)
- Lin Chang
- Center for Neurovisceral Sciences and Women's Health, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, and Veterans Affairs Greater Los Angeles Healthcare System, California 90073, USA.
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39
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Abstract
Irritable bowel syndrome (IBS) is a very common condition in the Western part of the world, and it accounts for a large proportion of the workload of a gastroenterologist. Unfortunately, the pathogenesis and pathophysiology of the syndrome are incompletely understood, and the treatment options are limited. However, hypnotherapy is one treatment option that has proven to be very useful in IBS. The mechanisms of action explaining why hypnosis is effective for IBS are not altogether known, but recent studies have shed some light on this issue. These studies, and what can be learned from them about how hypnosis impacts IBS, are reviewed in this article. Hypnosis may affect IBS partly through changes in colorectal sensitivity and improvement in psychological factors. The effects on GI motility and the autonomic nervous system are less clear and need further evaluation.
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Affiliation(s)
- Magnus Simrén
- Dept of Internal Medicine, Sahlgrenska University Hospital, Göteborg, Sweden.
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40
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Greenwood-Van Meerveld B, Venkova K, Hicks G, Dennis E, Crowell MD. Activation of peripheral 5-HT receptors attenuates colonic sensitivity to intraluminal distension. Neurogastroenterol Motil 2006; 18:76-86. [PMID: 16371086 DOI: 10.1111/j.1365-2982.2005.00723.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Tegaserod is a 5-HT(4) receptor partial agonist approved for the treatment of irritable bowel syndrome in women with constipation and in both men and women with chronic constipation. The efficacy of tegaserod is based on the importance of 5-HT(4) receptors regulating intestinal peristalsis and secretion, and possibly visceral sensory pathways. Our aim was to investigate the effect of tegaserod on colorectal sensitivity using models of normal and exaggerated responsiveness to colorectal distension (CRD). The visceromotor responses (VMR) to CRD at graded pressures (0-60 mmHg) were measured by the number of reflex abdominal contractions. Acute colorectal hypersensitivity was induced by intracolonic infusion of dilute acetic acid. Chronic hypersensitivity was observed in rats following spontaneous resolution of trinitrobenzenesulfonic acid-induced colitis. Rats with normosensitive colons served as controls. Tegaserod (0.1-10 mg kg(-1)) caused dose-dependent reduction of the VMR to CRD in control rats and in those with colonic hypersensitivity. 5-HT(4) antagonists reversed the effects of tegaserod in rats with normosensitive colons, and partially inhibited effects in rats with colonic hypersensitivity. Central administration of tegaserod had no inhibitory effect. These results support the assumption that colonic hypersensitivity could be normalized by tegaserod acting, at least in part, through peripheral 5-HT(4) receptors.
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Affiliation(s)
- B Greenwood-Van Meerveld
- Oklahoma Center for Neuroscience, University of Oklahoma Health Science Center, Oklahoma City, USA.
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41
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Harder H, Hernando-Harder AC, Franke A, Krammer HJ, Singer MV. Effect of high- and low-caloric mixed liquid meals on intestinal gas dynamics. Dig Dis Sci 2006; 51:140-6. [PMID: 16416227 DOI: 10.1007/s10620-006-3099-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2005] [Accepted: 02/24/2005] [Indexed: 12/12/2022]
Abstract
High-caloric meals can evoke postprandial abdominal complaints involving disturbances in intestinal gas balance. We aimed to determine the influence of the caloric content of meals on intestinal gas dynamics. Eight healthy subjects (five women, three men; age range, 25-43 years) underwent paired studies with low (1 kcal/min)- and high (3 kcal/min)-caloric meal infusion 35% fat, (45% carbohydrate, 20% protein) into the duodenum in random order and proximal jejunal gas infusion. Gas evacuation, perception, and abdominal girth were assessed. The low-caloric meal caused neither gas retention (-7 +/- 58 ml) nor girth changes (0 +/- 0 mm). In contrast, the high-caloric meal led to significant gas retention (705 +/- 56 ml) and increased abdominal perimeter (7 +/- 1 mm; P < 0.001 vs. the low-caloric meal for both). Thus, a high caloric load of nutrients arriving at the duodenum modulates both intestinal gas transit and abdominal perimeter.
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Affiliation(s)
- Hermann Harder
- Department of Medicine II (Gastroenterology, Hepatology and Infectious Diseases), University Hospital of Heidelberg at Mannheim, Mannheim, Germany.
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42
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Wilhelmsen I. Biological sensitisation and psychological amplification: gateways to subjective health complaints and somatoform disorders. Psychoneuroendocrinology 2005; 30:990-5. [PMID: 15963653 DOI: 10.1016/j.psyneuen.2005.01.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Accepted: 01/28/2005] [Indexed: 01/01/2023]
Abstract
Subjective health complaints without known physical pathology are common and might develop into somatoform disorders. Normalization of neuroticism and anxiety in patients with duodenal ulcer disease after a relapse-free state is acquired and maintained is an indication that biological factors influence psychological factors. Recent research has shown that psychological and behavioural changes, on the other hand, have the capacity to change the brain. Visceral hyperalgesia is an example of biological sensitisation, but the abnormal sensory perception can be normalised by hypnotherapy. The dual-etiology hypothesis of functional somatic syndromes implies that in some patients with somatoform disorders there is a predominant biological etiology, whereas in others there is a predominant psychological etiology. The theory is supported by recent research, and may result in better handling of patients. Cognitive factors like catastrofising amplifies subjective physical symptoms and emotions effect the perception of them. In preventive health care the following slogans are proposed as antidotes preventing subjective health complaints form developing into somatoform disorders: Do not listen to your body's signals! Do not trust your feelings! Do not trust your thoughts!
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Affiliation(s)
- Ingvard Wilhelmsen
- Institute of Medicine, University of Bergen, Haraldsplass Deaconal Hospital, 5009 Bergen, Norway.
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43
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Song GH, Leng PH, Gwee KA, Moochhala SM, Ho KY. Melatonin improves abdominal pain in irritable bowel syndrome patients who have sleep disturbances: a randomised, double blind, placebo controlled study. Gut 2005; 54:1402-7. [PMID: 15914575 PMCID: PMC1774717 DOI: 10.1136/gut.2004.062034] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 03/13/2005] [Accepted: 03/22/2005] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Melatonin, a sleep promoting agent, is involved in the regulation of gastrointestinal motility and sensation. We aimed to determine if melatonin was effective in improving bowel symptoms and sleep disturbances in irritable bowel syndrome (IBS) patients with sleep disturbance. METHODS Forty IBS patients (aged 20-64 years; 24 female) with sleep disturbances were randomly assigned to receive either melatonin 3 mg (n = 20) or matching placebo (n = 20) at bedtime for two weeks. Immediately before and after the treatment, subjects completed bowel, sleep, and psychological questionnaires, and underwent rectal manometry and overnight polysomnography. RESULTS Compared with placebo, melatonin taken for two weeks significantly decreased mean abdominal pain score (2.35 v 0.70; p<0.001) and increased mean rectal pain threshold (8.9 v -1.2 mm Hg; p<0.01). Bloating, stool type, stool frequency, and anxiety and depression scores did not significantly differ after treatment in both groups. Data from sleep questionnaires and polysomnography showed that the two week course of melatonin did not influence sleep parameters, including total sleep time, sleep latency, sleep efficiency, sleep onset latency, arousals, duration of stages 1-4, rapid eye movement (REM) sleep, and REM onset latency. CONCLUSIONS Administration of melatonin 3 mg at bedtime for two weeks significantly attenuated abdominal pain and reduced rectal pain sensitivity without improvements in sleep disturbance or psychological distress. The findings suggest that the beneficial effects of melatonin on abdominal pain in IBS patients with sleep disturbances are independent of its action on sleep disturbances or psychological profiles.
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Affiliation(s)
- G H Song
- Department of Medicine, National University of Singapore.
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44
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Noddin L, Callahan M, Lacy BE. Irritable bowel syndrome and functional dyspepsia: different diseases or a single disorder with different manifestations? MEDGENMED : MEDSCAPE GENERAL MEDICINE 2005; 7:17. [PMID: 16369243 PMCID: PMC1681633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Laura Noddin
- Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire, USA
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45
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Abstract
The most common symptoms associated with intestinal gas are eructation, flatulence, abdominal bloating, and distention. Aerophagia is an uncommon cause of eructation in which repetitive air swallowing results in belching, abdominal distention, and increased flatus. Few therapies have been shown to be effective in treating these symptoms. Eructation can be treated by decreasing excessive air swallowing. Occasionally, behavioral therapy and psychotherapy are employed. Bloating, distention, and other gas-related symptoms are common in functional gastrointestinal disorders; however, their pathophysiology is poorly understood. Additionally, evidence supporting the use of various available therapies in treating gas-related symptoms is either absent or poor. Dietary therapy may be effective in patients with excessive gas production. Excessive gas production, identified by increased flatus, may benefit from a low-carbohydrate diet. Many patients with gas-related symptoms have normal gas production but may have either impaired gas transport or transit through the gut or visceral hypersensitivity. Few studies have addressed the treatment of impaired gas transport.
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Affiliation(s)
- Michael P Jones
- Division of Gastroenterology, Northwestern University Feinberg School of Medicine, 251 East Huron Street, Galter Pavilion 4-104, Chicago, IL 60611-2908, USA.
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46
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Quigley EMM. Disturbances of motility and visceral hypersensitivity in irritable bowel syndrome: biological markers or epiphenomenon. Gastroenterol Clin North Am 2005; 34:221-33, vi. [PMID: 15862931 DOI: 10.1016/j.gtc.2005.02.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Motility and visceral hypersentitivity are regarded as the primary mechanisms of symptom development in irritable bowel syndrome(IBS). While a variety of motor abnormalities have been described throughout the gastrointestinal tract in IBS, their specificity and relationship to symptoms remain unclear. Visceral hypersensitivity is ubiquitous in functional gastrointestinal disease and is especially common in IBS. Again, however, its specificity for IBS has been questioned. Many factors, including stress and psychopathology,complicate the interpretation of these phenomena and new re-search suggests that mucosal inflammation and luminal factors may be more fundamental to the etiology of this common disorder.
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Affiliation(s)
- Eamonn M M Quigley
- Department of Medicine, Alimentary Pharmabiotic Centre, Cork University Hospital, Clinical Sciences Building, Cork, Ireland.
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47
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Gonlachanvit S, Rhee J, Sun WM, Chey WD. Effect of acute acoustic stress on anorectal function sensation in healthy human. Neurogastroenterol Motil 2005; 17:222-8. [PMID: 15810174 DOI: 10.1111/j.1365-2982.2004.00592.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Little is known about the effects of acute acoustic stress on anorectal function. To determine the effects of acute acoustic stress on anorectal function and sensation in healthy volunteers. Ten healthy volunteers (7 M, 3 F, mean age 34 +/- 3 years) underwent anorectal manometry, testing of rectal compliance and sensation using a barostat with and without acute noise stress on separate days. Rectal perception was assessed using an ascending method of limits protocol and a 5-point Likert scale. Arousal and anxiety status were evaluated using a visual analogue scale. Acoustic stress significantly increased anxiety score (P < 0.05). Rectal compliance was significantly decreased with acoustic stress compared with control P (P < 0.000001). In addition, less intraballoon volume was needed to induce the sensation of severe urgency with acoustic stress (P < 0.05). Acoustic stress had no effect on hemodynamic parameters, anal sphincter pressure, threshold for first sensation, sensation of stool, or pain. Acute acoustic stimulation increased anxiety scores, decreased rectal compliance, and enhanced perception of severe urgency to balloon distention but did not affect anal sphincter pressure in healthy volunteers. These results may offer insight into the pathogenesis of stress-in-induced diarrhoea and faecal urgency.
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Affiliation(s)
- S Gonlachanvit
- Division of Gastroenterology, Department of Internal Medicine, Chulalongkorn University, Bangkok, Thailand
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48
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Radin DI, Schlitz MJ. Gut feelings, intuition, and emotions: an exploratory study. J Altern Complement Med 2005; 11:85-91. [PMID: 15750366 DOI: 10.1089/acm.2005.11.85] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Investigate whether the gut feelings of one person, as measured with an electrogastrogram (EGG), respond to the emotions of a distant person. DESIGN In a double blind protocol, EGG activity was recorded in an individual relaxing in a heavily shielded chamber while, at a distance, a second person periodically viewed the live video image of the first person along with stimuli designed to evoke positive, negative, calming, or neutral emotions. SUBJECTS Twenty-six (26) pairs of healthy adult volunteers. OUTCOME MEASURES EGG maximum values recorded while the distant person was exposed to emotional stimuli were compared to similar values recorded during exposure to neutral stimuli. RESULTS EGG maximums were significantly larger on average when the distant person was experiencing positive (p = 0.006) and negative (p = 0.0009) emotions, as compared to neutral emotions. Nonparametric bootstrap procedures were employed to evaluate these differences, and the results survive correction for multiple analyses. CONCLUSIONS EGG activity increases in response to the emotions of a distant person, beyond the influence of ordinary sensory interactions. Relationships commonly reported between gut feelings and intuitive hunches may share a common, poorly understood, perceptive origin.
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Affiliation(s)
- Dean I Radin
- Institute of Noetic Sciences, Petaluma, CA 94952-9524, USA.
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49
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Tan G, Hammond DC, Joseph G. Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action. AMERICAN JOURNAL OF CLINICAL HYPNOSIS 2005; 47:161-78. [PMID: 15754863 DOI: 10.1080/00029157.2005.10401481] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Irritable bowel syndrome (IBS) is a functional gastrointestinal disorder characterized by abdominal pain, distension, and an altered bowel habit for which no cause can be found. Despite its prevalence, there remains a significant lack of efficacious medical treatments for IBS to date. In this paper we reviewed a total of 14 published studies (N=644) on the efficacy of hypnosis in treating IBS (8 with no control group and 6 with a control group). We concluded that hypnosis consistently produces significant results and improves the cardinal symptoms of IBS in the majority of patients, as well as positively affecting non-colonic symptoms. When evaluated according to the efficacy guidelines of the Clinical Psychology Division of American Psychological Association, the use of hypnosis with IBS qualifies for the highest level of acceptance as being both efficacious and specific. In reviewing the research on the mechanism of action as to how hypnosis works to reduce symptoms of IBS, some evidence was found to support both physiological and psychological mechanisms of action.
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Affiliation(s)
- Gabriel Tan
- Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, TX 77030, USA.
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50
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Lesbros-Pantoflickova D, Michetti P, Fried M, Beglinger C, Blum AL. Meta-analysis: The treatment of irritable bowel syndrome. Aliment Pharmacol Ther 2004; 20:1253-69. [PMID: 15606387 DOI: 10.1111/j.1365-2036.2004.02267.x] [Citation(s) in RCA: 124] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
To evaluate therapies available for the treatment of irritable bowel syndrome, and provide consensus recommendations for their use, a total of 51 double-blind clinical trials using bulking agents, prokinetics, antispasmodics, alosetron, tegaserod and antidepressants were selected. The quality of studies was assessed using 5-point scale. Meta-analyses were performed on all studies, and on 'high-quality studies'. The efficacy of fibre in the global irritable bowel syndrome symptoms relief (OR: 1.9; 95% CI:1.5-2.4) was lost after exclusion of low-quality trials (OR: 1.4; 95% CI: 1.0-2.0, P = 0.06). When excluding the low-quality trials, an improvement of global irritable bowel syndrome symptoms with all antispasmodics (OR: 2.1; 95% CI:1.8-2.9) was maintained only for octylonium bromide, but on the basis of only two studies. Antidepressants were effective (OR: 2.6, 95% CI: 1.9-3.5), even after exclusion of low-quality studies (OR: 1.9, 95% CI: 1.3-2.7). Alosetron (OR: 2.2; 95% CI: 1.9-2.6) and tegaserod (OR: 1.4; 95% CI: 1.2-1.5) showed a significant effect in women. We recommend the use of tegaserod for women with irritable bowel syndrome with constipation and alosetron for women with severe irritable bowel syndrome with diarrhoea. Antidepressants can be beneficial for irritable bowel syndrome with diarrhoea patients with severe symptoms. Loperamide can be recommended in painless diarrhoea. Evidence is weak to recommend the use of bulking agents in the treatment of irritable bowel syndrome with constipation.
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