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

Effects on gastrointestinal transit and antroduodenojejunal manometry after gut-directed hypnotherapy in irritable bowel syndrome (IBS)

BACKGROUND

Gut-directed hypnotherapy is an effective treatment in irritable bowel syndrome (IBS) but little is known about the mechanisms of action. In this study we aimed to investigate the effects on gastrointestinal motility when treating IBS with gut-directed hypnotherapy.

METHODS

We randomized 90 patients with IBS, refractory to standard management to receive gut-directed hypnotherapy 1 h/week for 12 weeks or supportive treatment for the same time period. Eighty-one subjects (40 hypnotherapy, 41 controls) could be evaluated by one or more of the following investigations, both before and after the intervention: gastric emptying time, small bowel transit time, colonic transit time, and antroduodenojejunal manometry.

RESULTS

No significant differences in gastric emptying time, small bowel transit time, or colonic transit time was found when comparing the baseline and post-intervention measurements in the hypnotherapy group or in the control group. The same was true concerning the results of the antroduodenojejunal manometry. However, there was a numerical trend toward a higher number of migrating motor complexes at manometry and an accelerated gastric emptying time after hypnotherapy that did not reach statistical significance.

CONCLUSIONS

In this study, we were not able to find evidence for long-standing effects on gastrointestinal motility as a mediator of the effects on IBS when treating the condition with gut-directed hypnotherapy. Further research to understand the mechanism of action is needed.

Anxiety and depression in various functional gastrointestinal disorders: do differences exist?

OBJECTIVE

To examine the differences in the prevalence and severity of anxiety and depression in patients with functional dyspepsia (FD), nonerosive reflux disease (NERD), irritable bowel syndrome (IBS) and healthy controls.

METHODS

Consecutive patients undergoing an index endoscopic examination for various symptoms were interviewed. All the three functional gastrointestinal disorders (FGIDs) were diagnosed according to the Rome III criteria. Anxiety and depression were diagnosed using a locally validated version of the hospital anxiety and depression scale.

RESULTS

A total of 248 patients were recruited (62 in FD, NERD, IBS and control groups each) with no differences in the basic characteristics. There was a higher prevalence of anxiety and depression in FD, NERD and IBS groups than that in the control group (43.5%, 45.2% and 67.7% vs 14.5%, P<0.001; and 22.6%, 33.9% and 38.7% vs 6.5%, P<0.0001). Using the cut-off score (>8) for anxiety or depression, IBS patients had a higher rate of anxiety than FD (P=0.01) and NERD (P=0.02), while no significant differences in depression rates were observed among all three groups.

CONCLUSION

[corrected] Anxiety is more common in patients with IBS than in those with FD and NERD, indicating a possible causal link in the former.

Gut memories: towards a cognitive neurobiology of irritable bowel syndrome

The brain and the gut are engaged in continual crosstalk along a number of pathways collectively termed the 'brain-gut axis'. Over recent years it has become increasingly clear that dysregulation of the axis at a number of levels can result in disorders such as irritable bowel syndrome (IBS). With recent advances in neuroimaging technologies, insights into the neurobiology of IBS are beginning to emerge. However the cognitive neurobiology of IBS has remained relatively unexplored to date. In this review we summarise the available data on cognitive function in IBS. Moreover, we specifically address three key pathophysiological factors, namely; stress, immune activation and chronic pain, together with other factors involved in the manifestation of IBS, and explore how each of these components may impact centrally, what neurobiological mechanisms might be involved, and consider the implications for cognitive functioning in IBS. We conclude that each factor addressed could significantly impinge on central nervous system function, supporting the view that future research efforts must be directed towards a detailed assessment of cognitive function in IBS.

Hypnosis for functional abdominal pain

Chronic abdominal pain is a common pediatric condition affecting 20% of the pediatric population worldwide. Most children with this disorder are found to have no specific organic etiology and are given the diagnosis of functional abdominal pain. Well-designed clinical trials have found hypnotherapy and guided imagery to be the most efficacious treatments for this condition. Hypnotic techniques used for other somatic symptoms are easily adaptable for use with functional abdominal pain. The author discusses 2 contrasting hypnotic approaches to functional abdominal pain and provides implications for further research. These approaches may provide new insights into this common and complex disorder.

Visceral hypersensitivity in irritable bowel syndrome

Altered central processing, abnormal gastrointestinal motility and visceral hypersensitivity may be possible major pathophysiology of irritable bowel syndrome (IBS). These factors affect each other and are probably associated with development of IBS symptoms. It has been confirmed that lower pain threshold to colonic distention was observed in most of patients with IBS than healthy subjects. We have investigated pain perception of the descending colon among different subtypes of IBS. There was no difference in pain threshold to colonic distention between IBS with diarrhea and constipation. Some brain regions such as the anterior cingulate cortex (ACC) may play a major role for generating pain and/or pain-related emotion in humans. IBS patients showed greater activation in the perigenual ACC during painful rectal distention compared with healthy subjects. Inflammation, stress and the combination of both stimuli can induce significant increase in visceral sensitivity in animal models. Serotonin (5-HT) can modulate visceral perception. It has been thought that 5-HT(3) receptors may play an important role for conveying visceral sensation from the gut. Corticotropin-releasing hormone (CRH) may also modulate visceral pain hypersensitivity in IBS. CRH receptor-1 antagonist significantly prevented an increase in gut sensitivity in rats. It has been demonstrated that non-specific CRH receptor antagonist α-helical CRH significantly reduced abdominal pain score during gut stimulus in patients with IBS. In conclusion, visceral hypersensitivity is common in IBS patients and probably plays a major role in development of the symptoms and both central and peripheral factors may enhance the pain sensitivity.

Centrally acting therapies for irritable bowel syndrome

Irritable bowel syndrome (IBS) and other functional gastrointestinal (GI) disorders typically defy traditional diagnostic methods based on structural abnormalities, and has led to the emergence of the discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiological feature of IBS. Centrally acting treatments can influence these pathways and improve the clinical manifestations of pain and bowel dysfunction associated with this disorder. To successfully implement these treatment strategies, it is important to recognize their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

Effect of autogenic training on general improvement in patients with irritable bowel syndrome: a randomized controlled trial

Autogenic training (AT) is a useful and comprehensive relaxation technique. However, no studies have investigated the effects of AT on irritable bowel syndrome (IBS). In this study we tested the hypothesis that AT improves symptoms of IBS. Twenty-one patients with IBS were randomly assigned to AT (n = 11, 5 male, 6 female) or control therapy (n = 10, 5 male, 5 female). AT patients were trained intensively, while the control therapy consisted of discussions about patients' meal habits and life styles. All patients answered a question related to adequate relief (AR) of IBS symptoms and four questionnaires: Self-induced IBS Questionnaire (SIBSQ), Self-reported Depression Scale (SDS), State-Trait Anxiety Inventory (STAI), and Medical Outcome Short Form 36 Health Survey (SF-36). The proportion of AR in the last AT session in the AT group (9/11, 81.8%) was significantly higher than that in the controls (3/10, 30.0%, Chi-square test, p = 0.048). Two subscales of the SF-36, i.e., social functioning and bodily pain, were significantly improved in the AT group (p < 0.05) as compared to the control group. Role emotional (p = 0.051) and general health (p = 0.068) showed a tendency for improvement in the AT group. AT may be useful in the treatment of IBS by enhancing self-control.

Challenges and prospects for pharmacotherapy in functional gastrointestinal disorders

Functional gastrointestinal disorders, such as irritable bowel syndrome and functional dyspepsia, are complex conditions with multiple factors contributing to their pathophysiology. As a consequence they are difficult to treat and have posed significant challenges to the pharmaceutical industry when trying to develop new and effective treatments. This review provides an overview of these difficulties and how the industry is reshaping its drug developmental strategies. It describes some of the more significant and encouraging advances that have occurred, and discusses how future research might embrace the opportunities provided by advances in genetic and in particular, epigenetic research.

No change in rectal sensitivity after gut-directed hypnotherapy in children with functional abdominal pain or irritable bowel syndrome

OBJECTIVES

Gut-directed hypnotherapy (HT) has recently been shown to be highly effective in treating children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS). This study was conducted to determine the extent to which this treatment success is because of an improvement in rectal sensitivity.

METHODS

A total of 46 patients (aged 8-18 years) with FAP (n=28) or IBS (n=18) were randomized to either 12 weeks of standard medical therapy (SMT) or HT. To assess rectal sensitivity, a pressure-controlled intermittent distension protocol (barostat) was performed before and after the therapy.

RESULTS

Rectal sensitivity scores changed in SMT patients from 15.1+/-7.3 mm Hg at baseline to 18.6+/-8.5 mm Hg after 12 weeks of treatment (P=0.09) and in HT patients from 17.0+/-9.2 mm Hg to 22.5+/-10.1 mm Hg (P=0.09). The number of patients with rectal hypersensitivity decreased from 6 of 18 to 0 of 18 in the HT group (P=0.04) vs. 6 of 20 to 4 of 20 in the SMT group (P=0.67). No relationship was established between treatment success and rectal pain thresholds. Rectal sensitivity scores at baseline were not correlated with intensity, frequency, or duration of abdominal pain.

CONCLUSIONS

Clinical success achieved with HT cannot be explained by improvement in rectal sensitivity. Furthermore, no association could be found between rectal barostat findings and clinical symptoms in children with FAP or IBS. Further studies are necessary to shed more light on both the role of rectal sensitivity in pediatric FAP and IBS and the mechanisms by which hypnotherapy results in improvement of clinical symptoms.

[Alternative treatments in irritable bowel syndrome]

Managing irritable bowel syndrome (IBS) is difficult and often a source of dissatisfaction for the patient, explaining the increasingly frequent recourse to alternative treatments. These highly varied treatments are often associated. They can be classed into four categories: reflexology methods, interventions on the psyche, biological therapies, and treatments using certain forms of energy. Although some studies show interesting results, currently there are not sufficient scientific arguments to recommend one or another of these alternative treatments. Multicenter controlled studies are needed to better evaluate the strategies that appear to be cost-effective.

Hypnotherapy for functional gastrointestinal disorders: a review

Patients with functional gastrointestinal disorders, such as irritable bowel syndrome, functional dyspepsia, and noncardiac chest pain, can suffer from a range of severe symptoms that often substantially erode quality of life. Unfortunately, these conditions are notoriously difficult to treat, with many patients failing to improve despite being prescribed a wide variety of conventional medications. As a consequence, the potential benefits of hypnotherapy have been explored with evidence that this approach not only relieves symptoms but also appears to restore many of the putative psychological and physiological abnormalities associated with these conditions toward normal. These observations suggest that this form of treatment has considerable potential in aiding the management of functional gastrointestinal disorders and should be integrated into the ongoing medical care that these patients are receiving.

Pain and inflammatory bowel disease

Abdominal pain is a common symptom of inflammatory bowel disease (IBD: Crohn's disease, ulcerative colitis). Pain may arise from different mechanisms, which can include partial blockage and gut distention as well as severe intestinal inflammation. A majority of patients suffering from acute flares of IBD will experience pain, which will typically improve as disease activity decreases. However, a significant percentage of IBD patients continue experiencing symptoms of pain despite resolving inflammation and achieving what appears to be clinical remission. Current evidence suggests that sensory pathways sensitize during inflammation, leading to persistent changes in afferent neurons and central nervous system pain processing. Such persistent pain is not only a simple result of sensory input. Pain processing and even the activation of sensory pathways is modulated by arousal, emotion, and cognitive factors. Considering the high prevalence of iatrogenic as well as essential neuropsychiatric comorbidities including anxiety and depression in IBD patients, these central modulating factors may significantly contribute to the clinical manifestation of chronic pain. The improved understanding of peripheral and central pain mechanisms is leading to new treatment strategies that view pain as a biopsychosocial problem. Thus, improving the underlying inflammation, decreasing the excitability of sensitized afferent pathways, and altering emotional and/or cognitive functions may be required to more effectively address the difficult and disabling disease manifestations.

Psychopharmacologic and behavioral treatments for functional gastrointestinal disorders

Functional gastrointestinal disorders (FGIDs) are commonly seen gastrointestinal (GI) conditions that are diagnosed using established symptom-based criteria. These disorders that typically defy traditional diagnostic methods based on structural abnormalities have intrigued researchers for several decades. This has led to the emergence of the current discipline of neurogastroenterology or the study of the "brain-gut axis," which is based on dysregulation of neuroenteric pathways as a key pathophysiologic feature of the FGIDs. Psychopharmacologic and behavioral treatments can influence the dysregulation of these pathways, especially at the severe end of the spectrum, and improve the clinical manifestations of these conditions, visceral discomfort or pain and bowel dysfunction. Their actions are mostly at spinal and supraspinal levels with some direct benefits at the level of the gut. Improvements in coping, global distress, and overall quality of life (QOL) have been shown more consistently with these treatments compared with improvement in GI symptoms. A successful approach to patients with these treatments requires a good physician-patient relationship. Strategizing treatments with these modalities is based on recognition of their dual effects on brain and gut, understanding the nature and severity of the GI symptoms and their psychosocial concomitants, and applying them within the context of the patient's understanding of their value.

Hypnosis and upper digestive function and disease

Hypnosis is a therapeutic technique that primarily involves attentive receptive concentration. Even though a small number of health professionals are trained in hypnosis and lingering myths and misconceptions associated with this method have hampered its widespread use to treat medical conditions, hypnotherapy has gained relevance as an effective treatment for irritable bowel syndrome not responsive to standard care. More recently, a few studies have addressed the potential influence of hypnosis on upper digestive function and disease. This paper reviews the efficacy of hypnosis in the modulation of upper digestive motor and secretory function. The present evidence of the effectiveness of hypnotherapy as a treatment for functional and organic diseases of the upper bowel is also summarized, coupled with a discussion of potential mechanisms of its therapeutic action.

Manometric, sensorimotor, and neurophysiologic evaluation of anorectal function

With advances in diagnostic technology, it is now accepted that in the field of functional bowel disorders, symptom-based assessment is unsatisfactory as the sole means of directing therapy. A robust taxonomy based on underlying pathophysiology has been suggested, highlighting a crucial role for physiologic testing in clinical practice. A wide number of complementary investigations currently exist for the assessment of anorectal structure and function, some of which have a clinical impact in patients with functional disorders of evacuation and continence by markedly improving diagnostic yield and altering management. The techniques, limitations, measurements, and clinical use of manometric, sensorimotor, and neurophysiologic tests of anorectal function are presented.

The effect of hypnosis on systemic and rectal mucosal measures of inflammation in ulcerative colitis

OBJECTIVES

Hypnotherapy is effective in several diseases with a psychosomatic component. Our aim was to study the effects of one session of hypnosis on the systemic and rectal mucosal inflammatory responses in patients with active ulcerative colitis (UC).

METHODS

In total, 17 patients with active UC underwent a 50-min session of gut-focused hypnotherapy. Before and after each procedure, the systemic inflammatory response was assessed by serum interleukin (IL)-6 and IL-13 concentrations, tumor necrosis factor-alpha (TNF-alpha) and IL-6 production by lipopolysaccharide (LPS)-stimulated whole blood, leukocyte count, natural killer (NK) cell number, platelet activation, and platelet-leukocyte aggregate formation. Rectal inflammation was assessed by mucosal release of substance P (SP), histamine, IL-13 and TNF-alpha, reactive oxygen metabolite production, and mucosal blood flow. Eight patients with active UC underwent a control procedure.

RESULTS

Hypnosis decreased pulse by a median 7 beats per minute (bpm) (P= 0.0008); it also reduced the median serum IL-6 concentration by 53% (P= 0.001), but had no effect on the other systemic variables assessed. Hypnosis reduced rectal mucosal release of SP by a median 81% (P= 0.001), histamine by 35% (P= 0.002) and IL-13 by 53% (P= 0.003), and also, blood flow by 18% (P= 0.0004). The control protocol had no effect on any of the variables assessed.

CONCLUSIONS

Hypnosis reduced several components of the systemic and mucosal inflammatory response in active ulcerative colitis toward levels found previously in the inactive disease. Some of these effects may contribute to the anecdotally reported benefits of hypnotherapy and provide a rationale for controlled trials of hypnotherapy in UC.

Bloating and distention in irritable bowel syndrome: the role of visceral sensation

BACKGROUND & AIMS

Abdominal bloating is an extremely intrusive symptom of irritable bowel syndrome (IBS) that is not always accompanied by an increase in abdominal girth (distention), raising the possibility that these 2 features of the condition may not share a common pathophysiology. A number of mechanisms have been postulated for bloating and distention, but the role of visceral sensation, which is often abnormal in IBS, has not been previously investigated, and this study aimed to address this question.

METHODS

Abdominal girth measured by ambulatory abdominal inductance plethysmography and bloating severity was recorded over 24 hours in 39 IBS-constipation (ages, 18-73 years) and 29 IBS-diarrhea patients (ages, 20-59 years) meeting Rome II criteria. Within 1 week, rectal sensory thresholds were assessed with a barostat using the ascending method of limits and tracking.

RESULTS

IBS patients who suffered with bloating alone had lower thresholds for pain (P = .005), desire to defecate (P = .044), and first sensation (P = .07) compared with those who had concomitant distention irrespective of bowel habit. When patients were grouped according to sensory threshold, hyposensitive individuals had distention significantly more than those with hypersensitivity (P = .001), and this was observed more in the constipation subgroup. Static and dynamic compliance did not differ among any of the groups.

CONCLUSIONS

The symptom of bloating alone is associated with visceral hypersensitivity, suggesting that the pathogenesis of bloating and distention may not be the same. Consequently, treatment approaches may have to be different, and measuring visceral sensation could have utility in choosing the right therapeutic modality.

Hypnotherapy for irritable bowel syndrome: the response of colonic and noncolonic symptoms

There is now good evidence that hypnotherapy benefits a substantial proportion of patients with irritable bowel syndrome and that improvement is maintained for many years. Most patients seen in secondary care with this condition also suffer from a wide range of noncolonic symptoms such as backache and lethargy, as well as a number of musculoskeletal, urological, and gynaecological problems. These features do not typically respond well to conventional medical treatment approaches, but fortunately, their intensity is often reduced by hypnosis. The mechanisms by which hypnosis mediates its benefit are not entirely clear, but there is evidence that, in addition to its psychological effects, it can modulate gastrointestinal physiology, alter the central processing of noxious stimuli, and even influence immune function.

Integrative medicine in gastrointestinal disease: evaluating the evidence

Current Western therapies for many gastrointestinal diseases are suboptimal and potentially toxic. The majority of patients with digestive diseases are turning to complementary and alternative medicine for symptom relief and improved quality of life, due to dissatisfaction with conventional medical therapies. There is emerging evidence that many of these complementary and alternative medicine modalities are highly effective in modulating the immune system, disrupting the proinflammatory cascade and restoring digestive health while improving patients' quality of life. We present evidence to support the potential utility of complementary and alternative medicine modalities for irritable bowel syndrome and inflammatory bowel disease. For each condition, we detail the proposed mechanisms of action and explore the current data for the prevention and/or treatment of disease.

Hypnotherapy for children with functional abdominal pain or irritable bowel syndrome: a randomized controlled trial

BACKGROUND & AIMS

Functional abdominal pain (FAP) and irritable bowel syndrome (IBS) are highly prevalent in childhood. A substantial proportion of patients continues to experience long-lasting symptoms. Gut-directed hypnotherapy (HT) has been shown to be highly effective in the treatment of adult IBS patients. We undertook a randomized controlled trial and compared clinical effectiveness of HT with standard medical therapy (SMT) in children with FAP or IBS.

METHODS

Fifty-three pediatric patients, age 8-18 years, with FAP (n = 31) or IBS (n = 22), were randomized to either HT or SMT. Hypnotherapy consisted of 6 sessions over a 3-month period. Patients in the SMT group received standard medical care and 6 sessions of supportive therapy. Pain intensity, pain frequency, and associated symptoms were scored in weekly standardized abdominal pain diaries at baseline, during therapy, and 6 and 12 months after therapy.

RESULTS

Pain scores decreased significantly in both groups: from baseline to 1 year follow-up, pain intensity scores decreased in the HT group from 13.5 to 1.3 and in the SMT group from 14.1 to 8.0. Pain frequency scores decreased from 13.5 to 1.1 in the HT group and from 14.4 to 9.3 in the SMT group. Hypnotherapy was highly superior, with a significantly greater reduction in pain scores compared with SMT (P < .001). At 1 year follow-up, successful treatment was accomplished in 85% of the HT group and 25% of the SMT group (P < .001).

CONCLUSIONS

Gut-directed HT is highly effective in the treatment of children with longstanding FAP or IBS.

Hypnotherapy for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder of unknown aetiology. Current pharmacological treatments have limited value. Hypnotherapy has been reported to have beneficial effects for IBS symptoms.

OBJECTIVES

To evaluate the efficacy of hypnotherapy for the treatment of irritable bowel syndrome.

SEARCH STRATEGY

Published and unpublished randomised clinical trials and quasi-randomised clinical trials were identified through structured searches of MEDLINE (1966 to March 2006), EMBASE (1980 to March 2006), PsycINFO (1806 to March 2006), CINAHL (Cumulative Index to Nursing and Allied Health Literature, 1982 to March 2006), AMED (Allied and Complementary Medicine Database, 1985 to March 2006) and The Cochrane Central Register of Controlled trials. Conference proceedings from Digestive Disease Week (1980 to 2005) were also searched.

SELECTION CRITERIA

Eligible studies included all randomised and quasi-randomised clinical studies comparing hypnotherapy for the treatment of irritable bowel syndrome with no treatment or another therapeutic intervention.

DATA COLLECTION AND ANALYSIS

All studies were evaluated for eligibility for inclusion. Included studies were assessed for quality and data were extracted independently by four authors. The primary outcome measure of interest was the overall bowel symptom severity score which combines abdominal pain, diarrhoea or constipation and bloating. Secondary outcomes included abdominal pain, diarrhoea, constipation, bloating, quality of life, patient's overall assessment of well-being, psychological measures as per validated questionnaires, and adverse events.

MAIN RESULTS

Four studies including a total of 147 patients met the inclusion criteria. Only one study compared hypnotherapy to an alternative therapy (psychotherapy and placebo pill), two studies compared hypnotherapy with waiting-list controls and the final study compared hypnotherapy to usual medical management. Data were not pooled for meta-analysis due to differences in outcome measures and study design. The therapeutic effect of hypnotherapy was found to be superior to that of a waiting list control or usual medical management, for abdominal pain and composite primary IBS symptoms, in the short term in patients who fail standard medical therapy. Harmful side-effects were not reported in any of the trials. However, the results of these studies should be interpreted with caution due to poor methodological quality and small size.

AUTHORS' CONCLUSIONS

The quality of the included trials was inadequate to allow any conclusion about the efficacy of hypnotherapy for irritable bowel syndrome. More research with high quality trials is needed.

Altered rectal perception in irritable bowel syndrome is associated with symptom severity

BACKGROUND & AIMS

Diverging results exist regarding the connection between altered visceral perception and gastrointestinal (GI) symptoms, as well as the effects of psychological status on visceral sensitivity. We sought to investigate different aspects of rectal perception in irritable bowel syndrome (IBS) and the association with GI and psychological symptoms.

METHODS

We included 109 patients with IBS meeting Rome II criteria (77 women; age range, 20-71 years) and 29 healthy controls (21 women; age range, 20-68 years). They underwent rectal balloon distentions determining sensory thresholds for discomfort and pain, the perceived intensity of unpleasantness, and the viscerosomatic referral area. The fifth percentile (thresholds) and 95th percentile (unpleasantness and referral area) in controls were used to define altered perception. Questionnaires were used to assess severity of IBS-related GI symptoms and psychological symptoms.

RESULTS

When combining the 3 aspects of perception, 67 patients (61%) had altered rectal perception. These patients, compared with normosensitive patients, more frequently reported moderate or severe pain (73% vs 44%; P < .01), bloating (73% vs 36%; P < .0001), diarrhea (47% vs 21%; P < .01), satiety (39% vs 13%; P < .01), and clinically significant anxiety (31% vs 12%; P < .05). In a multivariate analysis, only pain and bloating remained associated with altered rectal perception.

CONCLUSIONS

Altered rectal perception is common in IBS and seems to be one important pathophysiologic factor associated with GI symptom severity in general and pain and bloating in particular. It is not just a reflection of the psychological state of the patient.

New insights into the pathogenesis and pathophysiology of irritable bowel syndrome

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.

[Functional gastrointestinal disorders]

The functional gastrointestinal disorders (FGID) are the most frequent clinical conditions seen in practice. The FGID are associated with significant work absenteeism, impaired quality of life and increased medical costs. Most patients also suffer from psychosocial problems. Therefore it is important to define the patient's complaints in terms of a biopsychosocial disorder rather than just a medical illness. Physicians must acknowledge the relevance of the psychosocial aspects to prepare the patient for a referral to a specialist (in psychosomatic medicine or a psychotherapist) and to get the patient interested in the psychological factors involved as well as further explore their cause. Most of the research on psychotherapy in FGID to date has focused on the irritable bowel syndrome, and different methods of treatments have been studied (e. g., cognitive-behavioral therapy, dynamic psychotherapy, hypnotherapy, and relaxation). Randomised controlled studies have shown that psychotherapy is superior to conventional medical therapy. Hypnotherapy seems to be very successful. Predictors of a positive response to psychological treatment generally are: (1) awareness that stress exacerbates their bowel symptoms, (2) mild anxiety or depression, (3) the predominant bowel symptom is abdominal pain or diarrhea and not constipation, (4) the abdominal pain waxes and wanes in response to eating, defecation, or stress rather than being constant pain, and (5) the symptoms are of relatively short duration. Psychotherapy is initially relatively expensive because it requires multiple, long sessions. However, its benefits persist or even increase over time, and in the long run, there may be a reduction in clinic visits and health care costs which offsets the initial cost of psychological treatment.

[Psychosomatic aspects of bowel diseases]

Functional gastrointestinal disorders (FGID) and inflammatory bowel diseases (IBD) are the most frequently studied bowel disorders in the context of a bio psycho-social model. FGID are associated with significant work absenteeism, impaired quality of life, and increased medical costs. Many patients also suffer from psychosocial problems. Most of the research in FGID to date has focused on the irritable bowel syndrome. Randomised controlled studies have shown that psychotherapy is superior to conventional medical therapy. The gut-focussed hypnotherapy seems to be very successful. For IBD it is increasingly recognized that the psycho-neuro-endocrine network can modulate inflammation and pain perception and that psychosocial factors are related to exacerbation of and coping with IBD. The psychosocial consequences of the illness become more significant with increasing severity of the disease. Therefore integrated psychosomatic care should be provided, the patient's psychosocial status and the demand for additional psychological care should be assessed and offered, if indicated.

Systematic review: the effectiveness of hypnotherapy in the management of irritable bowel syndrome

AIM

To systematically review the literature evaluating hypnotherapy in the management of irritable bowel syndrome (IBS).

METHODS

Electronic databases were searched (Cochrane Library, Medline, CINAHL, AMED, Embase, PsycINFO, CISCOM, TRIP and the Social Science Citation index), bibliographic references scanned and main authors contacted. No restrictions were placed on language or publication year. Eligible studies involved adults with IBS using single-component hypnotherapy. All studies, except single case or expert opinion, were sought and all patient-related outcomes eligible.

RESULTS

Out of 299 unique references identified, 20 studies (18 trials of which four were randomized, two controlled and 12 uncontrolled) and two case series were eligible. These tended to demonstrate hypnotherapy as being effective in the management of IBS. Numbers of patients included were small. Only one trial scored more than four out of eight on internal validity.

CONCLUSION

The published evidence suggests that hypnotherapy is effective in the management of IBS. Over half of the trials (10 of 18) indicated a significant benefit. A randomized placebo-controlled trial of high internal validity is necessary to establish the effectiveness of hypnotherapy in the management of IBS. Until such a trial is undertaken, this form of treatment should be restricted to specialist centres caring for the more severe forms of the disorder.

Where does hypnotherapy stand in the management of irritable bowel syndrome? A systematic review

BACKGROUND

Irritable bowel syndrome (IBS) is a gastrointestinal disorder characterized by chronic abdominal pain and altered bowel habits in the absence of any organic cause. Despite its prevalence, there remains a significant lack of efficient medical treatment for IBS to date. However, according to some previous research studies, hypnosis has been shown to be effective in the treatment of IBS.

AIM

To determine the definite efficacy of hypnosis in the treatment of irritable bowel syndrome.

METHODS

A systematic review of the literature on hypnosis in the treatment of IBS from 1970 to 2005 was performed using MEDLINE. Full studies published in English were identified and selected for inclusion. We excluded case studies and those studies in which IBS symptoms were not in the list of outcome measures. All studies were reviewed on the basis of the Rome Working Team recommendations for design of IBS trials.

RESULTS

From a total of 22 studies, seven were excluded. The results of the reviewed studies showed improved status of all major symptoms of IBS, extracolonic symptoms, quality of life, anxiety, and depression. Furthermore these improvements lasted 2-5 years.

CONCLUSIONS

Although there are some methodologic inadequacies, all studies show that hypnotherapy is highly effective for patients with refractory IBS, but definite efficacy of hypnosis in the treatment of IBS remains unclear due to lack of controlled trials supporting this finding.

Rectal hyposensitivity

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension that is diagnosed during anorectal physiologic investigation. There have been few direct studies of this physiologic abnormality, and its contribution to the development of functional bowel disorders has been relatively neglected. However, it appears to be common in patients with such disorders, being most prevalent in patients with functional constipation with or without fecal incontinence. Indeed, it may be important in the etiology of symptoms in certain patients, given that it is the only "apparent" identifiable abnormality on physiologic testing. Currently, it is usually diagnosed on the basis of elevated sensory threshold volumes during balloon distension in clinical practice, although such a diagnosis may be susceptible to misinterpretation in the presence of altered rectal wall properties, and thus it is uncertain whether a diagnosis of RH reflects true impairment of afferent nerve function. Furthermore, the etiology of RH is unclear, although there is limited evidence to support the role of pelvic nerve injury and abnormal toilet behavior. The optimum treatment of patients with RH is yet to be established. The majority are managed symptomatically, although "sensory-retraining biofeedback" appears to be the most effective treatment, at least in the short term, and is associated with objective improvement in the rectal sensory function. Currently, fundamental questions relating to the contribution of this physiologic abnormality to the development of functional bowel disorders remain unanswered. Acknowledgment of the potential importance of RH is thus required by clinicians and researchers to determine its relevance.

Functional bowel disorders

Employing a consensus approach, our working team critically considered the available evidence and multinational expert criticism, revised the Rome II diagnostic criteria for the functional bowel disorders, and updated diagnosis and treatment recommendations. Diagnosis of a functional bowel disorder (FBD) requires characteristic symptoms during the last 3 months and onset > or =6 months ago. Alarm symptoms suggest the possibility of structural disease, but do not necessarily negate a diagnosis of an FBD. Irritable bowel syndrome (IBS), functional bloating, functional constipation, and functional diarrhea are best identified by symptom-based approaches. Subtyping of IBS is controversial, and we suggest it be based on stool form, which can be aided by use of the Bristol Stool Form Scale. Diagnostic testing should be guided by the patient's age, primary symptom characteristics, and other clinical and laboratory features. Treatment of FBDs is based on an individualized evaluation, explanation, and reassurance. Alterations in diet, drug treatment aimed at predominant symptoms, and psychotherapy may be beneficial.

Functional diarrhea

Functional diarrhea occurs as part of the irritable bowel syndrome (IBS) and as an isolated symptom as functional (painless) diarrhea. Progress has been made in defining these disorders and in identifying new mechanisms involved in symptom production. A strong link exists between intestinal infection and IBS, as is the role of 5-hydroxytryptamine (5-HT). The importance of persistent subclinical inflammation is also emerging as a potential etiologic factor, particularly in post-infectious IBS. Although changes in the bacterial flora and bacterial overgrowth have been put forward as additional new contributors to symptom production, the case is not strong. These developments in pathogenesis have facilitated the introduction of new therapies. 5-HT(3) antagonists reduce bowel frequency and pain in women with diarrhea-predominant IBS, but their use is limited because of ischemic colitis. Prednisolone lacks efficacy, and early results with probiotics and herbal remedies are encouraging but require confirmation by larger trials.

Hypnosis for irritable bowel syndrome: the quest for the mechanism of action

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.

Hypnosis for irritable bowel syndrome: the empirical evidence of therapeutic effects

Irritable bowel syndrome (IBS) is a complex and prevalent functional gastrointestinal disorder that is treated with limited effectiveness by standard medical care. Hypnosis treatment is, along with cognitive-behavioral therapy, the psychological therapy best researched as an intervention for IBS. Eleven studies, including 5 controlled studies, have assessed the therapeutic effects of hypnosis for IBS. Although this literature has significant limitations, such as small sample sizes and lack of parallel comparisons with other treatments, this body of research consistently shows hypnosis to have a substantial therapeutic impact on IBS, even for patients unresponsive to standard medical interventions. The median response rate to hypnosis treatment is 87%, bowel symptoms can generally be expected to improve by about half, psychological symptoms and life functioning improve after treatment, and therapeutic gains are well maintained for most patients for years after the end of treatment.

Review article: The history of hypnotherapy and its role in the irritable bowel syndrome

Hypnosis is a technique by which an individual can gain a degree of control over physiological as well as psychological function. This paper reviews the history of the phenomenon as well as the accumulating evidence that it is effective in relieving the symptoms of irritable bowel syndrome and improving the quality of life of sufferers. The physiological effects of hypnosis are also discussed coupled with an outline of how a hypnotherapy service might be provided.

Biological sensitisation and psychological amplification: gateways to subjective health complaints and somatoform disorders

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!

Functional abdominal pain

Functional abdominal pain or functional abdominal pain syndrome (FAPS) is an uncommon functional gut disorder characterised by chronic or recurrent abdominal pain attributed to the gut but poorly related to gut function. It is associated with abnormal illness behaviour and patients show psychological morbidity that is often minimised or denied in an attempt to discover an organic cause for symptoms. Thus the conventional biomedical approach to the management of such patients is unhelpful and a person's symptom experience is more usefully investigated using a biopsychosocial evaluation, which necessarily entails a multidisciplinary system of healthcare provision. Currently the pathophysiology of the disorder is poorly understood but is most likely to involve a dysfunction of central pain mechanisms either in terms of attentional bias, for example, hypervigilance or a failure of central pain modulation/inhibition. Although modern neurophysiological investigation of patients is promising and may provide important insights into the pathophysiology of FAPS, current clinical management relies on an effective physician-patient relationship in which limits on clinical investigation are set and achievable treatment goals tailored to the patient's needs are pursued.

Abdominal bloating

Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect. Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception. All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception. Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods. Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.

Bloating and intestinal gas

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.

Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders

Abdominal bloating is an extremely common symptom affecting up to 96% of patients with functional gastrointestinal disorders and even 30% of the general population. To date bloating has often been viewed as being synonymous with an actual increase in abdominal girth, but recent evidence suggests that this is not necessarily the case. This review examines the relationship between the symptom of bloating and the physical sign of abdominal distension, as well as examining the epidemiology, pathophysiology and treatment options available for this debilitating aspect of the functional gastrointestinal disorders. Pathophysiological mechanisms explored include psychological factors, intestinal gas accumulation, fluid retention, food intolerance and malabsorption of sugars, weakness of abdominal musculature, and altered sensorimotor function. Treatment options are currently rather limited but include dietary changes, pharmacological approaches, probiotics and hypnotherapy.

Disturbances of motility and visceral hypersensitivity in irritable bowel syndrome: biological markers or epiphenomenon

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.

Rectal hyposensitivity: a disorder of the rectal wall or the afferent pathway? An assessment using the barostat

OBJECTIVES

Rectal hyposensitivity (RH) relates to a diminished perception of rectal distension. Diagnosis on the basis of abnormal threshold volumes on balloon distension alone may be inaccurate due to the influence of differing rectal wall properties. The aim of this study was to investigate whether RH was actually due to impaired afferent nerve function or whether it could be secondary to abnormalities of the rectal wall.

METHODS

A total of 50 patients were referred consecutively to a tertiary referral unit for physiologic assessment of constipation (Rome II criteria), 25 of whom had associated fecal incontinence. Thirty patients had RH (elevated threshold volumes on latex balloon distension), and 20 patients had normal rectal sensation (NS). Results were compared with those obtained in 20 healthy volunteers (HV). All subjects underwent standard anorectal physiologic investigation, and assessment of rectal compliance, adaptive response to isobaric distension at urge threshold, and postprandial rectal response, using an electromechanical barostat.

RESULTS

Mean rectal compliance was significantly elevated in patients with RH compared to NS and HV (p < 0.001). However, 16 patients with RH (53%) had normal compliance. Intensity of the urge to defecate during random phasic isobaric distensions was significantly reduced in patients with RH compared to NS and HV (p < 0.001). The adaptive response at urge threshold was reduced in patients with RH compared to NS and HV (p < 0.001), although spontaneous adaptation at operating pressure was similar in all three groups studied (p= 0.3). Postprandially, responses were similar between groups.

CONCLUSIONS

In patients found to have RH on simple balloon distension, impaired perception of rectal distension may be partly explained in one subgroup by abnormal rectal compliance. However, a second subgroup exists with normal rectal wall properties, suggestive of a true impairment of the afferent pathway. The barostat has an important role in the identification of these subgroups of patients.

Hypnosis and irritable bowel syndrome: a review of efficacy and mechanism of action

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.

Options for patients with irritable bowel syndrome: contrasting traditional and novel serotonergic therapies

This article reviews the efficacy and tolerability of traditional therapies for irritable bowel syndrome (IBS) and concludes that they are limited by both poor efficacy and adverse effects. Serotonin, a neurotransmitter found mainly in the gut, appears to represent a link in IBS pathophysiological processes -- altered gut motility, abnormal intestinal secretion and visceral hypersensitivity. Recently, available treatments for IBS have targeted serotonin receptors that are involved in motor, sensory and secretory functions of the gut. Serotonergic agents, such as alosetron (a 5-HT3 receptor antagonist) and tegaserod (a selective 5-HT4 receptor partial agonist), provide global relief of the multiple symptoms of IBS with diarrhoea and IBS with constipation, respectively, and represent important additions to the IBS treatment armamentarium.

Alterations of sensori-motor functions of the digestive tract in the pathophysiology of irritable bowel syndrome

Pathophysiology of irritable bowel syndrome (IBS) is based upon multiple factors that have been organised in a comprehensive model centred around the brain-gut axis. The brain-gut axis encompasses nerve pathways linking the enteric and the central nervous systems and contains a large proportion of afferent fibres. Functionally and anatomically, visceral nerves are divided in to two categories: the parasympathetic pathways distributing to the upper gut through the vagi and to the hindgut, through the pelvic and pudendal nerves, and the sympathetic pathways, arising form the spinal cord and distributing to the midgut via the paravertebral ganglia. Several abnormalities of gut sensori-motor function have been described in patients with IBS. Abnormal motility patterns have been described at the intestinal and colonic levels. Changes in colonic motility are mainly related to bowel disturbances linked to IBS but do not correlate with pain. More recently, visceral hypersensitivity has been recognised as a main characteristic of patients with IBS. It is defined by an exaggerated perception of luminal distension of various segments of the gut and related to peripheral changes in the processing of visceral sensations as well as modulation of perception by centrally acting factors including mood and stress. Viscero-visceral reflexes link the two edges of the brain-gut axis and may account for the origin of symptoms in some pathological conditions. Recent advances in the understanding of the role of myenteric plexus allowed recognition of several neurotransmitters involved at the level of both the afferent and efferent pathways. Targeting the receptors of these neurotransmitters is a promising way for development of new treatments for IBS.

Treatment of Excessive Intestinal Gas

Symptoms of excessive intestinal gas may be related to eructation, excessive or odoriferous gas evacuation, and/or abdominal symptom attributed to gas retention. Patients with aerophagia and excessive eructation can be usually retrained to control air swallowing, but if present, basal dyspeptic symptoms may remain. Patients with excessive or odoriferous gas evacuation may benefit from a low-flatulogenic diet. In patients with gas retention due to impaired anal evacuation, anal incoordination can be resolved by biofeedback treatment, which also improves fecal retention, and thereby reduces the time for fermentation. Other patients complaining of abdominal symptoms that they attribute to intestinal gas, probably have irritable bowel syndrome or functional bloating, and their treatment options specifically targeting gas-related symptoms basically include prokinetics and spasmolytics. There is no consistent evidence to support the use of gas-reducing substances, such as charcoal or simethicone.

Irritable bowel syndrome in women: a common health problem

Irritable bowel syndrome is a common but complex problem that disproportionately affects women. Nurses are ideally situated to provide accurate information regarding the disorder and to provide symptom management. Currently, the diagnosis is based on the presence of abdominal pain and alterations in bowel habits. A multicomponent approach beginning with education and reassurance is more likely to be effective than one focused on a predominant symptoms (eg., constipation) alone. Building a therapeutic relationship with the patient over time will likely enhance the effectiveness of the prescribed therapy. Treatment paradigms that include new drugs that affect more than one symptom of IBS, along with nondrug therapies (eg, relaxation and cognitive behavioral strategies), will likely hold the greatest promise for management.

Cognitive change in patients undergoing hypnotherapy for irritable bowel syndrome

OBJECTIVE

Impaired quality of life and psychological distress are common in irritable bowel syndrome (IBS) and may be associated with unhelpful cognitions. Hypnotherapy (HT) is effective in improving both symptoms and quality of life in patients with IBS, and this study was designed to determine whether this improvement is reflected in cognitive change using a validated scale recently developed for use in such patients.

METHOD

A total of 78 IBS patients completed a validated symptom-scoring questionnaire, the Hospital Anxiety and Depression (HAD) Scale and the Cognitive Scale for Functional Bowel Disorders (FBDs), before and after 12 sessions of gut-focused HT.

RESULTS

HT resulted in improvement of symptoms, quality of life and scores for anxiety and depression (all P's<.001). IBS-related cognitions also improved, with reduction in the total cognitive score (TCS; P<.001) and all component themes related to bowel function (all P<.001). Cognitions were related to symptom severity because the most abnormal cognitive scores were observed in patients with the highest symptom scores (P<.001). Furthermore, a reduction in symptom score following treatment correlated with an improvement in the cognitive score (P<.001). Regression analysis confirmed that the cognitive score had independence from the other scores and did not serve solely as a proxy for symptom improvement.

CONCLUSION

This study shows that symptom improvement in IBS with HT is associated with cognitive change. It also represents an initial step in unravelling the many possible mechanisms by which treatments such as HT might bring about improvement.