ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Burden of illness and treatment attitudes among participants meeting Rome IV criteria for irritable bowel syndrome: A nationwide survey in the United States

BACKGROUND

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction characterized by abdominal pain and altered bowel habits, with patient-perceived dissatisfaction of treatment symptom control. We assessed disease burden, satisfaction with medication use, and impact on activities, in participants with IBS with constipation (IBS-C) and diarrhea (IBS-D).

METHODS

This study assessed data from a large, United States survey of adults querying demographics, comorbid conditions, quality of life, medication use, satisfaction with symptom control, and work productivity. Participants were grouped into the IBS-C or IBS-D cohort if they met Rome IV criteria, with controls matched 1:1 according to age, sex, race, region, and Charlson Comorbidity Index score. All data were self-reported.

KEY RESULTS

Nine hundred and ten participants with IBS-C and 669 with IBS-D were matched to controls. The most reported symptoms were abdominal discomfort for IBS-C and abdominal pain and abdominal discomfort for IBS-D. Among the IBS-C and IBS-D cohorts, 74.2% and 65.9%, respectively, took prescription and/or over-the-counter medication for their symptoms. Respondents were more dissatisfied than satisfied with control of their symptoms. Respondents taking prescription medication(s) with or without over-the-counter medication(s) reported better symptom control than respondents only taking over-the-counter medications (p < 0.001). There was significantly higher mean presenteeism, work productivity loss, and daily activity impairment (p < 0.001 for all) in respondents with IBS compared with controls.

CONCLUSIONS AND INFERENCES

This study provides insight into respondents' experiences of IBS symptoms, including the impact on daily activity, as well as satisfaction with control of symptoms and prescription and over-the-counter medications.

The Role of Virtual Reality in the Management of Irritable Bowel Syndrome

PURPOSE OF REVIEW

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction that significantly impacts health-related quality of life (HRQOL). This article explores the potential role of virtual reality (VR)-based cognitive behavioral therapy (CBT) in treating patients with IBS.

RECENT FINDINGS

While CBT is a proven, skills-based therapy approach that modifies behaviors and alters dysfunctional thinking patterns to influence the gut-brain axis and improve IBS symptoms, it is rarely prescribed given a paucity of CBT-trained clinicians. We developed a novel VR program that delivers a standardized CBT program over an 8-week period to help patients manage their symptoms. In initial qualitative validation testing, patients expressed positive perceptions about using VR CBT for IBS. Home-based, standardized VR CBT has the potential to be an effective and scalable treatment option for patients with IBS. While initial studies have shown proof-of-concept definitive randomized controlled trials are needed to demonstrate the efficacy of self-administered VR CBT in IBS.

Review article: The role of the gut-brain axis in inflammatory bowel disease and its therapeutic implications

BACKGROUND

Treatments targeting the gut-brain axis (GBA) are effective at reducing symptom burden in irritable bowel syndrome (IBS). The prevalence of common mental disorders and IBS-type symptom reporting is significantly higher in inflammatory bowel disease (IBD) than would be expected, suggesting potential GBA effects in this setting. Manipulation of the GBA may offer novel treatment strategies in selected patients with IBD. We present a narrative review of the bi-directional effects of the GBA in IBD and explore the potential for GBA-targeted therapies in this setting.

METHODS

We searched MEDLINE, EMBASE, EMBASE Classic, PsychINFO, and the Cochrane Central Register of Controlled Trials for relevant articles published by March 2024.

RESULTS

The bi-directional relationship between psychological well-being and adverse longitudinal disease activity outcomes, and the high prevalence of IBS-type symptom reporting highlight the presence of GBA-mediated effects in IBD. Treatments targeting gut-brain interactions including brain-gut behavioural treatments, neuromodulators, and dietary interventions appear to be useful adjunctive treatments in a subset of patients.

CONCLUSIONS

Psychological morbidity is prevalent in patients with IBD. The relationship between longitudinal disease activity outcomes, IBS-type symptom reporting, and poor psychological health is mediated via the GBA. Proactive management of psychological health should be integrated into routine care. Further clinical trials of GBA-targeted therapies, conducted in selected groups of patients with co-existent common mental disorders, or those who report IBS-type symptoms, are required to inform effective integrated models of care in the future.

Current opinion: functional dyspepsia

PURPOSE OF REVIEW

Functional dyspepsia is a common gastrointestinal disease that is under-recognized and under-diagnosed. It is a complex disorder of gut-brain interaction with no FDA-approved treatment options. The purpose of this review is to highlight updates in the proposed pathophysiology and present new data regarding potential therapies for functional dyspepsia.

RECENT FINDINGS

Alterations in the intestinal microbiome and integrity of the intestinal membrane may play a crucial role in the pathogenesis of functional dyspepsia. The low FODMAP diet, in addition to modulating the microbiome with antibiotics and probiotics, are targets for large future studies. Novel methods of delivery of gut-brain therapies have shown promising results, especially virtual reality.

SUMMARY

The pathophysiology and management of functional dyspepsia is complex and there is still much unknown; however, continued research is identifying new targets for treatment. New and more targeted treatment options provide clinicians a variety of tools to offer patients with functional dyspepsia.

When and What to Test for Diarrhea: Focus on Stool Testing

INTRODUCTION

To review stool diagnostic tests in acute and chronic diarrhea.

METHODS

Narrative review of published literature.

RESULTS

In acute diarrhea, stool tests are indicated when there is strong pretest probability of infectious etiology or Clostridioides difficile infection suggested by > 3 unformed bowel movements per 24 hours, symptoms lasting >7 days, and circumstances that are suggestive of infection. Several commercially available rapid tests for bacterial, viral, or protozoal infections may be offered in addition to traditional methods (e.g. culture, microscopy) and provide a result within 6 hours. For C . difficile infections, a highly sensitive test such as glutamate dehydrogenase test is required; however, this does not distinguish infection from carrier state. That differentiation requires specialized nucleic acid amplification test (for toxin B) or enzyme immunoassays for toxin A or B, which are unfortunately not generally offered by microbiology laboratories. Chronic diarrhea may result from inflammatory, fatty, osmotic, or secretory causes; the commonest cause is diarrhea-predominant irritable bowel syndrome/functional diarrhea. Current recommendations in societal guidelines or clinical practice updates regarding stool tests in diarrhea-predominant irritable bowel syndrome/functional diarrhea in the absence of alarm symptoms include testing for Giardia, calprotectin, fecal immunochemical test, and bile acid diarrhea. Comprehensive stool biochemical analyses (osmolality, pH, electrolytes) differentiate osmotic from secretory diarrhea and identify laxative abuse. Specific stool diagnostic tests for bile acid diarrhea and exocrine pancreatic insufficiency can lead to specific diagnosis and treatments. Surrogate markers associated with high fecal output and rapid transit in chronic diarrhea are stool form and colonic transit.

DISCUSSION

Fecal testing is still very relevant in the practice of gastroenterology and deserves introduction of advanced microbiological and biochemical tests.

Practices and Barriers in Implementing the Low FODMAP Diet for Irritable Bowel Syndrome Among Malaysian Dietitians: A Qualitative Study

The low fermentable oligo-, di-, mono-saccharides and polyols (FODMAP) diet (LFD) is a second-line dietary intervention for irritable bowel syndrome (IBS) patients, involving FODMAP restriction, reintroduction, and personalization, and it needs to be delivered by dietitians. However, the application of this diet among Malaysian IBS patients is not well understood. This study aimed to explore the practices and barriers in delivering the LFD among Malaysia dietitians. Semi-structured qualitative interviews were conducted online with practicing dietitians until the data reached saturation. All the interview sessions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. Eleven dietitians were interviewed, with 36.4% (n = 4) having more than 10 years of experience. The following four themes regarding their practices emerged: 1. dietary advice on FODMAP restriction; 2. duration of FODMAP restriction phase; 3. references used to get information about FODMAPs, and 4. strategies on reintroduction. Meanwhile, the following seven barriers were identified: 1. lack of culturally relevant educational materials; 2. limited knowledge about the LFD; 3. inadequate formal training among dietitians; 4. lack of integration in multi-disciplinary care; 5. low health literacy of patients; 6. low compliance rate among patients, and 7. restrictions for certain populations. LFD implementation in Malaysia is not standardized as only experienced dietitians can provide dietary evidence-based advice. Lack of training and culturally specific resources are some of the main barriers that were identified to be limiting the implementation of the diet. Therefore, there is a need for training programs and resource development to support Malaysian dietitians in managing IBS patients.

Chronic Overlapping Pain Conditions in people with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): a sample from the Multi-site Clinical Assessment of ME/CFS (MCAM) study

BACKGROUND

Chronic overlapping pain conditions (COPCs), pain-related conditions that frequently occur together, may occur in patients with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and could impact illness severity. This study aimed to identify comorbid COPCs in patients with ME/CFS and evaluate their impact on illness severity.

METHODS

We used data from 923 participants in the Multi-Site Clinical Assessment of ME/CFS study, conducted in seven U.S. specialty clinics between 2012 and 2020, who completed the baseline assessment (595 ME/CFS and 328 healthy controls (HC)). COPCs included chronic low back pain (cLBP), chronic migraine/headache (cMHA), fibromyalgia (FM), interstitial cystitis/irritable bladder (IC/IB), irritable bowel syndrome (IBS), temporomandibular disorder (TMD). Illness severity was assessed through questionnaires measuring symptoms and functioning. Multivariate analysis of variance and analysis of covariance models were used for analyses. Log-binomial regression analyses were used to compute prevalence of COPCs and prevalence ratios (PR) between groups with 95% confidence intervals. Both unadjusted and adjusted results with age and sex are presented.

RESULTS

76% of participants with ME/CFS had at least one COPCs compared to 17.4% of HC. Among ME/CFS participants, cMHA was most prevalent (48.1%), followed by FM (45.0%), cLBP (33.1%), and IBS (31.6%). All individual COPCs, except TMD, were significantly more frequent in females than males. The unadjusted PR (ME/CFS compared to HC) was highest for FM [147.74 (95% confidence interval (CI) = 20.83-1047.75], followed by cLBP [39.45 (12.73-122.27)], and IC/IB [13.78 (1.88-101.24)]. The significance and order did not change after age and sex adjustment. The COPC comorbidities of cLBP and FM each had a significant impact on most health measures, particularly in pain attributes (Cohen's d effect size 0.8 or larger). While the impact of COPC comorbidities on non-pain attributes and quality of life measures was less pronounced than that on pain, statistically significant differences between ME/CFS participants with and without COPCs were still evident.

CONCLUSIONS

More than 75% of ME/CFS participants had one or more COPCs. Multiple COPCs further exacerbated illness severity, especially among females with ME/CFS. Assessment and management of COPCs may help improve the health and quality of life for patients with ME/CFS.

Gut microbiota and irritable bowel syndrome: status and prospect

Irritable bowel syndrome (IBS) is a very common gastrointestinal disease that, although not as aggressive as tumors, affects patients' quality of life in different ways. The cause of IBS is still unclear, but more and more studies have shown that the characteristics of the gut microbiota, such as diversity, abundance, and composition, are altered in patients with IBS, compared to the healthy population, which confirms that the gut microbiota plays a crucial role in the development of IBS. This paper aims to identify the commonalities by reviewing a large body of literature. Changes in the characteristics of gut microbiota in patients with different types of IBS are discussed, relevant mechanisms are described, and the treatment modalities of gut microbiota in IBS are summarized. Although there are more clinical trials that have made good progress, more standardized, more generalized, larger-scale, multi-omics clinical studies are what is missing. Overall, gut microbiota plays a crucial role in the development of IBS, and there is even more potential for treating IBS by modulating gut microbiota.

Impact of Enteric Nervous Cells on Irritable Bowel Syndrome: Potential Treatment Options

Irritable bowel syndrome (IBS) is a condition that significantly impacts the lifestyle, health, and habits of numerous individuals worldwide. Its diagnosis and classification are based on the Rome criteria, updated periodically to reflect new research findings in this field. IBS can be classified into different types based on symptoms, each with distinct treatment approaches and some differences in their pathophysiology. The exact pathological background of IBS remains unclear, with many aspects still unknown. Recent research developments suggest that disorders in the brain-gut-microbiota axis are key contributors to the symptoms and severity of IBS. The central nervous system (CNS) interacts bidirectionally with intestinal processes within the lumen and the intestinal wall, with the autonomic nervous system, particularly the vagus nerve, playing an important role. However, the enteric nervous system (ENS) is also crucial in the pathophysiological pathway of IBS. The apeline-corticotropin-releasing factor (CRF)-toll-like receptor 4 (TLR4) signaling route via enteric glia and serotonin production in enteroendocrine cells at the enteric barrier are among the most well-understood new findings that affect IBS through the ENS. Additionally, the microbiota regulates neuronal signals, modifying enteric function by altering the number of enteric bacteria and other mechanisms. Given the limited therapeutic options currently available, it is essential to identify new treatment targets, with the brain-gut axis, particularly the enteric nervous system, being a promising focus. This study aims to delineate the molecular mechanisms that induce IBS and to suggest potential targets for future research and treatment of this potentially debilitating disease.

A Synbiotic Combining Chitin-Glucan and Lactobacillus acidophilus NCFM Induces a Colonic Molecular Signature Soothing Intestinal Pain and Inflammation in an Animal Model of IBS

Chitin-glucan (CG) is a new generation of prebiotic. Lactobacillus acidophilus NCFM® (NCFM) is a probiotic with the ability to decrease abdominal pain. We evaluate the functional and molecular gastrointestinal responses to a synbiotic administration combining CG and NCFM in a rat model of long-lasting colon hypersensitivity. The intracolonic pressure was assessed during the 9-week experiment in animals receiving CG in association or not with NCFM and compared to that in Lacticaseibacillus paracasei Lpc-37®-treated animals and control rats receiving tap water. The effects of the synbiotic were evaluated using the Wallace score, the quantification of colon myeloperoxidase (MPO) and the master genes driving analgesia and inflammation. CG 1.5 alone and NCFM 109 colony forming units (CFU) alone similarly decreased the visceral pain sensitivity. Lpc-37 had no significant effect. The best profile of pain perception inhibition was obtained with the combination of CG 1.5 g and NCFM 109 CFU, confirming a synbiotic property. This synbiotic treatment significantly reduced macroscopic colonic lesions and MPO concentrations, and induced master genes involved in analgesia (CB1, CB2, MOR, PPARα), with a downregulation of inflammatory cytokines (IL-1β, TNFα) and an induction of IL-10 and PPARγ. In conclusion, CG 1.5 g + NCFM 109 CFU significantly decreased visceral pain perception and intestinal inflammation through the regulation of master genes.

Adjunctive use of hypnosis for clinical pain: a systematic review and meta-analysis

Systematic reviews suggest that stand-alone hypnotic suggestions may improve pain outcomes compared with no treatment, waitlist, or usual care. However, in clinical practice, hypnosis is often provided adjunctively with other interventions, which might have different effects than those reported in previous reviews. This systematic review aimed to summarize the analgesic effects of adjunctive hypnosis in adults with clinical pain. Seven databases (MEDLINE, Embase, PsycINFO, Emcare, SCOPUS, CENTRAL, Cochrane) were searched up to January 2024. Randomised controlled trials comparing the analgesic effects of adjunctive hypnosis (hypnosis + primary intervention) with those of the primary intervention alone were included. Meta-analyses (random-effects model) calculated mean differences (MD, [95% confidence intervals]) for pain intensity (0-100). Seventy studies were pooled in meta-analyses (n = 6078). Hypnosis adjunctive to usual care had a small additional analgesic effect (chronic pain: -8.2 [-11.8, -1.9]; medical procedures/surgical pain: -6.9 [-10.4, -3.3]; burn wound care: -8.8 [-13.8, -3.9]). Hypnosis adjunctive to education had a medium additional analgesic effect for chronic pain (-11.5 [-19.7, 3.3]) but not postsurgery pain (-2.0 [-7.8, 3.7]). When paired with psychological interventions, hypnosis slightly increased analgesia in chronic pain only at the three-month follow-up (-2 [-3.7, -0.3]). Hypnosis adjunctive to medicines had a medium additional analgesic effect for chronic pain (-13.2, [-22.5, -3.8]). The overall evidence certainty is very low; therefore, there is still uncertainty about the analgesic effects of adjunctive hypnosis. However, hypnosis adjunct to education may reduce pain intensity for chronic pain. Clarification of proposed therapeutic targets of adjunctive hypnosis to evaluate underlying mechanisms is warranted.

Celiac disease: Guideline update overview

ABSTRACT

The American College of Gastroenterology revised its recommendations for diagnosing and managing celiac disease in its updated 2023 clinical guideline. Celiac disease is an autoimmune disorder causing malabsorption following exposure to gluten. A wide range of both gastrointestinal and nongastrointestinal signs and symptoms can occur. This article provides an overview of the diagnosis and management of celiac disease, aiding the NP in developing a greater awareness of the condition both to diagnose it and to refer patients as needed to gastroenterology for evaluation.

Effect of Brain-Gut Behavioral Treatments on Abdominal Pain in Irritable Bowel Syndrome: Systematic Review and Network Meta-Analysis

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.

Barriers to Engagement with Gastrointestinal Health Management

BACKGROUND

Although behavioral interventions have been effective in gastrointestinal (GI) conditions, barriers exist in implementing these interventions into clinical practice. The majority of previously published studies have focused on workforce limitations and have not considered individual and social determinants of health (SDoH) factors that can impact engagement in GI behavioral healthcare.

AIMS

To characterize barriers to engagement in appointment attendance and health management, explore individual and SDoH factors impacting GI behavioral healthcare engagement, and identify barriers that occur more often for patients with SDoH-related vulnerability (low health literacy and/or financial insecurity).

METHODS

A survey was distributed to adult patients who had been seen in Gastroenterology at the Dartmouth-Hitchcock Medical Center from June 2022 to December 2022.

RESULTS

One hundred participants [mean age = 58 years, 57.1% women] completed the survey. SDoH vulnerability was present in 32.3% of the population. For the entire sample, 73% reported at least one barrier to accessing care and 75% reported at least one factor which impacted health management. Those with SDoH vulnerability reported significantly more barriers to attending appointments and to managing health. In addition, they were significantly more likely to endorse physical health problems, difficulty affording medical bills, pain, mobility issues, trauma experiences, significant stress, and difficulty with concentration.

CONCLUSIONS

Patients in a GI clinic reported multiple barriers to accessing care and participating in health management. Innovative, multi-level strategies are needed to address barriers to ensure that all patients are able to obtain quality GI behavioral health services.

Prevalence and Predictors of Irritable Bowel Syndrome (IBS) Among Medical Students at the University of Sharjah, UAE

Background Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder (FGID), with different subtypes based on symptoms. Psychological stress has been found to have a significant impact on intestinal function and is associated with self-reported IBS and gastrointestinal symptoms. Aims This study aimed to determine the prevalence of irritable bowel syndrome (IBS) among medical students at the University of Sharjah in the United Arab Emirates and to identify potential predictors of IBS. Methods A cross-sectional study was conducted in 2019 at the University of Sharjah. A multistage stratified random sampling technique was employed to recruit undergraduate students from medicine, dentistry, pharmacy, and health sciences colleges. A questionnaire consisting of 27 questions was administered to 471 medical students, which incorporated both standardized tools (Perceived Stress Scale (PSS-4), Hospital Anxiety and Depression Scale (HADS), and Rome IV criteria) and custom-developed sections (demographics and food frequency questionnaire). The data collected was analyzed using descriptive and bivariate statistics. The level of significance was set at 5% (p < 0.05). Results The research found that a moderate prevalence (17.3%) of IBS was present among medical students at UOS, with stress, anxiety, and smoking being the most significant predictors. No significant correlation was found between the occurrence of IBS and both gender and dietary factors. Conclusion The study identified a moderate prevalence (17.3%) of IBS among medical students, in which stress, anxiety, and smoking were the most significant predictors. Screening programs for IBS and psychological problems are recommended, along with stress coping strategies courses and raising awareness among the general population about IBS. The study also suggests conducting similar studies among the general population in the UAE to determine the prevalence of IBS and identify potential risk factors.

Pediatric to adult transition care in neurogastroenterology and motility: A position paper from the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility

Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM.

Trastornos de la interacción cerebro-intestino (trastornos funcionales digestivos): neuromoduladores en la práctica clínica (parte II)

Introducción: este artículo continúa la revisión de los neuromoduladores utilizados en la práctica clínica y su papel en el tratamiento de los diferentes trastornos de la interacción cerebro-intestino (TICI), en particular los gástricos, intestinales y anales. Materiales y métodos: el grupo de trabajo revisó las patologías más frecuentes y los medicamentos según la bibliografía más reciente, y de acuerdo con la mejor evidencia clínica en cada caso. Resultados: debido a la diversidad de trastornos, tipos de estudios y opciones terapéuticas, se decidió presentar aquellas evidencias con los mejores resultados para cada caso, en los que se determinaron las dosis utilizadas, sus resultados y efectos colaterales. Conclusiones: se presenta la mejor evidencia disponible de los medicamentos utilizados en cada TICI; al finalizar se presenta una tabla en la que se resaltan para cada condición clínica los medicamentos más utilizados, sus dosis y sus efectos gastrointestinales, y en otra tabla, los efectos secundarios más importantes. Dado que la evidencia disponible no resulta definitiva, se requiere para cada condición más ensayos clínicos controlados que puedan confirmar la efectividad y seguridad de estos.

Evaluating Equity in Clinical Trial Accessibility: An Analysis of Demographic, Socioeconomic, and Educational Disparities in Irritable Bowel Syndrome Drug Trials

INTRODUCTION

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, imposes a significant economic burden because of its high prevalence and the chronic nature of its symptoms. IBS currently has 7 United States Food and Drug Administration-approved treatments. Despite efforts to improve diversity in randomized controlled trials' participation, significant disparities remain in various medical fields; yet, these have not been thoroughly examined within the context of IBS. We aimed to investigate the demographic, socioeconomic, educational, and geographic disparities in IBS drug trials.

METHODS

We conducted a systematic review of phase 3 randomized controlled trials on United States Food and Drug Administration-approved drugs for the treatment of IBS with constipation and IBS with diarrhea in the United States. Data on participant demographics and trial site locations were extracted and analyzed to identify disparities.

RESULTS

Our analysis included 17 studies encompassing 21 trials with 17,428 participants. Approximately 77.3% of participants were female, with a mean age of 45.4 years. Race was reported in 95% of the trials, but only 35% disclosed ethnicity. White participants constituted the majority at 79.3%. Hispanics accounted for only 5.9%. Counties without trial sites had smaller average population sizes compared with trial and trial-adjacent counties. Socioeconomic indicators such as poverty rates, median household income, educational attainment, and broadband internet access were lower in counties without trial sites, with higher average Area Deprivation Index scores indicating greater deprivation.

DISCUSSION

The findings highlight significant disparities in IBS trial participation across race, ethnicity, gender, and socioeconomic backgrounds. This raises potential concerns about generalizability of trial outcomes and underscores the need for strategies to enhance inclusivity in clinical research.

Sinisan Alleviates Stress-Induced Intestinal Dysfunction and Depressive-like Behaviors in Mice with Irritable Bowel Syndrome by Enhancing the Intestinal Barrier and Modulating Central 5-Hydroxytryptamine

Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder and is strongly associated with an increased risk of depression and anxiety. The brain-gut axis plays an important role in the pathophysiologic changes in IBS, yet effective treatments for IBS are still lacking. Sinisan, originating from the Treatise on Typhoid Fever by the medical sage Zhang Zhongjing, is a classic formula in the Eight Methods of Traditional Chinese Medicine (TCM) that focuses on dispersing the liver and regulating the spleen, relieving depression and transmitting evils, and has been widely used in the treatment of liver-depression and spleen-deficiency, diarrhea, and related liver and stomach disorders. However, the therapeutic effect of sinisan in IBS has not been clarified. The aim of this study was to investigate the effects of sinisan on stress-induced intestinal dysfunction and depressive behavior in IBS mice. We established a diarrhea-predominant irritable bowel syndrome (IBS-D) mouse model using a 4% acetic acid enema combined with restraint stress, and analyzed the results using behavioral tests, relevant test kits, hematoxylin-eosin (HE) staining, immunofluorescence (IF), Western blot (WB), and quantitative fluorescence polymerase chain reaction (qRT-PCR). The results showed that sinisan administration significantly alleviated intestinal dysfunction and depressive-like behaviors in IBS-D mice, improved mild colonic inflammation and intestinal mucosal permeability, up-regulated the expression of tight junction proteins ZO-1 and occludin. Sinisan significantly alleviated intestinal dysfunction and depressive-like behaviors in IBS-D mice by decreasing the expression of TNF-α, promoting the expression of tight junction proteins (occludin, ZO-1) expression, and inhibiting the Tlr4/Myd88 signaling pathway, thereby attenuating the inflammatory response, protecting the intestinal barrier, and alleviating symptoms in the IBS-D mouse model. Taken together, sinisan may ameliorate intestinal inflammation and the intestinal barrier by regulating 5-HT expression and the Tlr4/Myd88 pathway, thereby alleviating stress-induced intestinal dysfunction and depressive behaviors in IBS-D mice.

Traditional Chinese medicine for functional gastrointestinal disorders and inflammatory bowel disease: narrative review of the evidence and potential mechanisms involving the brain-gut axis

Functional gastrointestinal disorders (FGIDs) and inflammatory bowel disease (IBD) are common clinical disorders characterized by recurrent diarrhea and abdominal pain. Although their pathogenesis has not been fully clarified, disruptions in intestinal motility and immune function are widely accepted as contributing factors to both conditions, and the brain-gut axis plays a key role in these processes. Traditional Chinese Medicine (TCM) employs a holistic approach to treatment, considers spleen and stomach impairments and liver abnormality the main pathogenesis of these two diseases, and offers a unique therapeutic strategy that targets these interconnected pathways. Clinical evidence shows the great potential of TCM in treating FGIDs and IBD. This study presents a systematic description of the pathological mechanisms of FGIDs and IBD in the context of the brain-gut axis, discusses clinical and preclinical studies on TCM and acupuncture for the treatment of these diseases, and summarizes TCM targets and pathways for the treatment of FGIDs and IBD, integrating ancient wisdom with contemporary biomedical insights. The alleviating effects of TCM on FGID and IBD symptoms are mainly mediated through the modulation of intestinal immunity and inflammation, sensory transmission, neuroendocrine-immune network, and microbiota and their metabolism through brain-gut axis mechanisms. TCM may be a promising treatment option in controlling FGIDs and IBD; however, further high-quality research is required. This review provides a reference for an in-depth exploration of the interventional effects and mechanisms of TCM in FGIDs and IBD, underscoring TCM's potential to recalibrate the dysregulated brain-gut axis in FGIDs and IBD.

Irritable Bowel Syndrome: Current Landscape of Diagnostic Guidelines and Therapeutic Strategies

Irritable bowel syndrome (IBS) is a disorder of the gut–brain axis with pronounced adverse effects on physical health, psychological health, and overall quality of life. Diagnostic strategies can vary, highlighting a need to synthesize best-practice guidelines. Particularly, the American College of Gastroenterology and the British Society of Gastroenterology both support a positive diagnostic strategy; evaluation with C-reactive protein, fecal calprotectin, and fecal lactoferrin; and evaluation with celiac disease serology. Both guidelines do not support routine colonoscopy, and both differ in recommendations for anorectal physiology testing. Given there is currently no curative treatment available, IBS management focuses on symptomatic relief, and challenges exist in achieving and maintaining this relief. Many treatments, both pharmacologic and nonpharmacologic, exist to alleviate the uncomfortable, painful symptoms of the disorder; however, stratifying the quality of evidence behind each option is critical for application to clinical management and for tailoring this management to each patient. Lifestyle adjustments, especially in relation to diet, can be effective first-line therapies and supplements to pharmacologic therapy. Pharmacologic treatment is broadly categorized in accordance with the subtypes of IBS, with indications for different populations and mechanisms that work to target components of IBS pathophysiology. The aim of this article is to comprehensively compare updated diagnostic guidelines, review standard treatments, and outline recent pharmacologic advancements.

Probiotics plus vitamin D in irritable bowel syndrome: a prospective multicentric non-interventional study

BACKGROUND

Patients with irritable bowel syndrome (IBS) experience recurrent symptoms and anxiety disorders that significantly impact their quality of life (QoL). The aim of the study was to assess in daily practice the benefit of the combination of three probiotic strains (Lactobacillus plantarum CETC 7484 and CETC 7485; Pediococcus acidilactici CECT 7483) plus vitamin D in patients with diarrhea-predominant IBS (IBS-D) or IBS with mixed bowel movements (IBS-M).

METHODS

This was a prospective, multicenter, non-interventional study in adult patients with IBS-D or IBS-M (Rome IV criteria) followed by private-practice gastroenterologists. Patients received daily one sachet of a combination of probiotics (3×109 CFU) and vitamin D (10 μg) for 42 days. The primary endpoint was the responder rate at D42 (≥50% and/or ≥100-point decrease of IBS-Severity Scoring System; IBS-SSS). Gut-related anxiety was measured with the Visceral Sensitivity Index (VSI).

RESULTS

The full analysis set population included 246 patients (mean age, 51.2±15.4 years; women, 73.2%; IBS-D, 56.1%; IBS-M, 43.9%). At D42, among the 89 patients with evaluable data, the responder rate was 62.9% with a mean decrease of IBS-SSS of 146.6±125.9 (P<0.0001). Changes of IBS-SSS were significantly correlated with changes of IBS-QoL (r=-0.78; P<0.0001), HAD-anxiety (r=0.46; P<0.0001), HAD-depression (r=0.61; P<0.001) and VSI (r=0.74; P<0.0001).

CONCLUSIONS

These real-life results are in line with a previous randomized clinical trial demonstrating the benefits of this combination in IBS-D and IBS-M. Symptom relief was associated with improvement of IBS-QoL, anxiety, depression and specifically gut-related anxiety.

Treatment and Management of Gastrointestinal Disorders

This article reviews the evaluation and management of several gastrointestinal disorders that are commonly encountered by gastroenterologists and primary care physicians. With a focus on newer therapies, we discuss the management of chronic constipation, irritable bowel syndrome, Clostridioides difficile infection, gastroparesis, steatotic liver disease, and diverticulitis.

From the kitchen to the medicine cabinet: Examples of food products and supplements used for therapeutic intent

"Food as medicine" has existed for centuries as the foundation of health for many cultures around the globe. It is a practice built on the knowledge that food and diet play important roles in disease prevention and management. Foods that claim to have therapeutic properties are often referred to as functional foods. These foods contain a number of nutritional and nonnutritional compounds that can interact with pharmacologically relevant receptors, either directly or indirectly via their metabolites, to regulate cellular biochemical processes. Although opinions are changing, the concept of food as a therapeutic intervention goes against conventional Western medicine. To provide guidance to clinicians interested in using these products, members of the Food as Medicine working group of the Nutrition Committee NASPGHAN, as part of a two-part review series, have created summaries of several frequently used nutritional products for therapeutic intent (i.e., fermented foods, fiber, and long-chain omega-3 fatty acids) that includes indications, doses, and caveats. Gaps in their use in pediatric patients are discussed. Evidence supporting their use for management of gastrointestinal conditions, especially in the pediatric population, is provided when available.

A Multicenter Randomized Controlled Trial of Microbiome-Based Artificial Intelligence-Assisted Personalized Diet vs Low-Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols Diet: A Novel Approach for the Management of Irritable Bowel Syndrome

INTRODUCTION

Personalized management strategies are pivotal in addressing irritable bowel syndrome (IBS). This multicenter randomized controlled trial focuses on comparing the efficacy of a microbiome-based artificial intelligence-assisted personalized diet (PD) with a low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols diet (FODMAP) for IBS management.

METHODS

One hundred twenty-one patients participated, with 70 assigned to the PD group and 51 to the FODMAP diet group. IBS subtypes, demographics, symptom severity (IBS-SSS), anxiety, depression, and quality of life (IBS-QOL) were evaluated. Both interventions spanned 6 weeks. The trial's primary outcome was the within-individual difference in IBS-SSS compared between intervention groups.

RESULTS

For the primary outcome, there was a change in IBS-SSS of -112.7 for those in the PD group vs -99.9 for those in the FODMAP diet group ( P = 0.29). Significant improvement occurred in IBS-SSS scores ( P < 0.001), frequency ( P < 0.001), abdominal distension ( P < 0.001), and life interference ( P < 0.001) in both groups. In addition, there were significant improvements in anxiety levels and IBS-QOL scores for both groups ( P < 0.001). Importantly, PD was effective in reducing IBS SSS scores across all IBS subtypes IBS-Constipation (IBS-C; P < 0.001), IBS-Diarrhea (IBS-D; P = 0.01), and IBS-Mixed (IBS-M; P < 0.001) while FODMAP diet exhibited comparable improvements in IBS-C ( P = 0.004) and IBS-M ( P < 0.001). PD intervention significantly improved IBS-QOL scores for all subtypes (IBS-C [ P < 0.001], IBS-D [ P < 0.001], and IBS-M [ P = 0.008]) while the FODMAP diet did so for the IBS-C ( P = 0.004) and IBS-D ( P = 0.022). Notably, PD intervention led to significant microbiome diversity shifts ( P < 0.05) and taxa alterations compared with FODMAP diet.

DISCUSSION

The artificial intelligence-assisted PD emerges as a promising approach for comprehensive IBS management. With its ability to address individual variation, the PD approach demonstrates significant symptom relief, enhanced QOL, and notable diversity shifts in the gut microbiome, making it a valuable strategy in the evolving landscape of IBS care.

Functional Abdominal Bloating and Gut Microbiota: An Update

(1) Background: Functional abdominal bloating and distension (FAB/FAD) are common disorders of the gut-brain interaction. Their physiopathology is complex and not completely clarified, although gut microbiota imbalances play a central role. The treatment of FAB/FAD still represents a clinical challenge for both patients and healthcare providers. Gut microbiota modulation strategies might play a crucial role in their management. The aim of this narrative review was to update the current evidence on FAB/FAD, with a focus on gut microbiota. (2) Methods: In October 2023, a review was conducted through the Medline, PubMed, and Embase databases. Selected literature included all available English-edited studies (randomized controlled trials and cross-sectional, cohort, and case-control studies). (3) Results: Twelve studies were selected, most of which investigated the relationship between IBS and microbiota, with bloating being one of its symptoms. The studies suggest that restoring a balanced microbiome appears to be the most promising solution for better management of FAB/FAD. Targeted approaches, such as the use of probiotics, prebiotics, antibiotics such as rifaximin or dietary modifications, may hold the key to alleviating symptoms. Other therapeutic options, such as diet, neuromodulators, and brain-gut behavioral therapies (i.e., cognitive-behavioral therapy) have shown promising outcomes, but strong data are still lacking. (4) Conclusions: Targeted approaches that focus on the gut microbiota, such as the use of probiotics, prebiotics, and antibiotics, are essential in managing FAB/FAD. Understanding the complex relationship between gut microbiota and FAB/FAD is crucial for developing effective treatments. Further studies are needed to explore the specific roles of different microbial populations in patients with FAB/FAD to enhance therapeutic strategies.

Moving beyond Symptom Criteria to Diagnose and Treat Functional Disorders: Patient-Reported Symptoms of Functional Lower Gastrointestinal Disorders Correlate Poorly with Objective Assessment of Luminal Contents Seen on Intestinal Ultrasound

Background/Objectives: The diagnosis of lower functional gastrointestinal disorders (FGIDs) is currently based on subjective and unreliable patient-reported symptoms, with significant clinical overlap between diagnosed phenotypes. Objective biomarkers are urgently sought. Gastrointestinal ultrasound (GIUS) can objectively and non-invasively assess luminal contents. This study aimed to assess the utility of GIUS in phenotyping patients with lower FGIDs. Methods: Patients with lower FGIDs underwent a GIUS and completed the Rome IV Diagnostic Questionnaire, SAGIS questionnaire, and 100 mm VAS score for overall symptom severity. The faecal loading score (FLS) was obtained using a modified Leech score, where an FLS of >37 was consistent with clinically significant constipation. Results: Eighty-eight patients fulfilled the study requirements. In total, 56 met the Rome IV criteria for irritable bowel syndrome (IBS) subtypes, while 23 met the criteria for functional constipation (FC), 4 for functional diarrhoea (FD), and 5 for other diagnoses. Patients reporting constipation-predominant symptoms had a significantly higher median FLS than those describing diarrhoea-predominant symptoms (FLS = 40 [IQR 20.0-53.3] vs. 13.3 [IQR 6.7-40.0], respectively). However, 27% of patients describing diarrhoea had significant faecal loading on GIUS, and of those who described constipation, 34% did not have significant faecal loading. Sensitivity and specificity for the detection of FLS-indicated constipation by the Rome IV criteria were low at 59% and 66%, respectively. Conclusions: The symptom-based diagnosis of FGID subtypes based on the Rome IV criteria is a poor predictor of faecal loading. These findings should prompt further exploration of the limitations of symptom-based assessment and a shift towards physiological assessment of patients with FGIDs such as gastrointestinal ultrasound to develop more targeted therapy. Future research is underway to determine if targeting objective physiological endpoints results in improved clinical outcomes.

Prospect and Challenges of Volatile Organic Compound Breath Testing in Non-Cancer Gastrointestinal Disorders

Breath analysis, despite being an overlooked biomatrix, has a rich history in disease diagnosis. However, volatile organic compounds (VOCs) have yet to establish themselves as clinically validated biomarkers for specific diseases. As focusing solely on late-stage or malignant disease biomarkers may have limited relevance in clinical practice, the objective of this review is to explore the potential of VOC breath tests for the diagnosis of non-cancer diseases: (1) Precancerous conditions like gastro-esophageal reflux disease (GERD) and Barrett's esophagus (BE), where breath tests can complement endoscopic screening; (2) endoluminal diseases associated with autoinflammation and dysbiosis, such as inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and coeliac disease, which currently rely on biopsy and symptom-based diagnosis; (3) chronic liver diseases like cirrhosis, hepatic encephalopathy, and non-alcoholic fatty liver disease, which lack non-invasive diagnostic tools for disease progression monitoring and prognostic assessment. A literature search was conducted through EMBASE, MEDLINE, and Cochrane databases, leading to an overview of 24 studies. The characteristics of these studies, including analytical platforms, disorder type and stage, group size, and performance evaluation parameters for diagnostic tests are discussed. Furthermore, how VOCs can be utilized as non-invasive diagnostic tools to complement existing gold standards is explored. By refining study designs, sampling procedures, and comparing VOCs in urine and blood, we can gain a deeper understanding of the metabolic pathways underlying VOCs. This will establish breath analysis as an effective non-invasive method for differential diagnosis and disease monitoring.

Role of Bacillus coagulans (Heyndrickxia coagulans)BCP92 in managing irritable bowel syndrome: A randomized, double-blind, multicenter, placebo-controlled clinical trial

BACKGROUND

Irritable bowel syndrome (IBS) is a major global healthcare burden that requires effective and well-tolerated intervention. This study aimed to investigate the effectiveness and safety of Bacillus coagulans BCP92, a probiotic, in managing IBS symptoms.

METHODS

This randomized controlled trial included 100 participants who strictly adhered to the protocol. Various parameters such as IBS severity, digestive symptom frequency, gastrointestinal symptom frequency, stool consistency, interleukin-6 levels, stress relief, and anxiety levels were evaluated over 12 weeks.

RESULTS

B. coagulans BCP92 significantly improved IBS severity (P < .001), and gastrointestinal symptom frequency (P < .001) compared with that in the control group. The stool consistency significantly improved (P < .001). Mental stress relief was remarkable (P = .001), differentiating the test and control groups. No significant change in interleukin-6 levels was observed; however, the safety assessment revealed an excellent profile with no reported severe adverse events.

CONCLUSION

B. coagulans BCP92 is one of the most promising therapeutic options for the management of IBS because it has shown significant efficacy in alleviating symptoms among patients suffering from this condition, resulting in improved stool consistency changes in addition to improving overall mental well-being for its users, thereby foreseeing the elimination of any potential side effects experienced during the implementation of this approach strategy within our health care system, thereby improving patient outcomes and leading to individualization of treatment plans among all individuals diagnosed with this disease entity who may have symptoms, including abdominal pain or discomfort associated with changes in bowel habits.

Review of the Patient Burden and Therapeutic Landscape of Irritable Bowel Syndrome with Constipation in the United States

Irritable bowel syndrome (IBS) is a common disorder of the gut-brain axis. IBS with constipation (IBS-C) accounts for approximately one-third of IBS cases and is associated with substantial burden of illness and decreased quality of life. This narrative review provides an overview of the current and upcoming treatment options and disease management for IBS-C from a US perspective and discusses the importance of the relationship between patient and health care provider in diagnosis and treatment. A positive diagnostic strategy for IBS-C is recommended, based on clinical history, physical examination, and minimal laboratory tests. An effective communication strategy between patients and health care professionals is essential to ensure early diagnosis and reduce both health care costs and overall disease burden. Treatment typically begins with lifestyle interventions and nonpharmacologic options, such as dietary interventions, fiber supplements, and osmotic laxatives. In patients with inadequate response to these therapies, 4 currently available therapies (lubiprostone, linaclotide, plecanatide, and tenapanor) approved by the US Food and Drug Administration may relieve IBS-C symptoms. These agents are generally well tolerated and efficacious in improving IBS-C symptoms, including constipation and abdominal pain. In patients with persistent abdominal pain and/or psychological symptoms, brain-gut behavioral therapy or neuromodulator therapy may be beneficial.

Healthcare Costs of Irritable Bowel Syndrome and Irritable Bowel Syndrome Subtypes in the United States

INTRODUCTION

Contemporaneous data on healthcare costs of irritable bowel syndrome (IBS) in the United States are lacking. We aimed to estimate all-cause and IBS-specific costs in patients with and without IBS and to compare costs across IBS subtypes.

METHODS

Using Optum's deidentified Clinformatics Data Mart Database, we performed a retrospective cohort analysis of patients with and without IBS using data spanning 2016-2021. Patients with IBS were identified by ICD-10 codes. Controls were randomly selected from Clinformatics Data Mart Database participants. Primary outcomes were total all-cause and IBS-specific healthcare costs. Secondary outcomes were costs of individual services associated with any claim. Costs were compared between IBS and control groups and across IBS subtypes using propensity score weighting. Comorbidities were measured with the Elixhauser Comorbidity Index.

RESULTS

Comparison of 102,887 patients with IBS (77.9% female; mean ± SD age 60.3 ± 18.4 years; 75.8% white) and 102,887 controls demonstrated higher median (interquartile range) total costs per year ( P < 0.001) for patients with IBS ($13,288 [5,307-37,071]) than controls ($5,999 [1,800-19,426]). IBS was associated with increased healthcare utilization and higher median annual costs per patient for all services. Median (interquartile range) annual IBS-specific spending was $1,127 (370-5,544) per patient. Propensity score-weighted analysis across IBS subtypes revealed differences in total all-cause and IBS-specific costs and in costs of individual services. Highest spending was observed in IBS with constipation (all-cause $16,005 [6,384-43,972]; IBS-specific $2,222 [511-7,887]).

DISCUSSION

Individuals with IBS exhibit higher healthcare utilization and incur substantially higher all-cause costs than those without. Care costs differ by IBS subtype.

Short-term effects of bowel function on global health quality of life after radical cystectomy

BACKGROUND

Radical cystectomy (RC) shows an important impact on quality of life (QoL), for various clinical aspects. The aim of our study was to evaluate the short-term bowel function in patients that underwent RC.

METHODS

Two hundred and six patients with MIBC underwent RC with ONB or IC urinary diversion. QoL was measured using the EORTC QLQ C30 and the Short-Form SF-36 questionnaires before surgery and at 12 months postoperatively. Baseline characteristics, including demographic profile, BMI, Charlson Comorbidity Index (CCI), modified Frailty Index (m-FI), pathological tumor stage, Clavien-Dindo grade, and neo-adjuvant chemotherapy were recorded and compared.

RESULTS

The uni-variate and multivariate analysis (OR) were performed for constipation, diarrhea and m-FI of patients underwent RC for localized MIBC according to global health status score (poor/good vs. very good). Multivariate analysis showed that constipation medium/high was significant associated with global health status poor/good (OR=2.39; 95% CI: 1.22-4.71; P=0.01); Diarrhea medium/high was associated with global health status poor/good (OR=2.85; 95% CI:1.18-6.92; P=0.02), and m-FI ≥2 score (OR=2.13; 95% CI: 0.99-4.57; P=0.05).

CONCLUSIONS

Diarrhea and constipation are associated with a lower QoL in cystectomized patients, both with ONB or IC urinary diversion; such association is especially significant in more fragile patients (Frailty Index ≥2).

DOMINO trial post hoc analysis: evaluation of the diet effects on symptoms in IBS subtypes

Background

Irritable bowel syndrome (IBS) is a disorder of gut-brain interaction characterized by recurrent abdominal pain related to defecation and/or associated to a change in bowel habits. According to the stool type, four different IBS subtypes can be recognized, constipation predominant (IBS-C), diarrhea predominant (IBS-D), mixed (IBS-M), and undefined (IBS-U). Patients report that their IBS symptoms are exacerbated by food. Thus, it is important to find a nutritional approach that could be effective in reducing IBS symptoms.

Objective

The present work is a post hoc analysis of the previously published DOMINO trial. It aimed to evaluate the effects of a self-instructed FODMAP-lowering diet smartphone application on symptoms and psychosocial aspects in primary care IBS stratifying the results for each IBS subtypes.

Design

Post hoc analysis.

Methods

Two hundred twenty-two primary care IBS patients followed a FODMAP-lowering diet for 8 weeks with the support of a smartphone application. Two follow-up visits were scheduled after 16 and 24 weeks. IBS-Symptoms Severity Score (IBS-SSS), quality of life (QoL), and adherence and dietary satisfaction were evaluated.

Results

After 8 weeks, IBS-SSS improved in all IBS subtypes (p < 0.0001). Physician Health Questiionnaire (PHQ-15) improved only in IBS-D (p = 0.0006), whereas QoL improved both in IBS-D (p = 0.01) and IBS-M (p = 0.005).

Conclusion

This post hoc analysis showed that the app is useful in all IBS subtypes; thus, it could be used as an effective tool by both general practitioners and patients to manage symptoms in primary care.

Trial registration

Ethical Commission University Hospital of Leuven reference number: S59482. Clinicaltrial.gov reference number: NCT04270487.

Navigating through 65 years of insights: lessons learned on functional abdominal pain in children

In 1958, Apley and Naish authored a groundbreaking paper in Archives of Disease in Childhood, elucidating the epidemiology and risk factors of recurrent abdominal pain in children-a subject that had confounded clinicians of their time. Surprisingly, even after 65 years, there are several unanswered questions regarding the etiology, pathophysiology, and management of pediatric abdominal pain. Contrary to the prevailing notion that children naturally outgrow functional abdominal pain, compelling evidence suggests it's possible these children develop a number of clinically significant psychological issues that could profoundly impact their quality of life and, consequently, future health and educational outcomes. In this light, we aimed to comprehensively review the current literature to update the knowledge of practicing clinicians on functional abdominal pain, summarizing the evidence from the last 65 years.Conclusion: The enduring unanswered questions surrounding childhood abdominal pain continue to challenge clinicians, resulting in unnecessary investigations, thereby contributing to substantial healthcare expenditures. It is also evident that children with long-standing symptoms would progress to adulthood with the potential to develop irritable bowel syndrome and many psychological disturbances. Several key interventions using pharmacological agents, such as amitriptyline, showed that some of these drugs are no more effective than the placebo in clinical trials. Several research during the recent past suggest that psychological interventions such as gut-directed hypnotherapy alleviate symptoms and ensure better prognosis in the long run. Therefore, clinicians and researchers must join hands to explore the pathophysiological mechanisms underpinning functional abdominal pain and novel therapeutic strategies to ensure the well-being of these children. What is Known: • Functional abdominal pain disorders are common among children, with a worldwide prevalence of 13.5% of children suffering from at least one of these disorders • These disorders contribute to a significant reduction in the quality of life of affected children and their families and lead to an array of psychological problems What is New: • The biological basis of functional abdominal pain is becoming more explicit, including complex interactions between altered microbiome, deranged motility, and psychological dysfunction with gut-brain interactions • Novel approaches giving minimal emphasis on pharmacological interventions and exploring psychological interventions are showing promising results.

Diagnostic strategy of irritable bowel syndrome: a low- and middle-income country perspective

Irritable bowel syndrome (IBS) is a highly prevalent gastrointestinal disorder associated with substantial impairment which considerably burdens healthcare systems worldwide. Research on IBS has largely been conducted in high-income countries posing barriers to the application of diagnostic strategies in low- and middle-income countries (LMICs) due to differences in disease characteristics, healthcare resources, and socioeconomic factors. This review discusses the diagnostic issues associated with LMICs. We present a concise overview of the relevant approaches and propose a diagnostic strategy based on the latest evidence. A positive diagnostic strategy that relies on appropriate symptom-based criteria is crucial within the diagnostic framework. A combination of complete blood count, fecal occult blood test, and complete stool test may reliably identify individuals with suspected IBS who are more likely to have organic diseases, thus justifying the necessity for a colonoscopy. Eventually, we developed a diagnostic algorithm based on a limited setting perspective that summarizes the available evidence and may be applied in LMICs.

Presence and characteristics of disordered eating and orthorexia in irritable bowel syndrome

INTRODUCTION

Orthorexia, a harmful obsession with eating healthily, may develop from illnesses characterized by dietary restriction, including irritable bowel syndrome (IBS) and eating disorders (ED). Evidence of disordered eating in IBS exists, but orthorexia has not been assessed. This cross-sectional study in adults (≥18 years) assessed presence and characteristics of disordered eating and orthorexia in IBS, compared to control subjects (CS) and ED.

METHODS

IBS participants met Rome IV, and ED participants met DSM-5 criteria. Disordered eating was assessed using "sick, control, one-stone, fat, food" (SCOFF, ≥2 indicating disordered eating), and orthorexia by the eating habits questionnaire (EHQ). Secondary measures included stress (PSS); anxiety (HADS-A); food-related quality of life (Fr-QoL), and dietary intake (CNAQ).

KEY RESULTS

In 202 IBS (192 female), 34 ED (34 female), and 109 CS (90 female), more IBS (33%) and ED (47%) scored SCOFF≥2 compared to CS (16%, p < 0.001, chi-square). IBS and ED had higher orthorexia symptom severity compared to CS (EHQ IBS 82.9 ± 18.1, ED 90.1 ± 19.6, and CS 73.5 ± 16.9, p < 0.001, one-way ANOVA). IBS and ED did not differ for SCOFF or EHQ (p > 0.05). Those with IBS and disordered eating had higher orthorexia symptom severity (EHQ 78.2 ± 16.6 vs. 92.4 ± 17.5, p < 0.001, independent t-test), worse symptoms (IBS-SSS 211.0 ± 78.4 vs. 244.4 ± 62.5, p = 0.008, Mann-Whitney U test), higher stress (p < 0.001, independent t-test), higher anxiety (p = 0.002, independent t-test), and worse FR-QoL (p < 0.001, independent t-test).

CONCLUSIONS AND INFERENCES

Disordered eating and orthorexia symptoms occur frequently in IBS, particularly in those with worse gastrointestinal symptoms, higher stress, and anxiety. Clinicians could consider these characteristics when prescribing dietary therapies.

Ultra-Processed Food Consumption and Long-Term Risk of Irritable Bowel Syndrome: A Large-Scale Prospective Cohort Study

BACKGROUND & AIMS

The considerable disease burden of irritable bowel syndrome (IBS) has coincided with the increase of ultraprocessed food (UPF) consumption over the past few decades. However, epidemiologic evidence for an association is lacking. We aimed to examine the long-term risk of IBS associated with UPF consumption in a large-scale prospective cohort.

METHODS

Participants who completed 24-hour dietary recalls during 2009 to 2012 from the UK Biobank, and free of IBS, celiac disease, inflammatory bowel disease, and any cancer at baseline, were included (N = 178,711; 53.1% female). UPF consumption was defined according to the NOVA food classification system, expressed as a percentage of UPF content in the total diet intake (as grams per day). The primary outcome was incident IBS. A Cox proportional hazard model was performed to estimate associated risk.

RESULTS

The mean UPF consumption was 21.0% (SD, 11.0%) of the total diet. During a median of 11.3 years of follow-up, 2690 incident IBS cases were identified. An 8% higher risk of IBS (hazard ratio, 1.08; 95% CI, 1.04-1.12) was associated with every 10% increment of UPF consumption. Compared with the lowest quartile of UPF consumption, the highest quartile was associated with a significantly increased risk of incident IBS (hazard ratio, 1.19; 95% CI, 1.07-1.33; Ptrend < .001). Subgroup analyses by age, sex, body mass index, smoking, and alcohol drinking status also showed similar results, except for the never/previous drinking subgroup. Further sensitivity analyses confirmed the positive association with a higher UPF consumption.

CONCLUSIONS

Our findings provide evidence that a higher UPF consumption is associated with an increased risk of incident IBS, with a significant dose-response relationship.

Innovative concepts in diet therapies in disorders of gut-brain interaction

Diet therapy in disorders of gut-brain interaction (DGBI) is rapidly advancing, with accumulating evidence to support two innovative therapies-manipulation of dietary fibers and enzyme supplementation-that target specific DGBI pathophysiology and modulate digestion. Dietary fibers escape digestion in the upper gastrointestinal tract and can influence gut function by impacting digestion, improving laxation, and interacting with the microbiota. A more nuanced understanding of different fiber types and their ability to impact gut function in highly specific ways has shown that fibers can impact distinct gut symptoms and pathophysiology. By considering their functional characteristics of bulking, gel-forming, and fermentability, restriction or supplementation of specific fibers can offer clinical value in DGBI. Similarly to fiber specificity, emerging evidence suggests that supplemental digestive enzymes may be targeted to known food triggers with consideration that enzymes are substrate specific. Limited evidence supports use of lactase to target lactose, and α-galactosidase to target galacto-oligosaccharides. Application of enzymes during manufacturing of food products may prove to be an additional strategy, although evidence is scant. Both innovative therapies may be utilized in isolation or in combination with other diet and nondiet therapies. Implementation can be guided by the principles that fiber modulation can be targeted to specific symptomology or requirement for alterations to gut function, and digestive enzymes can be targeted to known food triggers. This review aims to summarize recent literature of these two innovative concepts and provide practical suggestions for their implementation in clinical practice.

Feeling gutted in chronic kidney disease (CKD): Gastrointestinal disorders and therapies to improve gastrointestinal health in individuals CKD, including those undergoing dialysis

Chronic kidney disease (CKD) affects 9.1% of the population worldwide. CKD may lead to structural and functional gastrointestinal alterations, including impairment in the intestinal barrier, digestion and absorption of nutrients, motility, and changes to the gut microbiome. These changes can lead to increased gastrointestinal symptoms in people with CKD, even in early grades of kidney dysfunction. Gastrointestinal symptoms have been associated with lower quality of life and reduced nutritional status. Therefore, there has been considerable interest in improving gastrointestinal health in this clinical population. Gastrointestinal health can be influenced by lifestyle and medications, particularly in advanced grades of kidney dysfunction. Therapies focused on gastrointestinal health have been studied, including the use of probiotics, prebiotics, and synbiotics, yielding limited and conflicting results. This review summarizes the alterations in the gastrointestinal tract structure and function and provides an overview of potential nutritional interventions that kidney disease professionals can provide to improve gastrointestinal health in individuals with CKD.

Irritable bowel syndrome: Clinical practice update

ABSTRACT

Irritable bowel syndrome (IBS) is a common and burdensome disorder characterized by chronic recurrent abdominal pain and altered bowel habits. IBS remains misunderstood, leading to delayed diagnosis, impaired quality of life, and substantial healthcare costs. Advancing clinicians' understanding of this complex biopsychosocial process, using a positive diagnostic strategy rather than a diagnosis of exclusion, and incorporating a multimodal treatment approach expedite time to diagnosis, facilitate symptom relief, and reduce financial expenditure.

Determination of the Frequency of Celiac Disease in Patients Presenting With Chronic Diarrhea

INTRODUCTION

Celiac disease (CD) is a chronic inflammatory disorder affecting mainly the digestive system and accounts for more than 50% of adult cases presenting to the gastrointestinal clinic with chronic diarrhea. Therefore, in our study, we aimed to determine the prevalence of CD in patients presenting with chronic diarrhea at the gastroenterology outpatient department of Jinnah Hospital, Lahore.

METHODS

This cross-sectional study was conducted from December 9, 2021, to June 8, 2022, and included 140 patients aged 18 to 50 years with chronic diarrhea. Exclusion criteria were lack of informed consent and history of abdominal trauma or surgery. Data collected included age, gender, family history of CD, and clinical symptoms. Diagnostic measures involved serum tissue transglutaminase antibody IgA and IgG levels, endoscopy, and duodenal biopsy. Statistical analysis was performed using SPSS version 23 (IBM Corp, Armonk, NY), with a p-value of ≤0.05 considered significant.

RESULTS

Among the 140 patients, 80 (57.14%) were males, with a mean age of 21 ± 4.35 years. Common symptoms included weight loss (73.5%), abdominal pain (20.7%), and stunted growth (5.7%). A family history of CD was reported in 14.29% of patients. Endoscopy findings included fissuring of the duodenal mucosa (77.9%), decreased height of duodenal folds (15.7%), and nodularity (6.4%). Histopathological examination revealed Marsh III b (65%), Marsh III c (21.4%), and Marsh III a (9.3%). CD was diagnosed in 23.57% of patients. Significant associations were found between CD and female gender, family history of CD, weight loss, stunted growth, and Marsh III c histopathology.

CONCLUSION

CD was diagnosed in 23.57% of patients with chronic diarrhea. It was more prevalent in females and those with a family history of CD. These findings emphasize the need for considering CD in the differential diagnosis of chronic diarrhea to ensure early detection and management.

The impact of transcutaneous electrical acustimulation (TEA) on rectal distension-induced pain in patients with irritable bowel syndrome (IBS)-A study to determine the optimal TEA delivery modalities and effects on rectal sensation and autonomic function

BACKGROUND

Treatment options for abdominal pain in IBS are inadequate. TEA was reported effective treatment of disorders of gut-brain interaction but its mechanism of action and optimal delivery method for treating pain in IBS are unknown. This study aims to determine the most effective TEA parameter and location to treat abdominal pain in patients with IBS-Constipation and delineate the effect of TEA on rectal sensation and autonomic function.

METHODS

Nineteen IBS-C patients underwent TEA at acupoints ST36 (leg), PC6 (wrist), or sham-acupoint. Each patient was studied in five randomized sessions on separate days: (1) TEA/ST36-100 Hz; (2) TEA/ST36-25 Hz; (3) TEA/PC6-100 Hz; (4) TEA/PC6-25 Hz; (5) TEA/Sham-25 Hz. In each session, barostat-guided rectal distention (RD) was performed before and after TEA. Patients graded the RD-induced pain and recorded three rectal sensation thresholds. A heart rate variability (HRV) signal was derived from the electrocardiogram for autonomic function assessment.

KEY RESULTS

Studied patients were predominantly female, young, and Caucasian. Compared with baseline, patients treated with TEA/ST36-100 Hz had significantly decreased pain scores at RD pressure-points 20-50 mmHg (p < 0.04). The average pain reduction was 40%. Post-treatment scores did not change significantly with other TEA modalities except with sham-TEA (lesser degree compared to ST36-100 Hz, p = 0.04). TEA/ST36-100, but not other modalities, increased the rectal sensation threshold (first sensation: p = 0.007; urge to defecate: p < 0.026). TEA/ST36-100 Hz was the only treatment that significantly decreased sympathetic activity and increased parasympathetic activity with and without RD (p < 0.04).

CONCLUSIONS & INFERENCES

TEA at ST36-100 Hz is superior stimulation point/parameter, compared to TEA at PC-6/sham-TEA, to reduce rectal distension-induced pain in IBS-C patients. This therapeutic effect appears to be mediated through rectal hypersensitivity reduction and autonomic function modulation.

Real-world outcomes for a digital prescription mobile application for adults with irritable bowel syndrome

BACKGROUND

Mahana™ IBS is a Food and Drug Administration-cleared prescription mobile application designed to deliver 3 months of gut-directed cognitive behavioral therapy (CBT) to adults ≥22 years old with irritable bowel syndrome (IBS). We assessed whether gut-directed CBT delivered digitally improved outcomes in IBS management.

METHODS

We studied users who had a dispensed physician prescription for Mahana™ IBS between August 2021 and August 2023. The primary outcome was change in IBS symptom severity (IBS-SSS) score.

KEY RESULTS

For the 843 patients, 324 (38%) completed half of the program up to session 5, and 162 (19%) of participants completed the full program up to session 10. Median age was 41 years, median IBS-SSS was 270 (moderate severity), IBS-mixed subtype was most common (23%) followed by IBS-C (20%) and IBS-D (19%). The change in IBS-SSS was -81.0 (p = < 0.001) after session 5 and - 104.4 (p = < 0.001) after session 10. In multivariate analyses, a higher baseline IBS-SSS (OR 1.59; 95% CI 1.26-2.01) and high baseline Perceived Stress Scale (PSS) score predicted non-response (OR 0.95; 95% CI 0.91-0.98) while older age (OR 1.10 per decade; 95% CI 1.01-1.20), prescription source from a healthcare provider (as opposed to third party telehealth encounter, OR 1.48; 95% CI 1.07-2.05), and payment for the app (OR 1.93; 95% CI 1.41-2.63) predicted adherence.

CONCLUSIONS & INFERENCES

Use of a digital mobile application for gut-directed CBT improved symptoms of IBS. Digital health applications have the potential to democratize CBT and allow integrated care to scale for patients with IBS.

Postprandial symptoms in disorders of gut-brain interaction and their potential as a treatment target

Postprandial, or meal-related, symptoms, such as abdominal pain, early satiation, fullness or bloating, are often reported by patients with disorders of gut-brain interaction, including functional dyspepsia (FD) or irritable bowel syndrome (IBS). We propose that postprandial symptoms arise via a distinct pathophysiological process. A physiological or psychological insult, for example, acute enteric infection, leads to loss of tolerance to a previously tolerated oral food antigen. This enables interaction of both the microbiota and the food antigen itself with the immune system, causing a localised immunological response, with activation of eosinophils and mast cells, and release of inflammatory mediators, including histamine and cytokines. These have more widespread systemic effects, including triggering nociceptive nerves and altering mood. Dietary interventions, including a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols, elimination of potential food antigens or gluten, IgG food sensitivity diets or salicylate restriction may benefit some patients with IBS or FD. This could be because the restriction of these foods or dietary components modulates this pathophysiological process. Similarly, drugs including proton pump inhibitors, histamine-receptor antagonists, mast cell stabilisers or even tricyclic or tetracyclic antidepressants, which have anti-histaminergic actions, all of which are potential treatments for FD and IBS, act on one or more of these mechanisms. It seems unlikely that food antigens driving intestinal immune activation are the entire explanation for postprandial symptoms in FD and IBS. In others, fermentation of intestinal carbohydrates, with gas release altering reflex responses, adverse reactions to food chemicals, central mechanisms or nocebo effects may dominate. However, if the concept that postprandial symptoms arise from food antigens driving an immune response in the gastrointestinal tract in a subset of patients is correct, it is paradigm-shifting, because if the choice of treatment were based on one or more of these therapeutic targets, patient outcomes may be improved.

[HYPNOSTRESS study: Interest of medical hypnosis in the evaluation of perceived stress and the experience of hospitalization in an internal medicine department]

BACKGROUND

Patients with chronic illnesses, especially rare autoimmune and/or systemic diseases associated with significant diagnostic uncertainty, have a representation of their illness and a sometimes prolonged hospitalization experience that can be traumatic and anxiety-provoking.

OBJECTIVE

The aim of this study was to evaluate the impact of a non-medicinal medical hypnosis intervention in reducing the stress state and improving the experience of patients hospitalized in an internal medicine department.

METHODS

We conducted a prospective study of 24 patients hospitalized in the Internal Medicine Department of Lille University Hospital in 2023. Twelve patients received a non-drug medical hypnosis intervention known as the "place of safety" (case group) and were compared with 12 patients who did not (control group). Stress was assessed by the STAI questionnaire and hospitalization experience by a satisfaction questionnaire.

RESULTS

The 24 patients, 13 of whom were women, had a mean age of 55±17 years at inclusion. On admission to hospital, the median STAI-ETAT between the two groups was 43.5 (38.0; 56.6) in the case group versus 42.0 (37.0; 48.5) in the control group (P=0.45). In the case group, the median STAI-ETAT questionnaire taken immediately after the hypnosis session was significantly lower than at the start of hospitalization (30.0 [25.5; 36.5] vs. 43.5 [38.0; 56.5] P=0.003), indicating a significant reduction in stress. At the end of hospitalization, there was also a significant persistence of the median significant reduction between cases and controls (29.5 [26.5; 35.0] for cases vs. 41.5 [33.5; 45.5] for controls P=0.002). Experience of hospitalization was better in the case group (median 5.0 [4.5; 5.0] vs. 4.0 [4.0; 4.5], P=0.016).

CONCLUSION

This study suggests that medical hypnosis is a promising non-medicinal supportive intervention for reducing perceived stress and improving the experience of stress in patients hospitalized on an internal medicine ward.

Intestinal Permeability, Irritable Bowel Syndrome with Constipation, and the Role of Sodium-Hydrogen Exchanger Isoform 3 (NHE3)

Increased intestinal permeability has been identified as one of the many pathophysiological factors associated with the development of irritable bowel syndrome (IBS), a common disorder of gut-brain interaction. The layer of epithelial cells that lines the intestine is permeable to a limited degree, and the amount of paracellular permeability is tightly controlled to enable the absorption of ions, nutrients, and water from the lumen. Increased intestinal permeability to macromolecules can be triggered by a variety of insults, including infections, toxins from food poisoning, or allergens, which in turn cause an inflammatory response and are associated with abdominal pain in patients with IBS. This review article discusses increased intestinal permeability in IBS, focusing on IBS with constipation (IBS-C) through the lens of a patient case with a reported prior diagnosis of "leaky gut syndrome" upon initial contact with a gastrointestinal specialist. We review advantages and disadvantages of several methods of measuring intestinal permeability in patients and discuss when measuring intestinal permeability is appropriate in the therapeutic journey of patients with IBS-C. Furthermore, we discuss a possible mechanism of restoring the intestinal barrier to its healthy state through altering intracellular pH by inhibiting sodium-hydrogen exchanger isoform 3 (NHE3). Tenapanor is a minimally absorbed, small-molecule inhibitor of NHE3 that has been approved by the US Food and Drug Administration for the treatment of IBS-C in adults. Preclinical studies showed that tenapanor may restore the intestinal barrier in IBS-C by affecting the conformation of tight junction proteins via NHE3 inhibition to block the paracellular transport of macromolecules from the intestinal lumen. Testing for increased permeability in patients with IBS-C who experience abdominal pain may help inform the choice of therapeutics and alter patients' misconceptions about "leaky gut syndrome".