An evidence-based position statement on the management of irritable bowel syndrome

The Low FODMAP Diet and Its Application in East and Southeast Asia

There is growing interest in using food choice/dietary change to influence clinical outcomes in patients with irritable bowel syndrome (IBS). The low fermentable oligo-, di-, mono-saccharides, and polyols (FODMAPs) diet is an evidence-based approach that is gaining popularity in many Western countries. The low FODMAP diet is based on restricting dietary intake of short chain carbohydrates that are slowly absorbed or indigestible and not absorbed during passage through the small intestine. These are collectively described as "FODMAPs" and comprise oligosaccharides (mostly fructans, galacto-oligosaccharides), sugar polyols, fructose in excess of glucose, and lactose in lactose malabsorbers. The general strategy of the diet is to avoid foods high in FODMAPs and replace them with foods low in FODMAPs, with long-term restriction limited to what is required to control symptoms. The likely mechanism of action is minimisation of the stimulation of mechanoreceptors exerted by distension of the intestinal lumen with water from osmotic effects and gases from bacterial fermentation in those with visceral hypersensitivity. The success of this dietary approach greatly depends on detailed knowledge about the FODMAP composition of food com - monly consumed in that country. While the content of foods associated with East and Southeast Asian cuisines has not been fully explored, major high FODMAP sources are frequently used and include onion, garlic, shallots, legumes/pulses, and wheat-based products. Thus, this dietary approach holds great promise in treating IBS patients in East and Southeast Asia. The aim of this review is to highlight how the diet is implemented, its efficacy, and troublesome ingredients frequently used in Asian dishes.

Serum biomarkers for irritable bowel syndrome

Background and aim

Irritable bowel syndrome (IBS) is one of the most frequent and common functional gastrointestinal diseases. For its diagnosis, clinical criteria are still used. Our objective was to asses if there are specific serum biomarkers for the diagnosis of IBS, and as secondary purpose we aimed to analyze the specificity and sensitivity – where determined – for the proposed biomarkers.

Methods

We performed a review in order to find potential serum biomarkers useful for the diagnosis of IBS. MEDLINE and Cochrane databases were searched in May 2015. Inclusion criteria were: original studies that assessed serological markers in IBS patients, markers potentially useful for diagnosing IBS or in differentiating subtypes of IBS. Exclusion criteria were biomarkers assessed in IBS patients not for the diagnosis of IBS, but used in order to exclude other conditions or diseases in these patients; or markers that were not addressed to IBS; or papers that assessed only fecal biomarkers, or histological or surrogate - indirect biomarkers.

Results

From the 268 papers retrieved by our initial search, using a modified strategy we identified 58 papers. Out of the 58 papers retrieved by the search, six papers were selected and other nine studies were eventually analyzed. Of the results of the computerized search, a number of papers were not included for various reasons: some were not related to the subject (26), others were not appropriate for the subject (19) because they addressed inflammatory bowel disorders, in others fecal markers were the subject of the study, six were reviews, others were impossible to gain access to (1). Twelve out of the 14 studies included are case-control studies, IBS diagnosis being established in all of the selected results based on the Rome criteria. A higher sensitivity of 81% was found using a combination of markers but with lower specificity, while one study that assessed also a combination of markers, found a higher specificity but sensitivity was only 50 %; none reached the characteristics for an ideal biomarker.

Conclusions

For the moment, just one serum biomarker with a high specificity and sensitivity useful in the diagnosis of IBS was identified. We consider that in the future a combination of several biomarkers could better identify IBS than a single biomarker. Therefore, clinical criteria are still to be used for the diagnosis of IBS in attendance for newer research or validation of results.

Effect of administering a multi-species probiotic mixture on the changes in fecal microbiota and symptoms of irritable bowel syndrome: a randomized, double-blind, placebo-controlled trial

We assessed the effect of multi-species probiotic mixture on the changes in fecal microbiota and irritable bowel syndrome (IBS) symptoms. Eighty-one IBS patients were randomly assigned to receive either probiotic mixture (n = 39; containing Lactobacillus acidophilus, L. rhamnosus, Bifidobacterium breve, B. actis, B. longum, and Streptococcus thermophilus) or placebo (n = 42) for 4 weeks. A questionnaire regarding general symptom relief was administered. The change in total symptom scores (sum of 10 IBS symptoms) and subtotal scores in 4 domains (pain, constipation, diarrhea, and bloating/gas) were evaluated. The change in fecal flora was determined by quantitative real-time PCR. The concentration of probiotic strains significantly increased after ingestion in probiotics group (B. bifidum, p = 0.043; B. lactis, p<0.001; L. acidophilus, p = 0.016; L. rhamnosus, p<0.001). The proportion of patients with adequate symptom relief was higher in probiotics group than in placebo group (74.4% vs 61.9%, p = 0.230). The decrease in total symptom score over time was not significantly different between the groups (p = 0.703). Among subtotal scores of 4 IBS symptom domains, the time effect was significantly different for diarrhea-symptom score between the groups (p = 0.017). A 4-week administration of multi-species probiotic mixture significantly increased the fecal concentration of most probiotic strains and improved diarrhea-symptom scores in IBS patients.

Diagnosis of Irritable Bowel Syndrome: Role of Potential Biomarkers

Irritable bowel syndrome is a disorder diagnosed on symptom-based criteria without inclusion of any objective parameter measurable by known diagnostic methods. Heterogeneity of the disorder and overlapping with more serious organic diseases increase uncertainty for the physician's work and increase the cost of confirming the diagnosis. This paper is an attempt to summarize the efforts to find adequate biomarkers for irritable bowel syndrome, which should shorten the time to diagnosis and reduce the cost. Most of the reviewed papers were observational studies from secondary care institutions. Since publication of the Rome III criteria in 2006, most recent studies use these for the recruitment of IBS patients. This is a positive step forward as future studies should use the same criteria, facilitating comparison of their results. Among the studied biomarkers, most evidence is provided for fecal calprotectin. Cutoff values for fecal calprotectin have still to be investigated prior to inclusion in the irritable bowel syndrome diagnostic algorithm.

Profile of rifaximin and its potential in the treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic functional gastrointestinal disorder characterized by recurrent abdominal pain and abnormal bowel patterns. Alteration in gut flora, visceral hypersensitivity, and abnormal bowel motility are among numerous factors in the complex pathophysiology of IBS. Antibiotics have been used adjunctively to treat IBS for many years but are associated with various systemic side effects. Rifaximin is a nonabsorbable, broad-spectrum antimicrobial that inhibits bacterial RNA synthesis by binding the β-subunit of microbial RNA polymerase. It targets the gastrointestinal tract and works by reducing the quantity of gas-producing bacteria and altering the predominant species of bacteria present. In vivo animal studies suggest additional beneficial mechanisms of rifaximin, including reducing mucosal inflammation and visceral hypersensitivity. Clinical studies have demonstrated that rifaximin improves symptoms associated with IBS, such as bloating, flatulence, stool consistency, and abdominal pain, and has a side-effect profile similar to placebo. Although additional investigation into optimal dosing, treatment duration, and potential resistance is required, rifaximin presents as a safe and beneficial addition to the current management options for IBS.

Herbal prescription Chang'an II repairs intestinal mucosal barrier in rats with post-inflammation irritable bowel syndrome

AIM

The herbal prescription Chang'an II is derived from a classical TCM formula Tong-Xie-Yao-Fang for the treatment of liver-qi stagnation and spleen deficiency syndrome of irritable bowel syndrome (IBS). In this study we investigated the effects of Chang'an II on the intestinal mucosal immune barrier in a rat post-inflammation IBS (PI-IBS) model.

METHODS

A rat model of PI-IBS was established using a multi-stimulation paradigm including early postnatal sibling deprivation, bondage and intrarectal administration of TNBS. Four weeks after TNBS administration, the rats were treated with Chang'an II (2.85, 5.71 and 11.42 g · kg(-1) · d(-1), ig) for 14 d. Intestinal sensitivity was assessed based on the abdominal withdrawal reflex (AWR) scores and fecal water content. Open field test and two-bottle sucrose intake test were used to evaluate the behavioral changes. CD4(+) and CD8(+) cells were counted and IL-1β and IL-4 levels were measured in intestinal mucosa. Transmission electron microscopy was used to evaluate ultrastructural changes of the intestinal mucosal barrier.

RESULTS

PI-IBS model rats showed significantly increased AWR reactivity and fecal water content, and decreased locomotor activity and sucrose intake. Chang'an II treatment not only reduced AWR reactivity and fecal water content, but also suppressed the anxiety and depressive behaviors. Ultrastructural study revealed that the gut mucosal barrier function was severely damaged in PI-IBS model rats, whereas Chang'an II treatment relieved intestinal mucosal inflammation and repaired the gut mucosal barrier. Furthermore, PI-IBS model rats showed a significantly reduced CD4(+)/CD8(+) cell ratio in lamina propria and submucosa, and increased IL-1β and reduced IL-4 expression in intestinal mucosa, whereas Chang'an II treatment reversed PI-IBS-induced changes in CD4(+)/CD8(+) cell ratio and expression of IL-1β and IL-4.

CONCLUSION

Chang'an II treatment protects the intestinal mucosa against PI-IBS through anti-inflammatory, immunomodulatory and anti-anxiety effects.

Therapeutic strategies for functional dyspepsia and irritable bowel syndrome based on pathophysiology

Functional gastrointestinal disorders (FGIDs) are common and distressing. They are so named because a defined pathophysiology in terms of structural or biochemical pathways is lacking. Traditionally FGIDs have been conceptualized as brain-gut disorders, with subgroups of patients demonstrating visceral hypersensitivity and motility abnormalities as well as psychological distress. However, it is becoming apparent that there are certain structural or biochemical gut alterations among subsets with the common FGIDs, most notably functional dyspepsia (FD) and irritable bowel syndrome (IBS). For example, a sodium channel mutation has been identified in IBS that may account for 2 % of cases, and subtle intestinal inflammation has been observed in both IBS and FD. Other research has implicated early life events and stress, autoimmune disorders and atopy and infections, the gut microbiome and disordered mucosal immune activation in patients with IBS or FD. Understanding the origin of symptoms in FGIDs will allow therapy to be targeted at the pathophysiological changes, not at merely alleviating symptoms, and holds hope for eventual cure in some cases. For example, there are promising developments in manipulating the microbiome through diet, prebiotics and antibiotics in IBS, and testing and treating patients for Helicobacter pylori infection remains a mainstay of therapy in patients with dyspepsia and this infection. Locally acting drugs such as linaclotide have been an advance in treating the symptoms of constipation-predominant IBS, but do not alter the natural history of the disease. A role for a holistic approach to patients with FGIDs is warranted, as brain-to-gut and gut-to-brain pathways appear to be activated.

Irritable Bowel Syndrome: Yoga as Remedial Therapy

Irritable bowel syndrome (IBS) is a group of symptoms manifesting as a functional gastrointestinal (GI) disorder in which patients experience abdominal pain, discomfort, and bloating that is often relieved with defecation. IBS is often associated with a host of secondary comorbidities such as anxiety, depression, headaches, and fatigue. In this review, we examined the basic principles of Pancha Kosha (five sheaths of human existence) concept from an Indian scripture Taittiriya Upanishad and the pathophysiology of a disease from the Yoga approach, Yoga Vasistha's Adhi (originated from mind) and Vyadhi (ailment/disease) concept. An analogy between the age old, the most profound concept of Adhi-Vyadhi, and modern scientific stress-induced dysregulation of brain-gut axis, as it relates to IBS that could pave way for impacting IBS, is emphasized. Based on these perspectives, a plausible Yoga module as a remedial therapy is provided to better manage the primary and secondary symptoms of IBS.

A systematic review of integrated traditional Chinese and Western medicine for managing irritable bowel syndrome

Traditional Chinese medicine (TCM) has been commonly used by Chinese practitioners to treat irritable bowel syndrome (IBS). However, the effectiveness of combining TCM with Western medicine in managing IBS has not been evaluated systematically. In this study, we evaluated the clinical effectiveness of combining TCM and Western medicine in the treatment of IBS via meta-analyses. We reviewed 72 eligible randomized controlled trials from January 2009 to December 2013 investigating the effectiveness of integrated TCM and Western medicine in the management of IBS. In the meta-analyses, the relative risks (RRs) and 95% confidence interval (95%CI) were calculated using raw data from each study, and low heterogeneity was detected. When compared to the Western medicine treatment alone, our result showed TCM combined with Western interventions significantly improved IBS global symptoms (RR, 1.21; 95%CI: 1.18-1.24). Additionally, there was no significant difference in therapeutic effects of the integrated approach in the meta-analyses involving the various IBS subtypes. Likewise, both Chinese proprietary herbal medicine plus conventional treatment and compound herbal preparations plus conventional treatment showed similar and statistically significant effects on global improvement compared with western treatment alone, with RRs of 1.22 (95%CI: 1.14-1.30) and 1.22 (95%CI: 1.18-1.27), respectively. These results demonstrated that treating IBS with integrated traditional Chinese and Western medicines showed better effectiveness than conventional Western medicine alone. Although due to the quality of the included studies, our results might possess a high risk of bias. TCM, particularly Chinese proprietary medicine, with the benefits of low-cost, easy to use, and good palatability, would be an attractive option to be used in conjunction with conventional Western medicine to manage IBS patients.

The efficacy of Shugan Jianpi Zhixie therapy for diarrhea-predominant irritable bowel syndrome: a meta-analysis of randomized, double-blind, placebo-controlled trials

Background

Shugan Jianpi Zhixie therapy (SJZT) has been widely used to treat diarrhea-predominant irritable bowel syndrome (IBS-D), but the results are still controversial. A meta-analysis of randomized, double-blind, placebo-controlled trials was performed to assess the efficacy and tolerability of SJZT for IBS-D.

Methods

The MEDLINE, EMBASE, Cochrane Library, the China National Knowledge Infrastructure database, the Chinese Biomedical Literature database and the Wanfang database were searched up to June 2014 with no language restrictions. Summary estimates, including 95% confidence intervals (CI), were calculated for global symptom improvement, abdominal pain improvement, and Symptom Severity Scale (BSS) score.

Results

Seven trials (N=954) were included. The overall risk of bias assessment was low. SJZT showed significant improvement for global symptom compared to placebo (RR 1.61; 95% CI 1.24, 2.10; P =0.0004; therapeutic gain = 33.0%; number needed to treat (NNT) = 3.0). SJZT was significantly more likely to reduce overall BSS score (SMD –0.67; 95% CI –0.94, –0.40; P < 0.00001) and improve abdominal pain (RR 4.34; 95% CI 2.64, 7.14; P < 0.00001) than placebo. The adverse events of SJZT were no different from those of placebo.

Conclusions

This meta-analysis suggests that SJZT is an effective and safe therapy option for patients with IBS-D. However, due to the high clinical heterogeneity and small sample size of the included trials, further standardized preparation, large-scale and rigorously designed trials are needed.

Imaging for chronic abdominal pain in adults

Diagnostic imaging is often not indicated in chronic abdominal pain. In particular, undifferentiated abdominal pain is rarely an indication for a CT scan. CT scanning is overused even when imaging is required. Other modalities may be preferable. A normal CT scan does not rule out cancer. Alarm symptoms, including anaemia, blood in the stool, waking at night with gastrointestinal symptoms, and weight loss, should be investigated. The most appropriate modality depends on the symptoms. Clinical information on request forms for CT scans should be specific and include the suspected condition as this helps the radiologist to determine an appropriate imaging protocol.

New therapeutic option for irritable bowel syndrome: Serum-derived bovine immunoglobulin

Oral prescription medical foods have long been used in hospital settings but are also appropriate therapies for gastrointestinal disorders in outpatient medical practice. Oral serum-derived bovine immunoglobulin/protein isolate (SBI) has been shown in clinical studies to reduce loose stools and improve stool consistency as well as other symptoms (i.e., abdominal pain, bloating, and urgency) in patients with irritable bowel syndrome with diarrhea (IBS-D) and human immunodeficiency virus-associated enteropathy. This case series reports the outcomes of 14 IBS patients who received SBI as an addition to standard of care at an individual physician’s clinical practice. The patients: 2 IBS with constipation (IBS-C), 7 IBS-D, 2 mixed diarrhea and constipation IBS (IBS-M) and 3 undefined IBS (IBS-U; also described by some physicians as IBS-Bloating), ranged in age from 22-87 years. SBI (5 g or 10 g daily dose) was added to the patient’s current standard care and followed for several weeks to determine if symptoms were improved with the addition of SBI. Overall, 12 of the 14 patients indicated some level of improvement through direct questioning of the patients regarding changes from the prior visit. One IBS-Bloating patient had a resolution of symptoms and two patients (1 IBS-Bloating and 1 IBS-C) discontinued therapy because of insufficient relief. The 12 patients who continued on therapy reported an overall improvement in symptoms with better stool consistency, decreased frequency as well as reductions in abdominal pain, bloating, distention, and incontinence. In most cases, therapeutic effects of SBI were seen within the first four weeks of therapy with continued improvements at subsequent visits. SBI has a multifaceted mechanism of action and may help to manage IBS by providing a distinct protein source required to normalize bowel function, gastrointestinal microbiota, and nutritionally enhance tight junction protein expression between intestinal epithelial cells. SBI as a medical food provides a safe option for patients with IBS-D but may have application in other forms of IBS.

Effect of Changkang Fang on serotonin transporter expression in brain-gut axis of visceral hypersensitive rats with irritable bowel syndrome

AIM: To investigate the effect of Changkang Fang on the expression of serotonin transporter (SERT) in the brain-gut axis of visceral hypersensitive rats with irritable bowel syndrome (IBS).

METHODS: Seventy-two male immature SD rats were randomly divided into either a blank control group or a model group. AL-Chaer's modeling method was used in this study. After successful modeling, the model rats were randomly divided into a model group, a Western medicine group, high-, medium- and low-dose Chinese medicine groups. After 70 d, brain and intestinal mucosal tissues were taken for detecting the expression of SERT by immunohistochemistry.

RESULTS: The expression levels of SERT in intestinal mucosal and brain tissues of visceral hypersensitive IBS rats were significantly lower compared with normal controls (P < 0.05, P < 0.001). The expression levels of SERT in intestinal mucosal and brain tissues were significantly improved in the high-dose Chinese medicine group (P < 0.001 for both) and the medium-dose Chinese medicine group (P < 0.001, P < 0.05).

CONCLUSION: Changkang Fang can regulate the expression of SERT in the brain-gut axis of visceral hypersensitive IBS rats.

Childhood functional abdominal pain: mechanisms and management

Chronic abdominal pain is one of the most common clinical syndromes encountered in day to day clinical paediatric practice. Although common, its definition is confusing, predisposing factors are poorly understood and the pathophysiological mechanisms are not clear. The prevailing viewpoint in the pathogenesis involves the inter-relationship between changes in hypersensitivity and altered motility, to which several risk factors have been linked. Making a diagnosis of functional abdominal pain can be a challenge, as it is unclear which further diagnostic tests are necessary to exclude an organic cause. Moreover, large, well-performed, high-quality clinical trials for effective agents are lacking, which undermines evidence-based treatment. This Review summarizes current knowledge regarding the epidemiology, pathophysiology, risk factors and diagnostic work-up of functional abdominal pain. Finally, management options for children with functional abdominal pain are discussed including medications, dietary interventions, probiotics and psychological and complementary therapies, to improve understanding and to maximize the quality of care for children with this condition.

Evidence-Based Approach to Fiber Supplements and Clinically Meaningful Health Benefits, Part 2: What to Look for and How to Recommend an Effective Fiber Therapy

Dietary fiber that is intrinsic and intact in fiber-rich foods (eg, fruits, vegetables, legumes, whole grains) is widely recognized to have beneficial effects on health when consumed at recommended levels (25 g/d for adult women, 38 g/d for adult men). Most (90%) of the US population does not consume this level of dietary fiber, averaging only 15 g/d. In an attempt to bridge this “fiber gap,” many consumers are turning to fiber supplements, which are typically isolated from a single source. Fiber supplements cannot be presumed to provide the health benefits that are associated with dietary fiber from whole foods. Of the fiber supplements on the market today, only a minority possess the physical characteristics that underlie the mechanisms driving clinically meaningful health benefits. In this 2-part series, the first part (previous issue) described the 4 main characteristics of fiber supplements that drive clinical efficacy (solubility, degree/rate of fermentation, viscosity, and gel formation), the 4 clinically meaningful designations that identify which health benefits are associated with specific fibers, and the gel-dependent mechanisms in the small bowel that drive specific health benefits (eg, cholesterol lowering, improved glycemic control). The second part (current issue) of this 2-part series will focus on the effects of fiber supplements in the large bowel, including the 2 mechanisms by which fiber prevents/relieves constipation (insoluble mechanical irritant and soluble gel-dependent water-holding capacity), the gel-dependent mechanism for attenuating diarrhea and normalizing stool form in irritable bowel syndrome, and the combined large bowel/small bowel fiber effects for weight loss/maintenance. The second part will also discuss how processing for marketed products can attenuate efficacy, why fiber supplements can cause gastrointestinal symptoms, and how to avoid symptoms for better long-term compliance.

Treatment of irritable bowel syndrome in China: A review

Irritable bowel syndrome (IBS) is a common, chronic, functional gastrointestinal disorder with a high incidence rate in the general population, and it is common among the Chinese population. The pathophysiology, etiology and pathogenesis of IBS are poorly understood, with no evidence of inflammatory, anatomic, metabolic, or neoplastic factors to explain the symptoms. Treatment approaches are mainly focused on symptom management to maintain everyday functioning and to improve quality of life for patients with IBS. However, prescribed medications often result in significant side effects, and many IBS sufferers (particularly Chinese) do not improve. Instead of taking a variety of conventional medications, many have turned to taking traditional Chinese medicine or integrated Chinese and Western medicine for remedy. A number of clinical trials have shown that Chinese herbal, acupuncture or integrative therapies presented improved treatment outcomes and reduced side effects in IBS patients. The purpose of this review article is to examine the treatment approaches of IBS that have been published in recent years, especially in China, to assess the possible differences in treating IBS between China and other countries. This would provide some useful information of unique treatment approach in clinical practice for physicians in the management of IBS in China, thus offering more treatment options for IBS patients with potentially better treatment outcomes while reducing the medical cost burden.

An exploration of the barriers to the confident diagnosis of irritable bowel syndrome: A survey among general practitioners, gastroenterologists and experts in five European countries

BACKGROUND

The diagnostic processes for chronic abdominal conditions are challenging. Despite their tendency for diagnostic tests in patients with irritable bowel syndrome (IBS) symptoms, clinicians are encouraged to make a positive diagnosis based on symptom criteria without alarm signs. We explored how European physicians diagnose and manage patients suffering from IBS.

METHODS

We conducted a vignette-based survey to evaluate the diagnostic approaches in four standardized patients with IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), inflammatory bowel disease (IBD) and chronic constipation (CC). General practitioners (GP, n = 104), gastroenterologists (GE, n = 100) and IBS experts (n = 25) from five European countries participated.

RESULTS

Experts showed the highest rates of correct diagnoses (88%-92%) for all cases except CC (only 60%) and were more prone to a positive diagnosis (64%/68% in IBS-C/CC), whereas GEs and GPs tended toward a diagnosis by exclusion (63%/63% and 62%/60% in IBS-C/CC). In the CC vignette, conducting tests was more frequent than prescribing treatment among 44% experts, 63% GEs and 36% GPs. The diagnosis of IBD presented little difficulty for any of the participants.

CONCLUSIONS

This study highlights the difficulties in confidently diagnosing chronic functional bowel conditions, especially for non-experts, whereas IBD caused little difficulty. Differentiating between IBS-C and CC seemed particularly challenging, even for experts.

Human Immunodeficiency Virus-Associated Diarrhea: Still an Issue in the Era of Antiretroviral Therapy

Over half of patients with human immunodeficiency virus (HIV) experience diarrhea that contributes negatively to quality of life and adherence to antiretroviral therapy (ART). Opportunistic infectious agents that cause diarrhea in patients with HIV span the array of protozoa, fungi, viruses, and bacteria. With global use of ART, the incidence of diarrhea because of opportunistic infections has decreased; however, the incidence of noninfectious diarrhea has increased. The etiology of noninfectious diarrhea in patients with HIV is multifactorial and includes ART-associated diarrhea and gastrointestinal damage related to HIV infection (i.e., HIV enteropathy). A basic algorithm for the diagnosis of diarrhea in patients with HIV includes physical examination, a review of medical history, assessment of HIV viral load and CD4+ T cell count, stool microbiologic assessment, and endoscopic evaluation, if needed. For patients with negative diagnostic results, the diagnosis of noninfectious diarrhea may be considered. Pharmacologic options for the treatment of noninfectious diarrhea are primarily supportive; however, the use of many unapproved agents is based on unstudied and anecdotal information. In addition, these agents can be associated with treatment-limiting adverse events (AEs), such as drug-drug interactions with ART regimens, abuse liability, and additional gastrointestinal AEs. Currently, crofelemer, an antisecretory agent, is the only therapy approved in the USA for the symptomatic relief of noninfectious diarrhea in patients with HIV on ART.

Optimal management of constipation associated with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common chronic functional disorder of the gastrointestinal tract, meanly characterized by recurrent abdominal pain or discomfort and altered bowel habit. It is a complex disorder involving biological, environmental, and psychosocial factors. The diagnosis is achieved according to the Rome III criteria provided that organic causes have been excluded. Although IBS does not constitute a life-threatening condition, it has a remarkable prevalence and profoundly reduces the quality of life with burdening socioeconomic costs. One of the principal concerns about IBS is the lack of effective therapeutic options. Up to 40% of patients are not satisfied with any available medications, especially those suffering from chronic constipation. A correct management of IBS with constipation should evolve through a global approach focused on the patient, starting with careful history taking in order to assess the presence of organic diseases that might trigger the disorder. Therefore, the second step is to examine lifestyle, dietary habits, and psychological status. On these bases, a step-up management of disease is recommended: from fiber and bulking agents, to osmotic laxative drugs, to new molecules like lubiprostone and linaclotide. Although new promising tools for relief of bowel-movement-related symptoms are being discovered, a dedicated doctor-patient relationship still seems to be the key for success.

Therapeutic effects of Lactobacillus in treating irritable bowel syndrome: a meta-analysis

OBJECTIVE

As the lack of reliable treatment for irritable bowel syndrome (IBS) prompts interest in the development of new therapies, we aimed to systematically evaluate the effect of Lactobacillus in treating this disease.

METHODS

We searched MEDLIINE, PubMed, Scopus, Web of Science and the Cochrane Central Register of Controlled Trials for the period from 1966 to August 2013 for double-blind, placebo-controlled trials investigating the efficacy of Lactobacillus treatment in the management of IBS. The studies were screened for inclusion based on randomization, controls and reported measurable outcomes. We used the Jadad score to assess the quality of the articles. The STATA 11.0 and Revman 5.0 software packages were used for the meta-analysis. The STATA 11.0 software program was also used to assess indicators of publication bias according to Begg's and Egger's tests.

RESULTS

Six randomized, placebo-controlled clinical trials met the criteria and were included in the meta-analysis. The Jadad score of the articles was >3, and three articles were of high quality. We analyzed the heterogeneity of the studies and found no heterogeneity in the meta-analysis. In the forest plot, the diamond was on the right side of the vertical line and did not intersect with the line. The pooled relative risk for clinical improvement with Lactobacillus treatment was 7.69 (95% confidence interval: 2.33-25.43, p=0.0008). For adults, the pooled relative risk for clinical improvement with Lactobacillus treatment was 17.62 (95% confidence interval: 5.12-60.65, p<0.00001). For children, the pooled relative risk for clinical improvement with Lactobacillus treatment was 3.71 (95% confidence interval:1.05-13.11, p=0.04). Using the STATA 10.0 and Revman 5.0 software programs, we confirmed that Lactobacillus exhibited significant efficacy in treating IBS.

CONCLUSION

Compared with the placebo, Lactobacillus treatment was found to be associated with a significantly higher rate of treatment responders in the overall population with IBS, without any side effects. As to limitations of the analysis, additional research is needed.

Computed tomography colonography in 2014: an update on technique and indications

Twenty years after its introduction, computed tomographic colonography (CTC) has reached its maturity, and it can reasonably be considered the best radiological diagnostic test for imaging colorectal cancer (CRC) and polyps. This examination technique is less invasive than colonoscopy (CS), easy to perform, and standardized. Reduced bowel preparation and colonic distention using carbon dioxide favor patient compliance. Widespread implementation of a new image reconstruction algorithm has minimized radiation exposure, and the use of dedicated software with enhanced views has enabled easier image interpretation. Integration in the routine workflow of a computer-aided detection algorithm reduces perceptual errors, particularly for small polyps. Consolidated evidence from the literature shows that the diagnostic performances for the detection of CRC and large polyps in symptomatic and asymptomatic individuals are similar to CS and are largely superior to barium enema, the latter of which should be strongly discouraged. Favorable data regarding CTC performance open the possibility for many different indications, some of which are already supported by evidence-based data: incomplete, failed, or unfeasible CS; symptomatic, elderly, and frail patients; and investigation of diverticular disease. Other indications are still being debated and, thus, are recommended only if CS is unfeasible: the use of CTC in CRC screening and in surveillance after surgery for CRC or polypectomy. In order for CTC to be used appropriately, contraindications such as acute abdominal conditions (diverticulitis or the acute phase of inflammatory bowel diseases) and surveillance in patients with a long-standing history of ulcerative colitis or Crohn's disease and in those with hereditary colonic syndromes should not be overlooked. This will maximize the benefits of the technique and minimize potential sources of frustration or disappointment for both referring clinicians and patients.

Are IBD patients more likely to have a prior diagnosis of irritable bowel syndrome? Report of a case-control study in the General Practice Research Database

BACKGROUND

Inflammatory bowel disease (IBD) patients are sometimes first diagnosed with irritable bowel syndrome (IBS), which may be construed as a misdiagnosis.

OBJECTIVE

The objective of this article is to determine if this occurs more than expected by chance.

METHODS

We conducted a case-control study nested in the General Practice Research Database. We selected incident cases of IBD and up to 10 matched controls for each. We assessed the proportions with IBS recorded prior to the IBD diagnosis and variation by age, sex, and calendar time. We compared proportions affected in fixed time periods and conducted conditional logistic regression to derive odds ratios.

RESULTS

The 20, 193 cases were three times as likely as controls to have a prior record of IBS. Fifteen per cent of IBD cases and 5% of controls had IBS coded before diagnosis with 11% having a code for IBS over one year before IBD (cf. 5% of controls) and 6% over five years earlier (cf. 3%). These figures roughly doubled if typical antispasmodic therapies were assumed to represent IBS diagnoses.

CONCLUSION

If excess IBS diagnoses represent misdiagnoses of IBD, our results suggest that about 10% of IBD patients are misdiagnosed and in 3% of cases this may persist for five or more years.

Ehealth: Low FODMAP diet vs Lactobacillus rhamnosus GG in irritable bowel syndrome

AIM: To investigate the effects of a low fermentable, oligosaccharides, disaccharides, monosaccharides and polyols diet (LFD) and the probiotic Lactobacillus rhamnosus GG (LGG) in irritable bowel syndrome (IBS).

METHODS: Randomised, unblinded controlled trial on the effect of 6-wk treatment with LFD, LGG or a normal Danish/Western diet (ND) in patients with IBS fulfilling Rome III diagnostic criteria, recruited between November 2009 and April 2013. Patients were required to complete on a weekly basis the IBS severity score system (IBS-SSS) and IBS quality of life (IBS-QOL) questionnaires in a specially developed IBS web self-monitoring application. We investigated whether LFD or LGG could reduce IBS-SSS and improve QOL in IBS patients.

RESULTS: One hundred twenty-three patients (median age 37 years, range: 18-74 years), 90 (73%) females were randomised: 42 to LFD, 41 to LGG and 40 to ND. A significant reduction in mean ± SD of IBS-SSS from baseline to week 6 between LFD vs LGG vs ND was revealed: 133 ± 122 vs 68 ± 107, 133 ± 122 vs 34 ± 95, P < 0.01. Adjusted changes of IBS-SSS for baseline covariates showed statistically significant reduction of IBS-SSS in LFD group compared to ND (IBS-SSS score 75; 95%CI: 24-126, P < 0.01), but not in LGG compared to ND (IBS-SSS score 32; 95%CI: 18-80, P = 0.20). IBS-QOL was not altered significantly in any of the three groups: mean ± SD in LFD 8 ± 18 vs LGG 7 ± 17, LFD 8 ± 18 vs ND 0.1 ± 15, P = 0.13.

CONCLUSION: Both LFD and LGG are efficatious in patients with IBS.

The role of FODMAPs in irritable bowel syndrome

PURPOSE OF REVIEW

Irritable bowel syndrome (IBS) is a condition affecting approximately 10-15% of Western populations. The Rome III criteria are applied to many studies to validate the diagnosis of IBS. The low fermentable oligo, di, monosaccharides and polyol (FODMAP) diet has been the subject of many robust clinical trials and is now used as the primary dietary therapy internationally. This review examines the current evidence for the role of the low FODMAP diet in IBS.

RECENT FINDINGS

Detailed commentary on original research involving FODMAPs and IBS symptoms from 2013 to 2014 is provided.

SUMMARY

The low FODMAP diet has been shown to be an efficacious therapy for reduction of functional gastrointestinal symptoms seen in IBS. Recent publications provide randomized controlled trial and prospective observational evidence in support of the diet for symptom management. The low FODMAP diet appears to be superior to a gluten-free diet in people with self-reported nonceliac gluten sensitivity. Although the low FODMAP diet has not been shown to reduce the prebiotic effect in the colon, total colonic bacterial load was reduced. Further research investigating the potential health implications of both this and the nutritional adequacy of the liberalized low FODMAP diet is required.

Dietary Renaissance in IBS: Has Food Replaced Medications as a Primary Treatment Strategy?

OPINION STATEMENT

The medical community has only recently started to focus attention on the role of food in the pathogenesis of irritable bowel syndrome (IBS), though the association between food and gastrointestinal (GI) symptoms has been recognized by patients for decades. Health care providers receive little formal training in the dietary management of IBS and have traditionally viewed dietary interventions with skepticism. There is mounting evidence that links food to changes in motility, visceral sensation, microbiome, permeability, immune activation, and brain-gut interactions-all key elements in the pathogenesis of IBS. The role of specific dietary modification in the management of IBS has not been rigorously investigated until recently. There is now credible evidence suggesting that targeted dietary carbohydrate exclusion provides clinical benefits to IBS patients. There is emerging evidence to suggest that proteins such as gluten, as well as food chemicals, may play a role in IBS.

The effects of eupatilin (stillen®) on motility of human lower gastrointestinal tracts

Gastrointestinal motility consists of phasic slow-wave contractions and the migrating motor complex (MMC). Eupatilin (Stillen®) has been widely used to treat gastritis and peptic ulcers, and various cytokines and neuropeptides are thought to be involved, which can affect gastrointestinal motility. We performed a study to identify the effects of eupatilin on lower gastrointestinal motility with electromechanical recordings of smooth muscles in the human ileum and colon. Ileum and colon samples were obtained from patients undergoing bowel resection. The tissues were immediately stored in oxygenated Krebs-Ringer's bicarbonate solution, and conventional microelectrode recordings from muscle cells and tension recordings from muscle strips and ileal or colonic segments were performed. Eupatilin was perfused into the tissue chamber, and changes in membrane potentials and contractions were measured. Hyperpolarization of resting membrane potential (RMP) was observed after administration of eupatilin. The amplitude, AUC, and frequency of tension recordings from circular and longitudinal smooth muscle strips and bowel segments of the ileum and colon were significantly decreased after admission of eupatilin. Eupatilin elicited dose-dependent decreases during segmental tension recordings. In conclusion, eupatilin (Stillen®) showed inhibitory effects on the human ileum and colon. We propose that this drug may be useful for treating diseases that increase bowel motility, but further studies are necessary.

Current and emerging pharmacotherapeutic options for irritable bowel syndrome

Treatment of irritable bowel syndrome (IBS) is challenging for both primary care physicians and gastroenterologists because of the heterogeneity of the patient population and the multifactorial pathophysiologies responsible for the symptoms in IBS. This review focuses on the current and emerging pharmacological treatments for IBS. Many of the current medications used to treat this disorder have distinct properties such as efficacy for different symptoms, safety profiles, contraindications, costs, dosing regimens, treatment duration and long-term data. All of these factors, in addition to patient preference and cognitive, food and environmental triggers, must be considered prior to any medication selection. This review will focus on randomized controlled trials with a general uniformity in study design, a rigorous patient selection and appropriate treatment durations. We will also discuss other exciting emerging treatments for IBS such as the µ-opioid receptor (agonists and antagonists), selective κ-opioid receptor agonists, anti-inflammatory drugs, serotonergic agents, bile acid modulators and intestinal bile acid transporters, which may prove promising in treating our patients.

What about OMT and nutrition for managing the irritable bowel syndrome? An overview and treatment plan

A chronic continuous or intermittent gastrointestinal tract dysfunction, the irritable bowel syndrome (IBS), appears to be due to dysregulation of brain-gut-microbiota communication. Furthermore, the "microbiota" greatly impacts the bi-directional brain-gut axis communication. This article describes IBS in relation to similar diseases, presents the background to osteopathy, and proposes osteopathic manipulative treatment (OMT) to manage IBS. In IBS, OMT focuses on the nervous and circulatory systems, spine, viscera, and thoracic and pelvic diaphragms in order to restore homeostatic balance, normalize autonomic activity in the intestine, promote lymphatic flow, and address somatic dysfunction. Lymphatic and venous congestion are treated by the lymphatic pump techniques and stimulation of Chapman׳s reflex points. A simple treatment plan designed to lessen chronic pain and inflammation in IBS is presented based on current evidence-based literature. Since food itself, food allergies, and intolerance could contribute to symptom onset or even cause IBS, this article also provides dietary modifications to consider for patients.

Irritable bowel syndrome: A clinical review

Irritable bowel syndrome (IBS) remains a clinical challenge in the 21^st century. It’s the most commonly diagnosed gastrointestinal condition and also the most common reason for referral to gastroenterology clinics. Its can affect up to one in five people at some point in their lives, and has a significantly impact of life quality and health care utilization. The prevalence varies according to country and criteria used to define IBS. Various mechanisms and theories have been proposed about its etiology, but the biopsychosocial model is the most currently accepted for IBS. The complex of symptoms would be the result of the interaction between psychological, behavioral, psychosocial and environmental factors. The diagnosis of IBS is not confirmed by a specific test or structural abnormality. It is made using criteria based on clinical symptoms such as Rome criteria, unless the symptoms are thought to be atypical. Today the Rome Criteria III is the current gold-standard for the diagnoses of IBS. Secure positive evidence of IBS by means of specific disease marker is currently not possible and cannot be currently recommended for routine diagnosis. There is still no clinical evidence to recommend the use of biomarkers in blood to diagnose IBS. However, a number of different changes in IBS patients were demonstrated in recent years, some of which can be used in the future as a diagnostic support. IBS has no definitive treatment but could be controlled by non-pharmacologic management eliminating of some exacerbating factors such certain drugs, stressor conditions and changes in dietary habits.The traditional pharmacologic management of IBS has been symptom based and several drugs have been used. However, the cornerstone of its therapy is a solid patient physician relationship. This review will provide a summary of pathophysiology, diagnostic criteria and current and emerging therapies for IBS.

Fermentable oligosaccharides, disaccharides, monosaccharides and polyols: role in irritable bowel syndrome

Irritable bowel syndrome (IBS) was previously left poorly treated despite its high prevalence and cost. Over the past decade, significant research has been conducted providing new dietary strategies for IBS management. The 'low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet' has shown symptom improvement in 68-76% of patients. Randomized, controlled trials have now proven its efficacy. The diet, low in poorly absorbed and fermentable carbohydrates, uses dietary restriction and re-challenge to determine individual tolerance to various short-chain carbohydrates. However there may be potential detrimental effects of the diet in the long term, due to potential changes to the gastrointestinal microbiota. Appropriate dietary education and management of the diet is imperative. Future research should focus on the relevance of changes to the microbiota and ways to liberalize the dietary restrictions.

Advances in the management of constipation-predominant irritable bowel syndrome: the role of linaclotide

Constipation-predominant irritable bowel syndrome (IBS-C) is a commonly prevalent and clinically challenging disorder to treat. Until recently, most therapeutic agents had limited ability to address the complexity of symptoms inherent to the syndrome. The development of linaclotide provides a physiologically sound approach to treatment of the multiple symptoms of IBS-C. Clinical trials demonstrate the efficacy of linaclotide, and a platform to better understand the symptomatology of IBS-C. Based on recent clinical evidence, linaclotide should be considered for patients with IBS-C because it improves abdominal pain and bowel symptoms. In phase III trials, linaclotide met the US Food and Drug Administration responder endpoint with a number needed to treat (NNT) of 5.1-7.9, and European Medicines Agency coprimary endpoints at 12 weeks with a NNT of 4.39-7.69, and at 26 weeks with a NNT of 4.93-5.68. It is safe and effective, with diarrhea reported as the most common adverse effect, which leads to discontinuation of the medication in approximately 5% of patients.

An insight into the gastrointestinal component of fibromyalgia: clinical manifestations and potential underlying mechanisms

Fibromyalgia syndrome is characterized by chronic generalized pain accompanied by a broad symptomatologic spectrum. Besides chronic fatigue, sleep disturbances, headaches and cognitive dysfunction that are extensively described in the literature, a considerable proportion of patients with fibromyalgia experience gastrointestinal symptoms that are commonly overlooked in the studies that are not specifically dedicated to evaluate these manifestations. Nevertheless, various attempts were undertaken to explore the gastrointestinal dimension of fibromyalgia. Several studies have demonstrated an elevated comorbidity of irritable bowel syndrome (IBS) among patients with fibromyalgia. Other studies have investigated the frequency of presentation of gastrointestinal symptoms in fibromyalgia in a nonspecific approach describing several gastrointestinal complaints frequently reported by these patients such as abdominal pain, dyspepsia and bowel changes, among others. Several underlying mechanisms that require further investigation could serve as potential explanatory hypotheses for the appearance of such manifestations. These include sensitivity to dietary constituents such as gluten, lactose or FODMAPs or alterations in the brain-gut axis as a result of small intestinal bacterial overgrowth or subclinical enteric infections such as giardiasis. The gastrointestinal component of fibromyalgia constitutes a relevant element of the multidisciplinary pathophysiologic mechanisms underlying fibromyalgia that need to be unveiled, as this would contribute to the adequate designation of relevant treatment alternatives corresponding to these manifestations.

Treatment of abdominal pain in irritable bowel syndrome

Functional abdominal pain in the context of irritable bowel syndrome (IBS) is a challenging problem for primary care physicians, gastroenterologists and pain specialists. We review the evidence for the current and future non-pharmacological and pharmacological treatment options targeting the central nervous system and the gastrointestinal tract. Cognitive interventions such as cognitive behavioral therapy and hypnotherapy have demonstrated excellent results in IBS patients, but the limited availability and labor-intensive nature limit their routine use in daily practice. In patients who are refractory to first-line therapy, tricyclic antidepressants (TCA) and selective serotonin reuptake inhibitors are both effective to obtain symptomatic relief, but only TCAs have been shown to improve abdominal pain in meta-analyses. A diet low in fermentable carbohydrates and polyols (FODMAP) seems effective in subgroups of patients to reduce abdominal pain, bloating, and to improve the stool pattern. The evidence for fiber is limited and only isphagula may be somewhat beneficial. The efficacy of probiotics is difficult to interpret since several strains in different quantities have been used across studies. Antispasmodics, including peppermint oil, are still considered the first-line treatment for abdominal pain in IBS. Second-line therapies for diarrhea-predominant IBS include the non-absorbable antibiotic rifaximin and the 5HT3 antagonists alosetron and ramosetron, although the use of the former is restricted because of the rare risk of ischemic colitis. In laxative-resistant, constipation-predominant IBS, the chloride-secretion stimulating drugs lubiprostone and linaclotide, a guanylate cyclase C agonist that also has direct analgesic effects, reduce abdominal pain and improve the stool pattern.

Helicobacter pylori and functional dyspepsia: An unsolved issue?

Patients with Helicobacter pylori (H. pylori) infection may complain of dyspeptic symptoms without presence of macroscopic lesions on gastroduodenal mucosa. Such a condition is usually recognized as functional dyspepsia, and different pathogenetic mechanisms are involved. The role of H. pylori in these patients is controversial. Several trials assessed the potential role of H. pylori eradication in improving dyspeptic symptoms, and data of some meta-analyses demonstrated that cure of infection is associated with a small (10%), but significant therapeutic gain as compared to placebo. The reason for which dyspeptic symptoms regress in some patients following bacterial eradication, but persist in others remains unclear. Regrettably, trials included in the meta-analyses are somewhat different for study design, definition of symptoms, assessment of symptoms changes, and some may be flawed by potential pitfalls. Consequently, the information could be not consistent. We critically reviewed the main available trials, attempting to address future research in this field

Irritable bowel syndrome: a concise review of current treatment concepts

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders causing patients to seek medical treatment. It is relatively resource intensive and the source of significant morbidity. Recent insights into the pathophysiology and treatment of IBS has given clinicians more options than ever to contend with this disorder. The purpose of our paper is to review older, "classic" treatments for IBS as well as newer agents and "alternative" therapies. We discuss the evidence base of these drugs and provide context to help develop appropriate treatment plans for IBS patients.

Breath volatile organic compounds for the gut-fatty liver axis: Promise, peril, and path forward

The worldwide interest in the gut microbiome and its impact on the upstream liver highlight a critical upside to breath research: it can uniquely measure otherwise unmeasurable biology. Bacteria make gases [volatile organic compounds (VOCs)] that are directly relevant to pathophysiology of the fatty liver and associated conditions, including obesity. Measurement of these VOCs and their metabolites in the exhaled breath, therefore, present an opportunity to safely and easily evaluate, on both a personal and a population level, some of our most pressing public health threats. This is an opportunity that must be pursued. To date, however, breath analysis remains a slowly evolving field which only occasionally impacts clinical research or patient care. One major obstacle to progress is that breath analysis is inherently and emphatically mutli-disciplinary: it connects engineering, chemistry, breath mechanics, biology and medicine. Unbalanced or incomplete teams may produce inconsistent and often unsatisfactory results. A second impediment is the lack of a well-known stepwise structure for the development of non-invasive diagnostics. As a result, the breath research landscape is replete with orphaned single-center pilot studies. Often, important hypotheses and key observations have not been pursued to maturation. This paper reviews the rationale and requirements for breath VOC research applied to the gut-fatty liver axis and offers some suggestions for future development.

Irritable bowel syndrome: A disease still searching for pathogenesis, diagnosis and therapy

Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder in primary and secondary care. It is characterised by abdominal discomfort, pain and changes in bowel habits that can have a serious impact on the patient’s quality of life. The pathophysiology of IBS is not yet completely clear. Genetic, immune, environmental, inflammatory, neurological and psychological factors, in addition to visceral hypersensitivity, can all play an important role, one that most likely involves the complex interactions between the gut and the brain (gut-brain axis). The diagnosis of IBS can only be made on the basis of the symptoms of the Rome III criteria. Because the probability of organic disease in patients fulfilling the IBS criteria is very low, a careful medical history is critical and should pay particular attention to the possible comorbidities. Nevertheless, the severity of the patient’s symptoms or concerns sometimes compels the physician to perform useless and/or expensive diagnostic tests, transforming IBS into a diagnosis of exclusion. The presence of alarming symptoms (fever, weight loss, rectal bleeding, significant changes in blood chemistry), the presence of palpable abdominal masses, any recent onset of symptoms in patient aged over 50 years, the presence of symptoms at night, and a familial history of celiac disease, colorectal cancer and/or inflammatory bowel diseases all warrant investigation. Treatment strategies are based on the nature and severity of the symptoms, the degree of functional impairment of the bowel habits, and the presence of psychosocial disorders. This review examines and discusses the pathophysiological aspects and the diagnostic and therapeutic approaches available for patients with symptoms possibly related to IBS, pointing out controversial issues and the strengths and weaknesses of the current knowledge.

Constipation-predominant irritable bowel syndrome: A review of current and emerging drug therapies

Irritable bowel syndrome (IBS) is a highly prevalent medical condition that adversely affects patient quality of life and constitutes a significant economic burden on healthcare resources. A large proportion of patients suffer from the constipation subtype of IBS (IBS-C), most commonly afflicting older individuals and those with a lower socioeconomic status. Conventional pharmacologic and nonpharmacologic treatment options have limited efficacies and/or significant adverse events, which lead to increased long-term health care expenditures. Failure to effectively treat IBS-C patients over the past decades has largely been due to a poor understanding of disease pathophysiology, lack of a global view of the patient, and an inappropriate selection of patients and treatment endpoints in clinical trials. In recent years, however, more effective and safer drugs have been developed for the treatment of IBS-C. The advancement in the area of pharmacologic treatment is based on new knowledge of the pathophysiologic basis of IBS-C and the development of drugs with increased selectivity within pharmacologic classes with recognized efficacies. This narrative review covers the spectrum of available drugs and their mechanisms of action, as well as the efficacy and safety profiles of each as determined in relevant clinical trials that have investigated treatment options for IBS-C and chronic constipation. A brief summary of laxative-based treatment options is presented, followed by up-to-date assessments for three classes of drugs: prokinetics, prosecretory agents, and bile acid modulators.

Recent advances in pharmacological treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a highly prevalent functional disorder that reduces patients’ quality of life. It is a chronic disorder characterized by abdominal pain or discomfort associated with disordered defecation in the absence of identifiable structural or biochemical abnormalities. IBS imposes a significant economic burden to the healthcare system. Alteration in neurohumoral mechanisms and psychological factors, bacterial overgrowth, genetic factors, gut motility, visceral hypersensitivity, and immune system factors are currently believed to influence the pathogenesis of IBS. It is possible that there is an interaction of one or more of these etiologic factors leading to heterogeneous symptoms of IBS. IBS treatment is predicated upon the patient’s most bothersome symptoms. Despite the wide range of medications and the high prevalence of the disease, to date no completely effective remedy is available. This article reviews the literature from January 2008 to July 2013 on the subject of IBS peripherally acting pharmacological treatment. Drugs are categorized according to their administration for IBS-C, IBS-D or abdominal pain predominant IBS.

Traditional Chinese medicine (Shun-Qi-Tong-Xie Granule) for irritable bowel syndrome: study protocol for a randomised controlled trial

Background

Irritable bowel syndrome (IBS) is a common gastrointestinal functional disorder with no effective therapy. Traditional Chinese medicine (TCM) is one of the most common complementary therapies in China. We designed this study to evaluate the efficacy and safety of Shun-Qi-Tong-Xie Granule (SQTX Granule), a TCM treatment, in patients with IBS with diarrhea (IBS-D).

Methods/Design

A randomised, double-blinded, placebo-controlled, multi-centre, superiority clinical trial to evaluate the efficacy and safety of SQTX Granule is proposed. Eligible patients (Rome III) with IBD-S will be randomly assigned into SQTX Granule group and the placebo group. Patients will receive a 28-day treatment and a 2-month follow-up. The primary outcome measures include the scores of IBS-quality of life (IBS-QOL) rating scale and IBS-symptom severity scale (IBS-SSS) rating scale. The secondary outcome measures include the improvement of symptom scores, and the duration of abdominal pain and diarrhea.

Discussion

According to TCM theory, SQTX Granule has a regulating effect on abdominal pain, diarrhea and the syndrome of liver-spleen disharmony, which is similar to the symptoms of IBS-D. This study will provide objective evidence to evaluate the efficiency and safety of SQTX Granule in IBS-D treatment.

Trial registration

ChiCTR-TRC-14004241.

Date of registration: 9 February 2014.

The effects of multi-strain probiotic compound on symptoms and quality-of-life in patients with irritable bowel syndrome: A randomized placebo-controlled trial

Background:

Evidence has shown beneficial effects of probiotics in the treatment of irritable bowel syndrome (IBS); however, there is still a lack of data in this regard. We evaluated the efficacy of a multi-strain probiotic compound on IBS symptoms and quality-of-life (QOL).

Materials and Methods:

Adult IBS patients (n = 132) were randomized to receive a probiotic compound containing seven bacteria species including Lactobacillus strains, Bifidobacterium strains and Streptococcus thermophiles or similar placebo, twice daily after a meal for 14 consecutive days. Improvement of IBS symptoms was assessed in categories of abdominal pain and distension and improvement of bowel habit. Improvement in patients QOL was assessed by the IBS-QOL instrument. Patients were evaluated for symptoms and QOL at baseline and then 1 month after completion of the treatment.

Results:

After treatment, there was a decrease in abdominal pain and distension severity in both probiotic and the placebo groups (P<0.001), but there was no difference between the two groups in this regard (P>0.05). Improvement in bowel habit was observed in 33.3% of the probiotic and 36.5% of the placebo group (P = 0.910). There was no significant difference between the two groups in QOL after the treatment (P >0.05).

Conclusions:

We found no beneficial effects over placebo for a 2-week treatment with the above mentioned multi-strain probiotic compound in the treatment of IBS. Further, trials are yet required before a clear conclusion in this regards.

Placebo effect in clinical trial design for irritable bowel syndrome

Ongoing efforts to improve clinical trial design in irritable bowel syndrome have been hindered by high placebo response rates and ineffective outcome measures. We assessed established strategies to minimize placebo effect as well as the various approaches to placebo effect which can affect trial design. These include genetic markers such as catechol-O-methyltransferase, opioidergic and dopaminergic neurobiologic theory, pre-cebo effect centered on expectancy theory, and side effect unblinding grounded on conditioning theory. We reviewed endpoints used in the study of IBS over the past decade including adequate relief and subjective global relief, emphasizing their weaknesses in fully evaluating the IBS condition, specifically their motility effects based on functional net value and relative benefit-harm based on dropouts due to adverse events. The focus of this review is to highlight ongoing efforts to improve clinical trial design which can lead to better outcomes in a real-world setting.

Irritable bowel syndrome: Pathogenesis, diagnosis, treatment, and evidence-based medicine

Irritable bowel syndrome (IBS) is a chronic and debilitating functional gastrointestinal disorder that affects 9%-23% of the population across the world. The percentage of patients seeking health care related to IBS approaches 12% in primary care practices and is by far the largest subgroup seen in gastroenterology clinics. It has been well documented that these patients exhibit a poorer quality of life and utilize the health care system to a greater degree than patients without this diagnosis. The pathophysiology of IBS is not clear. Many theories have been put forward, but the exact cause of IBS is still uncertain. According to the updated ROME III criteria, IBS is a clinical diagnosis and presents as one of the three predominant subtypes: (1) IBS with constipation (IBS-C); (2) IBS with diarrhea (IBS-D); and (3) mixed IBS (IBS-M); former ROME definitions refer to IBS-M as alternating IBS (IBS-A). Across the IBS subtypes, the presentation of symptoms may vary among patients and change over time. Patients report the most distressing symptoms to be abdominal pain, straining, myalgias, urgency, bloating and feelings of serious illness. The complexity and diversity of IBS presentation makes treatment difficult. Although there are reviews and guidelines for treating IBS, they focus on the efficacy of medications for IBS symptoms using high-priority endpoints, leaving those of lower priority largely unreported. Therefore, the aim of this review is to provide a comprehensive evidence-based review of the diagnosis, pathogenesis and treatment to guide clinicians diagnosing and treating their patients.

Complementary and alternative medicine and mind-body therapies for treatment of irritable bowel syndrome in women

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder, characterized by chronic or recurrent abdominal pain with constipation, diarrhea and/or an alternation of the two, and often bloating. Complementary and alternative medicine (CAM) consists of a group of medical treatments that are not commonly considered to be a part of traditional medicine. CAM is commonly used for difficult-to-treat chronic medical conditions. Many patients choose CAM because there are only a limited number of treatments available for IBS or because they would like to have a 'natural therapy'. Mind-body therapies for IBS have proven efficacy, but have not been well accepted by patients or practitioners for treatment. This article reviews the use of CAM and mind-body therapies in IBS, with a focus on probiotics, acupuncture, herbal medicines and psychological therapies.

Gut-directed hypnotherapy in children with irritable bowel syndrome or functional abdominal pain (syndrome): a randomized controlled trial on self exercises at home using CD versus individual therapy by qualified therapists

Background

Irritable bowel syndrome (IBS) and functional abdominal pain (syndrome) (FAP(S)) are common pediatric disorders, characterized by chronic or recurrent abdominal pain. Treatment is challenging, especially in children with persisting symptoms. Gut-directed hypnotherapy (HT) performed by a therapist has been shown to be effective in these children, but is still unavailable to many children due to costs, a lack of qualified child-hypnotherapists and because it requires a significant investment of time by child and parent(s). Home-based hypnotherapy by means of exercises on CD has been shown effective as well, and has potential benefits, such as lower costs and less time investment. The aim of this randomized controlled trial (RCT) is to compare cost-effectiveness of individual HT performed by a qualified therapist with HT by means of CD recorded self-exercises at home in children with IBS or FAP(S).

Methods/Design

260 children, aged 8-18 years with IBS or FAP(S) according to Rome III criteria are included in this currently conducted RCT with a follow-up period of one year. Children are randomized to either 6 sessions of individual HT given by a qualified therapist over a 3-month period or HT through self-exercises at home with CD for 3 months.

The primary outcome is the proportion of patients in which treatment is successful at the end of treatment and after one year follow-up. Treatment success is defined as at least 50% reduction in both abdominal pain frequency and intensity scores. Secondary outcomes include adequate relief, cost-effectiveness and effects of both therapies on depression and anxiety scores, somatization scores, QoL, pain beliefs and coping strategies.

Discussion

If the effectiveness of home-based HT with CD is comparable to, or only slightly lower, than HT by a therapist, this treatment may become an attractive form of therapy in children with IBS or FAP(S), because of its low costs and direct availability.

Trial registration

Dutch Trial Register number NTR2725 (date of registration: 1 February 2011)

Frequency of abnormal fecal biomarkers in irritable bowel syndrome

PRIMARY STUDY OBJECTIVE

Determine the frequency of abnormal fecal biomarker test results in patients with 13 irritable bowel syndrome (IBS)-related ICD-9 (International Statistical Classification of Diseases and Related Health Problems) codes.

STUDY DESIGN

Quantitative review of de-identified records from patients in whom IBS was a possible diagnosis.

METHODS

Records were selected for analysis if they included any of 13 IBS-related diagnostic codes and laboratory test results of fecal testing for all biomarkers of interest. Data collection was restricted to one 12-month period. Frequency distributions were calculated to identify rates of abnormal results for each biomarker within the total number of tests conducted in the eligible population.

RESULTS

Two thousand, two hundred fifty-six records were included in the study, of which 1867 (82.8%) included at least one abnormal value. Quantitative stool culture for beneficial bacteria (Lactobacillus and Bifidobacterium) indicated low growth suggestive of intestinal dysbiosis in 73.1% of records, followed by abnormally elevated eosinophil protein X (suggestive of food allergy) in 14.3%, elevated calprotectin (suggestive of inflammation) in 12.1%, detection of parasites in 7.5%, and low pancreatic elastase (suggestive of exocrine pancreatic insufficiency) in 7.1%.

CONCLUSIONS

Abnormal fecal biomarkers are prevalent in patients with diagnoses suggestive of IBS. Abnormal fecal biomarker testing, if confirmed in additional independent clinical trials, could substantially reduce the economic costs associated with diagnosis and management of IBS.