Type, rather than number, of mental and physical comorbidities increases the severity of symptoms in patients with irritable bowel syndrome

Psychiatric Co-Morbidities and Profile of Patients with Irritable Bowel Syndrome in Northern India

OBJECTIVES

To study sociodemographic and clinical variables, including psychiatric co-morbidities, in patients with irritable bowel syndrome.

METHODS

A total of 158 patients attending a medical gastroenterology clinic in a tertiary care center in Northern India were screened, from whom 100 were selected for the study. Rome IV criteria were used to diagnose IBS, and the severity of symptoms was assessed by the Irritable Bowel Syndrome Symptom Severity Scale (IBS-SSS). Psychiatric co-morbidities were screened via clinical evaluation, and if present, a diagnosis was made as per DSM-5. The Depression, Anxiety, and Stress Scale-21 (DASS-21) and Somatic Symptom Scale-8 (SSS-8) were used to assess depression, anxiety, stress, and somatic symptoms.

RESULT

The mean age of cases was 35.6 years' old, and the majority of cases (i.e., 38.0%) were between 18 and 29 years' old. Males comprised 62.0% of the sample and females 38.0%. Moderate IBS was present in 61.0% of the cases. Evaluation via DASS-21 revealed that 53.0% were in the moderate category of depression, 43.0% had moderate anxiety, and 36.0% had moderate stress. The somatic symptom scale revealed that 48.0% patients were in the high category. Psychiatric co-morbidities were present in 29.0% of cases. Depressive disorders were the most common psychiatric co-morbidity.

CONCLUSIONS

Patients with IBS presenting to a tertiary care center in Northern India were primarily young males living in semi-urban areas who belonged to the Hindu religion, were married, and had a nuclear family. Patients with IBS commonly have associated psychiatric disorders; anxiety disorders and depression are most common.

Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common, debilitating disorder characterized by abdominal pain and disordered bowel habits. Current pharmacologic treatments often provide incomplete symptom relief and may be poorly tolerated. Furthermore, alleviation of gastrointestinal symptoms does not always translate into improved quality of life for IBS patients. Current treatment guidelines recommend brain-gut behavior therapy (BGBT) in conjunction with other IBS therapies, and, in randomized controlled trials, BGBT has been shown to improve symptoms, patient satisfaction, functioning, and quality of life. Access to BGBT is limited by lack of adequately trained gastrointestinal psychologists, patient time constraints, and cost. Furthermore, clinician knowledge that BGBT is specific, and different from psychotherapy approaches for common mental health disorders, may limit referrals even where available. This review provides an overview of the pathophysiology of IBS, disease burden, unmet therapeutic needs, evidence base of novel digital therapeutics for IBS, and guidance on the introduction and appropriateness of these interventions for patients.

METHODS

We searched the literature for available published data relating to the use of novel digital therapeutics to provide cognitive behavioral therapy and gut-directed hypnotherapy in the treatment of irritable bowel syndrome.

RESULTS

Clinical trial data support the development and utility of digital therapeutics designed to deliver self-guided cognitive behavioral therapy and hypnotherapy for the treatment of IBS.

CONCLUSIONS

BGBTs are effective, guideline-recommended treatments for IBS. Digital therapeutic devices offer accessible, cost-effective treatment options for delivery of adjunctive BGBT for the treatment of IBS. The decision to recommend digital BGBTs should be guided by careful patient assessment that includes mental health screening and risk assessment.

Baizhu shaoyao decoction restores the intestinal barrier and brain-gut axis balance to alleviate diarrhea-predominant irritable bowel syndrome via FoxO1/FoxO3a

BACKGROUND

Diarrhea-predominant irritable bowel syndrome (IBS-D) is a common functional gastrointestinal disease. Besides, baizhu shaoyao decoction (BSD) is an effective treatment for IBS-D; however, its mechanism of action remains unclear.

PURPOSE

This study aims to assess the ability of BSD to therapy IBS-D and to elucidate the underlying mechanism.

METHODS

First, comprehensive analyses, including ADME (absorption, distribution, metabolism, excretion) screening, Venn analysis, Gene Ontology (GO) analysis, and network construction, were performed to characterize IBS-D-related pathways and explore the synergistic effects of BSD active compounds. Next, an IBS-D model was constructed using a three-factor superposition method of neonatal maternal separation, chronic immobilization stress stimulation, and Sennae folium aqueous extract lavage. Moreover, the impact of BSD was assessed based on the body weight, fecal water content, and abdominal withdrawal reflex (AWR), and the results of the open field test, sucrose preference test, intestinal permeability assessment, transmission electron microscopy, and TdT-mediated dUTP nick-end labeling (TUNEL) analysis. The factors that regulate the BSD effects on IBS-D were estimated using immunoblotting, quantitative reverse transcription polymerase chain reaction (q-RTPCR), immunohistochemistry, and transcriptome sequencing analyses.

RESULTS

We found that BSD improved depressive behavior, brain-gut peptide levels, and intestinal permeability induced by IBS-D by increasing the abundance of intestinal tight junctions. In addition, BSD reduced secretory immunoglobulin A levels and the number of intestinal mast cells in IBS-D rats. Network pharmacology and transcriptome sequencing analysis further revealed that the forkhead box O (FoxO) signaling pathway contributed to the BSD-induced alleviation of IBS-D, as BSD regulated the protein and mRNA levels of FoxO1, glycogen synthase kinase 3β, and FoxO3a. Importantly, a FoxO1 inhibitor effectively alleviated IBS-D symptoms in rats, whereas a FoxO3a agonist had the opposite effects.

CONCLUSION

These results demonstrate that BSD alleviates depression and intestinal symptoms by regulating brain-gut peptide expression and restoring the intestinal barrier function via the FoxO signaling pathway. Furthermore, our study uses serum pharmacochemistry technology to analyze the in vivo components of TCM formula under effective condition, solving the problem of the discovery of the effective components of TCM to some extent.

Washed microbiota transplantation targeting both gastrointestinal and extraintestinal symptoms in patients with irritable bowel syndrome

OBJECTIVE

Fecal microbiota transplantation (FMT) has been reported with the treatment potential for irritable bowel syndrome (IBS). However, the knowledge of its effect on extraintestinal symptoms of IBS is limited. This study aimed to evaluate the efficacy of the improved methodology of FMT, washed microbiota transplantation (WMT), on sleep disturbances, and psychological and gastrointestinal symptoms among patients with IBS.

METHODS

This was a prospective observational study involving patients with IBS who underwent WMT. The Pittsburgh Sleep Quality Index (PSQI) was used to assess sleep quality. The Gastrointestinal Symptom Rating Scale (GSRS) and IBS Severity Scoring System (IBS-SSS) were used to evaluate gastrointestinal symptoms and IBS severity, respectively. The Self-rating Depression Scale (SDS) and Self-rating Anxiety Scale (SAS) were used to evaluate depression and anxiety, respectively. All the symptoms were evaluated at baseline and one month after WMT. A multiple logistic regression model was used to determine the predictive factors of sleep improvement one month after WMT.

RESULTS

Seventy-three patients with IBS were included in the study. Sleep quality (Z = -4.211, P < 0.001), anxiety (Z = -4.775, P < 0.001), depression (Z = -4.610, P < 0.001), gastrointestinal symptoms (Z = -5.364, P < 0.001), and IBS severity (Z = -6.468, P < 0.001) significantly improved one month after WMT in all patients. The scores of the five components of PSQI including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, and sleep disturbances decreased in 52 patients with poor sleep quality (all P < 0.05). Baseline sleep duration scores were identified as an independent predictive factor of sleep improvement one month after WMT in patients with poor sleep quality (OR 2.180 [95% CI = 1.017-4.673]; P = 0.045). Patients that experienced sleep improvement demonstrated greater alleviation in depression (Z = -1.990, P = 0.047) and IBS severity (Z = -2.486, P = 0.013) compared with patients without sleep improvement.

CONCLUSION

This study suggested that WMT might be a promising therapy for patients with IBS, especially those with comorbid sleep and psychological disorders.

Pain Catastrophizing and Clinical Outcomes Among Patients Receiving a Novel Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: An Experimental Therapeutics Approach

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) condition treated by GI and primary care physicians. Although IBS symptoms (abdominal pain, bowel problems) are generally refractory to medical therapies, consistent research has shown that they improve following cognitive-behavioral therapy (CBT). Notwithstanding empirical support for CBT, there is less research explicating the reasons for why or how it works. Like other pain disorders, the focus on change mechanisms for behavioral pain treatments has focused on pain-specific cognitive-affective processes that modulate pain experience, few of which are more important than pain catastrophizing (PC). The fact that PC changes are seen across treatments of differing theoretical and technical orientation, including CBT, yoga, and physical therapy, suggests that it may be a nonspecific (vs. theory-based) change mechanism akin to therapeutic alliance and treatment expectancy. Therefore, the current study examined change in PC as a concurrent mediator of IBS symptoms severity, global GI symptom improvement, and quality of life among 436 Rome III-diagnosed IBS patients enrolled in a clinical trial undergoing two dosages of CBT versus a nonspecific comparator emphasizing education and support. Results from structural equation modeling parallel process mediation analyses suggest that reduction in PC during treatment are significantly associated with improvement in IBS clinical outcomes through 3-month follow-up. Results from the current study provide evidence that PC may be an important, albeit nonspecific change mechanism, during CBT for IBS. Overall, reducing the emotional unpleasantness of pain through cognitive processes is associated with improved outcomes for IBS.

Comorbidities, biomarkers and cause specific mortality in patients with irritable bowel syndrome: A phenome-wide association study

BACKGROUND

Irritable bowel syndrome (IBS) is one of the most common functional digestive disorders. Our understanding about its comorbidities, biomarkers, or long-term risks is still incomplete.

OBJECTIVE

To characterize comorbidities and biomarkers for IBS and establish the effect of IBS on overall- and cause specific mortality.

METHODS

We analyzed data from the population-based cohort of the UK Biobank (UKB) with 493,974 participants, including self-reported physician-diagnosed (n = 20,603) and ICD-10 diagnosed (n = 7656) IBS patients, with a mean follow-up of 11 years. We performed a phenome-wide association study (PheWAS) and competing risk analysis to characterize common clinical features in IBS patients.

RESULTS

In PheWAS analyses, 260 PheCodes were significantly overrepresented in self-reported physician-diagnosed IBS patients, 633 in patients with ICD-10 diagnosed IBS (ICD-10-IBS), with 221 (40%) overlapping. In addition to gastrointestinal diseases, psychiatric, musculoskeletal, and endocrine/metabolic disorders represented the most strongly associated PheCodes in IBS patients. Self-reported physician-diagnosed IBS was not associated with increased overall mortality and the risk of death from cancer was decreased (hazard ratio [HR] = 0.78 [95% CI = 0.7-0.9]). Lastly, we evaluated changes in serum metabolites in IBS patients and identified glycoprotein acetyls (GlycA) as a potential biomarker in IBS. One standard deviation increase in GlycA raised the risk of self-reported IBS/ICD-10 coded by 9%-20% (odds ratio [OR] = 1.09 [95% CI = 1.1-1.1]/OR = 1.20 [95% CI = 1.1-1.3]) and the risk of overall mortality in ICD-10-IBS patients by 28% (HR = 1.28 [95% CI = 1.1-1.5]).

CONCLUSION

Our large-scale association study determined IBS patients having an increased risk of several different comorbidities and that GlycA was increased in IBS patients.

Eluxadoline-Loaded Eudragit Nanoparticles for Irritable Bowel Syndrome with Diarrhea: Formulation, Optimization Using Box-Behnken Design, and Anti-Diarrheal Activity

Eluxadoline (ELD), a recently approved drug, exhibits potential therapeutic effects in the management and treatment of IBS-D. However, its applications have been limited due to poor aqueous solubility, leading to a low dissolution rate and oral bioavailability. The current study's goals are to prepare ELD-loaded eudragit (EG) nanoparticles (ENPs) and to investigate the anti-diarrheal activity on rats. The prepared ELD-loaded EG-NPs (ENP1-ENP14) were optimized with the help of Box-Behnken Design Expert software. The developed formulation (ENP2) was optimized based on the particle size (286 ± 3.67 nm), PDI (0.263 ± 0.01), and zeta potential (31.8 ± 3.18 mV). The optimized formulation (ENP2) exhibited a sustained release behavior with maximum drug release and followed the Higuchi model. The chronic restraint stress (CRS) was successfully used to develop the IBS-D rat model, which led to increased defecation frequency. The in vivo studies revealed a significant reduction in defecation frequency and disease activity index by ENP2 compared with pure ELD. Thus, the results demonstrated that the developed eudragit-based polymeric nanoparticles can act as a potential approach for the effective delivery of eluxadoline through oral administration for irritable bowel syndrome diarrhea treatment.

Significant Differences in Gut Microbiota Between Irritable Bowel Syndrome with Diarrhea and Healthy Controls in Southwest China

BACKGROUND

Irritable bowel syndrome (IBS) is a heterogeneous disease, which is closely related to environmental factors and gut microbiota.

OBJECTIVE

To study gut microbiota in IBS-D of Han nationality in Southwest China and explore its relationship with environmental factors.

METHODS

One hundred and twenty cases of IBS-D and 63 cases of HCs were recruited; baseline data such as age, height, and weight were collected. HAMA, HAMD, IBS-SSS, IBS-QOL, and laboratory tests were performed. Feces were collected for 16S rDNA sequencing. Then, the differences of gut microbiota were analyzed and looked for biomarkers of each. FAPROTAX was used to predict the functional differences of gut microbiota. Spearman analysis was conducted between the phylum level and environmental factor.

RESULTS

There were significant differences in daily life between IBS-D and HCs, especially in the spicy taste. The scores of HAMA and HAMD, urea, and transaminase in IBS-D were significantly higher than those of HCs. The richness of gut microbiota in IBS-D was significantly lower than that of HCs, as well as the beta diversity, but not diversity. The biomarkers of IBS-D were Prevotella, Clostridiales, and Roseburia, and the biomarkers of HCs were Veillonellaceae, Bacteroides coprocola, and Bifidobacteriales. The functions of gut microbiota in IBS-D were significantly different from HCs. Correlation analysis showed that multiple gut microbiota were closely related to HAMA, IBS-SSS, IBS-QOL, inflammatory indexes, and liver enzymes.

CONCLUSION

There are significant differences in richness of gut microbiota, flora structure, and flora function between IBS-D and HCs in Southwest China. These differences may be closely related to environmental factors such as eating habits, living habits, and mental and psychological factors.

CLINICAL TRIAL REGISTRATION

The trial was registered and approved in China Clinical Trial Registry (Registration No. ChiCTR2100045751).

Genetics of irritable bowel syndrome: shifting gear via biobank-scale studies

The pathophysiology of irritable bowel syndrome (IBS) is multifactorial and probably involves genetic predisposition and the effect of environmental factors. Unlike other gastrointestinal diseases with a heritable component, genetic research in IBS has been scarce and mostly characterized by small underpowered studies, leading to inconclusive results. The availability of genomic and health-related data from large international cohorts and population-based biobanks offers unprecedented opportunities for long-awaited, well-powered genetic studies in IBS. This Review focuses on the latest advances that provide compelling evidence for the importance of genes involved in the digestion of carbohydrates, ion channel function, neurotransmitters and their receptors, neuronal pathways and the control of gut motility. These discoveries have generated novel information that might be further refined for the identification of predisposed individuals and selection of management strategies for patients. This Review presents a conceptual framework, the advantages and potential limitations of modern genetic research in IBS, and a summary of available evidence.

Psychopathological and neuropsychological disorders associated with chronic primary visceral pain: Systematic review

The World Health Organization (WHO), in its last review of its International Classification of Diseases, established a new classification for chronic pain. Among the principal categories, of particular interest is chronic primary pain as a new type of diagnosis in those cases in which the etiology of the disease is not clear, being termed as chronic primary visceral pain when it is situated in the thorax, abdomen, or pelvis. Due to the novelty of the term, the objective of the systematic review was to examine the psychopathological and neuropsychological disorders associated with chronic primary visceral pain. We carried out a search of the scientific literature following the PRISMA directives using the Pubmed, Medline, PsycInfo and Scopus databases. A total of 33 articles were selected after applying the inclusion and exclusion criteria. The analysis of the studies showed that most persons with chronic primary visceral pain suffer from at least one psychological disorder; the most prevalent being anxiety, depressive or somatoform disorders. The most frequent psychopathological symptoms are anxiety, depression and somatization. Similarly, the findings are insufficient to determine the existence of deficits in the domains of executive functioning, memory and intelligence. However, the existence of attention biases does seem to be clear. This review supposes a starting point for conceptualizing chronic primary visceral pain. It is necessary to continue further research so as to obtain a better understanding of this pathology and the disorders associated.

Study protocol and methods for Easing Pelvic Pain Interventions Clinical Research Program (EPPIC): a randomized clinical trial of brief, low-intensity, transdiagnostic cognitive behavioral therapy vs education/support for urologic chronic pelvic pain syndrome (UCPPS)

Background

Urologic chronic pelvic pain syndrome (UCPPS) encompasses several common, costly, diagnoses including interstitial cystitis/bladder pain syndrome and chronic prostatitis/chronic pelvic pain syndrome that are poorly understood and inadequately treated with conventional medical therapies. Behavioral strategies, recommended as a first-line treatment for managing symptoms, are largely inaccessible, time and labor intensive, and technically complex. The Easing Pelvic Pain Interventions Clinical Research Program (EPPIC) is a clinical trial examining the efficacy of low-intensity cognitive behavioral therapy (Minimal Contact CBT or MC-CBT) for UCPPS and its durability 3 and 6 months post treatment. Additional aims include characterizing the operative processes (e.g., cognitive distancing, context sensitivity, coping flexibility, repetitive negative thought) that drive MC-CBT-induced symptom relief and pre-treatment patient variables that moderate differential response.

Methods

UCPPS patients (240) ages 18–70 years, any gender, ethnicity, and race, will be randomized to 4-session MC-CBT or a credible, non-specific education comparator (EDU) that controls for the generic effects from simply going to treatment. Efficacy assessments will be administered at pre-treatment, 2 weeks, and 3 and 6 months post treatment-week acute phase. A novel statistical approach applied to micro-analytic mediator assessment schedule will permit the specification of the most effective CBT component(s) that drive symptom relief.

Discussion

Empirical validation of a low-intensity self-management therapy transdiagnostic in scope has the potential to improve the health of chronic pelvic pain patients refractory to medical therapies, reduce social and economic costs, conserve health care resources, as well as inform evidence-based practice guidelines. Identification of change mechanisms and moderators of treatment effects can provide proactive patient-treatment matching fundamental to goals of personalized medicine.

Trial Registration

Clinicaltrials.gov NCT05127616. Registered on 9/19/21.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06554-9.

Do I really have to do my homework? The role of homework compliance in cognitive behavioral therapy for irritable bowel syndrome

Treatment guidelines identify cognitive behavioral therapy (CBT) as a treatment of choice for irritable bowel syndrome (IBS). As a learning-based treatment, homework assignments are regarded as important for optimizing outcomes for CBT-treated patients. However, their actual benefit for IBS is unknown. This study examined whether homework completion corresponds with immediate and sustained treatment response in IBS patients enrolled in CBT treatment. Subjects were 358 IBS patients receiving clinic-based CBT (10 session), home-based CBT (4 session), or a 4 session, non-specific IBS education comparator as part of a large NIH trial. Homework completion was rated by clinician at each session. IBS symptom improvement was measured with the Clinician Global Improvement Scale at treatment week 5, post-treatment (week 12), and at follow-ups (weeks 22, 34, 46, 62). Homework completion rates over the 10-week acute phase corresponded with greater IBS symptom improvement and patient satisfaction at post-treatment. Early treatment homework completion did not predict early treatment response. Contrary to expectations, homework compliance rates were not greater among in-clinic session patients than home-based patients. Data lend empirical support to the clinical value of homework in teaching patients how to self-manage painful GI symptoms refractory to conventional medical and dietary therapies.

Baseline Predictors of Discontinuation of Prescription Drug Therapy for IBS-C: Cohort Analysis at an Integrated Healthcare System

BACKGROUND

Effective prescription drug treatment of constipation-predominant irritable bowel syndrome (IBS-C) requires patients to remain on daily therapy, yet predictive factors to optimize treatment selection are unknown.

AIMS

We assessed whether common comorbidities including chronic overlapping pain conditions (COPCs), mood disorders, or concurrent medications influence the risk of discontinuing IBS-C prescription drug therapy.

METHODS

We included all IBS-C patients who initiated treatment with the secretagogues linaclotide or lubiprostone across the Michigan Medicine healthcare system between 2012 and 2016. A Cox proportional hazards model was constructed to model time-to-treatment discontinuation as a valid, quantifiable measure of IBS medication persistence using hazards ratios (HR) with 95% confidence intervals (CI).

RESULTS

Our cohort included 225 patients on linaclotide and 492 on lubiprostone (mean age 48.3 years, 86.9% women, 46.6% with at least one COPC, 60.3% with at least one mood disorder) with an average follow-up of 2.1 years. Patients with at least one COPC (HR = 0.566; 95%CI = 0.371-0.863) and also women (HR = 0.535; 95%CI = 0.307-0.934) had a lower risk of discontinuing linaclotide, while COPCs predicted a trend toward increased discontinuation of lubiprostone (HR = 1.254; 95%CI = 0.997-1.576). Age, comorbid mood disorders, and baseline use of narcotics or benzodiazepines did not significantly mediate the risk of treatment discontinuation; our findings remained stable in univariate and multivariable analyses.

CONCLUSIONS

COPCs and sex appear to influence the likelihood of discontinuation of two commonly prescribed secretagogues, while mood disorders, narcotics, and benzodiazepines may not. Routine assessment for comorbid COPCs prior to initiating therapy may optimize IBS-C treatment selection and outcomes in practice.

Eating and Psychiatric Disorders Are Independent Risk Factors for Rumination Syndrome

GOAL

The goal of this study was to evaluate whether a history of eating disorders (EDs) or psychiatric disorders (PDs) are risk factors for rumination syndrome (RS).

BACKGROUND

RS is a disorder of gut-brain interaction characterized by an effortless postprandial retrograde flow of ingested contents. Disorder of gut-brain interactions have been associated with psychiatric and behavioral comorbidities. No prior comparative study has assessed the relationship between RS and ED or PD.

METHODS

This was a case-control study of adults with RS at a tertiary center in January 2013 to January 2018. Two age-matched/gender-matched controls per RS case were identified. The Fisher exact test (categorical)/Student t test (continuous) and forward stepwise logistic regression were performed for univariate and multivariable analyses, respectively.

RESULTS

Seventy-two patients (24 cases/48 controls) were included. Baseline demographics and characteristics were similar between cases and controls. Among RS patients, 9 (37.5%) had a history of ED, including 3 (12.5%) anorexia nervosa and 4 (16.7%) bulimia nervosa; and 20 (83.3%) had a PD, including 9 (37.5%) anxiety and 7 (29.2%) depression. Prevalence of ED (37.5% vs. 4.2%, P=0.0002) and PD (83.3% vs. 50.0%, P=0.0062) were higher among RS patients than controls. Specifically, the risks of anorexia nervosa (16.7% vs. 0%, P=0.005) and bulimia nervosa (21.1% vs. 0%, P=0.001) were both increased in RS patients. On multivariable analysis, ED (adjusted odds ratio=16.4, P=0.0033) and PD (adjusted odds ratio=4.47, P=0.029) remained independent predictors for RS.

CONCLUSIONS

A history of ED and PD were independent risk factors for RS. Abnormal eating behaviors and psychiatric comorbidities may contribute to the pathogenesis of RS. Evaluation of RS should include a detailed history for ED and PD.

Review article: Physical and psychological comorbidities associated with irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders encountered by physicians in primary and secondary care. Patients with IBS commonly present with various extraintestinal complaints, which account for a substantial clinical and economic burden. The common extraintestinal comorbidities associated with IBS include anxiety, depression, somatisation, fibromyalgia, chronic fatigue syndrome, chronic pelvic pain, interstitial cystitis, sexual dysfunction and sleep disturbance. The presence of comorbidity in IBS poses a diagnostic and therapeutic challenge with patients frequently undergoing unnecessary investigations and interventions, including surgery. This review discusses the different physical and psychological comorbidities associated with IBS, the shared pathophysiological mechanisms and potential management strategies.

Functional gastrointestinal disorders. Overlap syndrome Clinical guidelines of the Russian Scientific Medical Society of Internal Medicine and Gastroenterological Scientific Society of Russia

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The Gut-Brain Axis

Preclinical evidence has firmly established bidirectional interactions among the brain, the gut, and the gut microbiome. Candidate signaling molecules and at least three communication channels have been identified. Communication within this system is nonlinear, is bidirectional with multiple feedback loops, and likely involves interactions between different channels. Alterations in gut-brain-microbiome interactions have been identified in rodent models of several digestive, psychiatric, and neurological disorders. While alterations in gut-brain interactions have clearly been established in irritable bowel syndrome, a causative role of the microbiome in irritable bowel syndrome remains to be determined. In the absence of specific microbial targets for more effective therapies, current approaches are limited to dietary interventions and centrally targeted pharmacological and behavioral approaches. A more comprehensive understanding of causative influences within the gut-brain-microbiome system and well-designed randomized controlled trials are needed to translate these exciting preclinical findings into effective therapies. Expected final online publication date for the Annual Review of Medicine, Volume 73 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Costunolide ameliorates intestinal dysfunction and depressive behaviour in mice with stress-induced irritable bowel syndrome via colonic mast cell activation and central 5-hydroxytryptamine metabolism

Irritable bowel syndrome (IBS) is a common chronic functional bowel disease, associated with a high risk of depression and anxiety. The brain-gut axis plays an important role in the pathophysiological changes involved in IBS; however, an effective treatment for the same is lacking. The natural compound costunolide (COS) has been shown to exert gastroprotective, enteroprotective, and neuroprotective effects, but its therapeutic effects in IBS are unclear. Our study explored the effect of COS on intestinal dysfunction and depressive behaviour in stress-induced IBS mice. Mice were subjected to chronic unpredictable mild stress to trigger IBS, and some were administered COS. Behavioural tests, histochemical assays, western blotting, and measurement of 5-hydroxytryptamine (5-HT) levels in the colon and hippocampus were applied to monitor the physiological and molecular consequences of COS treatment in IBS mice. COS administration relieved intestinal dysfunction and depression-like behaviours in IBS mice. Improvements in low-grade colon inflammation and intestinal mucosal permeability, inhibition of the activation of mast cells, upregulation of colonic Occludin expression, and downregulation of Claudin 2 expression were also observed. COS was also found to upregulate GluN2A, BDNF, p-ERK1/2, and p-CREB expression and 5-HT levels in hippocampal cells but inhibited 5-HT metabolism. Molecular docking showed that COS could form hydrogen bonds with the serotonin transporter (SERT) to affect the reuptake of 5-HT in the intercellular space. In conclusion, COS alleviates intestinal dysfunction and depressive behaviour in stress-induced IBS mice by inhibiting mast cell activation in the colon and regulating 5-HT metabolism in the central nervous system.

Deciphering the synergistic network regulation of active components from SiNiSan against irritable bowel syndrome via a comprehensive strategy: Combined effects of synephrine, paeoniflorin and naringin

BACKGROUND

SiNiSan (SNS) is an ancient Chinese herbal prescription, and the current clinical treatment of irritable bowel syndrome (IBS) is effective. In the previous study of the research team, the multi-functional co-synergism of SNS against IBS was presented. Some potential drug targets and candidate ligands were predicted.

PURPOSE

This study attempts to explore the crucial ingredient combinations from SNS formula and reveal their synergistic mechanism for IBS therapy.

MATERIALS AND METHODS

In present study, a comprehensive strategy was performed to reveal IBS related pathways and biological modules, and explore synergistic effects of the ingredients, including ADME (absorption, distribution, metabolism, excretion) screening, Text mining, Venn analysis, Gene ontology (GO) analysis, Pathway cluster analysis, Molecular docking, Network construction and Experimental verification in visceral hypersensitivity (VHS) rats.

RESULTS

Three compressed IBS signal pathways were derived from ClueGO KEGG analysis of 63 IBS genes, including Neuroactive ligand-receptor interaction, Inflammatory mediator regulation of TRP (transient receptor potential) channels and Serotonergic synapse. A multi-module network, composed of four IBS therapeutic modules (psychological, inflammation, neuroendocrine and cross-talk modules), was revealed by Target-Pathway network. Nine kernel targets were considered closely associated with the IBS pathways, including ADRA2A, HTR2A, F2RL1, F2RL3, TRPV1, PKC, PKA, IL-1Β and NGF. In silico analysis revealed that three crucial ingredients (synephrine, paeoniflorin and naringin) were assumed to coordinate the network of those IBS therapeutic modules by acting on these kernel targets in the important pathways. In vivo experimental results showed that the crucial ingredient combinations synergistically affected the expressions of the kernel biological molecules, and improved the minimum capacity threshold of AWR in VHS rats.

CONCLUSION

The study proposes the important IBS associated pathways and the network regulation mechanisms of the crucial ingredients. It reveals the multi-target synergistic effect of the crucial ingredient combinations for the novel therapy on IBS.

Specific and common mediators of gastrointestinal symptom improvement in patients undergoing education/support vs. cognitive behavioral therapy for irritable bowel syndrome

Objective: This study sought to characterize change mechanisms that underlie gastrointestinal (GI) symptom improvement in IBS patients undergoing two dosages of CBT for IBS as compared to a nondirective education/support (EDU) condition. Method: Data were collected in the context of a large clinical trial that randomized 436 Rome III-diagnosed IBS patients (Mage = 41, 80 % female) to standard, clinic-based CBT (S-CBT), a largely home-based version with minimal therapist contact (MC-CBT) or Education/Support that controlled for nonspecific effects. Outcome was measured with the IBS-version of the Clinical Global Improvement scale that was administered at Week 5 and 2-week posttreatment (Week 12). Potential mediators (IBS Self-efficacy (IBS-SE), pain catastrophizing, fear of GI symptoms, and treatment alliance were assessed at Weeks 3, 5, and 8 during treatment with the exception of treatment expectancy that was measured at the end of Session 1. Results: IBS-SE, a positive treatment expectancy for symptom improvement, and patient-therapist agreement on tasks for achieving goals mediated effects of CBT early in treatment (rapid response, RR) and at posttreatment. Notwithstanding their different intensities, both CBT conditions had comparable RR rates (43%-45%) and significantly greater than the EDU RR rate of 22%. While pain catastrophizing, fear of GI symptoms, and patient-therapist emotional bonding related to posttreatment symptom improvement, none of these hypothesized mediators explained differences between CBT and EDU, thereby lacking the mechanistic specificity of IBS-SE, task agreement, and treatment expectancy. Conclusion: Findings suggest that CBT-induced GI symptom improvement may be mediated by a constellation of CBT-specific (IBS-SE) and nonspecific (task agreement, treatment expectancy) processes that reciprocally influence each other in complex ways to catalyze, improve, and sustain IBS symptom relief. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

IBS Patients' Treatment Expectancy and Motivation Impacts Quality of the Therapeutic Alliance With Provider: Results of the IBS Outcome Study

BACKGROUND

In the absence of a satisfactory medical or dietary treatment, the quality of the therapeutic alliance between irritable bowel syndrome (IBS) patients and their provider is deemed critical to managing refractory IBS. Surprisingly, little research has been conducted on the nature of the therapeutic alliance, factors that influence it, or practical strategies to improve it. This study sought to identify actionable variables that impact therapeutic alliance in patients with refractory IBS.

METHODS

Subjects included a total of 436 Rome III-diagnosed IBS patients (80% female, mean age=41.39 y) who completed a battery of clinical measures at the beginning of the acute treatment phase of an National Institutes of Health (NIH) behavioral trial. Pretreatment candidate predictor variables were organized into 4 categories: sociodemographic, extraintestinal, interpersonal, clinical (eg, symptom severity, pain intensity), cognitive (eg, treatment motivation, expectancy for improvement). Alliance was assessed by patient and clinician-rated measures of the Working Alliance Inventory after first treatment session.

RESULTS

Patient reports of alliance were most strongly and consistently predicted by patient access to interpersonal support [β=0.16; 95% confidence interval (CI)=0.07-0.25], motivation for IBS symptom improvement (β=0.12; 95% CI=0.02-0.21), and expectancy of IBS symptom improvement (β=0.35; 95% CI=0.25-0.44). Therapist ratings of alliance also were predicted by patient expectancy of IBS symptom improvement (β=0.16; 95% CI=0.05-0.26).

CONCLUSION

When managing IBS, a focus on dynamic factors of treatment motivation, social support, and treatment expectancy may be useful in improving the quality of the therapeutic alliance between patient and clinical gastroenterologist.

Usability Evaluation of a Smartphone Medication Reminder Application in Patients Treated With Short-term Antibiotic

Medication adherence is poor in persons with chronic disease, especially in those with multiple chronic diseases, one of which is a psychological disorder. Social support, medication education, and external reminders have been identified as facilitators of adherence. Mobile health applications have the potential to enhance adherence; however, it is unknown if publicly available applications are user-friendly and useful. We aimed to examine the usability and feasibility of the "MediSafe" medication reminder application in adults with diarrhea-predominant irritable bowel syndrome undergoing short-term antibiotic therapy and a "Medfriend" from their social support network (N = 14). A mixed-methods study was conducted. All patient participants used the MediSafe application daily for 14 days. Ease of use, ease of learning, and satisfaction scales were rated highest by both patient participants and Medfriends, whereas usefulness was rated lowest by both groups, with Medfriends' usefulness rating significantly lower than that of patient participants. Telephone interviews identified patient participants found the application instrumental in facilitating medication adherence, and Medfriends viewed themselves as active participants in the patient participants' care. The MediSafe medication reminder application is easy to use and accepted by both patients and their designated Medfriend. The MediSafe is instrumental in facilitating short-term antibiotic adherence and social support engagement.

Increasing Rates of Opioid Prescriptions for Gastrointestinal Diseases in the United States

INTRODUCTION

Pain control is an important management approach for many gastrointestinal conditions. Because of the ongoing opioid crisis, public health efforts have focused on limiting opioid prescriptions. This study examines national opioid prescribing patterns and factors associated with opioid prescriptions for gastrointestinal conditions.

METHODS

We conducted a repeated cross-sectional study using the National Ambulatory Medical Care Survey data from 2006 to 2016. The International Classification of Diseases codes were used to identify ambulatory visits with a primary gastrointestinal diagnosis. Data were weighted to calculate national estimates for opioid prescriptions for gastrointestinal disease. Joinpoint regression was used to analyze temporal trends. Multivariable logistic regression was used to examine factors associated with opioid prescriptions.

RESULTS

We analyzed 12,170 visits with a primary gastrointestinal diagnosis, representing 351 million visits. The opioid prescription rate for gastrointestinal visits was 10.1% (95% confidence interval [CI] 9.0%-11.2%). Opioid prescription rates for gastrointestinal disease increased by 0.5% per year from 2006 to 2016 (P = 0.04). Prescription rates were highest for chronic pancreatitis (25.1%) and chronic liver disease (13.9%) visits. Seventy-one percent of opioid prescriptions were continuations of an existing prescription. Patient characteristics associated with continued opioid prescriptions included rural location (adjusted odds ratio [aOR] 1.46; 95% CI 1.11-1.93), depression (aOR 1.83; 95% CI 1.33-2.53), and Medicaid insurance (aOR 1.57; 95% CI 1.15-2.13).

DISCUSSION

Opioid prescription rates for gastrointestinal disease visits increased from 2006 to 2016. Our findings suggest an inadequate response to the opioid epidemic by providers managing gastrointestinal conditions. Further clinical interventions are needed to limit opioid use for gastrointestinal disease.(Equation is included in full-text article.).

Management of irritable bowel syndrome with diarrhea: focus on eluxadoline

OBJECTIVE

We sought to summarize current recommendations for the diagnosis of diarrhea-predominant irritable bowel syndrome (IBS-D) and describe available management options, highlighting a newer US Food and Drug Administration (FDA)-approved agent, eluxadoline.

METHODS

Literature on IBS-D was assessed up to January 2020 using PubMed, with key search terms including "IBS-D diagnosis", "IBS-D management", and "eluxadoline".

RESULTS

IBS is a common gastrointestinal disorder affecting up to 14% of US adults and is particularly prevalent in women and those aged under 50. Symptoms include abdominal pain associated with altered bowel habits (i.e. diarrhea and/or constipation subtyped based on the predominant stool pattern). As IBS-D is challenging to manage with varying symptom severity, effective treatment requires a personalized management approach. Evidence-based therapeutic options endorsed by the American Gastroenterological Association and the American College of Gastroenterology can be used to effectively guide treatment. Dietary and lifestyle modifications, including adequate hydration, reducing caffeine and alcohol intake, and increasing soluble fiber intake may lead to symptom improvement. Over-the-counter medications such as loperamide are frequently recommended and may improve stool frequency and rectal urgency; however, for the outcome of abdominal pain, mixed results have been observed. Several off-label prescription medications are useful in IBS-D management, including tricyclic antidepressants, bile acid sequestrants, and antispasmodics. Three prescription medications have been approved by the FDA for IBS-D: alosetron, eluxadoline, and rifaximin.

CONCLUSIONS

IBS-D can be effectively managed in the primary care setting in the absence of alarm features. Benefits and risks of pharmacologic interventions should be weighed during treatment selection.

Subtypes and Severity of Irritable Bowel Syndrome Are Not Related to Patients' Self-Reported Dietary Triggers: Results From an Online Survey in Dutch Adults

BACKGROUND

Diet plays an important role in symptom management of irritable bowel syndrome (IBS). However, current diet therapies are not optimal nor successful for everyone.

OBJECTIVE

To investigate whether subgroups based on IBS subtypes or severity identify different self-reported dietary triggers, and whether these are associated with severity and psychological factors.

DESIGN

Online cross-sectional survey PARTICIPANTS: Patients with IBS (n = 1601) who fulfilled the Rome IV criteria or had an IBS diagnosis.

MAIN OUTCOMES

Self-reported response to 44 preselected dietary triggers, IBS quality of life, and anxiety and depression. Subgroups were based on subtypes or severity.

STATISTICAL ANALYSIS

Response to dietary triggers was analyzed using multiple correspondence analysis. Moreover, a food score was calculated to quantify the number and severity of responses to dietary triggers.

RESULTS

Response to greasy foods, onions, cabbage, and spicy and fried foods were mentioned most often (ranging between 55% and 65%). Response to dietary triggers differed between subtypes and severity groups, but absolute differences were small. Multiple correspondence analysis did not reveal clustering between dietary triggers, and ellipses for the subtypes overlapped. Some clustering was seen when ellipses were drawn for severity, which indicates that severity explained a fraction of the variation in response to dietary triggers, and subtypes did not. The food score was not significantly different between subtypes but was significantly higher with higher levels of severity (mild = 20.9 ± 17, moderate = 29.2 ± 19, severe = 37.9 ± 20, P < .001), having depressive (no = 31.4 ± 20, yes = 37.4 ± 20, P < .001) or anxious symptoms (no = 30.7 ± 20, yes = 35.2 ± 20, P < .001), and lower quality of life (lower quality of life = 38.5 ± 19, higher quality of life = 26.5 ± 19, P < .001).

CONCLUSION

Patients with different IBS subtypes or IBS severity do not identify different self-reported dietary triggers. Patients with more severe IBS and who experience anxiety or depression tend to have severe responses to more dietary triggers. IBS severity seems a better classifier than Rome IV criteria regarding diet. Dietary treatment needs to be individualized under guidance of a dietitian.

Common mental disorders in irritable bowel syndrome: pathophysiology, management, and considerations for future randomised controlled trials

The frequent co-occurrence of irritable bowel syndrome and the common mental disorders of anxiety and depression is well established. A range of biological and psychosocial disease mechanisms are common to both disorders, many of which contribute to a dysregulated gut-brain axis. Clinical and subthreshold psychological comorbidity adds to the functional impairment and disease burden in individuals with irritable bowel syndrome. Progress is being made with regard to understanding irritable bowel syndrome in the clinical setting from a biopsychosocial perspective. However, until now, most trials of irritable bowel syndrome treatment still consider the disease as a gut disorder in isolation, which leaves major gaps in knowledge about disease-disease interactions and treatment outcomes in irritable bowel syndrome. In this Viewpoint, we review the epidemiology, pathophysiology, and management of anxiety and depression in individuals with irritable bowel syndrome. We also provide methodological recommendations for future randomised controlled trials and outline guidance for research that better incorporates psychiatric comorbidity into its design, with a view to improve treatment outcomes for individuals with irritable bowel syndrome.

Fatigue in irritable bowel syndrome is associated with plasma levels of TNF-α and mesocorticolimbic connectivity

Irritable bowel syndrome (IBS) is a symptom-based disorder of gut-brain interactions generating abdominal pain. It is also associated with a vulnerability to develop extraintestinal symptoms, with fatigue often reported as one of the most disturbing. Fatigue is related to brain function and inflammation in several disorders, however, the mechanisms of such relations in IBS remain elusive. This study aimed to elucidate fatigue and its association with a resting state network of mesocorticolimbic regions of known importance in fatigue, and to explore the possible role of circulating TNF-α levels in IBS and healthy controls (HC). Resting state functional magnetic resonance imaging (fMRI) was conducted in 88 IBS patients and 47 HC of similar age and gender to investigate functional connectivity between mesocorticolimbic regions. Further, fatigue impact on daily life and plasma levels of the proinflammatory cytokine tumor necrosis factor-α (TNF-α), of known relevance to immune activation in IBS, were also measured. The selected mesocorticolimbic regions indeed formed a functionally connected network in all participants. The nucleus accumbens (NAc), in particular, exhibited functional connectivity to all other regions of interest. In IBS, fatigue impact on daily life was negatively correlated with the connectivity between NAc and dorsolateral prefrontal cortex bilaterally (left p = 0.019; right p = 0.038, corrected for multiple comparisons), while in HC, fatigue impact on daily life was positively correlated to the connectivity between the right NAc and anterior middle insula in both hemispheres (left p = 0.009; right p = 0.011). We found significantly higher levels of TNF-α in IBS patients compared to HC (p = 0.001) as well as a positive correlation between TNF-α and fatigue impact on daily life in IBS patients (rho = 0.25, p = 0.02) but not in HC (rho = -0.13, p = 0.37). There was no association between functional connectivity in the mesocorticolimbic network and plasma levels of TNF-α in either group In summary, this novel multimodal study provides the first evidence that the vulnerability to fatigue in IBS is associated with connectivity within a mesocorticolimbic network as well as immune activation. These findings warrant further investigation, both peripherally and potentially with measurements of central immune activation as well.

Psychological, physical, and sleep comorbidities and functional impairment in irritable bowel syndrome: Results from a national survey of U.S. adults

BACKGROUND/AIMS

Patients with irritable bowel syndrome (IBS) in referral practice commonly report mental disorders and functional impairment. Our aim was to determine the prevalence of mental, physical and sleep-related comorbidities in a nationally representative sample of IBS patients and their impact on functional impairment.

METHODS

IBS was defined by modified Rome Criteria based on responses to the chronic conditions section of the National Comorbidity Survey-Replication. Associations between IBS and mental, physical and sleep disorders and 30-day functional impairment were examined using logistic regression models.

RESULTS

Of 5,650 eligible responders, 186 met criteria for IBS {weighted prevalence 2.5% (SE = 0.3)}. Age >60 years was associated with decreased odds (OR = 0.3; 95% CI:.1-.6); low family income (OR = 2.4; 95% CI:1.2-4.9) and unemployed status (OR = 2.3; 95% CI:1.2-4.2) were associated with increased odds of IBS. IBS was significantly associated with anxiety, behavior, mood disorders (ORs 1.8-2.4), but not eating or substance use disorders. Among physical conditions, IBS was associated with increased odds of headache, chronic pain, diabetes mellitus and both insomnia and hypersomnolence related symptoms (ORs 1.9-4.0). While the association between IBS and patients' role impairment persisted after adjusting for mental disorders (OR = 2.4, 95% CI 1.5-3.7), associations with impairment in self-care, cognition, and social interaction in unadjusted models (ORs 2.5-4.2) were no longer significant after adjustment for mental disorders.

CONCLUSION

IBS is associated with socioeconomic disadvantage, comorbidity with mood, anxiety and sleep disorders, and role impairment. Other aspects of functional impairment appear to be moderated by presence of comorbid mental disorders.

The patient with irritable bowel syndrome-type symptoms: when to investigate and how?

PURPOSE OF REVIEW

Irritable bowel syndrome (IBS) is a very common disorder whose clinical presentation varies considerably between patients as well as within the same individual over time. Many of its symptoms, such as pain, diarrhea, constipation and bloating, may be manifestations of a host of other gastrointestinal diseases; some accompanied by increased mortality. This presents the clinician with a real dilemma: how to sensibly investigate the patient in which one suspects IBS but there is a nagging doubt that 'it could be something else'? Could one miss 'something serious'? This short review attempts to provide both an evidence-based response to these vexing questions and a practical guide to detecting alternative diagnoses in the subject with IBS-type symptoms.

RECENT FINDINGS

Clinical features, patient demographics and the clinical context can help to significantly narrow the differential diagnosis of the individual with IBS-type symptoms and may permit a positive diagnosis of IBS. The advent of noninvasive serological and stool tests has greatly facilitated differentiation from celiac disease and inflammatory bowel disease, respectively. In the older, female diarrhea sufferer microscopic colitis should be considered. The role of bile acid diarrhea in the individual with diarrhea-predominant IBS is emphasized; the status of small intestinal bacterial overgrowth in IBS remain uncertain.

SUMMARY

Attention to detail in the clinical evaluation of the individual with IBS-like symptoms will facilitate a selective and targeted approach to investigation. Wherever indicated, widely available serological and fecal tests will serve to bolster the diagnosis by excluding other options. Proceeding to more invasive testing should be dictated by clinical presentation and scenario with the threshold for intervention being generally lower among those with prominent diarrhea.

Network approach of mood and functional gastrointestinal symptom dynamics in relation to childhood trauma in patients with irritable bowel syndrome and comorbid panic disorder

OBJECTIVE

Irritable bowel syndrome (IBS) has a high comorbidity with mental disorders. The present paper aims to visualise the interplay between IBS and affect (anxiety and mood) in daily life. Furthermore, this interplay may be different depending on risk factors such as childhood trauma.

METHODS

Using momentary assessment (Experience Sampling Method), data of 24 individuals diagnosed with both IBS and panic disorder were analysed (15 non-trauma and 9 low-trauma-score patients). Networks were constructed, based on multilevel time-lagged linear regression analysis. Regression coefficients present network connections including three negative affect items (down, irritated, rushed), three positive affect items (happy, enthusiastic, cheerful), three abdominal complaints (abdominal pain, bloating, nausea) and one social item (feeling lonely). Those networks were stratified by levels of childhood trauma based on the Childhood Trauma Questionnaire.

RESULTS

Connections within the group of mood items and within the group of abdominal complaints were more frequent than between abdominal complaints and mood items. When data were stratified by childhood trauma, networks were different. In addition, node strengths were stronger in low-trauma than in non-trauma, although only one was significantly different (enthusiastic). Overall, there were mainly non-significant connections and a clear pattern was not visible.

CONCLUSIONS

A time-lagged network provides additional insight in connections between abdominal complaints and affective complaints, in patients with IBS and panic disorder, with different levels of childhood trauma. More research is needed to gain a better understanding of symptom formation and the impact of variation in context on individual symptom experiences in IBS with affective comorbidity. Baseline data of a clinical trial: NCT01551225 (http://www.clinicaltrials.gov).

Comorbid irritable bowel syndrome symptoms and headache have greater association with anxiety than depression: Annual health check-up survey results

High rates of co-existing irritable bowel syndrome (IBS) and headache have been reported in western countries. We investigated that comorbidity in individuals in Japan, along with anxiety and depression in subjects with and without IBS symptoms and/or headache.This cross-sectional study was performed from April 2012 to January 2013 at the Matsue Seikyo General Hospital Health Check Center. Questionnaires concerning symptoms related to IBS (Rome III) and headache, as well as anxiety/depression score were sent to individuals scheduled to undergo an annual health check-up, then returned during the visit and analyzed in a blinded manner.A total of 2885 individuals returned completed questionnaires and were enrolled, of whom 218 (7.6%) met the IBS criteria. The rates of co-existing headache in subjects with and without IBS symptoms were 44.0% (96/218) and 22.9% (611/2667), respectively, indicating a significantly higher rate of co-existing headache in subjects with as compared to without IBS (odds ratio [OR] 2.65, P < .001). Furthermore, the percentage of subjects with anxiety along with comorbid IBS symptoms and headache was significantly greater as compared to those with IBS (OR 3.01, P = .001) or headache (OR 2.41, P < .001) alone. Unlike anxiety, the percentage of subjects with depression was not significantly different among the IBS/non-headache, non-IBS/headache, and IBS/headache groups.Subjects with IBS symptoms had a higher rate of co-existing headache as compared to those without IBS. Furthermore, those with comorbid IBS symptoms and headache had a greater association with anxiety than with depression, as compared to those with only IBS or headache.

Depression and Structural Factors Are Associated With Symptoms in Patients of Irritable Bowel Syndrome With Diarrhea

Background/Aims

A strong correlation between depression and irritable bowel syndrome with diarrhea (IBS-D) has been identified. The aim of this study is to identify the correlations among depression, structural factors, gastrointestinal (GI) and extra-GI symptoms, and efficacy of neuromodulators in patients with IBS-D.

Methods

Patients meeting the Rome III Diagnostic Criteria for IBS-D were enrolled. The intestinal symptoms and psychological states were evaluated using IBS-specific symptom questionnaires and Hamilton Depression Rating Scale.

Results

In total, 410 patients with IBS-D were enrolled, 28.8% (118/410) had comorbid depression. Patients with depression did not readily experience improvement in abdominal pain/discomfort after defecation, and had a higher prevalence of passing mucus, overlapping functional dyspepsia, and extra-GI symptoms. The structural factor “mental disorders” significantly correlated with main bowel symptom score and degree of pre-defecation abdominal pain/discomfort. No structural factor significantly correlated with bowel movements or stool form. Patients who had passing mucus, overlapping functional dyspepsia and extra-GI painful symptoms have higher score of “anxiety/somatization.” Patients with sexual dysfunction have higher score of “retardation symptoms.” In total, 28.3% of patients with IBS-D were prescribed neuromodulators. Baseline scores of “anxiety/somatization” and “retardation symptoms” positively correlated with improvement of diarrhea after paroxetine, and “sleep disturbances” positively correlated with improvement of abdominal pain/discomfort and diarrhea after mirtazapine.

Conclusions

Comorbid depression and higher scores of structural factors might aggravate GI and extra-GI symptoms other than bowel movements and stool form. Structural factors of Hamilton Depression Rating Scale correlated with efficacy of paroxetine and mirtazapine in patients with IBS-D.

Underlying mechanisms for intestinal diseases arising from stress

Stress is an instinctive defense mechanism of the body in the competition for survival, but long-term or chronic stress will lead to systemic pathological manifestations. Intestinal diseases are closely related to pathological stress. This paper reviews the pathogenesis of intestinal diseases arising from stress.

Mucosal Tuft Cell Density Is Increased in Diarrhea-Predominant Irritable Bowel Syndrome Colonic Biopsies

Tuft cells are rare chemosensory sentinels found in the gut epithelium. When triggered by helminth infection, tuft cells secrete interleukin-25 (IL-25) basolaterally and subsequently evoke an immune response. Irritable bowel syndrome (IBS) is a common and heterogeneous disorder characterized by bowel dysfunction and visceral pain sensitivity. Dysfunctional gut-brain communication and immune activation contribute to the pathophysiology of this disorder. The study aims were to investigate changes in tuft cell density in non-post-infectious IBS patients. Immunofluorescent labeling of DCLK1-positive tuft cells was carried out in mucosal biopsies from the distal colons of diarrhea and constipation-predominant IBS patients and healthy controls. Tuft cell numbers were also assessed in animal models. Concentrations of interleukin-25 (IL-25) secreted from colonic biopsies and in plasma samples were analyzed using an immunoassay. The density of tuft cells was increased in diarrhea-but not constipation-predominant IBS patient colonic biopsies. Biopsy secretions and plasma concentrations of IL-25 were elevated in diarrhea-but not constipation-predominant IBS participants. Tuft cell hyperplasia was detected in a rat model of IBS but not in mice exposed to chronic stress. Tuft cell hyperplasia is an innate immune response to helminth exposure. However, the patients with diarrhea-predominant IBS have not reported any incidents of enteric infection. Moreover, rats exhibiting IBS-like symptoms displayed increased tuft cell density but were not exposed to helminths. Our findings suggest that factors other than helminth exposure or chronic stress lead to tuft cell hyperplasia in IBS colonic biopsies.

Comparison of Laughter Yoga and Anti-Anxiety Medication on Anxiety and Gastrointestinal Symptoms of Patients with Irritable Bowel Syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is the most common chronic gastrointestinal (GI) disorder. Patients with IBS usually suffer from anxiety and depression. A combination of psychological approaches and pharmacological treatments can be a significantly effective treatment for IBS. The main objective of the present study was to provide a therapeutic plan based on laughter yoga and anti-anxiety medication, employed for the very first time, and to determine the effectiveness of these treatments on the anxiety and GI symptoms of patients with IBS.

METHODS

In this randomized, controlled, clinical trial, the participants were 60 patients selected from those who referred to the GI clinic of Vali-asr Hospital (Birjand, Iran) during the study period (April 2017 to March 2017) and were diagnosed as having IBS based on ROME III criteria. The participants were randomly assigned to either the laughter yoga group, the anti-anxiety medication group, or the symptomatic treatment (control) group. Severity levels of anxiety and GI symptoms before and after intervention were determined and compared among these three groups according to approved protocols.

RESULTS

The severity of IBS symptoms after the interventions was more greatly reduced in the laughter yoga group than in the anti-anxiety medication and control groups (p = 0.006). The severity of anxiety after interventions decreased in all three groups, especially in the yoga treatment group, but the difference was not statistically significant (p = 0.1).

CONCLUSION

Laughter yoga is more effective than anti-anxiety medication in reducing the GI symptoms of patients with IBS. Therefore, applying laughter yoga along with common pharmacological therapies for patients with IBS might be strongly advised.

Electroacupuncture Regulates Disorders of Gut-Brain Interaction by Decreasing Corticotropin-Releasing Factor in a Rat Model of IBS

Objective

Acupuncture is effective for irritable bowel syndrome (IBS); however, the mechanisms of action are not fully understood. We aim to explore the mechanism of electroacupuncture (EA) in the dual regulation of disorders of gut-brain interaction.

Methods

A rat model of IBS was generated by chronic unpredictable mild stress (CUMS). Eight of 32 rats were assigned to the blank control group. The remaining 24 rats received CUMS for 14 days. Then, the rats surviving and successfully modelled were randomly divided into the CUMS group, the CUMS+EA group, and the CUMS+PB (pinaverium bromide) group. In the next 14 days of treatment, rats in the CUMS+EA group were acupunctured at ST25 (Tianshu), ST36 (Zusanli), SP6 (Sanyinjiao), and LR3 (Taichong) for 15 min every day. Rats in the CUMS+PB group were treated by the administration of gavage with 2.7 mg/mL pinaverium every day. Visceral pain threshold, the percentage of time spent in open arms (OT%) in the elevated plus maze test (EPMT), and the sucrose preference (SP%) in the sucrose preference test (SPT) were measured at baseline, day 15, and day 30. The expression of zonula occludens-1 (ZO-1), the morphology of the connective structure of intestinal epithelium, the CRF and CRF-R1 mRNA expression in the hypothalamus, and the double staining of intestinal mucosal mast cells (IMMC) and CRF-R1 were measured at the end of the experiment.

Results

Compared with the blank control group, visceral pain threshold pressure, the expression of ZO-1, OT%, SP%, CRF, and CRF-R1 mRNA expression in the hypothalamus, and double staining of IMMC and CRF-R1 were decreased significantly in the CUMS group. Meanwhile, the morphology of the connective structure in the CUMS group was indistinct. Compared with the CUMS group, SP% was significantly increased in the CUMS+EA group, but there was no significant difference for it in the CUMS+PB group. The morphology of the connective structure in the two treatment groups was clear and seeable. And the expression of other parameters mentioned above was apparently increased in the two treatment groups. Compared with the CUMS+PB group, the expression of ZO-1 in the CUMS+EA group was significantly enhanced. And no obvious difference for other parameters was found between the two treatment groups.

Conclusions

EA treatment can decrease the expression of hypothalamic CRF and CRF-R1, relieve anxiety and depression, meanwhile reduce the expression of CRF-R1 in the gastrointestinal mucosa, increase ZO-1 expression, and adjust tight junctions (TJs) to repair the intestinal mucosal barrier. The above roles suggest that EA may play a dual role in alleviating the gastrointestinal and psychological symptoms of IBS, suggesting a potentially dual therapeutic role for EA in regulating disorders of gut-brain interaction in IBS rats.

Effects of a comprehensive self-management intervention on extraintestinal symptoms among patients with IBS

OBJECTIVE

Adults with irritable bowel syndrome (IBS) often report extraintestinal pain, fatigue, and sleep disturbances in addition to abdominal pain. Few interventions have sought to reduce these extraintestinal symptoms within the IBS population. To address this, we compared the effects of a comprehensive self-management (CSM) intervention to a control intervention (usual care) on extraintestinal pain, fatigue, and sleep disturbances among patients with IBS.

METHOD

Data were obtained from 243 IBS patients participating in two CSM intervention trials. Daily symptom diaries were collected at baseline, 3 and 6 months post-randomization. Daily symptoms of headache, backache, muscle pain, joint pain, fatigue, sleepiness during the day, sleep quality, and refreshed by sleep were analyzed. Analysis of covariance was used to determine the effects of the intervention on each symptom at 3 and 6 months controlling for 'study' and baseline symptom levels.

RESULTS

Patients in the CSM intervention group reported decreased symptoms of fatigue, sleep disturbances, backache and headache compared to usual care at 3 and 6 months. The CSM group also reported significantly decreased joint pain at 3 months compared to usual care, but not 6 months. No significant difference was found for muscle pain.

CONCLUSIONS

An existing CSM intervention is effective in reducing fatigue and sleep disturbances. However, mixed results for extraintestinal pain indicates a need to better differentiate between underlying mechanisms. Addressing such symptoms is important to decrease the overall burden of IBS, reduce health care expenditures, and improve patients' quality of life.

TRIAL REGISTRATION

NCT00907790; NCT00167635.

Does symptom activity explain psychological differences in patients with irritable bowel syndrome and inflammatory bowel disease? Results from a multi-center cross-sectional study

OBJECTIVE

Irritable bowel syndrome (IBS) and inflammatory bowel diseases (IBD) have similar symptoms and are affected by psychological factors via gut-brain-interactions. However, previous studies on IBS and IBD showed inconsistent results regarding psychological factors, potentially because they failed to consider the impact of symptom activity. The aim of this study was 1) to compare psychological distress and psychological risk factors among patients with IBS, IBD and healthy controls (HC), and 2) to assess the impact of symptom activity.

METHODS

A controlled cross-sectional study was conducted. Patients with IBS and IBD were recruited in several primary, secondary, and tertiary medical care units between 02 and 12/2017 in Germany. Overall, 381 matched participants (127/group, 63% female) were included. For the second analyses, patients with IBD were distinguished in patients with active (n = 93) and non-active (n = 34) symptoms. Psychological distress (somatization, depression, anxiety, and illness anxiety) and risk factors (adverse childhood experiences, attachment style, and mentalizing capacity) were measured.

RESULTS

Patients with IBS showed higher psychological distress and more psychological risk factors than patients with IBD and HC. However, patients with IBD and active symptoms showed similar psychological distress than patients with IBS, except for lower illness anxiety (p < .001, η² = 0.069).

CONCLUSION

With the exception of higher illness anxiety in IBS patients, differences in psychological factors between patients with IBS and IBD were more strongly associated with symptom activity than with the underlying diagnosis. Therefore, this study challenges previous concepts of distinguishing functional and organic gastrointestinal diseases, but highlights the role of symptom activity and illness anxiety.

TRIAL REGISTRATION

DRKS00011685.

Factors Associated With Efficacy of Cognitive Behavior Therapy vs Education for Patients With Irritable Bowel Syndrome

BACKGROUND & AIMS

Among patients with irritable bowel syndrome (IBS), it would be helpful to identify those most likely to respond to specific treatments, yet few factors have been identified that reliably predict positive outcome. We sought to identify pretreatment baseline characteristics that associate with gastrointestinal symptom improvement in patients who received empirically validated regimens of cognitive behavior therapy (CBT) or IBS education.

METHODS

We analyzed data from the IBS Outcome Study, in which 436 patients with IBS (average age, 41 years; 80%, female) were randomly assigned to groups that received 4 or 10 sessions of cognitive behavior therapy or education over 10 weeks. Baseline data were collected from all participants on sociodemographic and clinical features and comorbidities. Interaction analyses used a modified linear probability model with Huber-White robust estimators to identify baseline factors that moderated as a function of treatment condition GI symptom improvement based on the IBS-version of the Clinical Global Impressions-Improvement Scale.

RESULTS

Whether the primary outcome of IBS symptom improvement was rated by patients or physician assessors blind to treatment 2 weeks after it ended, higher percentages of patients had symptom improvement after CBT compared with EDU among those with low levels of trait anxiety (71.3% vs 34.9%; P < .05) or anxiety sensitivity (71.7% vs 38.6%; P < .05) and for those with baseline typical levels of trait anxiety (66.0% vs 47.1%; P < .05) or anxiety sensitivity (66.3% vs 47.1%; P < .05). For patients with high trait anxiety or anxiety sensitivity, the difference in percentage of responders to CBT vs EDU was non-significant for trait anxiety (60.6% vs 59.2%) and anxiety sensitivity (60.9% vs 55.9%). If patients scored at or below 22 on the Trait Anxiety Inventory, CBT had a statistically significant advantage over EDU. If patients scored at or below 29 on the Anxiety Sensitivity Inventory, there was a statistically significant advantage for CBT vs EDU.

CONCLUSIONS

In analyses of outcomes of patients with treatment-refractory IBS, baseline levels of trait anxiety and anxiety sensitivity (fear of arousal symptoms) were associated with improved gastrointestinal symptoms following CBT compared to IBS education. These findings and approaches might be used to optimize selection of treatment for patients with IBS.

Systematic review with meta-analysis: the prevalence of anxiety and depression in patients with irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common and potential disabling functional gastrointestinal disorder. Studies have revealed a possible association between IBS and psychological problems, such as anxiety and depression. Existing systematic reviews have addressed only the levels of anxiety or depression in patients with IBS.

AIM

To investigate systematically the prevalence of anxiety or depression in IBS patients METHODS: A literature search was conducted using the related keywords from the bibliographic databases of Embase, PubMed, Scopus, Web of Science and POPLINE published until 1 January 2019 with no language restriction. Studies reporting the prevalence of anxiety/depressive symptoms/disorders in adult (≥15 years) IBS patients were evaluated. The pooled prevalence, odds ratio (OR) and 95% CI were calculated using stata software.

RESULTS

A total of 14 926 articles were initially screened, and finally 73 papers were included. The prevalence rates of anxiety symptoms and disorders in IBS patients were 39.1% (95% CI: 32.4-45.8) and 23% (95% CI: 17.2-28.8) respectively. The ORs for anxiety symptoms and disorders in IBS patients compared with healthy subjects were 3.11 (95% CI: 2.43-3.98) and 2.52 (95% CI: 1.99-3.20) respectively. The prevalence estimates of depressive symptoms and disorders in IBS patients were 28.8% (95% CI: 23.6-34) and 23.3% (95% CI: 17.2-29.4) respectively. The ORs for depressive symptoms and disorders in IBS patients compared to healthy subjects were 3.04 (95% CI: 2.37-3.91) and 2.72 (95% CI: 2.45-3.02) respectively.

CONCLUSION

Patients with IBS have a three-fold increased odds of either anxiety or depression, compared to healthy subjects.

Primary healthcare utilisation and self-rated health among patients with Irritable Bowel Syndrome: What are the impacts of comorbidities, gastrointestinal symptom burden, sense of coherence and stress?

OBJECTIVES

Irritable Bowel Syndrome (IBS) is a chronic gastrointestinal disease associated with impaired quality of life and an increased use of healthcare services. Self-ratings of health have proven a powerful predictor of health outcomes. The aim of this study was to evaluate the unique impacts of comorbidities, gastrointestinal symptoms, perceived stress and sense of coherence on the number of healthcare contacts and self-rated health of IBS patients in Swedish primary care.

METHODS

In this cross-sectional study, 186 primary-care IBS patients and 360 non-IBS patients (as a reference group) were administrated a test battery of validated questionnaires. Data on comorbidities and healthcare-seeking frequency were obtained from a registry.

RESULTS

In the reduced multivariable logistic regression model, average days of abdominal pain/week (OR = 0.83, 95% CI = 0.72-0.96), age (OR = 0.95, 95% CI = 0.92-0.97) and sense of coherence (OR = 1.07, 95% CI = 1.03-1.11) remained independent, statistically significant predictors of IBS (and non-IBS) patients reporting good health. Only the number of comorbidities in general (OR = 1.22, 95% CI = 1.14-1.32) and sleep disorders in particular (OR = 5.40, 95% CI = 1.85-15.76) independently predicted high levels of primary healthcare utilisation among IBS patients.

CONCLUSION

Lack of gastrointestinal symptoms, a high sense of coherence and younger age were associated with better self-rated health in both IBS and non-IBS patients. The number of comorbidities in general and sleep disorders in particular were associated with frequent PHC contacts in IBS patients. The association between frequent primary-care contacts and sleep disorders was not seen in the control group, indicating a unique association with IBS patients.

Constipation is associated with tension type headache in women

ABSTRACT Tension-type headaches (TTH) and irritable bowel syndrome (IBS) are comorbid diseases affecting, especially, women. One of the underlying mechanisms for both is autonomic dysfunction in the brain-gut axis. We aimed to evaluate the factors accompanying TTH and their relation to functional gastrointestinal disorders. Methods: Women diagnosed with TTH were questioned about headache pattern and severity, and accompanying factors, as well as being screened for IBS according to the Rome III criteria. The participants were divided into two groups: constipation-dominant IBS (IBS-C) group and “others”, with a total of 115 individuals included in the study. Results: Of the 115 patients; 48 (41.8%) of the women had IBS-C criteria while 67 (58.2%) described mixed-type IBS or diarrhea-dominant IBS. There were no significant differences in terms of mean age (p = 0.290), body mass index (p = 0.212), visual analog scale (p = 0.965), duration of attacks (p = 0.692), and episodic/chronic type (p = 0.553). Osmophobia was seen in 43.5%; phonophobia in 68.7%, and photophobia in 47.0% of the patients, and only osmophobia was significantly associated in women in the IBS-C group (p = 0.001). Conclusion: In female patients with TTH, a higher level of constipation was detected. The relationship of these two diseases suggests that they may share common mechanisms. This is the first study showing the relationship of osmophobia with constipation.

Anhedonia in irritable bowel syndrome and in inflammatory bowel diseases and its relationship with abdominal pain

BACKGROUND

Anhedonia is the lowered ability to experience pleasure from rewarding or enjoyable activities and is considered a symptom of depression. Inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) are frequently accompanied by psychiatric disorders such as depression. However, to our knowledge, studies have yet to investigate the anhedonia in these patients. Our aim was to study the level of anhedonia in patients with IBD and IBS in comparison with healthy controls (HC), and to relate anhedonia levels with the severity of abdominal pain.

METHODS

We consecutively recruited IBD and IBS patients. All patients fulfilled the Snaith-Hamilton Pleasure Scale (SHAPS), a self-rating scale consisting of 14 items that cover the domains of social interaction, food, and drink, sensory experiences, achievement and pastimes, and the Beck Depression Inventory-II (BDI-II) to screen for depression. Moreover, we calculated abdominal pain on a (0-100) Visual Analog Scale (VAS) in all patients.

KEY RESULTS

We enrolled 120 patients (64 IBD and 56 IBS) and 81 HC. Among IBD patients, 34 had Crohn's disease and 30 ulcerative colitis. All patients as a whole had significantly higher SHAPS and BDI-II scores than HC (1.3 ± 1.5 vs 0.8 ± 0.1; P = 0.01 and 10.4 ± 7.5 vs 5.9 ± 4.9; P < 0.001, respectively), while no significant differences were found among groups. SHAPS score showed a significant correlation in only a few statements of BDI-II. In our cohort, a multivariate regression analysis showed that SHAPS score was significantly related to current abdominal pain (0-100 VAS) (P = 0.03) independent of gender and age.

CONCLUSIONS AND INFERENCES

The level of anhedonia was higher in all patients compared to healthy controls. The more the subject is anhedonic, the higher the VAS scale for abdominal pain. This study suggests that anhedonia would need to be very carefully weighed in IBD and IBS patients.

Durability and Decay of Treatment Benefit of Cognitive Behavioral Therapy for Irritable Bowel Syndrome: 12-Month Follow-Up

BACKGROUND

There is a need for safe and effective IBS treatments that provide immediate and sustained improvement of IBS symptoms, particularly among more severe patients. The aim was to assess long-term clinical response of cognitive behavioral therapy (CBT) with reference to IBS education.

METHODS

A total of 436 Rome III-diagnosed IBS patients (80% F, M age = 41 years) were randomized to: 4 session home-based CBT (minimal contact (MC-CBT)), 10 session clinic-based CBT (standard (S-CBT)), or 4 session IBS education (EDU). Follow-up occurred at 2 weeks and 3, 6, 9, and 12 months following treatment completion. Treatment response was based a priori on the Clinical Global Improvement Scale (global IBS symptom improvement) and IBS Symptom Severity Scale (IBS-SSS).

RESULTS

Post-treatment CGI gains were generally maintained by MC-CBT patients at quarterly intervals through 12-month follow-up with negligible decay. For MC-CBT and S-CBT, 39 and 33% of respondents maintained treatment response at every follow-up assessment. The corresponding percent for EDU was 19%, which was significantly lower (p < 0.05) than for the CBT groups. On the IBS-SSS, therapeutic gains also showed a pattern of maintenance with trends towards increased efficacy over time in all conditions, with the mean unit reductions between baseline and follows-up being approximately -76 at immediate and approximately -94 at 12 months (-50 = clinically significant).

CONCLUSIONS

For treatment-refractory IBS patients, home- and clinic-based CBT resulted in substantial and enduring relief of multiple IBS symptoms that generally extended to 12-month post treatment.

Exercise influence on the microbiome-gut-brain axis

The microbiome in the gut is a diverse environment, housing the majority of our bacterial microbes. This microecosystem has a symbiotic relationship with the surrounding multicellular organism, and a balance and diversity of specific phyla of bacteria support general health. When gut bacteria diversity diminishes, there are systemic consequences, such as gastrointestinal and psychological distress. This pathway of communication is known as the microbiome-gut-brain axis. Interventions such as probiotic supplementation that influence microbiome also improve both gut and brain disorders. Recent evidence suggests that aerobic exercise improves the diversity and abundance of genera from the Firmcutes phylum, which may be the link between the positive effects of exercise on the gut and brain. The purpose of this review is to explain the complex communication pathway of the microbiome-gut-brain axis and further examine the role of exercise on influencing this communication highway.

The Relationship Between Daytime Salivary Melatonin and Gastrointestinal Symptoms in Young Adults Seeking Psychiatric Care

OBJECTIVE

The pathophysiology of irritable bowel syndrome (IBS) is not completely understood, although we do know that patients with IBS have a high prevalence of psychiatric comorbidity (mainly depression and anxiety disorders). Melatonin, produced in the gastrointestinal tract, influences gut motility. Psychiatric conditions are associated with circadian disturbances in peripheral melatonin levels. This study aimed to investigate associations between daytime salivary melatonin and gastrointestinal symptoms in young adult psychiatric patients.

METHODS

Ninety-six patients (86% women), aged 18-25 years (M (SD) = 21 (2)), seeking psychiatric care with primarily anxiety disorders, affective disorders, or both were included in the study. Total scores from the Gastrointestinal Symptoms Rating Scale - IBS were compared with salivary melatonin measured at three time points (30 minutes after waking up, at 11:00 hours and 30 minutes after lunch) during the waking hours of 1 day.

RESULTS

After adjustment for potential confounders, melatonin levels in saliva 30 minutes after lunch remained significantly correlated to the total Gastrointestinal Symptoms Rating Scale - IBS score after correction for multiple testing (B = 0.016, SE = 0.006, p = .015, q = 0.045). In a post hoc analysis, symptoms of gastrointestinal pain and bloating contributed most to this association.

CONCLUSIONS

In young adult psychiatric patients, salivary melatonin levels after lunch are associated with gastrointestinal symptoms, which is consistent with the proposed effect of elevated levels of gastrointestinal melatonin on gut motility. This result suggests a link between IBS symptoms and regulation of melatonin in patients with psychiatric disorders.