Definition and classification of irritable bowel syndrome: current consensus and controversies

Predictors of pelvic pain in a general urology clinic population

Objectives

To assess the prevalence and predictors of chronic pelvic pain in a general urology population presenting for evaluation of unrelated non-painful complaints.Generalized pelvic pain is estimated to afflict between 6% and 26% of women and is often multifactorial in aetiology. A paucity of prospective research exists to characterize chronic pelvic pain patterns and to understand related predictors.

Materials and Methods

This is a prospective, cross-sectional survey-based study of female patients presenting to a general urology clinic over a 10-month period (7/2018-5/2019). Patients completed a 32-item survey with questions pertaining to demographics, comorbidities and chronic pelvic pain characteristics. Comparison tests (chi-squared, Fisher's exact) and stepwise multivariable logistic modelling were performed to assess for predictors of chronic pelvic pain.

Results

A total of 181 women completed the survey, with a mean age of 56 years. Overall, 75 (41%) women reported chronic pelvic pain. Those with chronic pelvic pain were younger compared to those without (52 vs 59 years, p = 0.001). Univariable logistic regression analysis identified BMI, depression, fibromyalgia, overactive bladder and any bowel symptoms as possible positive predictors of chronic pelvic pain. Final best-fit multivariable model found overactive bladder, fibromyalgia and presence of bowel symptoms as independent positive predictors of chronic pelvic pain.

Conclusions

Our study is one of the few studies that has prospectively analysed chronic pelvic pain and its predictors. The present study identified significant associations with overactive bladder, fibromyalgia and bowel symptoms. Further research is needed to better understand the aetiologies of chronic pelvic pain and the possible relationship with identified clinical predictors.

Antinociceptive Effects of an Anti-CGRP Antibody in Rat Models of Colon-Bladder Cross-Organ Sensitization

Irritable bowel syndrome (IBS) and bladder pain syndrome/interstitial cystitis (BPS/IC) are comorbid visceral pain disorders seen commonly in women with unknown etiology and limited treatment options and can involve visceral organ cross-sensitization. Calcitonin gene-related peptide (CGRP) is a mediator of nociceptive processing and may serve as a target for therapy. In three rodent models, we employed a monoclonal anti-CGRP F(ab')2 to investigate the hypothesis that visceral organ cross-sensitization is mediated by abnormal CGRP signaling. Visceral organ cross-sensitization was induced in adult female rats via transurethral infusion of protamine sulfate (PS) into the urinary bladder or infusion into the colon of trinitrobenzene sulfonic acid (TNBS). Colonic sensitivity was assessed via the visceromotor response to colorectal distension (CRD). Bladder sensitivity was assessed as the frequency of abdominal withdrawal reflexes to von Frey filaments applied to the suprapubic region. PS- or TNBS-induced changes in colonic and bladder permeability were investigated in vitro via quantification of transepithelial electrical resistance (TEER). Peripheral administration of an anti-CGRP F(ab')2 inhibited PS-induced visceral pain behaviors and colon hyperpermeability. Similarly, TNBS-induced pain behaviors and colon and bladder hyperpermeability were attenuated by anti-CGRP F(ab')2 treatment. PS into the bladder or TNBS into the colon significantly increased the visceromotor response to CRD and abdominal withdrawal reflexes to suprapubic stimulation and decreased bladder and colon TEER. These findings suggest an important role of peripheral CGRP in visceral nociception and organ cross-sensitization and support the evaluation of CGRP as a therapeutic target for visceral pain in patients with IBS and/or BPS/IC. SIGNIFICANCE STATEMENT: A monoclonal antibody against calcitonin gene-related peptide (CGRP) was found to reduce concomitant colonic and bladder hypersensitivity and hyperpermeability. The results of this study suggest that CGRP-targeting antibodies, in addition to migraine prevention, may provide a novel treatment strategy for multiorgan abdominopelvic pain following injury or inflammation.

The Potential Role of Human Milk Oligosaccharides in Irritable Bowel Syndrome

Irritable Bowel Syndrome (IBS) is the most common gastrointestinal (GI) disorder in Western populations and therefore a major public health/economic concern. However, despite extensive research, psychological and physiological factors that contribute to the aetiology of IBS remain poorly understood. Consequently, clinical management of IBS is reduced to symptom management through various suboptimal options. Recent evidence has suggested human milk oligosaccharides (HMOs) as a potential therapeutic option for IBS. Here, we review literature concerning the role of HMOs in IBS, including data from intervention and in vitro trials. HMO supplementation shows promising results in altering the gut microbiota and improving IBS symptoms, for instance by stimulating bifidobacteria. Further research in adults is required into HMO mechanisms, to confirm the preliminary results available to date and recommendations of HMO use in IBS.

A Monoclonal Anti-Calcitonin Gene-Related Peptide Antibody Decreases Stress-Induced Colonic Hypersensitivity

Irritable bowel syndrome (IBS) is a brain-gut disorder characterized by abdominal pain and altered bowel habits. Although the etiology of IBS remains unclear, stress in adulthood or in early life has been shown to be a significant factor in the development of IBS symptomatology. Evidence suggests that aberrant calcitonin gene-related peptide (CGRP) signaling may be involved in afferent sensitization and visceral organ hypersensitivity. Here, we used a monoclonal anti-CGRP divalent antigen-binding fragment [F(ab')₂] antibody to test the hypothesis that inhibition of peripheral CGRP signaling reverses colonic hypersensitivity induced by either chronic adult stress or early life stress. A cohort of adult male rats was exposed to repeated water avoidance stress. Additionally, a second cohort consisting of female rats was exposed to a female-specific neonatal odor-attachment learning paradigm of unpredictable early life stress. Colonic sensitivity was then assessed in adult animals via behavioral responses to colorectal distension (CRD). To analyze spinal nociceptive signaling in response to CRD, dorsal horn extracellular signal-regulated kinase (ERK) 1/2 phosphorylation was measured via immunohistochemistry. Repeated psychologic stress in adulthood or unpredictable stress in early life induced colonic hypersensitivity and enhanced evoked ERK1/2 phosphorylation in the spinal cord after CRD in rats. These phenotypes were reversed by administration of a monoclonal anti-CGRP F(ab')₂ fragment antibody. Stress-induced changes in visceral sensitivity and spinal nociceptive signaling were reversed by inhibition of peripheral CGRP signaling, which suggests a prominent role for CGRP in central sensitization and the development of stress-induced visceral hypersensitivity. SIGNIFICANCE STATEMENT: Targeting peripheral calcitonin gene-related peptide (CGRP) with a monoclonal anti-CGRP divalent antigen-binding fragment antibody reduced central sensitization and attenuated colonic hypersensitivity induced by either chronic adult stress or early life stress. CGRP-targeting antibodies are approved for migraine prevention, and the results of this study suggest that targeting CGRP may provide a novel treatment strategy for irritable bowel syndrome-related, stress-induced visceral pain.

Corneal neuropathic pain in irritable bowel syndrome: clinical findings and in vivo corneal confocal microscopy

PURPOSE

Ocular discomfort is a common symptom in central sensitization syndromes. The aim of this study was to evaluate ocular surface discomfort and related corneal changes in patients with irritable bowel syndrome.

METHODS

Twenty-nine patients with IBS (20 female, 9 male, mean age: 45.3 ± 10.1 years) and 37 healthy control subjects (25 female, 12 male, mean age: 44.95 ± 9.76 years) were included. A detailed ophthalmological examination was performed to all participants including tear break-up time (TBUT) and Schirmer test I with anesthetic (SIT). Ocular discomfort was evaluated using the ocular surface disease index (OSDI) questionnaire and corneal sensation was evaluated with Cochet-Bonnet esthesiometer. Corneal subbasal nerve plexus was evaluated with in vivo corneal confocal microscopy (IVCM).

RESULTS

There was no significant difference between the groups for age, gender distribution, and visual acuity. OSDI scores were significantly higher (p = 0.008) and TBUT was significantly reduced in patients with IBS compared to controls (p = 0.001 for right eye, p = 0.014 for left eye). However, there was no significant difference in corneal touch sensation and SIT results between the groups. IVCM revealed that corneal nerve fiber density, corneal nerve branch density, and corneal nerve fiber length were significantly reduced in patients with IBS (p < 0.001, p < 0.001, and p = 0.023, respectively).

CONCLUSION

Patients with IBS have increased dry eye-associated ocular surface complaints and nerve fiber loss in corneal subbasal nerve plexus. IBS should be remembered in the differential diagnosis, when there is discordance between the level of ocular surface discomfort and dry eye disease associated corneal findings.

Peripheral Guanylate Cyclase-C modulation of corticolimbic activation and corticotropin-releasing factor signaling in a rat model of stress-induced colonic hypersensitivity

BACKGROUND

Psychological stress is a risk factor for irritable bowel syndrome, a functional gastrointestinal pain disorder featuring abnormal brain-gut connectivity. The guanylate cyclase-C (GC-C) agonist linaclotide has been shown to relieve abdominal pain in IBS-C and exhibits antinociceptive effects in rodent models of post-inflammatory visceral hypersensitivity. However, the role GC-C signaling plays in psychological stress-induced visceral hypersensitivity is unknown. Here, we test the hypothesis that GC-C agonism reverses stress-induced colonic hypersensitivity via inhibition of nociceptive afferent signaling resulting in normalization of stress-altered corticotropin-releasing factor (CRF) expression in brain regions involved in pain perception and modulation.

METHODS

Adult female rats were exposed to water avoidance stress or sham stress for 10 days, and the effects of linaclotide on stress-induced changes in colonic sensitivity, corticolimbic phospho-extracellular signal-regulated kinase (pERK), and CRF expression were measured using a combination of behavioral assessments, immunohistochemistry, and qRT-PCR.

KEY RESULTS

Stressed rats exhibited colonic hypersensitivity and elevated corticolimbic pERK on day 11, which was inhibited by linaclotide. qRT-PCR analysis revealed dysregulated CRF expression in the medial prefrontal cortex, paraventricular nucleus of the hypothalamus, and central nucleus of the amygdala on day 28. Dysregulated CRF expression was not affected by linaclotide treatment.

CONCLUSIONS AND INFERENCES

Our results demonstrate that exposure to repeated stress induces chronic colonic hypersensitivity in conjunction with altered corticolimbic activation and CRF expression. GC-C agonism attenuated stress-induced colonic hypersensitivity and ERK phosphorylation, but had no effect on CRF expression, suggesting the analgesic effects of linaclotide occur independent of stress-driven CRF gene expression in corticolimbic circuitry.

Monocyte chemotactic protein-1 and nitrotyrosine in irritable bowel syndrome

Irritable bowel syndrome (IBS) is one the most frequent and common functional gastrointestinal disorders that has a multifactorial etiopathogenesis. Multiple biomarkers have been tested in search for a reliable and specific biomarker, but there is not yet a specific biomarker for IBS. The aim of this study was to evaluate two biomarkers of different putative pathways of the pathogenesis of IBS: the monocyte chemotactic protein-1 (MCP-1) and nitrotyrosine, in order to establish their role as potential biomarkers. We enrolled 42 consecutive IBS patients diagnosed by Rome III criteria and 35 consecutive healthy controls. Serum concentrations for the two biomarkers (MCP-1 and nitrotyrosine) were determined using commercial ELISA kits. Serum levels of MCP-1 were not statistically significantly higher in IBS patients than in controls (204±130 vs. 174±73 pg/ml; P=0.311). Nitrotyrosine levels were statistically significantly lower in IBS patients than in controls (30±12 vs. 353±14 nM; P=0.050). MCP-1 levels were higher in IBS patients with metabolic syndrome versus IBS patients without metabolic syndrome (239±153 vs. 168±120 pg/ml; P=0.948) and in controls with metabolic syndrome (174±56 pg/ml). MCP-1 serum levels were statistically significantly higher in IBS patients with metabolic syndrome than in controls (239±153 vs. 157±89 pg/ml; P=0.037), suggesting multiple factors being involved, particularly the diet and its relation with the metabolic syndrome, and it suggests that MCP-1 could be a marker of subclinical atherosclerosis. Low-grade inflammation might be related to oxidative stress, which plays an underestimated role in the pathogenesis of IBS.

Feasibility of Low Fermentable Oligosaccharide, Disaccharide, Monosaccharide, and Polyol Diet and Its Effects on Quality of Life in an Italian Cohort

The low Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet has demonstrated excellent results in terms of symptom control and health-related quality of life (HRQoL) in irritable bowel syndrome (IBS) sufferers, but patients have complained about unsatisfying taste, difficulty in following the diet, and time consumption. To investigate the feasibility of the low FODMAP diet in an Italian (Sardinian) cohort, sixty consecutive eligible outpatients (11 men and 49 women) with IBS were enrolled and followed a low FODMAP diet (gluten allowed, restriction phase of four weeks, reintroduction phase of four weeks). Food habits were assessed using 24-hour dietary recall, Bristol Stool Scale for stool consistency, Visual Analogue Scale for abdominal bloating, VAS (Visual Analogue Scale) for abdominal pain, IBS Severity Scoring System for perceived disease severity, and a 12-item Short Form Survey for HRQoL (psychological component summary + mental component summary) were applied at baseline (T0) and at the end of each phase (T1-four weeks and T2-eight weeks). Statistical analysis was performed by dividing the cohort into diarrhoea-dominant IBS (IBS-D) and other IBS subtypes (selected IBS-others). Comparisons between T1 and T2 vs. T0 and T2 vs. T1 were performed. The low FODMAP diet lowered VASp (VAS pain), VASb (VAS bloating), and IBS SSS (IBS Severity Scoring System), and increased PCS (Physical Component Summary) and MCS (Mental Component Summary) in both subgroups. Bristol Stool Scale (BSS) only improved in the IBS-D subgroup. The dropout mean values for MCS were higher than treated subjects and the percentage of unemployment was lower in the dropouts. According to the dropout features, the low FODMAP diet seems to show greater feasibility for patients with more time to dedicate to the diet (unemployed, homemakers, housewives, or students), more motivation, and more severe clinical features, independent of their place of residence.

µ-opioid receptor, β-endorphin, and cannabinoid receptor-2 are increased in the colonic mucosa of irritable bowel syndrome patients

BACKGROUND AND AIMS

The gut immune, cannabinoid, and opioid systems constitute an integrated network contributing to visceral sensation and pain modulation. We aimed to assess the expression of the µ-opioid receptor (MOR), its ligand β-endorphin (β-END), and cannabinoid receptor-2 (CB2 ) in patients with irritable bowel syndrome (IBS) and asymptomatic controls (AC) and their correlation with sex and symptom perception.

METHODS

Mucosal biopsies were obtained from the left colon of 31 IBS patients (45% women) with predominant constipation (IBS-C, 9) or diarrhea (IBS-D, 10) or with mixed bowel habits (IBS-M, 12) and 32 AC (44% women) and processed for qRT-PCR, Western blotting, and immunohistochemistry.

KEY RESULTS

µ-opioid receptor and CB2 mRNA and protein expression and β-END protein levels were increased in patients with IBS compared to AC (all Ps=0.021). A significant sex by IBS interaction was found in relation to CB2 mRNA expression (P = .003) with women showing a markedly higher expression to men (P = .035). In contrast, in AC, men had higher expression than women (P = .033). β-END, MOR, and CB2 immunoreactivities (IR) were localized to CD4+T cells including EMR-1+ eosinophils and CD31+ T cells but not to mast cells.

CONCLUSIONS

The increased expression of MOR, β-END, and CB2 in the mucosa of IBS patients, where they are localized to immune cells, suggests that opioid and cannabinoid systems play an immune-related compensatory role in visceral pain in IBS patients. Further work is necessary to support this hypothesis.

Gastrointestinal symptoms - an illness burden that affects daily work in patients with IBS

Background

Irritable Bowel Syndrome (IBS) is a chronic gastrointestinal disorder characterised by recurrent abdominal pain and disturbed bowel habits and unclear aetiology. IBS is also associated with psychosocial factors, impaired quality of life and lost work productivity. This study sought to determine whether the association between IBS and lost work productivity might be accounted for by poor coping strategies and loss of confidence in the healthcare system.

Methods

Case–control design was employed sampling IBS and non-gastrointestinal (non-GI) primary healthcare seekers in a defined region in Sweden. Non-GI patients were of similar age and sex distribution to the IBS patients. Questionnaires applied in this study included instruments designed to measure confidence in the social security system and in the community, as well as questions about whether gastrointestinal problems might affect working life and Sense of coherence (SOC) questionnaire. The study’s primary hypothesis was evaluated via an a priori path model.

Results

Statistically significant differences were found between IBS cases (n = 305) and controls (n = 369) concerning abdominal pain or discomfort affecting everyday performance at work (p <  0.0001). IBS cases also showed significantly lower (p = 0.001) confidence in public healthcare. The study’s hypothesis was supported with the finding of a statistically significant indirect association via poor coping strategies, although the indirect associations were lesser in magnitude than the direct association.

Conclusions

This study found a clear association between clinically diagnosed IBS status and interference in work by gastrointestinal symptoms in which sense of coherence might be of importance.

Linaclotide inhibits colonic and urinary bladder hypersensitivity in adult female rats following unpredictable neonatal stress

BACKGROUND

Irritable bowel syndrome (IBS) and bladder pain syndrome (BPS) are female-predominant, chronic functional pain disorders that are associated with early life stress (ELS) and therapeutic options for such patients remain limited. Linaclotide, a guanylate cyclase-C (GC-C) agonist, relieves abdominal pain and bowel symptoms in adult patients suffering from IBS with constipation. Here, we test the hypothesis that linaclotide will reverse colon and bladder hyperalgesia in a female-specific rodent model of adverse early life experience.

METHODS

Neonatal rats were exposed to an odor-attachment learning paradigm of early life stress (ELS). In adulthood, the effect of linaclotide (3 μg kg^-1  d^-1 , p.o.) on colonic and bladder sensitivity was assessed via quantification of the visceromotor response to colorectal distension and the frequency of withdrawal responses to the application of von Frey hairs to the suprapubic region. In another cohort of rats, the effect of linaclotide on ELS-induced colonic and bladder permeability was investigated via measurements of transepithelial electrical resistance (TEER).

KEY RESULTS

Rats exposed to unpredictable ELS exhibited colonic and bladder hypersensitivity that was significantly reduced by linaclotide compared to vehicle-treated controls. Colonic and bladder tissue isolated from adult rats exposed to unpredictable ELS exhibited a decrease in colonic and bladder TEER that was reversed by linaclotide.

CONCLUSIONS AND INFERENCES

Our results demonstrate that neonatal rats exposed to unpredictable ELS develop increased sensitivity and permeability of the colon and bladder in adulthood through a mechanism involving activation of peripheral GC-C signaling.

Quantifying Rome symptoms for diagnosis of the irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder, diagnosed on symptom-based criteria. Many have reported discrepancies between formal Rome criteria and diagnoses made in clinical practice. The aim of the study was to explore whether a quantitative version of the Rome criteria would better represent a clinical diagnosis of IBS than the current dichotomous criteria for symptom measure.

METHODS

As part of a large, case-control study, participants completed a validated bowel disease questionnaire. Rome criteria were analyzed based on 15 individual symptoms. Penalized logistic regression model with stepwise selection was used to identify significant symptoms of IBS which were independently associated with case-control status.

KEY RESULTS

In cases with a clinical diagnosis of IBS, 347 (70%) met Rome criteria for IBS. Increasing number of Rome symptoms were found related to the odds of being diagnosed with IBS. Nearly half of the Rome-negative case group experienced infrequent symptoms suggesting milder disease. Five of 15 Rome symptoms were associated with predicting case-control status in the final model, with 96% correctly classified among Rome-positive cases, 76% for Rome-negative cases, and 91% for controls.

CONCLUSIONS AND INFERENCES

Irritable bowel syndrome appears to be a spectrum disorder. Quantifying individual symptoms of Rome criteria has greater utility than the current application in representing the degree of IBS affectedness and appears to better reflect a clinical diagnosis of IBS applied by physicians. The use of a quantitative diagnostic Rome "score" may be helpful in clinical practice and research studies to better reflect the degree an individual is affected with IBS.

Linaclotide Attenuates Visceral Organ Crosstalk: Role of Guanylate Cyclase-C Activation in Reversing Bladder-Colon Cross-Sensitization

Bladder pain syndrome (BPS) is poorly understood; however, there is a female predominance and comorbidity with irritable bowel syndrome (IBS). Here we test the hypothesis that linaclotide, a guanylate cyclase-C (GC-C) agonist approved for the treatment of IBS with constipation (IBS-C), may represent a novel therapeutic for BPS acting through a mechanism involving an inhibition of visceral organ cross-sensitization. We showed previously that infusion of dilute protamine sulfate (PS) into the bladder increased sensitivity and permeability in the bladder and colon. PS was infused into the bladder of female rats; sensitivity was assessed via application of von Frey filaments applied to the suprapubic area and the frequency of withdrawal responses was recorded. Colonic sensitivity was measured via visceromotor behavioral response to graded pressures of colorectal distension (CRD). Permeability was measured in vitro via transepithelial electrical resistance (TEER) and conductance (G). Linaclotide (3 µg/kg, p.o.) or vehicle was administered daily for 7 days prior to experiments. Rats treated with PS bladder infusion exhibited visceral hyperalgesia, as shown by a significantly higher response frequency to individual von Frey filaments and increased behavioral responses to CRD. Linaclotide attenuated bladder and colonic hyperalgesia to control levels. PS infusion into the bladder increased bladder and colon permeability measured as a decrease in TEER and increased G. Linaclotide significantly inhibited PS-induced colonic hyperpermeability while having no effect on bladder hyperpermeability. Our findings suggest a novel treatment paradigm for GC-C agonism in IBS-C and BPS mediated through a mechanism involving visceral organ crosstalk.

Factors Influencing the Life Experiences of Individuals With Inflammatory Bowel Disease

Inflammatory bowel disease has a negative impact on individuals perception of their health status and is associated with disabling processes that have physical, social, and work repercussions. The objectives of this study were to describe the life experiences of individuals with Crohn disease and ulcerative colitis and to develop a theoretical framework to describe the relationships of these diseases with personal and clinical factors. A qualitative study on the basis of grounded theory was conducted, involving individual and semistructured interviews on the life experiences of 14 adults of different ages with inflammatory bowel disease in relapse or inactive phase. The individuals in relapse phase and those with a short time since diagnosis had the most negative perceptions of their health, and experienced impaired ability for daily activities. The life experiences of individuals with inflammatory bowel disease were influenced by the time since diagnosis and the disease phase, with no gender difference in either factor. The predominant strategy of participants for coping with the disease was to pursue normality. According to these findings, nursing interventions should focus on the initial adaptation phase and on coping strategies during active phases of the disease.

Empirically derived dietary habits are associated with irritable bowel syndrome

BACKGROUND/OBJECTIVES

The associations between empirically derived dietary habits and irritable bowel syndrome (IBS) have not been investigated. This study aimed to assess the relationship between empirically derived dietary habits and IBS in a large population of Iranian adults.

SUBJECTS/METHODS

In a cross-sectional study, dietary habits of 4763 adults were assessed in three domains, "meal pattern", "eating rate" and "intra-meal fluid intake". We used latent class analysis to identify classes of dietary habits. IBS was defined based on ROME III criteria.

RESULTS

IBS was prevalent in 20.3% (n = 966) of the study population. Two distinct classes of meal patterns: "regular" and "irregular", three classes of eating rates: "moderate", "moderate-to-slow" and "moderate-to-fast" and two classes of fluid ingestion with meals: "moderate" and "heavy intra-meal drinking" were identified. After adjustment for confounders, "heavy intra-meal fluid intake" was protectively associated with IBS (OR = 0.79; 95% CI:0.64-0.96). When potential confounders were considered, "meal pattern" and "eating rate" were not significantly associated with IBS in the whole population. After adjustment for confounders, women with "irregular meal pattern" had a 30% greater risk of having IBS, compared with those with "regular meal pattern" (OR = 1.30; 95% CI:1.02-1.67). Overweight participants with "fast eating rate" were 70% more likely to have IBS, compared to those with "moderate eating rate" (OR = 1.70; 95% CI:1.13-2.55). "Irregular meal pattern" was related to frequency and severity of abdominal pain.

CONCLUSIONS

We found a significant association between heavy intra-meal fluid intake" and IBS. More large-scale prospective studies are needed to affirm this association.

The Severity of Symptoms Related to Irritable Bowel Syndrome is a Risk Factor for the Misclassification of Significant Organic Disease

BACKGROUND AND AIMS

The diagnosis of irritable bowel syndrome (IBS) is based mainly on clinical evaluation. The reported incidence of misclassification of significant organic diseases in previously diagnosed IBS patients differs between studies. The aim of this study was to examine the incidence and risk factors for the misclassification of significant organic disease [colon cancer, inflammatory bowel disease (IBD), Celiac disease, and thyroid dysfunction] in a cohort of young patients with symptoms attributed to IBS.

METHODS

In this population-based cohort study, we examined the incidence and risk factors for the diagnosis of a new significant organic diseases in a cohort of 2645 IBS patients.

RESULTS

During follow-up, organic disease was diagnosed in 27 subjects (1.03%): IBD in 23, Celiac disease in 2, IBD and Celiac disease in 1, and hypothyroidism in1. The mean interval from the diagnosis of IBS to the diagnosis of an organic disorder was 13.08±8.51 months. Increased symptom severity was the only significant risk factor for the misclassification of an organic disease (hazard ratio, 2.26; 95% confidence interval, 1.01-5.05; P=0.047). The risk ratio for misclassification of organic diseases in moderate to severe IBS was increased by 2.575 (95% confidence interval, 1.10-6.51; P=0.027) as compared with mild IBS.

CONCLUSIONS

The incidence of misclassification of major organic disease in IBS patients was low. Increased symptoms severity was the only significant risk factor for the misclassification of organic disorders. Further gastrointestinal evaluation should be considered in patients with moderate to severe symptoms attributed to IBS.

Symptom Clusters and Quality of Life According to the Survivorship Stage in Ovarian Cancer Survivors

This cross-sectional study evaluated a convenience sample comprising 182 ovarian cancer survivors to identify symptom clusters according to the cancer survivorship stage and to determine their effects on quality of life using the European Organization for Research and Treatment of Cancer Quality of Life-C30 and -OV28 questionnaires. Factor and multiple regression analyses were performed to identify symptom clusters according to the cancer survivorship stage and the symptom clusters that affected the quality of life in each cancer survivorship stage, respectively. Participants in the acute, extended, and permanent survival stages accounted for 33%, 36.3%, and 30.7% of subjects, respectively. Overall, the most common symptom cluster was fatigue-diarrhea, and the symptom clusters affecting the quality of life differed according to the cancer survivorship stage. Thus, to improve the quality of life of ovarian cancer survivors, the main symptom clusters of each cancer survivorship stage must be identified, and management strategies for the related symptoms must be designed.

Microscopic colitis: a missed diagnosis among patients with moderate to severe irritable bowel syndrome

OBJECTIVE

Irritable bowel syndrome (IBS) is a very common condition in general practise, affecting 10-20% of the population in the Western world. The clinical picture of diarrhoea-predominant IBS (IBS-D) resembles other chronic diarrhoeic conditions, such as microscopic colitis (MC). It is impossible to separate these by clinical examinations or lab-tests that can be done in general practise. The aim of this study was to detect any missed diagnoses when only using a symptom-based approach for the diagnosis of IBS.

MATERIAL AND METHODOLOGY

We examined 87 participants diagnosed with IBS by the Rome III criteria. All the participants underwent full clinical examination, lab-tests and colonoscopy including mucosa biopsies for histological examination.

RESULTS

The histological analysis revealed four cases of MC in participants who for years had been diagnosed with IBS. We found no biochemical or clinical markers that made it possible to differentiate between IBS and MC. MC was only found in the participants diagnosed with IBS-D.

CONCLUSION

When long-lasting, unresolved diarrhoeic conditions are present in patients over 45-50 years of age, colonoscopy with biopsy should be performed to rule out MC and other pathologies before diagnosing IBS. In younger patients with pronounced watery diarrhoea, one should consider colonoscopy individually if there is no response to IBS-treatment.

The possible role of gastrointestinal endocrine cells in the pathophysiology of irritable bowel syndrome

The etiology of irritable bowel syndrome (IBS) is unknown, but several factors appear to play a role in its pathophysiology, including abnormalities of the gastrointestinal endocrine cells. The present review illuminates the possible role of gastrointestinal hormones in the pathophysiology of IBS and the possibility of utilizing the current knowledge in treating the disease. Areas covered: Research into the intestinal endocrine cells and their possible role in the pathophysiology of IBS is discussed. Furthermore, the mechanisms underlying the abnormalities in the gastrointestinal endocrine cells in IBS patients are revealed. Expert commentary: The abnormalities observed in the gastrointestinal endocrine cells in IBS patients explains their visceral hypersensitivity, gastrointestinal dysmotility, and abnormal intestinal secretion, as well as the interchangeability of symptoms over time. Clarifying the role of the intestinal stem cells in the pathophysiology of IBS may lead to new treatment methods for IBS.

Oral probiotic treatment of Lactobacillus rhamnosus Lcr35® prevents visceral hypersensitivity to a colonic inflammation and an acute psychological stress

AIMS

This study evaluated the efficacy of a repeated oral treatment with two active pharmaceutical ingredients (Lcr Lenio^® and Lcr Restituo^® ) derivated from the probiotic bacterial strain Lactobacillus rhamnosus Lcr35^® in two animal models mimicking different features of irritable bowel syndrome (IBS). IBS is characterized by visceral pain associated with alteration of bowel transit. IBS patients present visceral hypersensitivity with peripheral and central origins.

METHODS AND RESULTS

The injection of 2,4,6-trinitrobenzenesulfonic acid (TNBS) into the proximal colon as well as an acute partial restraint stress (PRS) produces colonic hypersensitivity measured in conscious rats by a decrease in pain threshold in response to distal colonic distension. Visceral hypersensitivity was produced by injection of TNBS 7 days before colonic distension or by acute PRS on testing day. Treatments were performed once a day during eight consecutive days.

CONCLUSIONS

This study indicates that an 8-day probiotic treatment (Lcr Lenio and Lcr Restituo) produces an antihypersensitivity activity in both TNBS and PRS visceral pain models. As this probiotic strain attenuates peripherally and centrally induced visceral hypersensitivity in rats, it may be active in treatment of IBS symptoms. An immunomodulatory effect of the probiotics was highlighted in the TNBS model on the IL-23 secretion, suggesting a mechanism of action involving a regulation of the local IL-23/Th17 immune activation.

SIGNIFICANCE AND IMPACT OF THE STUDY

Two formulas of Lcr35^® probiotic strain show very encouraging results for the treatment of IBS patients. Further studies are needed to better understand the role and mechanisms of probiotics on the pathogenesis of IBS.

Postinfectious and sporadic functional gastrointestinal disorders have different prevalences and rates of overlap: results from a controlled cohort study 3 years after acute giardiasis

BACKGROUND

Irritable bowel syndrome (IBS) is a common complication following gastroenteritis, and a high prevalence of postgiardiasis IBS has previously been reported. This study aims to investigate the prevalence, adjusted relative risk (RRadj), and overlap of different functional gastrointestinal disorders (FGID) according to Rome III criteria following infection with Giardia lamblia.

METHODS

All patients ≥18 years of age with verified giardiasis during an outbreak in 2004, and a control group matched by age and gender, were mailed a questionnaire 3 years later.

KEY RESULTS

The prevalence of functional dyspepsia (FD) was 25.9% in the exposed and 6.9% in the control group, RRadj: 3.9 (95% confidence intervals [CI]: 3.1-4.8). The prevalence of IBS was 47.9% and 14.3%, respectively, with RRadj: 3.4 (95% CI: 3.0-3.8). Prevalence of other gastrointestinal symptoms ranged from 70.0% vs 39.7% for bloating (RRadj: 1.8) to 8.3% vs 2.9% for nausea (RRadj: 3.0) in the Giardia and the control group, respectively. Among individuals fulfilling criteria for IBS 44% in the exposed group and 29% in the control group also fulfilled criteria for FD. IBS subtypes based on Rome III criteria (stool consistency) showed poor agreement with subtypes based on frequency of bowel movements (Kappa-values: 0.17 and 0.27).

CONCLUSIONS & INFERENCES

There were high prevalences and RRs of IBS, FD and other gastrointestinal symptoms following acute giardiasis, and a high degree of overlap between the disorders. The agreement between different IBS subtype criteria varied, and there were also differences between the exposed and control group.

Recent advances in the diagnosis of irritable bowel syndrome

The symptom-based diagnosis of irritable bowel syndrome (IBS) has not been established in everyday clinical practice, and the diagnosis of this disorder remains one of exclusion. It has been demonstrated that the densities of duodenal chromogranin A, rectal peptide YY and somatostatin cells are good biomarkers for the diagnosis of sporadic IBS, and low-grade mucosal inflammation is a promising biomarker for the diagnosis of postinfectious IBS. Genetic markers are not useful as biomarkers for IBS since the potential risk genes have yet to be validated, and the intestinal microbiota cannot be used because of the lack of an association between a specific bacterial species and IBS. Furthermore, gastrointestinal dysmotility and visceral hypersensitivity tests produce results that are too nonconsistent and noncharacteristic to be used in the diagnosis of IBS. A combination of symptom-based assessment, exclusion of overlapping gastrointestinal diseases and positive biomarkers appears to be the best way to diagnose IBS.

Gut feelings 1. Mind, mood and gut in irritable bowel syndrome: approaches to psychiatric care

OBJECTIVE

Psychiatrists are likely to encounter patients with irritable bowel syndrome (IBS). We aim to provide a clinically-focused summary of psychiatric comorbidities and management.

CONCLUSIONS

IBS affects up to 15% of the population. Antidepressants and brief psychotherapy can reduce symptom severity and improve coping. These treatments are effective for patients without comorbid mental illness, as well as those with increased somatisation, health-care seeking and sexual abuse histories.

The risk of irritable bowel syndrome in patients with endometriosis during a 5-year follow-up: a nationwide population-based cohort study

PURPOSE

Studies have suggested that endometriosis may coexist with irritable bowel syndrome (IBS). Using a population-based cohort study, we followed subjects for a 5-year period to identify the risk of IBS after a diagnosis of endometriosis.

METHODS

This cohort study used the Taiwan National Health Insurance Database as a source of subjects. A total of 6076 patients with endometriosis from 2000 to 2005 were identified. Their data were compared with those of 30,380 age-matched controls without endometriosis who were randomly selected from the same database. All subjects were tracked for 5 years from the date of cohort entry to identify the risk of IBS. The Cox model was used to evaluate the 5-year event occurrence of IBS.

RESULTS

Nine hundred twenty-six patients were diagnosed with IBS, including 256 in the case cohort (4.2%) and 670 in the control cohort (2.2%). The Kaplan-Meier survival curves demonstrated significantly lower event-free rates in the case cohort than in the control cohort (P = 0.001). After adjusting for urbanization level, monthly income, residential region and comorbidities, the hazard ratio (HR) within 5 years revealed a 1.79-fold (95% confidence interval [CI] 1.55-2.07) greater risk among the cases than the controls. The HR was higher within the first year of follow-up (HR 1.90, 95% CI 1.42-2.55) and in those women aged 25-34 years (HR 2.17, 95% CI 1.61-2.92).

CONCLUSIONS

The risk of IBS among endometriosis patients persisted over 5 years of follow-up. The association detected in this study might have proceeded through shared risk and pathogenic factors.

Predictive factors for the diagnosis of irritable bowel syndrome in a large cohort of 440,822 young adults

BACKGROUND

The prevalence of irritable bowel syndrome (IBS) in the community has been reported in numerous cross-sectional surveys. However, little is known about the incidence and predictive factors for the clinical diagnosis of IBS.

METHODS

We examined the association of socioeconomic, anthropometric, and occupational factors with the incidence of IBS in a cohort of 440,822 young Israeli adults aged 18 to 39 who served in active military service during the years 2005 to 2011.

RESULTS

During the follow-up of 1,925,003 person-years, IBS was diagnosed de novo in 976 patients, giving an incidence rate of 221:100,000 (0.2%) person-years for the diagnosis of IBS. On multivariable Cox analysis, higher socioeconomic status [hazard ratio (HR) 1.629; 95% confidence interval (CI), 1.328-1.999; P<0.0001], Israeli birth (HR 1.362; 95% CI, 1.084-1.712; P=0.008), Jewish ethnicity (HR 2.089; 95% CI, 1.344-3.248; P=0.001), education ≥than 11 years (HR 1.674; 95% CI, 1.019-2.751; P=0.042), and a noncombat military position (HR 1.196; 95% CI, 1.024-1.397; P=0.024) were found to be risk factors for the diagnosis or for the worsening of IBS. Overweight (HR 0.744; 95% CI, 0.589-0.941; P=0.014), obesity (HR 0.698; 95% CI, 0.510-0.95; P=0.025), living in a rural settlement (HR 0.705; 95% CI, 0.561-0.886; P=0.003), and Middle Eastern (HR 0.739; 95% CI, 0.617-0.884; P=0.001,) or North African and Ethiopian origin (HR 0.702; 95% CI, 0.585-0.842; P<0.001) were found to be protective for the diagnosis or the worsening of IBS.

CONCLUSIONS

This study provides novel data on the socioeconomic, anthropometric, and occupational factors predictive for IBS development. The predictive factors for IBS diagnosis may point to the fact that stress had a lower impact on IBS incidence in our study cohort.

How individuals with the irritable bowel syndrome describe their own symptoms before formal diagnosis

AIM

To investigate how individuals fulfilling the Rome II criteria for irritable bowel syndrome (IBS) spontaneously described their symptoms.

METHOD

From a general population, 1,244 randomly sampled adults were asked to describe their gastrointestinal symptoms (if any) verbally, in their own words, at a semi-structured interview. Their own descriptions were sorted into five symptom clusters. The participants independently completed a written questionnaire (the Rome II Modular Questionnaire (RMIIMQ)).

RESULTS

A total of 601 participants reported at least one gastrointestinal symptom, and 128 had IBS according to the RMIIMQ. After exclusion of organic causes, previously diagnosed IBS, or additional gastrointestinal diagnosis, 81 participants with IBS according to RMIIMQ remained. Five participants (6%) described symptoms included in the full definition of IBS, but none fulfilled the Rome II criteria completely. Abdominal pain or other IBS-related symptoms were reported by 64 (79%), and 12 (15%) did not report any IBS-like symptom.

CONCLUSION

Previously undiagnosed individuals, who fulfil criteria for Rome II-IBS, often express their complaints in words that do not fit into the current diagnostic criteria.

Psychological features in patients with and without irritable bowel syndrome: A case-control study using Symptom Checklist-90-Revised

CONTEXT

Recent studies have demonstrated that a high proportion of irritable bowel syndrome (IBS) patients shows an association with psychological factors. A few studies were conducted on the investigation of psychological features of IBS patients in Iran.

AIMS

We aimed to evaluate the relationship of psychological distress with IBS in outpatient subjects.

SETTINGS AND DESIGN

A total of 153 consecutive outpatients met Rome III criteria, and 163 controls were interred to study and invited to complete the Symptom Checklist-90-Revised (SCL-90-R) instrument in order to assessment of psychological distress.

STATISTICAL ANALYSIS

Univariate (t-test and Chi-square) and multivariate (logistic regression) methods were used for data analysis.

RESULTS

A significant association of IBS with all nine subscale and three global indices including global severity index (GSI), positive symptom distress index (PSDI), and positive symptom total (PST) of the SCL-90-R were detected. Patients with IBS reported significantly higher levels of poor appetite, trouble falling asleep, thoughts of death or dying, early morning awakening, disturbed sleep, and feelings of guilt compared to the controls. Multivariate analysis indicated that interpersonal sensitivity, somatization, paranoid ideation, depression and phobic anxiety subscales, and PST, PSDI, and GSI global indices were significantly associated with IBS (age, gender, educational level, marital status, employment status, smoking, alcohol use, and body mass index).

CONCLUSIONS

Psychological features are strongly associated with IBS; notably, interpersonal sensitivity, somatization, paranoid ideation, depression, phobic anxiety, and all global indices including PST, PSDI, and GSI is significantly associated with. Hence, the appropriate psychological assessment in these patients is critically important.

Irritable bowel syndrome: focus on otilonium bromide

Irritable bowel syndrome is a prevalent and chronic disorder, characterized by recurrent abdominal pain/discomfort, bloating and altered bowel habits. This condition affects an estimated 10-15% of the population worldwide and impacts heavily on a patient's daily life and ability to work, as well as healthcare resource utilization. Drug therapy aimed at correcting the primary symptoms of diarrhea/constipation/bloating may have little effect on abdominal pain, which results from visceral hypersensitivity. Smooth muscle relaxants or antispasmodics decrease the tone and contractility of intestinal smooth muscle, effectively managing abdominal pain. Otilonium bromide has been widely used worldwide and has been found to be safe and well tolerated, and superior to placebo for the reduction of symptoms and the prevention of symptom relapse in patients with irritable bowel syndrome.

Autonomic functioning in irritable bowel syndrome measured by heart rate variability: a meta-analysis

OBJECTIVE

To analyze autonomic functioning which presented as the high frequency (HF) component of heart rate variability, a measurement of vagal tone, and the ratio of low frequency (LF) to HF (LF : HF), an indicator of sympathovagal balance in irritable bowel syndrome (IBS) patients.

METHODS

We identified relevant studies by performing a literature search of MEDLINE, EMBASE and the ISI Web of Knowledge to 31 March 2013. Pooled effect sizes with 95% confidence interval (CI) were calculated using a random effects model. Between-study heterogeneity was assessed using the Q test and I(2) statistic.

RESULTS

In all, 11 articles including 392 IBS patients and 263 controls met the inclusion criteria of the analysis. IBS patients had lower HF band power (Hedges's g = -0.38, 95% CI -0.68 to -0.09) than the controls (I(2)  = 63.6%, P = 0.003). Moreover, IBS patients showed a higher LF : HF (Hedges's g = 0.43, 95% CI 0.13-0.74), with no significant heterogeneity. A subgroup analysis of the HF index according to the recording time yielded different results for the IBS patients and controls. Additionally, constipation-predominant IBS (IBS-C) patients had decreased HF band power, whereas no significant difference was found in LF : HF.

CONCLUSIONS

Impaired parasympathetic functioning and abnormal sympathovagal balance may be involved in the pathogenesis of IBS. Vagal dysfunction is more obvious in the IBS-C subgroup.

Tyrosine phosphorylation of the NR2B subunit of the NMDA receptor in the spinal cord contributes to chronic visceral pain in rats

The roles of spinal N-methyl-d-aspartic acid receptor 2B (NR2B) subunit in central sensitization of chronic visceral pain were investigated. A rat model with irritable bowel syndrome (IBS) was established by colorectal distention (CRD) on post-natal days 8-14. Responses of the external oblique muscle of the abdomen to CRD were measured to evaluate the sensitivity of visceral pain in rats. The sensitivity of visceral pain significantly increased in IBS-like rats. Expressions of spinal NR2B subunit and phosphorylated NR2B subunit significantly increased by 50-55% in IBS-like rats when compared with those in control rats. Ro 25-6981, a selective antagonist of NR2B subunit, has a dose-dependent anti-allodynic and anti-hyperalgesic effect without causing motor dysfunction in IBS-like rats. Furthermore, the activation mechanism of the spinal NR2B subunit in chronic visceral pain was also investigated. Spinal administration of genistein, a specific inhibitor of tyrosine kinases, also decreased the visceral pain hypersensitivity of IBS-like rats in a dose-dependent manner. In addition, the expression of phosphorylated NR2B subunit was decreased after spinal administration of Ro 25-6981 or genistein in IBS-like rats. In conclusion, tyrosine kinase activation-induced phosphorylation of NR2B subunit may play a crucial role in central sensitization of chronic visceral pain.

Patients suspected of irritable bowel syndrome--cross-sectional study exploring the sensitivity of Rome III criteria in primary care

OBJECTIVES

The Rome III criteria for irritable bowel syndrome (IBS) are recommended by guidelines to help identify the syndrome. The majority of IBS patients are managed in primary care, where a pragmatic approach to diagnosis is usually adopted, using clinical judgment and knowledge about the patient. Many general practitioners (GPs) have no or limited knowledge of the diagnostic criteria, few use them, and many consider IBS a diagnosis of exclusion. The aim of this study is to explore the sensitivity of the Rome III criteria in relation to a GP-based clinical diagnosis of IBS, to identify differences between Rome III-positive and -negative patients, and to describe the agreement between the various symptom-based criteria.

METHODS

Patients aged 18-50 years, presenting in primary care with gastrointestinal complaints and identified as IBS patients by their GP, were referred for enrollment. The Manning and Rome I-III criteria were evaluated through interviews and patients completed the questionnaires The Gastrointestinal Symptom Rating Scale (GSRS)/The Gastrointestinal Symptom Rating Scale modified for use in patients with IBS (GSRS-IBS), Short Form 36, Irritable Bowel Syndrome Quality of Life measurement, Work Productivity and Activity Impairment questionnaire-irritable bowel version, and a questionnaire on use of health-care resources.

RESULTS

A total of 604 patients were referred and 499 were included (mean age 32.8 (s.d. 9.5) years, 75% were female). The Rome III criteria were fulfilled by 376 patients (sensitivity 0.75, 95% CI 71-79%). Rome III-positive patients more frequently reported disturbed defecation, had a higher symptom burden, and lower disease-specific health-related quality of life compared with Rome III-negative patients. The various symptom-based criteria identified slightly different subpopulations with the highest agreement between the Rome II and III criteria.

CONCLUSIONS

The Rome III criteria identified three in four patients labeled with IBS in primary care. The relevance of the Rome III for IBS in primary care is supported.

A new soy germ fermented ingredient displays estrogenic and protease inhibitor activities able to prevent irritable bowel syndrome-like symptoms in stressed female rats

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) often associated with psychological distress, is characterized by increased gut permeability and visceral sensitivity. In animals, stress increases intestinal paracellular permeability (IPP), visceral sensitivity and colonic proteolytic activity. Estradiol reduces IPP and affects visceral sensitivity in non-stressed ovariectomized rats, but whether estrogens affect stress-induced hyperpermeability and hypersensitivity in cyclic females remains unclear. We aimed to evaluate (i) the effects of a phytoestrogen-rich soy germ fermented ingredient (SG) on visceral hypersensitivity, hyperpermeability and other symptoms in stressed intact female rats, (ii) the mechanisms of action involved on the basis of both estrogenic and protease inhibitor activities of SG.

METHODS

Female rats received orally for 15-d either SG, 17β-estradiol benzoate (EB), or vehicles, with or without the estrogen receptor (ER) antagonist ICI182.780 before stress. Visceral sensitivity, IPP, faecal proteolytic activity, plasma corticosterone, rat mast cell protease II immunostaining, and occludin expression were assessed.

RESULTS

Stress increased IPP (concomitantly to a drop in occludin expression), visceral sensitivity, faecal proteolytic activity and plasma corticosterone. Similarly to EB, SG prevented the stress-induced hyperpermeability, and hypersensitivity, without changes in plasma corticosterone. SG inhibited the increase in faecal proteolytic activity, enhanced occludin expression, and reduced the colonic mast cell density. All SG effects, except decrease on faecal proteolytic activity, were blocked by ICI182.780.

CONCLUSION

A 2-wk oral treatment with SG prevented the stress-induced hyperpermeability and visceral hypersensitivity in cyclic rats through ER activation, and blocked the increase in colonic proteolytic activity, suggesting that SG can be promising in IBS management.

Prevention of gut leakiness by a probiotic treatment leads to attenuated HPA response to an acute psychological stress in rats

BACKGROUND AND AIMS

Intestinal barrier impairment is incriminated in the pathophysiology of intestinal gut disorders associated with psychiatric comorbidity. Increased intestinal permeability associated with upload of lipopolysaccharides (LPS) translocation induces depressive symptoms. Gut microbiota and probiotics alter behavior and brain neurochemistry. Since Lactobacillus farciminis suppresses stress-induced hyperpermeability, we examined whether (i) L. farciminis affects the HPA axis stress response, (ii) stress induces changes in LPS translocation and central cytokine expression which may be reversed by L. farciminis, (iii) the prevention of "leaky" gut and LPS upload are involved in these effects.

METHODS

At the end of the following treatments female rats were submitted to a partial restraint stress (PRS) or sham-PRS: (i) oral administration of L. farciminis during 2 weeks, (ii) intraperitoneal administration of ML-7 (a specific myosin light chain kinase inhibitor), (iii) antibiotic administration in drinking water during 12 days. After PRS or sham-PRS session, we evaluated LPS levels in portal blood, plasma corticosterone and adrenocorticotropic hormone (ACTH) levels, hypothalamic corticotropin releasing factor (CRF) and pro-inflammatory cytokine mRNA expression, and colonic paracellular permeability (CPP).

RESULTS

PRS increased plasma ACTH and corticosterone; hypothalamic CRF and pro-inflammatory cytokine expression; CPP and portal blood concentration of LPS. L. farciminis and ML-7 suppressed stress-induced hyperpermeability, endotoxemia and prevented HPA axis stress response and neuroinflammation. Antibiotic reduction of luminal LPS concentration prevented HPA axis stress response and increased hypothalamic expression of pro-inflammatory cytokines.

CONCLUSION

The attenuation of the HPA axis response to stress by L. farciminis depends upon the prevention of intestinal barrier impairment and decrease of circulating LPS levels.

Sleep disruption secondary to overnight call shifts is associated with irritable bowel syndrome in residents: a cross-sectional study

OBJECTIVES

Sleep disruption has been associated with irritable bowel syndrome (IBS). We hypothesized that residents with greater sleep disruption secondary to intermittent overnight call shifts would have a higher prevalence of IBS.

METHODS

Postgraduate residents completed a Web-based survey including demographic data, frequency and characteristics of call shifts, the Rome III questionnaire, and the IBS-quality of life measure.

RESULTS

For every hour of sleep deprivation while on call vs. off call, the odds ratio for an increased likelihood of IBS was 1.32, after adjustment for age and gender. The mean number of calls per block, sleep deprivation while on call, and specialty program vs. family practice each predicted the severity of IBS.

CONCLUSIONS

Sleep disruption secondary to overnight call in residents was associated with an increased prevalence of IBS.

The Rome II and Rome III criteria identify the same subtype-populations in irritable bowel syndrome: agreement depends on the method used for symptom report

BACKGROUND

For comparing trials using different classifications for irritable bowel syndrome (IBS) subtypes, it is important to know whether these identify the same sub-populations. Our aim was to determine the agreement between Rome II and Rome III subtypes, and to explore whether agreement depends on the symptom reporting method.

METHODS

Rome II IBS patients from two identical, randomized placebo-controlled trials of probiotics were included. Retrospective subtypes were based on the Rome II questionnaire. Prospective subtypes were based on diary cards for 2 weeks of run-in. Agreement was determined between: (i) retrospective Rome II and Rome III, (ii) prospective Rome II and Rome III, (iii) retrospective Rome II and prospectively Rome III, (iv) retrospective and prospective Rome II, and (v) retrospective and prospective Rome III.

KEY RESULTS

A total of 126 patients, 72% women, mean age 46 ± 15 years, were included. The agreement between subtypes using the same symptom reporting method was: (i) 90.3% (κ = 0.85) for retrospective subtypes, and (ii) 84% (κ = 0.76) for prospective subtypes. The agreement between subtypes using different symptom reporting methods was, (iii) 49% (κ = 0.23) for retrospective Rome II and prospective Rome III, (iv) 51% (κ = 0.26) for Rome II subtypes, and (v) 41% (κ = 0.25) for Rome III subtypes.

CONCLUSIONS & INFERENCES

Agreement between Rome II and Rome III subtypes is good to very good when using the same symptom reporting method. When mixing methods, agreement is only fair even within the same classification. This has implications for comparison of trials using different symptom reporting methods for subtyping.

Visceral sensitivity as a mediator of outcome in the treatment of irritable bowel syndrome

Patients with irritable bowel syndrome (IBS) experience anxiety about visceral sensations, leading to avoidance behaviors and hypervigilance that maintain IBS symptoms. The current study used data from a clinical trial that compared a treatment aimed at reducing anxiety about visceral sensations (interoceptive exposure; IE) to an attention control (AC) and a CBT-based stress-management treatment (SM) to examine whether changes in visceral sensitivity mediated IBS symptom and quality of life outcomes. Data from participants who completed one of the three treatments (N = 76) were subjected to mediation analyses. Visceral sensitivity mediated treatment outcomes across all outcome measures and across all treatment groups, with no differences between IE and the other treatment groups. This finding suggests that psychosocial treatments for IBS may work by decreasing visceral sensitivity, and the degree to which visceral sensitivity is decreased is related to outcome, suggesting IE may be the preferable treatment option.

Evaluation of harm in the pharmacotherapy of irritable bowel syndrome

OBJECTIVE

Current treatment options for irritable bowel syndrome are limited and often poorly studied. A select few drugs have been studied in irritable bowel syndrome, and the number needed to treat is frequently used to assess the relative efficacy of these treatments. However, side effects are an important consideration in the clinical decision on which particular treatment to use. This study examines trials of subjects with irritable bowel syndrome with diarrhea and constipation who are receiving a drug intervention deemed of merit by the American College of Gastroenterology task force and compares these therapies to examine the number needed to harm using a systematic review and meta-analysis approach.

METHODS

Potential studies of irritable bowel syndrome treatments were identified through a search of MEDLINE (1950 to April 2011), EMBASE (1980 to April 2011), the Cochrane central register of controlled trials, and the bibliography of recent meta-analyses. Clinical trials of pharmacotherapy for irritable bowel syndrome were eligible for inclusion only if a description of adverse events and the number of patients who discontinued treatment because of adverse events were reported. The relative risk of experiencing an adverse event requiring discontinuation of treatment was used to determine the number needed to harm. In addition, the number and severity of adverse events were summarized.

RESULTS

Twenty-six clinical trials (4 with selective serotonin reuptake inhibitors, 3 with lubiprostone, 6 with tricyclic antidepressants, 8 with alosetron, and 5 with rifaximin) were included. Lubiprostone was safe with insignificant harm in one combined phase III trial. Selective serotonin reuptake inhibitors did not have enough data for a reliable meta-analysis of harm but seemed to be safe. More rigorous data were available for tricyclic antidepressants, alosetron, and rifaximin; the numbers needed to harm were 18.3, 19.4, and 8971, respectively, and the numbers needed to treat were 8, 7.5, and 10.6, respectively. For tricyclic antidepressant and alosetron, an adverse event resulting in discontinuation of the study medication occurred for every 2.3 and 2.6 patients who benefited from a drug, respectively. For rifaximin, this number was 846 patients. In addition, adverse events were more common with tricyclic antidepressants and alosetron.

CONCLUSION

In irritable bowel syndrome with diarrhea, tricyclic antidepressants and alosetron are associated with a significant number needed to harm compared with rifaximin. Apart from lubiprostone, treatment of irritable bowel syndrome with constipation is limited to small studies (with poor descriptions of side effects), although lubiprostone and selective serotonin reuptake inhibitors appear safe.

Colonic butyrate- algesic or analgesic?

Irritable bowel syndrome (IBS) is a common health issue that is characterized by abdominal pain, abnormal bowel movements, and altered visceral perception. The complexity and variability in symptoms pose serious challenges in treating IBS. Current therapy for IBS is primarily focused on reducing the abdominal pain, thereby improving the quality of life to a significant extent. Although the use of fiber rich diet is widely recommended in treating IBS, some studies have questioned its use. Intra-colonic butyrate, a short-chain fatty acid, is primarily produced by the fermentation of dietary fibers in the colon. In the existing literature there are conflicting reports about the function of butyrate. In rats it is known to induce visceral hypersensitivity without altered pathology, whereas in humans it has been reported to reduce visceral pain. Understanding the molecular mechanisms responsible for this contrasting effect of butyrate is important before recommending fiber rich diet to IBS patients.

A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and debilitating medical condition with few efficacious pharmacological or psychosocial treatment options available. Evidence suggests that visceral anxiety may be implicated in IBS onset and severity. Thus, cognitive-behavioral treatment (CBT) that targets visceral anxiety may alleviate IBS symptoms.

METHODS

The current study examined the efficacy of a CBT protocol for the treatment of IBS which directly targeted visceral sensations. Participants (N = 110) were randomized to receive 10 sessions of either: (a) CBT with interoceptive exposure (IE) to visceral sensations; (b) stress management (SM); or (c) an attention control (AC), and were assessed at baseline, mid-treatment, post-treatment, and follow-up sessions.

RESULTS

Consistent with hypotheses, the IE group outperformed AC on several indices of outcome, and outperformed SM in some domains. No differences were observed between SM and AC. The results suggest that IE may be a particularly efficacious treatment for IBS.

CONCLUSIONS

Implications for research and clinical practice are discussed.

A cognitive-behavioral treatment for irritable bowel syndrome using interoceptive exposure to visceral sensations

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and debilitating medical condition with few efficacious pharmacological or psychosocial treatment options available. Evidence suggests that visceral anxiety may be implicated in IBS onset and severity. Thus, cognitive-behavioral treatment (CBT) that targets visceral anxiety may alleviate IBS symptoms.

METHODS

The current study examined the efficacy of a CBT protocol for the treatment of IBS which directly targeted visceral sensations. Participants (N = 110) were randomized to receive 10 sessions of either: (a) CBT with interoceptive exposure (IE) to visceral sensations; (b) stress management (SM); or (c) an attention control (AC), and were assessed at baseline, mid-treatment, post-treatment, and follow-up sessions.

RESULTS

Consistent with hypotheses, the IE group outperformed AC on several indices of outcome, and outperformed SM in some domains. No differences were observed between SM and AC. The results suggest that IE may be a particularly efficacious treatment for IBS.

CONCLUSIONS

Implications for research and clinical practice are discussed.

The features of adolescent irritable bowel syndrome in Japan

OBJECTIVE AND BACKGROUND

The onset of IBS is in adolescence in many cases. However, the features of adolescent IBS were generally lacking. The objective of this research was to know the features of adolescent IBS in Japan.

METHODOLOGY

In 2004 and 2009, we randomly selected Junior high school students in Miyagi prefecture, Japan, according to population of each area. Eight hundred thirty-three boys and 888 girls (age: 15 years old) in 2004 and 256 boys and 335 girls (age: 14 years old) in 2009 participated in this study. They fulfilled self-reported questionnaires those include Rome-II Modular Questionnaire, Self-reported IBS Questionnaire, Generalized Self-Efficacy Scale, Short Form-36 ver.2, other questions on their lives and Toronto Alexithymia Scale-20.

RESULTS

The prevalence of adolescent IBS was 14.6% in 2004 and 19% in 2009. Compare with students without abdominal symptoms, IBS showed lower health-related QOL and self-efficacy and complained more sleep disturbance, traumatic episodes and perceived stress in both researches. IBS girls were worse in both physical and psychological aspects. They also have alexithymic tendency and it influenced on severity of IBS symptoms.

CONCLUSIONS

Adolescent IBS had almost the same prevalence as adult IBS, however the rate of IBS subtypes was different. They also had psychological problems in addition to physical conditions even though most of them were non-consulters. Improvement of self-efficacy and alxithymia may help to prevent and treat IBS.

Epidemiology of IBS

Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder. Because not everyone needs to seek care, population-based studies are needed to truly understand the epidemiology of IBS. About 10% of the population has IBS at any one time and about 200 people per 100,000 will receive an initial diagnosis of IBS over the course of a year. IBS patients are more frequently younger in age, and a female predominance has been observed in Western countries and tertiary care settings. IBS patients commonly report overlapping upper GI, as well as a variety of non-GI, complaints.

Pathogenic factors involved in the development of irritable bowel syndrome: focus on a microbial role

Irritable bowel syndrome (IBS) is a symptom complex characterized by recurrent abdominal pain or discomfort, and accompanied by abnormal bowel habits, in the absence of any discernible organic abnormality. Its origin remains unclear, partly because multiple pathophysiologic mechanisms are likely to be involved. A significant proportion of patients develop IBS symptoms after an episode of gastrointestinal infection. In addition to gastrointestinal pathogens, recent evidence suggests that patients with IBS have abnormal composition and higher temporal instability of their intestinal microbiota. Because the intestinal microbiota is an important determinant of normal gut function and immunity, this instability may constitute an additional mechanism that leads to symptom generation and IBS. More importantly, a role for altered microbiota composition in IBS raises the possibility of therapeutic interventions through selective antibiotic or probiotic administration. The new concept of functional bowel diseases incorporates the bidirectional communication between the gut and the central nervous system (gut-brain axis), which may explain the multiple facets of IBS by linking emotional and cognitive centers of the brain with peripheral functioning of the gastrointestinal tract and vice versa.

Irritable bowel syndrome and chronic constipation in patients with endometriosis

AIM

The aim of this study was to evaluate how many patients with endometriosis have concomitant irritable bowel syndrome (IBS) and/or constipation according to the Rome III criteria. Furthermore, the value of an additional gastroenterological consultation with therapeutic advice was evaluated.

METHOD

Patients with proven endometriosis were included in a prospective, single-centre study. A questionnaire was undertaken regarding IBS and chronic constipation. Patients with symptoms consistent with the Rome III criteria for IBS were referred to our gastroenterological outpatient clinic.

RESULTS

In total 101 patients were included. Endometriosis was diagnosed surgically in 97% and visually in the vagina in 3%. Fifteen per cent of the patients with endometriosis also had IBS and 14% of the patients with endometriosis had functional constipation without IBS. Of the 22 patients finally presenting to the gastroenterologist, five had a significant stenotic rectosigmoid lesion and were treated surgically. The remaining 17 patients were treated conservatively. Defecation symptoms improved in 86% and pain was reduced in 64%.

CONCLUSION

In patients with endometriosis, 29% also had IBS or constipation. Referral to a gastroenterologist resulted in improvement of defaecation in 86%, and 64% reported a reduction in the degree of pain.

Irritable bowel syndrome and chronic pelvic pain: a population-based study

BACKGROUND

Women with irritable bowel syndrome (IBS) frequently report chronic pelvic pain, however, it is still unanswered whether these are truly separate entities. IBS negatively impacts on quality of life, but the impact of IBS on sexual function is not clear.

GOALS

We aimed to (1) describe the impact of IBS on sexual function, and (2) evaluate the association between pelvic pain and IBS, and in particular identify if there are unique characteristics of the overlap group.

STUDY

The Talley Bowel Disease Questionnaire was mailed to an age- and gender-stratified random sample of 1031 Olmsted County, Minnesota residents aged 30 to 64 years. Manning (at least 2 of 6 positive) and Rome criteria (Rome I and modified Rome III) were used to identify IBS. Pelvic pain was assessed by a single item. Somatization was assessed by the valid somatic symptom checklist.

RESULTS

Overall 648 (69%) of 935 eligible participants responded (mean age 52 years, 52% female). Self-reported sexual dysfunction was rare (0.9%; 95% CI 0.3-2.0%). Among women, 20% (95% CI 16-24%) reported pain in the pelvic region; 40% of those with pelvic pain met IBS by Manning, or Rome criteria. IBS and pelvic pain occurred together more commonly than expected by chance (P<0.01). The overall somatization score (and specifically the depression and dizziness item scores) predicted IBS-pelvic pain overlap versus either IBS alone or pelvic pain alone.

CONCLUSION

In a subset with pelvic pain, there is likely to be a common underlying psychologic process (somatization) that explains the link to IBS.