Wheat fibre and irritable bowel syndrome. A controlled trial

Diet for Functional Gastrointestinal Disorders/Disorders of Gut-Brain Interaction

Dietary interventions may alleviate symptoms related to functional gastrointestinal disorders, now termed disorders of gut-brain interaction. We reviewed which interventions have high-quality data to support their use in gastroesophageal reflux disease (GERD), functional dyspepsia (FD), irritable bowel syndrome, and chronic idiopathic constipation.

Irritable Bowel Syndrome: Food as a Friend or Foe?

Irritable bowel syndrome (IBS) affects 10% to 15% of the population and often is difficult to treat with available pharmacologic agents. Dietary therapies for IBS are of particular interest because up to 90% of IBS patients exclude certain foods to improve their gastrointestinal symptoms. Among the available dietary interventions for IBS, the low FODMAP diet has the greatest evidence for efficacy. Although dietary therapies rapidly are becoming first-line treatment of IBS, gastroenterologists need to be aware of the negative effects of prescribing restrictive diets and red flag symptoms of maladaptive eating patterns.

ACG Clinical Guideline: Management of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a highly prevalent, chronic disorder that significantly reduces patients' quality of life. Advances in diagnostic testing and in therapeutic options for patients with IBS led to the development of this first-ever American College of Gastroenterology clinical guideline for the management of IBS using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Twenty-five clinically important questions were assessed after a comprehensive literature search; 9 questions focused on diagnostic testing; 16 questions focused on therapeutic options. Consensus was obtained using a modified Delphi approach, and based on GRADE methodology, we endorse the following: We suggest that a positive diagnostic strategy as compared to a diagnostic strategy of exclusion be used to improve time to initiating appropriate therapy. We suggest that serologic testing be performed to rule out celiac disease in patients with IBS and diarrhea symptoms. We suggest that fecal calprotectin be checked in patients with suspected IBS and diarrhea symptoms to rule out inflammatory bowel disease. We recommend a limited trial of a low fermentable oligosaccharides, disacchardies, monosaccharides, polyols (FODMAP) diet in patients with IBS to improve global symptoms. We recommend the use of chloride channel activators and guanylate cyclase activators to treat global IBS with constipation symptoms. We recommend the use of rifaximin to treat global IBS with diarrhea symptoms. We suggest that gut-directed psychotherapy be used to treat global IBS symptoms. Additional statements and information regarding diagnostic strategies, specific drugs, doses, and duration of therapy can be found in the guideline.

The Dietary Management of Patients with Irritable Bowel Syndrome: A Narrative Review of the Existing and Emerging Evidence

Even though irritable bowel syndrome (IBS) has been known for more than 150 years, it still remains one of the research challenges of the 21st century. According to the current diagnostic Rome IV criteria, IBS is characterized by abdominal pain associated with defecation and/or a change in bowel habit, in the absence of detectable organic causes. Symptoms interfere with the daily life of patients, reduce health-related quality of life and lower the work productivity. Despite the high prevalence of approximately 10%, its pathophysiology is only partly understood and seems multifactorial. However, many patients report symptoms to be meal-related and certain ingested foods may generate an exaggerated gastrointestinal response. Patients tend to avoid and even exclude certain food products to relieve their symptoms, which could affect nutritional quality. We performed a narrative paper review of the existing and emerging evidence regarding dietary management of IBS patients, with the aim to enhance our understanding of how to move towards an individualized dietary approach for IBS patients in the near future.

Influence of Dietary Restriction on Irritable Bowel Syndrome

Up to two-thirds of patients with IBS attribute their gastrointestinal symptoms to food. The therapeutic focus of IBS has been to alleviate gastrointestinal symptoms, approached by pharmaceutical and non-pharmaceutical treatments. Although the most traditional approach has involved the use of medications such as bulking agents, anticholinergics, antispasmodics, and antidiarrheals, unfortunately these are only modestly effective and patients are left with a small menu of successful pharmacologic agents. These treatments, however, are not always enough to alleviate symptoms. Alternative approaches have therefore been tried, including dietary manipulation. This article aims to review dietary restrictions as a non-pharmaceutical management approach for IBS, covering literature on various dietary triggers and the impact of dietary manipulation on gastrointestinal symptoms.

Guidelines on the management of irritable bowel syndrome: In memory of Professor Witold Bartnik

These guidelines constitute an update of the previous "Recommendations on the management of irritable bowel syndrome" issued in 2008. They have been developed by a Task Force organized by the Governing Board of the Polish Society of Gastroenterology. They discuss, with particular emphasis on new scientific data covering papers published since 2008, the aetiology, epidemiology, clinical presentation, diagnostic principles and criteria for the diagnosis, and recommendations for the treatment of irritable bowel syndrome (IBS). The English-language acronym for the syndrome (IBS) has become popular in medical and popular scientific language. It is also widely recognized by patients who identify with this diagnosis. Therefore, in the discussed guidelines, this is what we will use.

The Role of Diet in the Treatment of Irritable Bowel Syndrome: A Systematic Review

Irritable bowel syndrome (IBS) is a multifaceted illness involving maladaptive shifts in the gut microbiota that affect the enteric nervous and immune systems, mucosal barrier function, the balance of neurotransmitters and hormones, and emotional well-being. There is abundant evidence indicating that certain foods elicit symptoms in IBS. Numerous elimination-type diets have been shown to alleviate symptoms. However, among these, the most controversial is a group of foods called fructo, oligo-, di-, and monosaccharides and polyols (FODMAPs). This paper reviews the role of diet and systematically analyze the literature for the role of FODMAPs in IBS.

The role of fiber supplementation in the treatment of irritable bowel syndrome: a systematic review and meta-analysis

Irritable bowel syndrome (IBS) is a functional bowel disorder associated with a wide variety of clinical symptoms. The use of fiber in treatment of IBS is well established, but recent reviews have shown conflicting evidence. The aim of our review was to study the effects of fiber (soluble and insoluble) on the symptoms of IBS. Medline, EMBASE, Cochrane Central, CINAHL, LILACS, and ClinicalTrials.gov were searched for appropriate studies. Two reviewers screened the title/abstract and full text against the inclusion criterion - that is, randomized control trials/crossover studies that compare fiber with placebo for its effect on IBS in an outpatient setting. Independent double data extraction was performed across multiple fields. An assessment of the risk of bias and tests for heterogeneity were carried out, along with a meta-analysis of the outcomes of interest. The search yielded 4199 unique records: 121 were selected after title/abstract screening and 22 after full screening. There was moderate clinical, methodological, and statistical heterogeneity across studies, with a moderate risk of bias. Overall, there was a significant improvement in global assessment of symptoms among those randomized to fiber [risk ratio: 1.27; 95% confidence interval (CI): 1.05-1.54]. Soluble fiber improved assessment of symptoms (risk ratio 1.49; 95% CI: 1.09-2.03), as well as the abdominal pain score (mean difference: -1.84; 95% CI: -2.72 to -0.97), with insoluble fiber not showing improvement in any outcome. Soluble fiber appears to improve symptoms of IBS, whereas there is no evidence for recommending insoluble fiber for IBS.

A systematic review of adherence to restricted diets in people with functional bowel disorders

Functional bowel disorders such as irritable bowel syndrome are commonly experienced within the population, and have an adverse impact on emotions, physical well-being, social activity, and occupational output. Adherence to a restricted diet can reduce symptoms, which in turn leads to increased quality of life and well-being. The aim of this review was to assess the extent to which predictors of dietary adherence have been considered in studies relating to functional bowel disorders and following a restricted diet. This was done firstly by examining such studies which contained a measure or indicator of adherence, and then by examining predictors of adherence within and between studies. A search of PsycINFO, Medline, CINAHL, Web of Science, and Cochrane databases was performed during July 2014, with the search criteria including relevant terms such as gastrointestinal disorder, irritable bowel syndrome, diet, and adherence. Of an initial 7927 papers, 39 were suitable for inclusion. Fourteen of the 39 studies included had a structured measure or indicator of dietary adherence, and the remaining 25 mentioned adherence without any structured levels of adherence. There was little investigation into the predictors of adherence, with symptom relief or induction being the primary goal of most of the studies. This review indicates that predictors of dietary adherence are rarely considered in research regarding functional bowel disorders. Further investigation is needed into the variables which contribute to rates of adherence to restricted diets, and more rigorous research is needed to characterise those individuals most likely to be non-adherent. Such research is necessary to ensure that people with these conditions can be provided with appropriate support and interventions.

The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis

OBJECTIVES

Fiber has been used for many years to treat irritable bowel syndrome (IBS). This approach had fallen out of favor until a recent resurgence, which was based on new randomized controlled trial (RCT) data that suggested it might be effective. We have previously conducted a systematic review of fiber in IBS, but new RCT data for fiber therapy necessitate a new analysis; thus, we have conducted a systematic review of this intervention.

METHODS

MEDLINE, EMBASE, and the Cochrane Controlled Trials Register were searched up to December 2013. Trials recruiting adults with IBS, which compared fiber supplements with placebo, control therapy, or "usual management", were eligible. Dichotomous symptom data were pooled to obtain a relative risk (RR) of remaining symptomatic after therapy as well as number needed to treat (NNT) with a 95% confidence interval (CI).

RESULTS

We identified 14 RCTs involving 906 patients that had evaluated fiber in IBS. There was a significant benefit of fiber in IBS (RR=0.86; 95% CI 0.80-0.94 with an NNT=10; 95% CI=6-33). There was no significant heterogeneity between results (I(2)=0%, Cochran Q=13.85 (d.f.=14), P=0.46). The benefit was only seen in RCTs on soluble fiber (RR=0.83; 95% CI 0.73-0.94 with an NNT=7; 95% CI 4-25) with no effect seen with bran (RR=0.90; 95% CI 0.79-1.03).

CONCLUSIONS

Soluble fiber is effective in treating IBS. Bran did not appear to be of benefit, although we did not uncover any evidence of harm from this intervention, as others have speculated from uncontrolled data.

Fiber and functional gastrointestinal disorders

Despite years of advising patients to alter their dietary and supplementary fiber intake, the evidence surrounding the use of fiber for functional bowel disease is limited. This paper outlines the organization of fiber types and highlights the importance of assessing the fermentation characteristics of each fiber type when choosing a suitable strategy for patients. Fiber undergoes partial or total fermentation in the distal small bowel and colon leading to the production of short-chain fatty acids and gas, thereby affecting gastrointestinal function and sensation. When fiber is recommended for functional bowel disease, use of a soluble supplement such as ispaghula/psyllium is best supported by the available evidence. Even when used judiciously, fiber can exacerbate abdominal distension, flatulence, constipation, and diarrhea.

Delayed meconium passage in small vs. appropriate for gestational age preterm infants: management and short-term outcome

OBJECTIVE

Delayed passage of stool is a result of both gestational immaturity and illness severity. Small for gestational age (SGA) preterm infants are at high risk of gastrointestinal (GI) complications. We aimed to analyse the effects of a strict nutrition and stool protocol on GI problems in SGA compared to appropriate for gestational age (AGA) preterm infants.

METHODS

Retrospective cohort analysis including all preterm infants with delayed meconium passage hospitalized at the Neonatal Intensive Care Unit of the Medical University of Graz, Austria. Infants were identified by a local data system and by the use of a strict feeding and stool protocol between 2001 and 2009. Main outcome parameters included neonatal morbidity, surgical intervention and mortality.

FINDINGS

Twenty-six SGA (median GA 28.6 weeks, birth weight 825 grams, 46% males) were compared to 101 AGA (median GA 28.4 weeks, birth weight 1168 grams, 55% males) preterm infants. Clinical signs of delayed meconium passage did not differ significantly between groups. Differences regarding percentage of necrotizing enterocolitis, ileus, spontaneous intestinal perforation, and surgical intervention did not differ between groups. Mortality rate was significantly higher in SGA (11.5%) compared to AGA (2.9%) infants (P=0.03).

CONCLUSION

Despite similar morbidity SGA infants exhibited higher lethal complication rates following delayed meconium passage compared to AGA infants.

Does a self-management program change dietary intake in adults with irritable bowel syndrome?

Making dietary changes such as increasing fiber intake is recommended for the management of irritable bowel syndrome symptoms. Few studies have explored the efficacy of education on compliance with recommendations such as increasing fiber, vegetable, and fruit intake in adults with irritable bowel syndrome. This study examined the effect of a multicomponent self-management intervention that included strategies to enhance fiber, vegetable, and fruit intake. Participants with medically diagnosed irritable bowel syndrome were randomized to usual care or individualized comprehensive self-management, delivered either in-person or by telephone. Since previously published analyses show the two delivery modes to be equally effective, the two intervention groups were combined. Of the 188 individuals randomized, 173 participants (113 in the self-management group and 60 in the usual care group; 23 men, 150 women) provided data on at least one of the three follow-up occasions (3, 6, and 12 months postrandomization). Fiber, vegetable, and fruit intakes were measured using the Food Frequency Questionnaire. Participants in the intervention group demonstrated increases (p < .05) in fiber and fruit intake and a trend in vegetable intake at 6 and 12 months postintervention. Improvement in dietary fiber intake following a self-management intervention for IBS continues to 1 year.

Bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common chronic gastrointestinal disorder. The role of pharmacotherapy for IBS is limited and focused mainly on symptom control.

OBJECTIVES

The objective of this systematic review was to evaluate the efficacy of bulking agents, antispasmodics and antidepressants for the treatment of irritable bowel syndrome.

SEARCH STRATEGY

Computer assisted structured searches of MEDLINE, EMBASE, The Cochrane library, CINAHL and PsychInfo were conducted for the years 1966-2009. An updated search in April 2011 identified 10 studies which will be considered for inclusion in a future update of this review.

SELECTION CRITERIA

Randomized controlled trials comparing bulking agents, antispasmodics or antidepressants with a placebo treatment in patients with irritable bowel syndrome aged over 12 years were considered for inclusion. Only studies published as full papers were included. Studies were not excluded on the basis of language. The primary outcome had to include improvement of abdominal pain, global assessment or symptom score.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the selected studies. Risk Ratios (RR) and Standardized Mean Differences (SMD) with 95% confidence intervals (CI) were calculated. A proof of practice analysis was conducted including sub-group analyses for different types of  bulking agents, spasmolytic agents or antidepressant medication. This was followed by a proof of principle analysis where only the studies with adequate allocation concealment were included.

MAIN RESULTS

A total of 56 studies (3725 patients) were included in this review. These included 12 studies of bulking agents (621 patients), 29 of antispasmodics (2333 patients), and 15 of antidepressants (922 patients). The risk of bias was low for most items. However, selection bias is unclear for many of the included studies because the methods used for randomization and allocation concealment were not described. No beneficial effect for bulking agents over placebo was found for improvement of abdominal pain (4 studies; 186 patients; SMD 0.03; 95% CI -0.34 to 0.40; P = 0.87), global assessment (11 studies; 565 patients; RR 1.10; 95% CI 0.91 to 1.33; P = 0.32) or symptom score (3 studies; 126 patients SMD -0.00; 95% CI -0.43 to 0.43; P = 1.00). Subgroup analyses for insoluble and soluble fibres also showed no statistically significant benefit. Separate analysis of the studies with adequate concealment of allocation did not change these results. There was a beneficial effect for antispasmodics over placebo for improvement of abdominal pain (58% of antispasmodic patients improved compared to 46% of placebo; 13 studies; 1392 patients; RR 1.32; 95% CI 1.12 to 1.55; P < 0.001; NNT = 7), global assessment (57% of antispasmodic patients improved compared to 39% of placebo; 22 studies; 1983 patients; RR 1.49; 95% CI 1.25 to 1.77; P < 0.0001; NNT = 5) and symptom score (37% of antispasmodic patients improved compared to 22% of placebo; 4 studies; 586 patients; RR 1.86; 95% CI 1.26 to 2.76; P < 0.01; NNT = 3). Subgroup analyses for different types of antispasmodics found statistically significant benefits for cimteropium/ dicyclomine, peppermint oil, pinaverium and trimebutine. Separate analysis of the studies with adequate allocation concealment found a significant benefit for improvement of abdominal pain. There was a beneficial effect for antidepressants over placebo for improvement of abdominal pain (54% of antidepressants patients improved compared to 37% of placebo; 8 studies; 517 patients; RR 1.49; 95% CI 1.05 to 2.12; P = 0.03; NNT = 5), global assessment (59% of antidepressants patients improved compared to 39% of placebo; 11 studies; 750 patients; RR 1.57; 95% CI 1.23 to 2.00; P < 0.001; NNT = 4) and symptom score (53% of antidepressants patients improved compared to 26% of placebo; 3 studies; 159 patients; RR 1.99; 95% CI 1.32 to 2.99; P = 0.001; NNT = 4). Subgroup analyses showed a statistically significant benefit for selective serotonin releasing inhibitors (SSRIs) for improvement of  global assessment and for tricyclic antidepressants (TCAs) for improvement of abdominal pain and symptom score. Separate analysis of studies with adequate allocation concealment found a significant benefit for improvement of symptom score and global assessment. Adverse events were not assessed as an outcome in this review.

AUTHORS' CONCLUSIONS

There is no evidence that bulking agents are effective for treating IBS.  There is evidence that antispasmodics are effective for the treatment of IBS. The individual subgroups which are effective include: cimetropium/dicyclomine, peppermint oil, pinaverium and trimebutine. There is good evidence that antidepressants are effective for the treatment of IBS. The subgroup analyses for SSRIs and TCAs are unequivocal and their effectiveness may depend on the individual patient. Future research should use rigorous methodology and valid outcome measures.

[Guidelines for the treatment of irritable bowel syndrome]

Traditional symptom-based therapies of irritable bowel syndrome (IBS) are directed at the relief of individual IBS symptoms, but they are often of limited efficacy in addressing the entire symptom complex. Combinations of drugs to target bothersome symptoms are suggested as the first-line pharmacologic treatment. Increasing knowledge of the pathophysiology and molecular mechanisms of IBS has resulted in the development of several new therapeutic approaches. Thirteen consensus statements for the treatment of IBS were developed using the modified Delphi approach. Exclusion diets have modest efficacy in improving symptoms in some IBS patients. Symptom-based therapies with dietary fiber, bulking agents, laxatives, antispasmodics and laxatives are effective in the improvement of some individual symptoms, e.g. dietary fiber and bulking agents for constipation, laxatives for constipation, antispasmodics for abdominal pain and discomfort, antidiarrheals for diarrhea. 5HT3 receptor antagonists and 5HT((4)) receptor agonists are effective in the relief of global IBS symptoms and individual symptoms such as abdominal pain and abnormal bowel habits. A short term course of nonabsorbable antibiotics may improve global IBS symptoms, particularly in patients with diarrhea- predominant IBS. Some probiotics appear to have the potential benefit in improving global IBS symptoms. Selective C-2 chloride channel activator is more effective than placebo at relieving global IBS symptoms in patients with constipation-predominant IBS. Both tricyclic antidepressants and selective serotonin reuptake inhibitors are equally effective in relieving global IBS symptoms, and have some benefits in treating abdominal pain. Certain types of psychologic therapy may be effective in improving global symptoms in some IBS patients. Further studies are strongly needed to develop better treatment strategies for Korean patients with IBS.

Errors in the conduct of systematic reviews of pharmacological interventions for irritable bowel syndrome

OBJECTIVES

Systematic reviews and meta-analyses are integral to evidence-based clinical decision making. Although flawed systematic reviews could compromise optimal decision making, their accuracy has received limited investigation. We assessed conduct of systematic reviews of pharmaceutical interventions for irritable bowel syndrome (IBS).

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews (up to June 2008) to identify and replicate all published systematic reviews and meta-analyses that examined pharmacological interventions for IBS. We identified trials appropriately and inappropriately included according to the investigators' own eligibility criteria and eligible trials the investigators failed to include, and assessed the accuracy of dichotomous data extraction from all truly eligible trials. We conducted meta-analyses of accurate data from all truly eligible trials, and examined the differences between these accurate estimates and those reported by the authors.

RESULTS

The search strategy identified 120 citations, and 13 appeared to be relevant. Five systematic reviews did not extract dichotomous data, leaving eight eligible for inclusion. In five of the eight meta-analyses 13-29% of included trials were ineligible according to investigators' criteria, constituting 8-26% of included patients. Six of the meta-analyses missed 17 separate published eligible trials; 3-11% of eligible patients were, as a result, not included. All eight meta-analyses contained errors in dichotomous data extraction, in 29-100% of truly eligible trials, leading to errors in 15 of 16 reported pooled treatment effects. There was a > or =10% relative difference in treatment effects between the reported and recalculated summary statistic in five (31%) cases, and a change in the statistical significance of the recalculated summary statistic in a further four (25%) cases.

CONCLUSIONS

We found many errors in both application of eligibility criteria and dichotomous data extraction in the eight meta-analyses studied. Independent verification of systematic reviews and meta-analyses may be required for full confidence in their results.

The treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is a highly prevalent functional bowel disorder routinely encountered by healthcare providers. Although not life-threatening, this chronic disorder reduces patients' quality of life and imposes a significant economic burden to the healthcare system. IBS is no longer considered a diagnosis of exclusion that can only be made after performing a battery of expensive diagnostic tests. Rather, IBS should be confidently diagnosed in the clinic at the time of the first visit using the Rome III criteria and a careful history and physical examination. Treatment options for IBS have increased in number in the past decade and clinicians should not be limited to using only fiber supplements and smooth muscle relaxants. Although all patients with IBS have symptoms of abdominal pain and disordered defecation, treatment needs to be individualized and should focus on the predominant symptom. This paper will review therapeutic options for the treatment of IBS using a tailored approach based on the predominant symptom. Abdominal pain, bloating, constipation and diarrhea are the four main symptoms that can be addressed using a combination of dietary interventions and medications. Treatment options include probiotics, antibiotics, tricyclic antidepressants, selective serotonin reuptake inhibitors and agents that modulate chloride channels and serotonin. Each class of agent will be reviewed using the latest data from the literature.

Complementary and alternative medicine for treatment of irritable bowel syndrome

OBJECTIVE

To review the evidence supporting selected complementary and alternative medicine approaches used in the treatment of irritable bowel syndrome (IBS).

QUALITY OF EVIDENCE

MEDLINE (from January 1966), EMBASE (from January 1980), and the Cochrane Database of Systematic Reviews were searched until March 2008, combining the terms irritable bowel syndrome or irritable colon with complementary therapies, alternative medicine, acupuncture, fiber, peppermint oil, herbal, traditional, yoga, massage, meditation, mind, relaxation, probiotic, hypnotherapy, psychotherapy, cognitive therapy, or behavior therapy. Results were screened to include only clinical trials, systematic reviews, and meta-analyses. Level I evidence was available for most interventions.

MAIN MESSAGE

Soluble fibre improves constipation and global IBS symptoms. Peppermint oil alleviates IBS symptoms, including abdominal pain. Probiotic trials show overall benefit for IBS but there is little evidence supporting the use of any specific strain. Hypnotherapy and cognitive-behavioural therapy are also effective therapeutic options for appropriate patients. Certain herbal formulas are supported by limited evidence, but safety is a potential concern. All interventions are supported by systematic reviews or meta-analyses.

CONCLUSION

Several complementary and alternative therapies can be recommended as part of an evidence-based approach to the treatment of IBS; these might provide patients with satisfactory relief and improve the therapeutic alliance.

Daily intake of high dietary fiber slows accelerated colonic transit induced by restrain stress in rats

BACKGROUND

Stress and central corticotropin releasing factor (CRF) are contributing factors to the pathogenesis of irritable bowel syndrome (IBS). It has been shown that restraint stress and central CRF stimulate colonic motility in rats. Short-chain fatty acids (SCFAs) are produced by bacterial fermentation from dietary fibers. It is controversial whether daily intake of dietary fiber is beneficial for patients with diarrhea-predominant IBS. We studied whether dietary fiber intake affects colonic transit and motility stimulated by restraint stress and central CRF in rats.

METHODS

Corn starch is digested almost completely in the small intestine, while potato starch shows substantial resistance to alpha-amylase and its consumption leads to stimulation of large-bowel fermentation. Four weeks after a corn starch, potato starch, or usual diet (rat chow), colonic transit and motility stimulated by restraint stress and intracisternal (ic) injection of CRF were studied. Fecal concentration of SCFAs in the cecum was measured by high-performance liquid chromatography (HPLC).

RESULTS

Four-week treatment with potato starch diet significantly increased cecal concentrations of SCFAs, compared to treatment with corn starch diet. Accelerated colonic transit induced by stress and ic injection of CRF (1 microg) were significantly attenuated in rats receiving potato starch diet compared to rats receiving corn starch diet. The incidence of unformed stool (diarrhea) induced by stress and CRF was also reduced in rats receiving potato starch diet compared to rats receiving corn starch diet and usual diet.

CONCLUSION

It is suggested that daily intake of a high-fiber diet may prevent stress- and CRF-induced acceleration of colonic transit and diarrhea. This study may contribute to treatment for the patients of diarrhea-predominant IBS.

Nutritional aspects in patients with functional gastrointestinal disorders and motor dysfunction in the gut. Working team report of the Swedish Motility Group (SMoG)

In reviews regarding the management of patients with functional gastrointestinal disorders and motility disturbances within the gut nutritional aspects and dietary advice is often put forward as being of great importance. However, there are relatively few high-quality, interventional studies in the literature supporting an important role for general dietary advice to improve symptoms in these patients. Nutritional supplementation to patients with malnutrition due to severe dysfunction of the gastrointestinal tract is of course less controversial, even though different views on how this should be performed exist. The content of this article is based on presentations given by the authors during the second meeting of the Swedish Motility Group held in Gothenburg in March 2005, and aims to give an overview on the role of dietary advice and nutritional supplementation to patients with gastrointestinal dysfunction of different severity.

Risk factors for irritable bowel syndrome in Turkish population: role of food allergy

GOALS

The aim of this study was to determine the prevalence of food hypersensitivity in Turkish patients with irritable bowel syndrome (IBS).

BACKGROUND

The IBS is a chronic disease of the gastrointestinal tract characterized by abdominal pain, distension, meteorism and either diarrhea or constipation. The role of diet in the pathogenesis of IBS remains controversial. Many investigators have shown that individual foods can trigger symptoms in some patients; nevertheless, the percentage of patients that benefit from dietary manipulation ranges from 15% to 67% in different reports.

STUDY

Skin prick test to 11 common allergens, total IgE, eosinophilic cationic protein and eosinophil counts were evaluated in 100 patients satisfying the Rome II criteria and compared with 25 healthy controls. The history and physical examination of the groups were recorded and Beck Depression and Anxiety Inventories were performed.

RESULTS

One hundred patients were entered into the study with a mean age of 45.63+/-12.91 years. Of the patients 53 had constipation predominant, 19 had diarrhea predominant, and 28 had alternating type IBS. Skin prick tests positivity were more common among the IBS patients in comparison with controls (25% and 1%, respectively, P<0.05). Mean IgE values were higher in patients than controls (70.83+/-66.05 and 15.20+/-14.01 IU/mL, respectively, P<0.000). Eosinophilic cationic protein values were also higher in IBS patients than controls (16.75+/-11.28 and 11.56+/-4.72, respectively, P<0.05) Evaluation of Beck Depression Inventory showed that tendency to depression in patients with IBS was 38% and 4% in controls (P<0.05).

CONCLUSIONS

According to our results, in patients complaining of IBS it is of importance to search for a food component. Clinical improvements can be observed after the introduction of an adequate exclusion diet.

Irritable Bowel Syndrome: A Practical Review

The epidemiology and current understanding of the pathophysiology of irritable bowel syndrome is reviewed, beginning with a historical perspective. The roles of genetics, environment, allergy, infection and inflammation, bacterial overgrowth, hormones and motility abnormalities are discussed. Using the current evidence-based literature, the practical approach of diagnosis and treatment is outlined, including traditional modalities and newer therapeutic agents such as serotonin modulators.

Systematic review: the efficacy of treatments for irritable bowel syndrome--a European perspective

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder, characterized by abdominal pain/discomfort, bloating and altered bowel habit.

AIM

To conduct a systematic evidence-based review of pharmacological therapies currently used, or in clinical development, for the treatment of IBS in Europe. The safety and tolerability of these therapies are the subject of an accompanying review.

METHODS

A literature search was completed for randomized controlled studies which included adult patients with IBS and an active or placebo control, assessed IBS symptoms, and were published in English between January 1980 and June 2005. The level of evidence for efficacy was graded according to the quality of the trial design and the study outcome.

RESULTS

There is some evidence for improvement of individual IBS symptoms with antidiarrhoeals (diarrhoea), antispasmodics (abdominal pain/discomfort), bulking agents (constipation), tricyclic antidepressants (abdominal pain/discomfort) and behavioural therapy. In contrast, there is strong evidence for the improvement of global IBS symptoms with two new serotonergic agents: the 5-HT4 selective agonist tegaserod (IBS with constipation) and the 5-HT3 antagonist alosetron (IBS with diarrhoea). Further data are required for the 5-HT3 antagonist, cilansetron, and the mixed 5-HT3 antagonist/5-HT4 agonist renzapride before their utility in IBS can be appraised.

CONCLUSIONS

There is limited evidence for the efficacy, safety and tolerability of therapies currently available in Europe for the treatment of IBS. Overall, there is an absence of pharmacological agents licensed specifically for the treatment of IBS subtypes, and new agents are awaited in Europe that will allow changes in clinical practice to focus on and improve global IBS symptoms.

Nutrition and motility disorders

The purpose of this article is to give an overview of the relation between feeding and gastrointestinal symptoms and complaints, and to review different motility disorders that have implications for food intake. We also report the consequences for nutrition state and the evidence-based principles of dietary modification in patients with motility disorders.

Efficacy of current drug therapies in irritable bowel syndrome: what works and does not work

Based on current evidence, bulking agents are not more effective than placebo at improving global irritable bowel syndrome (IBS)symptoms, although they may increase stool frequency in large doses. Tricyclic antidepressants are more effective than placebo for patients with diarrhea-predominant IBS. Imodium is more effective than placebo at improving stool consistency and decreasing stool frequency in patients with IBS, and it may be an important component for treating diarrhea-predominant IBS. Antispasmodics agents available in the United States are not more effective than placebo for treating IBS, although the studies are small and poorly designed. There are no randomized controlled trials examining the efficacy of laxatives for managing IBS. Tegaserod is more effective than placebo at improving global IBS symptoms in women with nondiarrhea-predominant IBS. Alosetron is more effective than placebo in women with diarrhea-predominant IBS, although its use should be limited to patients who have failed conventional therapy because of its adverse event profile.

Prevalence of irritable bowel syndrome, influence of lifestyle factors and bowel habits in Korean college students

BACKGROUND AND AIMS

Irritable bowel syndrome (IBS) is considered to be prevalent in the general population, but there are little data on bowel habits and IBS in Korea. Because nurses are frequently called on to help this patient population with IBS and help manage their symptoms, it is very necessary to get some practical information about patients' experiences and to outline a multifaceted approach to the practical management of patient with IBS. So this study aims to describe the bowel habits and the prevalence of IBS in young university students in Korea and to investigate the influence of lifestyle factors, including dietary habits, on IBS prevalence. Finally, we discuss the nursing needs for an holistic approach.

METHODS

A cross-sectional study, using the self-reported questionnaire based on previous studies done abroad and the Rome alpha criteria was applied with 1717 young university students.

RESULTS

The answers of 747 men and 970 women were included in the study. The prevalence of IBS, as defined by the Rome alpha criteria, was 5.7% of the subjects. The proportion of women (70.7%) was significantly higher than the proportion of men in the IBS group as compared to that in the non-IBS group (odds ratio 2.07, 95% CI 1.2-3.7). Residential type (odds ratio 1.27, 95% 1.06-1.5) and frequency of meals (odds ratio 1.69, 95% CI 1.2-2.5) significantly differed between the IBS group and non-IBS group. There was a trend towards the higher prevalence of IBS with fewer hours of exercise (odds ratio 0.99, 95% CI 0.95-1.04). 90.6% of respondents reported stool frequencies between three times per day and three times per week. Characteristics of defecation differed significantly between men and women (p<0.05, to p<0.0001).

CONCLUSION

The prevalence of IBS in healthy young people of Korea was lower compared with those reported in the West. This study shows that proportionately more women suffered from IBS than men and dietary factors and lifestyle were significantly related to IBS. From our study results, we found that there are multifaceted nursing aspects required to reduce symptoms, such as dietary education and encouragement to change lifestyle aimed at controlling stress.

Use of diet and probiotic therapy in the irritable bowel syndrome: analysis of the literature

GOAL

The goal of this report is to review the use of dietary intake and probiotics in patients with irritable bowel syndrome (IBS) in published reports.

BACKGROUND

Dietary factors can be important in inducing symptoms that occur in patients with the IBS. Dietary intolerances, dietary allergies, specific food metabolites, and regular diet contents all may act as triggers and aggravate the symptoms of IBS; but when any of these mechanisms can be proven to cause the symptoms, then their elimination results in the resolution of that patient's IBS.

METHODS

Our previous review was updated. In addition, a careful Medline search was made for the years from 1975 to 2004 to evaluate human research reports on diet and probiotics in the IBS. Forty-six manuscripts were reviewed on diet and six were available on probiotic use in IBS. The most common dietary factor evaluated in the literature was bran, and the most common probiotic used was Lactobacillus plantarum.

CONCLUSIONS

Although investigations have shown that bran may be helpful in some patients, a complete review of the literature does not reveal conclusive evidence that diet therapy is effective in IBS. From the limited reports on probiotics, there appears to be a trend to decreasing symptoms. It is clear that much more prospective research is needed to study both dietary factors and probiotics in these areas.

Assessment of the rectoanal inhibitory reflex in preterm infants with delayed meconium passage

BACKGROUND

There is an inverse relationship between gestational age, birth weight and the time of first neonatal bowel movement. The authors hypothesized that delayed passage of meconium might result from a delayed maturation of the recto-anal inhibitory reflex (RAIR) in premature infants.

OBJECTIVE

To evaluate whether the RAIR is absent in very preterm infants 28-32 weeks postmenstrual age with delayed meconium production.

STUDY DESIGN

Anorectal manometry was performed in 10 preterm infants (seven male) with delayed meconium production (no meconium in the first 48 hours). Median postmenstrual age was 30 weeks (28-31 weeks). Birth weight ranged from 780 to 1930 g (median, 1395 g). A micromanometric assembly (outer diameter, 2.0 mm) was used which incorporated a 1.5-cm-long sleeve sensor for measurement of resting anal sphincter pressure and relaxation. Four side-holes recorded anal and rectal pressures. Rectal distension was performed with direct air insufflation to elicit the RAIR.

RESULTS

The time from birth to passage of meconium ranged from 48 to 105 hours (median, 82 hours). The mean anal sphincter pressure, rectal pressure, and anal sphincter oscillation frequency were 22.0 +/- 5.0 mm Hg, 6.9 +/- 2.0 mm Hg, and 9.8 +/- 1.9/min, respectively. A normal RAIR was elicited in all infants.

CONCLUSION

Anorectal manometry recordings in premature infants with delayed passage of meconium showed normal anorectal pressures and a normal RAIR, suggesting that delayed meconium passage is not related to the absence of a RAIR.

Do interventions which reduce colonic bacterial fermentation improve symptoms of irritable bowel syndrome?

Abnormal fermentation may be an important factor in irritable bowel syndrome (IBS). Gastroenteritis or antibiotic therapy may damage the colonic microflora, leading to increased fermentation and the accumulation of gas. Gas excretion may be measured by whole-body calorimetry but there has only been one such study on IBS to date. We aimed to assess the relationship between IBS symptoms and fermentation rates in IBS. A purpose-built, 1.4-m3, whole-body calorimeter was used to assess excretion of H2 and CH4 in IBS subjects while consuming a standard diet and, again, after open randomization on either the standard diet together with the antibiotic metronidazole or a fiber-free diet to reduce fermentation. Metronidazole significantly reduced the 24-hr excretion of hydrogen (median value compared to the control group, 397 vs 230 ml/24 hr) and total gas (H2 + CH4; 671 vs 422 ml/min) and the maximum rate of gas excretion (1.6 vs 0.8 ml/min), as did a no-fiber polymeric diet (hydrogen, 418 vs 176 ml/min; total gas, 564 vs 205 ml/min; maximum rate of gas excretion, 1.35 vs 0.45 ml/min), with a significant improvement in abdominal symptoms. IBS may be associated with rapid excretion of gaseous products of fermentation, whose reduction may improve symptoms.

Inhibitory actions of a high fibre diet on intestinal gas transit in healthy volunteers

BACKGROUND

Fibre treatment often produces gaseous symptoms which have been attributed to fermentation by colonic bacteria with increased gas production. Effects of fibre ingestion on intestinal gas flow are unexplored.

AIMS

We aimed to test the hypothesis that consumption of a high fibre diet retards gas transit.

SUBJECTS

Ten healthy volunteers participated.

METHODS

To investigate the effects of fibre on gas dynamics, physiological gas mixtures were jejunally perfused at 12 ml/min x 2 hours after a standard diet for seven days with and without psyllium 30 g/day in a crossover fashion. Gas was collected from an intrarectal catheter to bypass the anus and evacuation was quantified in real time using a barostat.

RESULTS

On initiating gas perfusion under control conditions, an initial lag phase with no gas expulsion was observed (1129 (274) seconds). Thereafter, gas evacuation from the rectum proceeded with cumulative volumes of 1429 (108) ml by the end of the second hour. Evacuation was pulsatile with passage of 20.9 (2.5) boluses, with mean volumes of 68.2 (5.0) ml. Fibre prolonged the lag time (2265 (304) seconds; p<0.05) and reduced cumulative gas evacuation volumes (1022 (80) ml; p<0.05). Decreased gas evacuation resulted from reductions in the numbers of bolus passages (14.2 (1.1); p<0.05) but not bolus volumes (70.7 (3.4) ml; p = 0.66).

CONCLUSIONS

Consumption of a high fibre diet retards intestinal gas transit by decreasing bolus propulsion to the rectum. Thus, in addition to increasing gas production by colonic flora, fibre ingestion may elicit gaseous symptoms by promoting gas retention.

Dietary Treatment of the Irritable Bowel Syndrome

Most patients with functional gastrointestinal disorders report that food ingestion appears to exacerbate their symptoms and consequently conclude that they have some form of gastrointestinal food allergy or intolerance. Dietary management of functional gastrointestinal conditions is an attractive therapeutic option for the patient and physician alike because it is safe and economical and empowers the patient to help themselves. However, in practice, dietary manipulation frequently yields rather disappointing results. Exclusion diets can be helpful, but are labor intensive and occasionally can be very restrictive. Laboratory testing for immunoglobulin E food antibodies usually is not helpful, except in a small subgroup of patients with diarrhea, predominant irritable bowel syndrome (IBS), and atopy. There is some preliminary evidence to suggest that elimination diets based on immunoglobulin G food antibody testing may possibly have therapeutic potential in IBS, but this requires confirmation.

Evaluation of drug treatment in irritable bowel syndrome

The irritable bowel syndrome (IBS) remains a therapeutic challenge in part because of the limited understanding of the pathophysiology. The placebo response rate varies in randomized controlled trials from 20 to 70%, and can persist for up to at least 1 year. It is contentious whether dietary fibre and bulking agents relieve the symptoms of IBS; constipation probably improves. Anticholinergic and antispasmodic agents are of questionable benefit in IBS despite positive meta-analyses of poor quality trials. A meta-analysis concluded that the tricyclic antidepressants were superior to placebo in IBS, although the individual trial results were variable. Selective serotonin reuptake inhibitors are of uncertain benefit. Laxatives are used for constipation but probably poorly control the IBS symptom complex. Loperamide is superior to placebo in improvement of diarrhoea but not abdominal pain in IBS. Tegaserod is a well- tolerated aminoguanidine indole derivative of serotonin that is a partial 5HT4-receptor agonist with prokinetic properties; a therapeutic gain over placebo of 5% to 15% has been observed in constipation-predominant IBS in females. Alosetron is a 5HT3-receptor antagonist that is efficacious in females with diarrhoea-predominant IBS, with a 12% to 17% therapeutic gain; the risk of ischaemic colitis is 1 in 350, with very severe constipation occurring in about 1 in 1000. Optimizing study design remains a challenge in IBS. New visceral analgesic and motility modifying agents, as well as anti-inflammatory agents are in trials, and hopefully additional efficacious therapeutic options for patients with IBS will soon emerge.

Systematic review of treatments for recurrent abdominal pain

OBJECTIVE

To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children.

METHODS

Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results.

RESULTS

Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance.

CONCLUSIONS

Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.

Dietary treatment of irritable bowel syndrome: current evidence and guidelines for future practice

The aim of this literature review is to produce guidelines for dietetic practice in irritable bowel syndrome (IBS) by evaluating the research available. In this area randomized control trials (RCT) only account for a small proportion of the literature and have been concentrated in the modification of dietary fibre in patients with IBS. The bulk of the literature is mainly observational trials from which no indisputable conclusions can be extracted. In this review, the evidence available has been interpreted within the context of the current knowledge base. Conclusions are drawn to facilitate the development of guidelines, enabling a starting point for discussion and an evaluation of current practice. The literature available on therapeutic dietary manipulation in IBS patients is centred around non-starch polysaccharides (NSPs), mono and disaccharide sensitivity and food intolerance. The production of these guidelines has focused on research examining the role of dietary components in the therapeutic management of patients with IBS. However, where there is a deficiency in the literature directly relating dietary intake to management of IBS patients, physiological function in relation to dietary components has been relied upon to produce practical guidelines which can be applied realistically in a clinical environment. An interpretation of the evidence has revealed a limited role for exclusion diets, a move away from high-fibre diets towards the manipulation of fibre fractions in the diet, an evaluation of the effects of caffeine on gut function and the necessity for individual dietary assessment to identify dietary issues pertinent to the patient's symptoms. These guidelines outline a positive role for dietitians in the treatment of IBS patients which draws on the unique skills possessed by dietitians regarding the assessment of habitual eating habits and therapeutic dietary manipulation.

Complementary and alternative medicine and gastrointestinal diseases

Complementary and alternative medicine (CAM) is becoming increasingly utilized as a form of health care, with recent studies suggesting that over 40% of Americans use some form of CAM. This has major financial implications for the health care industry. Traditional physicians frequently are unaware of CAM use by their patients, and there are potential interactions between CAM and traditional forms of medical therapy. Many of the medicinal CAM agents have been used for their postulated anti-inflammatory and/or antifibrotic effects. CAM is especially frequently used in patients with chronic diseases. This review discusses CAM use in three types of chronic gastrointestinal diseases--liver disease, irritable bowel syndrome and dyspepsia, and inflammatory bowel disease.

Multidisciplinary approach to fibromyalgia. A pilot study

The aim of the study was to instruct a group of fibromyalgia patients how to solve problems related to activities of daily life. Sixteen female fibromyalgia patients completed a ten week multidisciplinary program, consisting of a cognitive and an exercise part. After ten weeks a reduction in general pain intensity (p < 0.05) was found. At six months follow-up sensory (somatic) pain intensity was reduced compared to baseline recordings (p = 0.05). All patients had made adjustments to their everyday life after ten weeks. Eight patients reported that they regularly practised relaxation techniques, and seven patients had undertaken dietary changes. Thus, the study shows that adjustment of activities in daily living may reduce pain in patients with fibromyalgia. Controlled studies are needed in the future.

Effect of wheat bran in treatment of chronic nonorganic constipation. A double-blind controlled trial

After a two-week basal period, 24 patients were randomly allocated to receive, with a crossover double-blind design, for two consecutive four-week periods, bran (20 g/24 hr) or placebo. The daily intake of water and dietary fibers was standardized. Symptomatology, oroanal transit time, bowel frequency, and stool weight were assessed in basal conditions and at week 4 and 8 of the treatment. Oroanal transit time decreased and bowel frequency and stool weight increased significantly during both bran and placebo administration in comparison with basal period. Bran treatment was more effective than placebo in improving bowel frequency and oroanal transit. During bran treatment oroanal transit time became normal only in patients with slow colonic transit and not in those with slow rectal transit. Neither the occurrence nor the severity of the most frequent accompanying symptoms of chronic constipation differed significantly between placebo and bran treatments.

Infant colic. A pediatric gastroenterologist's perspective

Colic is a syndrome of persistent crying in infants, with multiple causes. In most cases, it is within the spectrum of normal variability in infant behavior and can be treated with reassurance, education, and counseling about appropriate parental responses. In a minority of cases, careful analysis of the crying pattern and other infant behaviors may suggest an underlying gastrointestinal problem that may be amenable to more specific treatment. This article explores the evidence supporting the use of crying and behavioral diaries to determine an appropriate response to each colicky infant.

Bran supplementation in the treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome remains the commonest reason for referral to a gastroenterology clinic. Patients with irritable bowel syndrome are frequently advised to increase their intake of bran fibre, despite inconclusive experimental evidence of benefit.

METHODS

The effect of dietary supplementation with a bolus of bran fibre (12 g/day) was studied in a block-randomized, placebo-controlled, crossover study of 80 patients with irritable bowel syndrome referred to a District General Hospital outpatient clinic. Comparison of the benefits of bran and placebo was based upon personal assessment of individual and overall symptom profiles, determined from a simple daily symptom score and post-treatment interview.

RESULTS

Overall symptomatic improvement was reported with bran by 52% and with placebo by 54% of patients. Bran supplementation was no more effective than placebo in improving individual symptoms of irritable bowel syndrome, and for wind-related symptoms it was significantly less effective (P < 0.001).

CONCLUSION

Dietary supplementation with bran is of no value in the treatment of patients with irritable bowel syndrome referred to a hospital clinic.

Gastrointestinal symptoms and diet of members of an irritable bowel self-help group

A self-administered questionnaire was completed by 103 members of a self-help group for irritable bowel syndrome (IBS) and 130 controls, to compare the presence of IBS symptoms. Dietary fibre prescription, compliance and efficacy were documented in the IBS group. There were significant differences in the frequency of defaecation and number of symptoms present between the two groups. Most of the IBS subjects had been prescribed a high fibre diet but adherence to the diet and symptomatic improvement were poor. In contrast many IBS sufferers were following a range of diets not prescribed by their doctor. The seriousness of the IBS condition was highlighted by the fact that 8% of the IBS group had retired early due to their condition.