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Lu G, Zhang S, Wang R, Zhang Z, Wang W, Wen Q, Zhang F, Li P. Global Trends in Research of Pain-Gut-Microbiota Relationship and How Nutrition Can Modulate This Link. Nutrients 2023; 15:3704. [PMID: 37686738 PMCID: PMC10490108 DOI: 10.3390/nu15173704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
INTRODUCTION The link between gut microbiota and chronic painful conditions has recently gained attention. Nutrition, as a common intervention in daily life and medical practice, is closely related to microbiota and pain. However, no published bibliometric reports have analyzed the scientific literature concerning the link. METHODS AND RESULTS We used bibliometrics to identify the characteristics of the global scientific output over the past 20 years. We also aimed to capture and describe how nutrition can modulate the abovementioned link. Relevant papers were searched in the Web of Science database. All necessary publication and citation data were acquired and exported to Bibliometrix for further analyses. The keywords mentioned were illustrated using visualization maps. In total, 1551 papers shed light on the relationship from 2003 to 2022. However, only 122 papers discussed how nutritional interventions can modulate this link. The citations and attention were concentrated on the gut microbiota, pain, and probiotics in terms of the pain-gut relationship. Nutritional status has gained attention in motor themes of a thematic map. CONCLUSIONS This bibliometric analysis was applied to identify the scientific literature linking gut microbiota, chronic painful conditions, and nutrition, revealing the popular research topics and authors, scientific institutions, countries, and journals in this field. This study enriches the evidence moving boundaries of microbiota medicine as a clinical medicine.
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Affiliation(s)
- Gaochen Lu
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Sheng Zhang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Rui Wang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Zulun Zhang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Weihong Wang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Quan Wen
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
| | - Faming Zhang
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
- Department of Microbiotherapy, Sir Run Run Hospital, Nanjing Medical University, Nanjing 211166, China
- National Clinical Research Center for Digestive Diseases, Xi’an 710032, China
| | - Pan Li
- Department of Microbiota Medicine, Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, China; (G.L.); (S.Z.); (R.W.); (Z.Z.); (W.W.); (Q.W.)
- Key Lab of Holistic Integrative Enterology, Nanjing Medical University, Nanjing 210011, China
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Algera JP, Colomier E, Melchior C, Hreinsson JP, Midenfjord I, Clevers E, Simrén M, Törnblom H. Associations between postprandial symptoms, hydrogen and methane production, and transit time in irritable bowel syndrome. Neurogastroenterol Motil 2023; 35:e14482. [PMID: 36221245 PMCID: PMC10078221 DOI: 10.1111/nmo.14482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/05/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Abnormal oroanal transit time (OATT) and visceral hypersensitivity are key pathophysiological factors in irritable bowel syndrome (IBS). The lactulose nutrient challenge test (LNCT) has been developed to assess the postprandial symptoms and gut microbial fermentation. We aimed to investigate associations between OATT, rectal sensitivity, and LNCT in IBS patients. METHODS We included 263 IBS patients from two study cohorts, where the link between pathophysiology and symptoms was investigated. During the LNCT, severity of postprandial symptoms was graded, and breath hydrogen/methane concentrations were measured after ingestion of a combined lactulose nutrient drink every 15 min for 4 h. The patients underwent rectal sensitivity (rectal barostat) and OATT (radiopaque markers) investigations. Comorbid conditions (functional dyspepsia, anxiety, depression, and somatization) were assessed with questionnaires. KEY RESULTS After controlling for comorbid conditions, rectal sensitivity was associated with abdominal pain (p < 0.05), and more rapid OATT was associated with higher severity of abdominal discomfort, rumbling, nausea, and urgency (p < 0.05 for all) both pre- and post-prandially. Postprandial nausea, urgency, and abdominal pain changed differently over time depending on OATT (p < 0.05 for all). OATT, but not rectal sensitivity, was associated with hydrogen and methane concentrations (p = 0.002 for both). Trajectories over time of postprandial symptoms and exhaled hydrogen/methane concentrations were correlated with different correlations depending on OATT. CONCLUSION AND INFERENCES This study highlights the importance of oroanal transit and hydrogen and methane production in the pathophysiology of IBS and increases our understanding of pathophysiological factors involved in postprandial symptom generation. Treatments targeting oroanal transit and hydrogen and methane production may improve specific postprandial symptoms.
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Affiliation(s)
- Joost P Algera
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Esther Colomier
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Chloé Melchior
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Gastroenterology Department and INSERM CIC-CRB 1404, Rouen University Hospital, Rouen, France.,INSERM U1073, Rouen Normandy University, Rouen, France
| | - Jóhann P Hreinsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Irina Midenfjord
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Egbert Clevers
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Chronic Diseases, Metabolism and Aging (CHROMETA), Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Functional GI & Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Algera JP, Demir D, Törnblom H, Nybacka S, Simrén M, Störsrud S. Low FODMAP diet reduces gastrointestinal symptoms in irritable bowel syndrome and clinical response could be predicted by symptom severity: A randomized crossover trial. Clin Nutr 2022; 41:2792-2800. [PMID: 36384081 DOI: 10.1016/j.clnu.2022.11.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND & AIMS Fermentable oligo-, di-, monosaccharides and polyols (FODMAPs) can provoke symptoms in patients with irritable bowel syndrome (IBS). We aimed to compare the effects of diets with low vs. moderate FODMAP content on gastrointestinal (GI) symptoms and bowel habits, and to identify possible predictors of clinical response to a low FODMAP diet and FODMAP sensitivity in IBS. METHODS Adult participants with IBS (Rome IV criteria, n = 29) were included and adhered to two 7-day diet periods, with either low (4 g/day) or moderate (23 g/day) amounts of FODMAPs, in this randomized, double-blind, crossover study. The periods were separated by a wash-out period (≥14 days). IBS-Severity Scoring System (IBS-SSS) and a stool diary (Bristol Stool Form) were completed before and after the diet periods. At baseline, severity of GI symptoms and gut microbial fermentation were assessed (every 15 min, 4 h) during the Lactulose Nutrient Challenge Test (LNCT). Clinical response and FODMAP sensitivity were defined by reduction after low FODMAP period, and increase after moderate FODMAP period in IBS-SSS (≥50 points), respectively. RESULTS Severity of GI symptoms (P = 0.04), stool consistency (P = 0.01), and stool frequency (P = 0.01) differed between the interventions, with reduced overall GI symptom severity, abdominal pain intensity and frequency, bowel habits dissatisfaction, and daily life interference (P < 0.05 for all), as well as more firm (P = 0.03) and less frequent (P < 0.01) stools after low FODMAP intervention, but not after moderate FODMAP intervention. A third (34%) responded clinically to the low FODMAP diet, and the response could be predicted by higher IBS-SSS at baseline (P = 0.02). Although modest associations between FODMAP sensitivity (22%) and GI symptoms during LNCT were observed, no independent predictors could be identified. CONCLUSIONS A diet low in FODMAPs reduces GI symptoms and affects bowel habits in IBS, compared with a moderate FODMAP diet. Assessment of IBS severity before the intervention may be used to predict clinical response to a low FODMAP diet. Trial registry (http://www. CLINICALTRIALS gov): Registered under Clinical Trial number NCT05182593.
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Affiliation(s)
- Joost P Algera
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Dagsu Demir
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sanna Nybacka
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Center for Functional GI & Motility Disorders, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stine Störsrud
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Clusters of community-dwelling individuals empirically derived from stool diaries correspond with clinically meaningful outcomes. Eur J Gastroenterol Hepatol 2021; 33:e740-e745. [PMID: 34138762 DOI: 10.1097/meg.0000000000002236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Functional gastrointestinal disorders (FGIDs) are diagnosed according to expert consensus criteria based on recall of symptoms over periods of 3 months or longer. Whether the expert opinion concords with underlying disease process and whether individual recall is accurate are both in doubt. This study aimed to identify naturally occurring clusters of individuals with respect to symptom pattern, evaluate their significance, compare cluster profiles with expert opinion and evaluate their temporal stability. METHODS As part of a random population study of FGID-related symptoms, we first explored the use of prospective stool and symptom diaries combined with empirical grouping of individuals into clusters using nonhierarchical cluster analysis. RESULTS The analysis identified two clusters of individuals, one of which was characterized by elevated scores on all domains of symptoms (26% of the sample) and one that was low to average on all domains (74% of the sample). Cluster membership was found to be stable over a long interval. Clusters were found to differ on most domains of quality-of-life (d = 0.46-0.74), self-rated health (d = -0.42) and depression (d = -0.42) but not anxiety. Prevalence of clinically diagnosed irritable bowel syndrome (IBS) was higher in the more impacted cluster (33%) compared with the healthy cluster (13%; P < 0.0001). CONCLUSION A naturalistic classification of individuals challenges consensus criteria in showing that some IBS individuals have a symptom experience not unlike health. The proposed approach has demonstrated temporal stability over time, unlike consensus criteria. A naturalistic disease classification system may have practical advantages over consensus criteria when supported by a decision-analytic system.
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Schindler V, Giezendanner S, Van Oudenhove L, Murray FR, Buehler J, Bordier V, Hente J, Pohl D. Better response to low FODMAP diet in disorders of gut-brain interaction patients with pronounced hydrogen response to a nutrient challenge test. J Gastroenterol Hepatol 2021; 36:3322-3328. [PMID: 34107550 DOI: 10.1111/jgh.15573] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/03/2021] [Accepted: 06/05/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Previous studies have shown a reduction of gastrointestinal symptoms in irritable bowel syndrome (IBS) patients following a low FODMAP diet (LFD). It remains unknown which disorders of gut-brain interaction (DGBI) patients would benefit most from LFD. We aimed to analyze LFD response regarding a preceding nutrient challenge test (NCT). METHODS Data of 110 consecutive DGBI patients undergoing NCT and LFD between August 2015 and August 2018 were analyzed retrospectively. LFD response was assessed by changes in IBS Symptom Severity Score (IBS-SSS). In mixed-effects linear regression models, the impact of hydrogen values and abdominal symptoms during NCT, performed with 30-g lactulose and 400-mL liquid test meal, on IBS-SSS changes were analyzed. RESULTS Low FODMAP diet induced a significant IBS-SSS reduction of 78 points (95% confidence interval [CI] 50-96; P < 0.001). Patients with higher NCT-induced hydrogen increase during proximal intestinal transit had a significantly better LFD response (-66 IBS-SSS reduction per 10-ppm hydrogen increase, 95% CI -129 to -4, P = 0.045). Additionally, the higher the NCT-induced maximum hydrogen increase during mid-distal and distal intestinal transit, the better are the responses to LFD (-6 IBS-SSS per 10-ppm maximum delta hydrogen, 95% CI -11 to -1, P = 0.040). There was no association of LFD response with abdominal symptom generation during NCT. CONCLUSIONS Our study is the first one analyzing and demonstrating significant associations between NCT results and LFD response. These findings are of high clinical importance, as they identify a subgroup of DGBI patients that may profit most from a restrictive LFD as first-line therapy.
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Affiliation(s)
- Valeria Schindler
- Division of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | | | - Lukas Van Oudenhove
- Laboratory for Brain-Gut Axis Studies, Translational Research Centre for Gastrointestinal Disorders, Department of Chronic Diseases, Metabolism, and Ageing, KU Leuven, Leuven, Belgium.,Cognitive and Affective Neuroscience Lab, Department of Psychological and Brain Sciences, Dartmouth College, Hanover, New Hampshire, USA
| | - Fritz Ruprecht Murray
- Division of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Joelle Buehler
- Division of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | | | - Juliane Hente
- Division of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital of Zürich, Zürich, Switzerland
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Schindler V, Hente J, Murray FR, Hüllner M, Becker AS, Giezendanner S, Schnurre L, Bordier V, Pohl D. Adding a liquid test meal to a standardized lactulose hydrogen breath test significantly influences abdominal symptom generation and hydrogen values. Eur J Gastroenterol Hepatol 2021; 33:1485-1494. [PMID: 34609811 DOI: 10.1097/meg.0000000000002042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE While single sugar tests are controversially discussed, combination tests with meals are gaining more attention. The aim of this study was to analyze the impact of adding a test meal to lactulose hydrogen breath tests (LHBT) on hydrogen values and abdominal symptoms in patients with functional gastrointestinal disorders (FGIDs). METHODS Data of 81 FGID patients between 2014-2018 were analyzed. Patients underwent LHBT with 30 g lactulose + 300 mL water and a nutrient challenge test (NCT) including 400 mL liquid test meal + 30 g lactulose. To statistically assess the effect of a test meal on abdominal symptoms and H2, mixed-effect models were used. RESULTS Adding a test meal to LHBT showed a significant increase in nausea [odds ratio (OR) 1.4; 95% confidence interval (CI), 1.1-1.7], decrease in abdominal pain (OR 0.7; 95% CI, 0.6-0.9), borborygmi (OR 0.5; 95% CI, 0.4-0.6), diarrhea (OR 0.4; 95% CI, 0.3-0.6), and H2 production (estimate -5.3, SE 0.7, P < 0.001). The effect on bloating was only significant in functional dyspepsia, irritable bowel syndrome-functional dyspepsia mixed type and functional abdominal pain/bloating (OR 0.1; 95% CI, 0.0-0.2; OR 1.7; 95% CI, 1.2-2.3 resp OR 4.4; 95% CI, 1.8-10.6). CONCLUSIONS Significant effects on abdominal symptoms and H2 production by adding a test meal to LHBT in FGID patients are shown. Increased occurrence of nausea may be caused by gastric/duodenal hypersensitivity; decreased H2, diarrhea and borborygmi by slower and more physiologic gastric emptying resulting in later arrival of the test substance in the bowel. We recommend NCTs instead of LHBT to more physiologically represent FGID patients' meal-induced burden.
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Affiliation(s)
| | | | | | | | - Anton S Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich
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Hammer HF, Fox MR, Keller J, Salvatore S, Basilisco G, Hammer J, Lopetuso L, Benninga M, Borrelli O, Dumitrascu D, Hauser B, Herszenyi L, Nakov R, Pohl D, Thapar N, Sonyi M. European guideline on indications, performance, and clinical impact of hydrogen and methane breath tests in adult and pediatric patients: European Association for Gastroenterology, Endoscopy and Nutrition, European Society of Neurogastroenterology and Motility, and European Society for Paediatric Gastroenterology Hepatology and Nutrition consensus. United European Gastroenterol J 2021; 10:15-40. [PMID: 34431620 PMCID: PMC8830282 DOI: 10.1002/ueg2.12133] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction Measurement of breath hydrogen (H2) and methane (CH4) excretion after ingestion of test‐carbohydrates is used for different diagnostic purposes. There is a lack of standardization among centers performing these tests and this, together with recent technical developments and evidence from clinical studies, highlight the need for a European guideline. Methods This consensus‐based clinical practice guideline defines the clinical indications, performance, and interpretation of H2‐CH4‐breath tests in adult and pediatric patients. A balance between scientific evidence and clinical experience was achieved by a Delphi consensus that involved 44 experts from 18 European countries. Eighty eight statements and recommendations were drafted based on a review of the literature. Consensus (≥80% agreement) was reached for 82. Quality of evidence was evaluated using validated criteria. Results The guideline incorporates new insights into the role of symptom assessment to diagnose carbohydrate (e.g., lactose) intolerances and recommends that breath tests for carbohydrate malabsorption require additional validated concurrent symptom evaluation to establish carbohydrate intolerance. Regarding the use of breath tests for the evaluation of oro‐cecal transit time and suspected small bowel bacterial overgrowth, this guideline highlights confounding factors associated with the interpretation of H2‐CH4‐breath tests in these indications and recommends approaches to mitigate these issues. Conclusion This clinical practice guideline should facilitate pan‐European harmonization of diagnostic approaches to symptoms and disorders, which are very common in specialist and primary care gastroenterology practice, both in adult and pediatric patients. In addition, it identifies areas of future research needs to clarify diagnostic and therapeutic approaches.
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Affiliation(s)
- Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria
| | - Mark R Fox
- Centre for Integrative Gastroenterology, Digestive Function: Basel, Laboratory and Clinic for Motility Disorders and Functional Gastrointestinal Diseases, Klinik Arlesheim, Arlesheim, Switzerland.,Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Jutta Keller
- Department of Internal Medicine, Israelitic Hospital, Academic Hospital of the University of Hamburg, Hamburg, Germany
| | - Silvia Salvatore
- Pediatric Department, Hospital "F. Del Ponte", University of Insubria, Varese, Italy
| | - Guido Basilisco
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Johann Hammer
- Department of Gastroenterology and Hepatology, University Hospital of Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Loris Lopetuso
- UOC Medicina Interna e Gastroenterologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italia.,Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Marc Benninga
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Osvaldo Borrelli
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK
| | - Dan Dumitrascu
- Department of Gastroenterology, Clinica Medicala 2, Cluj-Napoca, Romania
| | - Bruno Hauser
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, KidZ Health Castle UZ Brussel, Brussels, Belgium
| | - Laszlo Herszenyi
- Department of Gastroenterology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | - Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Yoanna University Hospital, Medical University of Sofia, Sofia, Bulgaria
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Nikhil Thapar
- UCL Great Ormond Street Institute of Child Health and Department of Gastroenterology, Neurogastroenterology and Motility, Great Ormond Street Hospital, London, UK.,Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Marc Sonyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University, Graz, Austria.,Clinic for General Medicine, Gastroenterology, and Infectious Diseases, Augustinerinnen Hospital, Cologne, Germany
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Böhn L, Törnblom H, Van Oudenhove L, Simrén M, Störsrud S. A randomized double-blind placebo-controlled crossover pilot study: Acute effects of the enzyme α-galactosidase on gastrointestinal symptoms in irritable bowel syndrome patients. Neurogastroenterol Motil 2021; 33:e14094. [PMID: 33619835 DOI: 10.1111/nmo.14094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postprandial symptoms presumably related to intestinal gas production are common in patients with irritable bowel syndrome (IBS). The aim of the study was to assess if oral α-galactosidase is superior to placebo in reducing gastrointestinal (GI) symptoms and intestinal gas production after ingestion of carbohydrate-rich meals in adult patients with IBS. METHODS We studied the effect of 1200 GaIU/meal α-galactosidase (Nogasin® ) or placebo capsules on GI symptoms in patients with IBS after three standardized, meals high in oligosaccharides, in a randomized, double-blind, crossover study. The intensity of eight GI symptoms was rated, and breath hydrogen and methane were measured every 30 min during 7.5 h. The severity of GI symptoms the following morning was assessed and compared with baseline. S KEY RESULTS Twenty adult patients with IBS (19 females), mean age 49 years (range 22-75 years), were included. All test meals were well tolerated but induced a gradual increase in GI symptom severity. Neither GI symptom ratings over time, nor hydrogen and methane concentrations differed between the days with α-galactosidase or placebo. The severity of abdominal pain and bloating was lower the following morning, but with no differences between α-galactosidase and placebo. CONCLUSIONS & INFERENCES The use of α-galactosidase together with meals high in oligosaccharides was in this pilot study not superior to placebo in reducing postprandial GI symptoms or the concentration of hydrogen and methane in expired air in IBS.
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Affiliation(s)
- Lena Böhn
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases, Metabolism, and Ageing (CHROMETA), University of Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stine Störsrud
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Schindler V, Huellner M, Murray F, Schnurre L, Becker AS, Bordier V, Pohl D. Nutrient Challenge Testing Is Not Equivalent to Scintigraphy-Lactulose Hydrogen Breath Testing in Diagnosing Small Intestinal Bacterial Overgrowth. J Neurogastroenterol Motil 2020; 26:514-520. [PMID: 32989187 PMCID: PMC7547189 DOI: 10.5056/jnm19162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 06/07/2020] [Accepted: 07/03/2020] [Indexed: 11/20/2022] Open
Abstract
Background/Aims Small intestinal bacterial overgrowth (SIBO) is a common condition in disorders of gut-brain interaction (DGBI). Recently, a combined scintigraphy–lactulose hydrogen breath test (ScLHBT) was described as an accurate tool diagnosing SIBO. We aim to analyze whether a lactulose nutrient challenge test (NCT), previously shown to separate DGBI from healthy volunteers, is equivalent to ScLHBT in diagnosing SIBO. Methods We studied data of 81 DGBI patients undergoing ScLHBT with 30 g lactulose and 300 mL water as well as NCT with 30 g lactulose and a 400 mL liquid test meal. Differences in proportion of positive SIBO diagnoses according to specified cecal load and time criteria for NCT and ScLHBT, respectively, were tested in an equivalence trial. An odds ratio (OR) range of 0.80-1.25 was considered equivalent. Results Diagnosis of SIBO during NCT was not equivalent to SIBO diagnosis in ScLHBT, considering a hydrogen increase before cecal load of 5.0%, 7.5%, or 10.0%, respectively ([OR, 3.76; 90% CI, 1.99-7.09], [OR, 1.87; 90% CI, 1.06-3.27], and [OR, 1.11; 90% CI, 0.65-1.89]). Considering only time to hydrogen increase as criterion, the odds of a positive SIBO diagnosis in the NCT (0.65) was lower than in ScLHBT (1.70) (OR, 0.38; 90% CI, 0.23-0.65). Conclusions This study could not show an equivalence of NCT and ScLHBT in diagnosing SIBO. A possible explanation might be the different transit times owing to unequal testing substances. The effect of this deviation in relation to consecutive therapy regimens should be tested in further prospective studies.
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Affiliation(s)
- Valeria Schindler
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Martin Huellner
- Department of Nuclear Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fritz Murray
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Larissa Schnurre
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Anton S Becker
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Valentine Bordier
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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10
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Milan AM, Shrestha A, Karlström HJ, Martinsson JA, Nilsson NJ, Perry JK, Day L, Barnett MPG, Cameron-Smith D. Comparison of the impact of bovine milk β-casein variants on digestive comfort in females self-reporting dairy intolerance: a randomized controlled trial. Am J Clin Nutr 2020; 111:149-160. [PMID: 31773165 DOI: 10.1093/ajcn/nqz279] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/16/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Lactose malabsorption (LM) is a major cause of digestive discomfort from dairy products. Recently, a role for bovine β-casein A1 has been proposed. OBJECTIVES We examined whether there are distinct symptoms of digestive discomfort due to either lactose or differing bovine β-casein types. METHODS Women (n = 40; age: 25.2 ± 0.5 y) with self-reported varying dairy tolerance underwent a 50-g lactose challenge. Based on postchallenge LM and digestive discomfort, participants were classified as either lactose intolerant (LI; n = 10, self-reported intolerant, diagnosed lactose intolerant), nonlactose dairy intolerant (NLDI; n = 20, self-reported intolerant, diagnosed lactose tolerant), or dairy tolerant (DT; n = 10, self-reported tolerant, diagnosed lactose tolerant). In a double-blinded randomized sequence, participants consumed 750 mL conventional milk (CON; containing A1 and A2 β-casein and lactose), a2 Milk (A2M; exclusively containing A2 β-casein with lactose), or lactose-free conventional milk (LF-CON; containing A1 and A2 β-casein without lactose). Subjective digestive symptoms and breath hydrogen (measuring LM) were recorded regularly over 3 h, and further ad hoc digestive symptoms over 12 h. RESULTS LI subjects experienced prolonged digestive discomfort with CON milk. A2M reduced (P < 0.05) some symptoms (nausea: A2M 8 ± 3 mm compared with CON 15 ± 3mm; fecal urgency: A2M 4 ± 1 compared with CON 10 ± 3 mm), and attenuated the rise in breath hydrogen over 3 h, relative to CON milk (A2M 59 ± 23 compared with CON 98 ± 25 ppm at 150 min; P < 0.01). In contrast, NLDI subjects experienced rapid-onset, transient symptoms (abdominal distension, bloating, and flatulence) without increased breath hydrogen, irrespective of milk type. CONCLUSIONS In LI individuals, LM and digestive comfort with lactose-containing milks was improved with milk containing exclusively A2 β-casein. Furthermore, self-reported dairy intolerance without LM (NLDI) is characterized by early-onset digestive discomfort following milk ingestion, irrespective of lactose content or β-casein type. This trial was registered at www.anzctr.org.au as ACTRN12616001694404.
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Affiliation(s)
- Amber M Milan
- The Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Aahana Shrestha
- The Liggins Institute, The University of Auckland, Auckland, New Zealand
| | | | | | | | - Jo K Perry
- The Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Li Day
- AgResearch Limited, Grasslands Research Centre, Palmerston North, New Zealand
| | - Matthew P G Barnett
- AgResearch Limited, Grasslands Research Centre, Palmerston North, New Zealand.,Riddet Institute, Palmerston North, New Zealand.,The High-Value Nutrition National Science Challenge, Auckland, New Zealand
| | - David Cameron-Smith
- The Liggins Institute, The University of Auckland, Auckland, New Zealand.,AgResearch Limited, Grasslands Research Centre, Palmerston North, New Zealand.,Riddet Institute, Palmerston North, New Zealand
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11
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Microbiota: a novel regulator of pain. J Neural Transm (Vienna) 2019; 127:445-465. [PMID: 31552496 DOI: 10.1007/s00702-019-02083-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
Among the various regulators of the nervous system, the gut microbiota has been recently described to have the potential to modulate neuronal cells activation. While bacteria-derived products can induce aversive responses and influence pain perception, recent work suggests that "abnormal" microbiota is associated with neurological diseases such as Alzheimer's, Parkinson's disease or autism spectrum disorder (ASD). Here we review how the gut microbiota modulates afferent sensory neurons function and pain, highlighting the role of the microbiota/gut/brain axis in the control of behaviors and neurological diseases. We outline the changes in gut microbiota, known as dysbiosis, and their influence on painful gastrointestinal disorders. Furthermore, both direct host/microbiota interaction that implicates activation of "pain-sensing" neurons by metabolites, or indirect communication via immune activation is discussed. Finally, treatment options targeting the gut microbiota, including pre- or probiotics, will be proposed. Further studies on microbiota/nervous system interaction should lead to the identification of novel microbial ligands and host receptor-targeted drugs, which could ultimately improve chronic pain management and well-being.
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12
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Chen HB, Su XY. Efficacy and safety of lactulose for the treatment of irritable bowel syndrome. Medicine (Baltimore) 2019; 98:e17295. [PMID: 31574851 PMCID: PMC6775399 DOI: 10.1097/md.0000000000017295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In this study, investigators will evaluate the efficacy and safety of lactulose for the treatment of irritable bowel syndrome (IBS). METHODS Literature search for relevant studies up to present will be conducted in MEDICINE, EMBASE, Google Scholar, Web of Science, Cochrane Library, Wangfang, Allied and Complementary Medicine Database, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure. The included studies are randomized controlled trials of lactulose in patients with IBS. We will use RevMan 5.3 software using statistical analysis. RESULTS This study will provide a high-quality integration of current evidence of lactulose for treating IBS on several aspects including global IBS symptoms, abdominal pain, defecation urgency, stool frequency, stool consistency, quality of life, and adverse events. CONCLUSIONS This study will provide the evidence for the clinical efficacy and safety of lactulose for the treatment of IBS. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019140639.
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Affiliation(s)
| | - Xiao-Ying Su
- Department of Nursing, Shaanxi Second People's Hospital, Xi’an, China
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13
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Midenfjord I, Polster A, Sjövall H, Törnblom H, Simrén M. Anxiety and depression in irritable bowel syndrome: Exploring the interaction with other symptoms and pathophysiology using multivariate analyses. Neurogastroenterol Motil 2019; 31:e13619. [PMID: 31056802 DOI: 10.1111/nmo.13619] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Anxiety or depression, in other words, psychological distress, are common comorbidities in patients with irritable bowel syndrome (IBS), but their interaction with pathophysiological factors and other symptoms are unclear. METHODS Patients with IBS (Rome III criteria), thoroughly characterized regarding pathophysiology (colonic transit time, visceral sensitivity, and autonomic nervous system [ANS] function), symptom profile (IBS severity, somatic symptoms, gastrointestinal [GI]-specific anxiety and fatigue), and quality of life, were explored for differences regarding pathophysiology and symptoms between patients with and without reported psychological distress in univariate and multivariate analyses (Principal Component Analysis [PCA] with Hotelling's T2 and Orthogonal Partial Least Squares-Discriminant Analysis [OPLS-DA]). KEY RESULTS When using Hospital Anxiety and Depression Scale score ≥8 as cut-off score, including both borderline and clinically significant cases, 345 (44.9%) out of 769 IBS patients reported anxiety, and 198 (25.7%) depression. In univariate analyses, patients reporting psychological distress demonstrated more severe GI and non-GI symptoms, fatigue, GI-specific anxiety and lower quality of life, and differences for some pathophysiological measures. IBS patients with and without reported psychological distress showed significant differences between the multivariate means in symptom reporting (PCA; both P < 0.001), and in pathophysiological measures in patients with and without anxiety (P = 0.018). Visceral hypersensitivity, altered ANS function, more severe GI-specific anxiety, fatigue, and higher somatic non-GI symptoms were the factors that most strongly separated patients with and without psychological distress (OPLS-DA). CONCLUSIONS AND INFERENCES Reported anxiety and depression are common in IBS patients, and our study demonstrates that they are interwoven in the complex pathophysiological and clinical picture of IBS.
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Affiliation(s)
- Irina Midenfjord
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Annikka Polster
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Henrik Sjövall
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
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14
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Schindler V, Giezendanner S, Bütikofer S, Murray F, Runggaldier D, Schnurre L, Zweig A, Fried M, Pohl D. Differentiation of functional gastrointestinal disorders from healthy volunteers by lactulose hydrogen breath test and test meal. J Gastroenterol Hepatol 2019; 34:843-851. [PMID: 30562837 DOI: 10.1111/jgh.14551] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 10/30/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Functional dyspepsia (FD) is a common disorder of gut-brain interaction with incompletely understood pathophysiology. Consequently, heterogeneous expert opinions on diagnostic tests and assessment of treatment efficacies exist. So far, no consensus about the most relevant diagnostic and outcome tool has been reached. In this study, we aimed to analyze the significance of a combined lactulose hydrogen breath test (LHBT) and liquid meal, yet representing a standardized test in irritable bowel syndrome (IBS), in FD. METHODS We analyzed data of 146 FD, 204 IBS patients, and 50 healthy volunteers (HV). All patients underwent LHBT with a meal-drink consisting of 30-g Lactulose and 400-mL Ensure®. Effect of abdominal symptom generation in FD/IBS compared with HV was assessed on a patient-reported Likert-scale. RESULTS There was a significant difference between FD/IBS patients and HV in LHBT-induced abdominal pain (odds ratio [OR] 246.9, 95% confidence interval [CI] 26.6-2290.7; OR 161.2, 95% CI 16.9-1534.8), abdominal bloating (OR 384.8, 95% CI 92.9-2135.4; OR 524.1, 95% CI 114.7-3432.3), borborygmi (OR 9.9, 95% CI 2.2-46.9; OR 17.7, 95% CI 4.7-67.4), nausea only in FD (OR 174.4, 95% CI 15.5-5375.5), and diarrhea in IBS only (OR 25.8, 95% CI 2.0-7012.6). Hydrogen production was not significantly different in FD/IBS and HV. CONCLUSIONS In this study, we demonstrated significant differences in postprandial symptom generation in FD and IBS compared with HV after LHBT. This does not only allow us to discriminate FD/IBS from HV but may also represent a diagnostic and monitoring tool for FD/IBS in the future, including monitoring of treatment effects.
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Affiliation(s)
- Valeria Schindler
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | | | - Simon Bütikofer
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Fritz Murray
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Daniel Runggaldier
- Department of Otorhinolaryngology, University Hospital Zürich, Zürich, Switzerland
| | - Larissa Schnurre
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Annina Zweig
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Michael Fried
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
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15
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Le Nevé B, Derrien M, Tap J, Brazeilles R, Cools Portier S, Guyonnet D, Ohman L, Störsrud S, Törnblom H, Simrén M. Fasting breath H2 and gut microbiota metabolic potential are associated with the response to a fermented milk product in irritable bowel syndrome. PLoS One 2019; 14:e0214273. [PMID: 30946757 PMCID: PMC6448848 DOI: 10.1371/journal.pone.0214273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/25/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Aim of this study was to assess the effect of a fermented milk product containing Bifidobacterium lactis CNCM I-2494 (FMP) on gastrointestinal (GI) symptoms and exhaled H2 and CH4 during a nutrient and lactulose challenge in patients with irritable bowel syndrome (IBS). METHODS We included 125 patients with IBS (Rome III). Fasted subjects were served a 400ml liquid test meal containing 25g lactulose. The intensity of eight GI symptoms and the amount of exhaled H2 and CH4 were assessed before and during 4h after meal intake. The challenge was repeated after 14 days consumption of FMP or a control product in a double-blind, randomized, parallel design. The metabolic potential of fecal microbiota was profiled using 16S MiSeq analysis of samples obtained before and after the intervention. RESULTS 106 patients with IBS were randomized. No difference between FMP or control groups was found on GI symptoms or breath H2 and CH4 in the whole cohort. A post-hoc analysis in patients stratified according to their fasting H2 levels showed that in high H2 producers (fasting H2 level≥10ppm, n = 35), FMP consumption reduced fasting H2 levels (p = 0.003) and H2 production during the challenge (p = 0.002) and tended to decrease GI discomfort (p = 0.05) vs. control product. The Prevotella/Bacteroides metabolic potential at baseline was higher in high H2 producers (p<0.05) vs. low H2 producers and FMP consumption reduced this ratio (p<0.05) vs. control product. CONCLUSIONS The response to a fermented milk product containing Bifidobacterium lactis CNCM I-2494 (FMP) in patients with IBS seems to be associated with the metabolic potential of the gut microbiota. TRIAL REGISTRATION ClinicalTrial.gov NCT01252550. These results were presented as congress posters at Digestive Disease Week 2016 in San Diego, USA and United European Gastroenterology Week 2016 in Vienna, Austria.
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Affiliation(s)
| | | | - Julien Tap
- Danone Nutricia Research, Palaiseau, France
| | | | | | | | - Lena Ohman
- Department of Immunology and Microbiology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stine Störsrud
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, United States of America
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16
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Labus JS, Osadchiy V, Hsiao EY, Tap J, Derrien M, Gupta A, Tillisch K, Le Nevé B, Grinsvall C, Ljungberg M, Öhman L, Törnblom H, Simren M, Mayer EA. Evidence for an association of gut microbial Clostridia with brain functional connectivity and gastrointestinal sensorimotor function in patients with irritable bowel syndrome, based on tripartite network analysis. MICROBIOME 2019; 7:45. [PMID: 30898151 PMCID: PMC6429755 DOI: 10.1186/s40168-019-0656-z] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/07/2019] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND AIMS Evidence from preclinical and clinical studies suggests that interactions among the brain, gut, and microbiota may affect the pathophysiology of irritable bowel syndrome (IBS). As disruptions in central and peripheral serotonergic signaling pathways have been found in patients with IBS, we explored the hypothesis that the abundance of serotonin-modulating microbes of the order Clostridiales is associated with functional connectivity of somatosensory brain regions and gastrointestinal (GI) sensorimotor function. METHODS We performed a prospective study of 65 patients with IBS and 21 healthy individuals (controls) recruited from 2011 through 2013 at a secondary/tertiary care outpatient clinic in Sweden. Study participants underwent functional brain imaging, rectal balloon distension, a nutrient and lactulose challenge test, and assessment of oroanal transit time within a month. They also submitted stool samples, which were analyzed by 16S ribosomal RNA gene sequencing. A tripartite network analysis based on graph theory was used to investigate the interactions among bacteria in the order Clostridiales, connectivity of brain regions in the somatosensory network, and GI sensorimotor function. RESULTS We found associations between GI sensorimotor function and gut microbes in stool samples from controls, but not in samples from IBS patients. The largest differences between controls and patients with IBS were observed in the Lachnospiraceae incertae sedis, Clostridium XIVa, and Coprococcus subnetworks. We found connectivity of subcortical (thalamus, caudate, and putamen) and cortical (primary and secondary somatosensory cortices) regions to be involved in mediating interactions among these networks. CONCLUSIONS In a comparison of patients with IBS and controls, we observed disruptions in the interactions between the brain, gut, and gut microbial metabolites in patients with IBS-these involve mainly subcortical but also cortical regions of brain. These disruptions may contribute to altered perception of pain in patients with IBS and may be mediated by microbial modulation of the gut serotonergic system.
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Affiliation(s)
- Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA
| | - Vadim Osadchiy
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA
| | - Elaine Y Hsiao
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA
- UCLA Department of Integrative Biology and Physiology, Los Angeles, USA
| | - Julien Tap
- Danone Nutricia Research, Innovation, Science and Nutrition, Palaiseau, France
| | - Muriel Derrien
- Danone Nutricia Research, Innovation, Science and Nutrition, Palaiseau, France
| | - Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA
| | - Kirsten Tillisch
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA
| | - Boris Le Nevé
- Danone Nutricia Research, Innovation, Science and Nutrition, Palaiseau, France
| | - Cecilia Grinsvall
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Ljungberg
- Department of Radiation Physics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lena Öhman
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Immunology and Microbiology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simren
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress & Resilience, UCLA Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA CHS 42-210, MC737818, 10833 Le Conte Avenue, Los Angeles, CA, 90095-7378, USA.
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17
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Pohl D, Van Oudenhove L, Törnblom H, Le Nevé B, Tack J, Simrén M. Functional Dyspepsia and Severity of Psychologic Symptoms Associate With Postprandial Symptoms in Patients With Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2018; 16:1745-1753.e1. [PMID: 29702295 DOI: 10.1016/j.cgh.2018.04.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 03/18/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with irritable bowel syndrome (IBS) have an increased response of postprandial symptoms to a combined lactulose nutrient challenge test, compared with healthy volunteers. We investigated the associations among comorbid functional dyspepsia (FD), severity of psychologic symptoms, and breath test results in response to this test. METHODS We performed a prospective study of 205 patients with IBS (Rome III criteria), 94 of whom also had FD (IBS-FD), and 83 healthy volunteers in Sweden from 2008 through 2015. All participants completed a breath hydrogen test after a 400-mL liquid meal with 25 g lactulose. Gastrointestinal (GI) symptom severity was assessed using a graded scale and digestive comfort was recorded before the meal and every 15 minutes until 240 minutes after the meal. GI symptom scores over time were compared between groups using linear mixed models with anxiety, depression, and somatization as covariates. RESULTS Average levels of all GI symptoms varied over time among all groups (P < .0001). Patients with IBS-FD had higher levels of bloating (P = .004), abdominal pain (P = .005), and lower levels of digestive comfort (P < .01) than patients with only IBS. We observed a difference in increase in abdominal pain from baseline between IBS-FD and IBS groups (P = .013). Anxiety levels were associated with levels of all symptoms (all P < .025) except abdominal pain, which was associated with somatization severity (P < .0001). Furthermore, anxiety levels associated with level of exhaled hydrogen (P = .0042). CONCLUSIONS In a prospective study of patients with IBS, we found those with FD to have increased GI symptoms before and after a liquid meal with lactulose. Anxiety and somatization have an independent additional effect. The presence of comorbid FD and levels of psychologic symptoms affect reports of food-related symptoms in patients with IBS. ClinicalTrial.gov no: NCT01252550.
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Affiliation(s)
- Daniel Pohl
- Functional Diagnostics Laboratory, Division of Gastroenterology, University Hospital Zurich, Zurich, Switzerland.
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Belgium
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Sweden
| | | | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, University of Leuven, Belgium
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Sweden; Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
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18
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Simrén M, Tack J. New treatments and therapeutic targets for IBS and other functional bowel disorders. Nat Rev Gastroenterol Hepatol 2018; 15:589-605. [PMID: 29930260 DOI: 10.1038/s41575-018-0034-5] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Functional bowel disorders (FBDs) are a spectrum of disorders characterized by combinations of symptoms attributable to the lower gastrointestinal tract. Most current first-line therapies for IBS and other FBDs target the predominant symptom and mainly affect one symptom in the symptom complex. Additional broadly effective treatment alternatives targeting the entire symptom complex are needed. New drugs for FBDs (such as lubiprostone, linaclotide, plecanatide, prucalopride, eluxadoline and rifaximin) target key mechanisms in the pathophysiology of these disorders and improve both the abnormal bowel habit and other key symptoms, such as abdominal pain and bloating. The current development of new treatment alternatives is focusing on different aspects of the complex pathophysiology of IBS and other FBDs: gut microenvironment (via diet and modulation of gut microbiota), enterohepatic circulation of bile acids, gastrointestinal secretion, motility and sensation, gut-brain interactions, gut barrier function and the immune system within the gastrointestinal tract. Studies also suggest that personalized treatment of IBS and other FBDs is possible using various diagnostic markers.
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Affiliation(s)
- Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA.
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
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Depression but Not Symptom Severity is Associated With Work and School Absenteeism in Refractory Chronic Constipation. J Clin Gastroenterol 2018; 52:407-412. [PMID: 28059936 DOI: 10.1097/mcg.0000000000000782] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
GOALS We sought to determine the patient characteristics associated with increased absenteeism and Emergency Department (ED) utilization among patients with constipation. BACKGROUND Chronic constipation is associated with significant direct and indirect economic costs. There has been limited study of the predictors of direct and indirect costs in a population with refractory constipation. STUDY We conducted a cross-sectional cohort study of patients with chronic constipation who presented to a tertiary care center for anorectal manometry. We used standardized instruments to assess disease severity, quality of life, somatization, and psychiatric comorbidities. We used multivariable logistic regression to determine the predictors of work and school absenteeism as well as ED visits for constipation. RESULTS There were 148 consecutive patients enrolled (87% female, mean age 43) of whom 32 (21.6%) had high absenteeism and 36 (24.3%) visited the ED for constipation in the past year. Patients with high absenteeism and ED visits were more likely to be depressed (56.3% vs. 18.5%, P<0.0001 for high absenteeism; 47.2% vs. 19.6%, P<0.01 for ED visits). After multivariable adjustment and sensitivity analyses, only depression (OR, 4.41; P<0.01) was associated with increased absenteeism while there was a trend toward an association between depression and ED visits (OR, 2.57; P=0.067). Symptom severity was not associated with high absenteeism or ED utilization. CONCLUSIONS Among patients with chronic constipation, depression is a stronger predictor of absenteeism than symptom severity. Depression may drive a portion of the indirect costs of chronic constipation.
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Major G, Pritchard S, Murray K, Alappadan JP, Hoad CL, Marciani L, Gowland P, Spiller R. Colon Hypersensitivity to Distension, Rather Than Excessive Gas Production, Produces Carbohydrate-Related Symptoms in Individuals With Irritable Bowel Syndrome. Gastroenterology 2017; 152:124-133.e2. [PMID: 27746233 DOI: 10.1053/j.gastro.2016.09.062] [Citation(s) in RCA: 197] [Impact Index Per Article: 28.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 09/14/2016] [Accepted: 09/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Poorly digested, fermentable carbohydrates may induce symptoms of irritable bowel syndrome (IBS) via unclear mechanisms. We performed a randomized trial with magnetic resonance imaging (MRI) analysis to investigate correlations between symptoms and changes in small- and large-bowel contents after oral challenge. METHODS We performed a 3-period, cross-over study of 29 adult patients with IBS (based on Rome III criteria, with symptoms of abdominal pain or discomfort for at least 2 days/wk) and reported bloating. In parallel, we performed the same study of 29 healthy individuals (controls). Studies were performed in the United Kingdom from January 2013 through February 2015. On 3 separate occasions (at least 7 days apart), subjects were given a 500-mL drink containing 40 g of carbohydrate (glucose in the first period, fructose in the second, and inulin in the third, in a random order). Levels of breath hydrogen were measured and intestinal content was assessed by MRI before and at various time points after consumption of each drink. Symptoms were determined based on subjects' responses to the Hospital Anxiety and Depression Scale questionnaire and the Patient Health Questionnaire-15. The primary end point was whether participants had a clinically important symptom response during the 300 minutes after consumption of the drink. RESULTS More patients with IBS reached the predefined symptom threshold after intake of inulin (13 of 29) or fructose (11 of 29) than glucose (6 of 29). Symptoms peaked sooner after intake of fructose than inulin. Fructose increased small-bowel water content in both patients and controls whereas inulin increased colonic volume and gas in both. Fructose and inulin increased breath hydrogen levels in both groups, compared with glucose; fructose produced an earlier increase than inulin. Controls had lower symptom scores during the period after drink consumption than patients with IBS, despite similar MRI parameters and breath hydrogen responses. In patients who reached the symptom threshold after inulin intake, peak symptom intensity correlated with peak colonic gas (r = 0.57; P < .05). Changes in MRI features and peak breath hydrogen levels were similar in patients who did and did not reach the symptom threshold. CONCLUSIONS Patients with IBS and healthy individuals without IBS (controls) have similar physiological responses after intake of fructose or inulin; patients reported symptoms more frequently after inulin than controls. In patients with a response to inulin, symptoms related to levels of intraluminal gas, but peak gas levels did not differ significantly between responders, nonresponders, or controls. This indicates that colonic hypersensitivity to distension, rather than excessive gas production, produces carbohydrate-related symptoms in patients with IBS. Clinicaltrials.gov no: NCT01776853.
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Affiliation(s)
- Giles Major
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom
| | - Sue Pritchard
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Kathryn Murray
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Jan Paul Alappadan
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Caroline L Hoad
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Luca Marciani
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom
| | - Penny Gowland
- Sir Peter Mansfield Imaging Centre, University of Nottingham, Nottingham, United Kingdom
| | - Robin Spiller
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, United Kingdom.
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Zweig A, Pohl D. [Not Available]. PRAXIS 2017; 106:1229-1235. [PMID: 29088970 DOI: 10.1024/1661-8157/a002856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Funktionelle Magen-Darm-Beschwerden sind in der Allgemeinbevölkerung weit verbreitet, und das Reizdarmsyndrom (Irritable Bowel Syndrome, IBS) ist eines der häufigsten gastroenterologischen Krankheitsbilder. Trotz individuell sehr unterschiedlicher klinischer Präsentation berichtet ein Grossteil der Patienten über eine Abhängigkeit ihrer Beschwerden von der Nahrungsaufnahme bzw. von bestimmten Nahrungsmitteln. Die FODMAP-arme Diät, durch eine spezialisierte Ernährungsberatung instruiert, zeigt sich sehr wirksam zur Symptomreduktion bei IBS-Patienten. Sie basiert auf einer Reduktion fermentierbarer Kohlenhydrate. Ziel der Diät ist es, potenzielle nutritive Auslöser abdominaler Symptome zu identifizieren und diese in der täglichen Ernährung zu meiden.
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Affiliation(s)
- Annina Zweig
- 1 Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich
| | - Daniel Pohl
- 1 Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich
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Undseth R, Berstad A, Valeur J. Systemic symptoms in irritable bowel syndrome: An investigative study on the role of enterocyte disintegrity, endotoxemia and inflammation. Mol Med Rep 2016; 14:5072-5076. [PMID: 27779674 PMCID: PMC5355706 DOI: 10.3892/mmr.2016.5878] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 08/30/2016] [Indexed: 12/13/2022] Open
Abstract
Irritable bowel syndrome (IBS) is often accompanied by extra-intestinal symptoms, including fatigue and musculoskeletal pain. The present study aimed to investigate whether these symptoms were associated with markers of enterocyte disintegrity, endotoxemia and inflammation. Patients with IBS were recruited consecutively from our outpatient clinic (n=94) and compared with a group of healthy controls (n=20). Habitual symptoms were assessed using the IBS Severity Scoring System, the Fatigue Impact Scale and Visual Analogue Scales for measuring musculoskeletal pain. A lactulose challenge test was performed to induce post-prandial symptoms, and blood samples were obtained prior to and 90 min following lactulose ingestion to determine levels of intestinal fatty acid binding protein (iFABP), lipopolysaccharide (LPS), the LPS co-receptor soluble cluster of differentiation (sCD) 14, monocyte chemoattractant protein-1 (MCP-1) and calprotectin. Habitual symptom scores were high among the included patients, and lactulose ingestion induced significantly more symptoms in the patient group compared with the healthy control group (P=0.0001). Serum levels of iFABP were reduced in IBS patients compared with healthy controls, prior to and following lactulose ingestion (P=0.0002 and P=0.0001, respectively). Following lactulose ingestion, iFABP levels decreased in IBS patients (P=0.0001) and in healthy controls (P=0.02). Fasting levels of LPS, sCD14, MCP-1 and calprotectin were not significantly different between IBS patients and healthy controls. However, following lactulose ingestion, LPS levels increased in healthy controls (P=0.03), whereas MCP-1 levels decreased in IBS patients (P=0.008). Intestinal and extra-intestinal symptom severities were not correlated with levels of circulating biomarkers. No assessed biomarker in the present study appeared to be associated with symptom development in IBS patients. However, the implications of the low levels of iFABP observed require further investigation.
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Affiliation(s)
- Ragnhild Undseth
- Department of Radiology, Lovisenberg Diaconal Hospital, NO‑0440 Oslo, Norway
| | - Arnold Berstad
- Unger‑Vetlesen Institute, Lovisenberg Diaconal Hospital, NO‑0440 Oslo, Norway
| | - Jørgen Valeur
- Unger‑Vetlesen Institute, Lovisenberg Diaconal Hospital, NO‑0440 Oslo, Norway
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Abstract
The acute phase of IBD with inflamed gut and often ulcerated mucosa is clearly different from the apparently normal mucosa characteristic of IBS. However, more detailed assessment has detected immune activation, increased gut permeability, increased mucosal serotonin availability, abnormalities of enteric nerve structure and function, and dysbiosis in gut microbiota in IBS - all features seen in IBD. Furthermore, as treatments for inflammation in IBD have become more effective it is now apparent that ∼1 in 3 patients with IBD in remission from inflammation still have persistent abnormalities of sensation, motility and gut microbiota, which might cause IBS-like symptoms. This Perspective explores the overlap between IBS and IBD and their treatments, proposing future directions for research in this stimulating area.
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Affiliation(s)
- Robin Spiller
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and The University of Nottingham, Queens Medical Centre, E Floor West Block, Nottingham NG7 2UH, UK
| | - Giles Major
- NIHR Biomedical Research Unit in Gastrointestinal and Liver Diseases at Nottingham University Hospitals NHS Trust and The University of Nottingham, Queens Medical Centre, E Floor West Block, Nottingham NG7 2UH, UK
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Van Oudenhove L, Törnblom H, Störsrud S, Tack J, Simrén M. Depression and Somatization Are Associated With Increased Postprandial Symptoms in Patients With Irritable Bowel Syndrome. Gastroenterology 2016; 150:866-74. [PMID: 26602216 DOI: 10.1053/j.gastro.2015.11.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Revised: 11/05/2015] [Accepted: 11/11/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Patients with irritable bowel syndrome (IBS) have increased postprandial symptom responses and more psychosocial morbidities than healthy individuals. However, the relationship between psychosocial status and postprandial symptom responses in patients with IBS is unclear. We investigated this relationship in a prospective study of patients with IBS. METHODS A total of 193 IBS patients, diagnosed according to Rome II (n = 126) or Rome III (n = 67) criteria, consumed a standard breakfast (540 kcal: 36% fat, 15% proteins, 49% carbohydrates, and 8.9 g fiber). They completed visual analogue scales assessing the severity of 5 gastrointestinal symptoms (abdominal pain, bloating, nausea, gas, and fullness) before breakfast and every 30 minutes, up to 240 minutes after eating. All patients completed validated self-report questionnaires for their current levels of anxiety and depression; patients diagnosed based on Rome II criteria also completed a somatization questionnaire. The relationship between these variables and the course of gastrointestinal symptom scores over time was analyzed using linear mixed models, controlling for comorbid functional dyspepsia. RESULTS We observed a main effect of anxiety levels on fullness and bloating (P < .04), and of depression levels on abdominal pain (P = .007), reflecting a general upward shift of the entire symptom curve. Depression-by-time interactions were seen for nausea and gas (P < .03). Somatization levels had a main effect on all 5 symptoms (P < .0001), independent of anxiety and depression. We observed somatization-by-time interaction effects for bloating (P = .005), and nausea (P = .02), and a nonsignificant trend was found for pain (P = .054), reflecting a steeper early postprandial increase in symptoms among subjects with higher levels of somatization. CONCLUSIONS Based on a prospective study of patients with IBS, psychosocial morbidities are associated with increased levels of gastrointestinal symptoms in general. Depression and somatization levels are associated specifically with increased postprandial symptoms.
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Affiliation(s)
- Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium; Consultation-Liaison Psychiatry, University Psychiatric Centre KU Leuven, University Hospitals Leuven, Leuven, Belgium
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; University of Gothenburg Centre for Person-Centered Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stine Störsrud
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden; University of Gothenburg Centre for Person-Centered Care, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Le Nevé B, Brazeilles R, Derrien M, Tap J, Guyonnet D, Ohman L, Törnblom H, Simrén M. Lactulose Challenge Determines Visceral Sensitivity and Severity of Symptoms in Patients With Irritable Bowel Syndrome. Clin Gastroenterol Hepatol 2016; 14:226-33.e1-3. [PMID: 26492847 DOI: 10.1016/j.cgh.2015.09.039] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 09/23/2015] [Accepted: 09/29/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with irritable bowel syndrome (IBS) can be assigned to groups with different gastrointestinal (GI) symptoms based on results from a combined nutrient and lactulose challenge. We aimed to identify factors that predict outcomes to this challenge and to determine whether this can be used in noninvasive assessment of visceral sensitivity in patients with IBS. METHODS We performed a prospective study of 100 patients with IBS diagnosed according to Rome III criteria (all subtypes) and seen at a secondary or tertiary care center. After an overnight fast, subjects were given a liquid breakfast (400 mL; Nutridrink) that contained 25 g lactulose. Before the challenge, we assessed visceral sensitivity (via rectal barostat), oro-anal transit time, and fecal microbiota composition (via 16S ribosomal RNA pyrosequencing); we determined IBS severity using questionnaires. The intensity of 8 GI symptoms, the level of digestive comfort, and the amount of exhaled H2 and CH4 in breath were measured before and during a 4-hour period after the liquid breakfast. RESULTS Based on the intensity of 8 GI symptoms and level of digestive comfort during the challenge, patients were assigned to groups with high-intensity GI symptoms (HGS; n = 39) or low-intensity GI symptoms (LGS; n = 61); patients with HGS had more severe IBS (P < .0001), higher somatization (P < .01), and lower quality of life (P < .05-.01) than patients with LGS. Patients with HGS also had significantly higher rectal sensitivity to random phasic distensions (P < .05-.001, compared with patients with LGS). There were no significant differences between groups in fecal microbiota composition, exhaled gas in breath, or oro-anal transit time. CONCLUSIONS We found, in a prospective study, that results from a lactulose challenge test could be used to determine visceral sensitivity and severity of IBS. The intensity of patient symptoms did not correlate with the composition of the fecal microbiota. The lactulose challenge test may help better characterize patients with IBS and evaluate the efficacy of new treatments. ClinicalTrial.gov no: NCT01252550.
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Affiliation(s)
- Boris Le Nevé
- Danone Nutricia Research, Life Sciences Department, Palaiseau, France.
| | - Rémi Brazeilles
- Danone Nutricia Research, Life Sciences Department, Palaiseau, France
| | - Muriel Derrien
- Danone Nutricia Research, Life Sciences Department, Palaiseau, France
| | - Julien Tap
- Danone Nutricia Research, Life Sciences Department, Palaiseau, France; INRA (Institut National de la Recherche Agronomique) MetaGenoPolis, Jouy en Josas, France
| | - Denis Guyonnet
- Danone Nutricia Research, Life Sciences Department, Palaiseau, France
| | - Lena Ohman
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Affiliation(s)
- Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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Camilleri M, Shin A, Busciglio I, Carlson P, Acosta A, Bharucha AE, Burton D, Lamsam J, Lueke A, Donato LJ, Zinsmeister AR. Validating biomarkers of treatable mechanisms in irritable bowel syndrome. Neurogastroenterol Motil 2014; 26:1677-85. [PMID: 25244349 PMCID: PMC4245393 DOI: 10.1111/nmo.12421] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 08/06/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND A valid biomarker is 'an indicator of normal biologic or pathogenic processes, or pharmacological responses to a therapeutic intervention'. There is no validated biomarker for irritable bowel syndrome (IBS). The aim of the study was to assess ability of three quantitative traits to identify treatable processes to discriminate between IBS-diarrhea (IBS-D) patients, IBS-constipation (IBS-C) patients and healthy volunteers (HV). METHODS In 30 HV, 30 IBS-C patients and 64 IBS-D patients, we characterized bowel symptoms and quantitated pathophysiological mechanisms: bile acid (BA) synthesis (serum C4 and FGF19), fecal BA and fat, colonic transit (CT), and intestinal permeability (IP). We used multiple logistic regression and receiver-operating characteristic (ROCAUC ) to appraise three factors (fecal BA, CT, and IP) individually and in combination to identify discriminant targets for treatment in IBS. KEY RESULTS There were significant associations between the three subgroups and symptoms reflecting bowel function and the quantitative traits. There were significant associations between fecal BA and CT at 48 h (r = 0.43; p < 0.001) and between fecal BA and IP (r = 0.23; p = 0.015). Individually, fecal BA and CT48 (but not IP) were significant independent predictors for distinguishing HV from IBS. In combination, they discriminated HV from IBS-D patients (ROCAUC 0.70), HV from IBS-C patients (ROCAUC 0.73), and IBS-C patients from IBS-D patients (ROCAUC 0.86). Colonic transit and fecal BA excretion together discriminate between healthy volunteers and IBS-C patients or IBS-D patients, or between the IBS subgroups with 75-90% specificity at 60% sensitivity. CONCLUSIONS & INFERENCES Colonic transit and fecal BA individually and together constitute useful biomarkers to identify treatable mechanisms in IBS and to differentiate subgroups of IBS.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Alan Lueke
- Department of Laboratory Medicine and Pathology, Mayo Clinic College
of Medicine, Rochester, Minnesota
| | - Leslie J. Donato
- Department of Laboratory Medicine and Pathology, Mayo Clinic College
of Medicine, Rochester, Minnesota
| | - Alan R. Zinsmeister
- Division of Biomedical Statistics and Informatics, Department of Health
Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota
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Undseth R, Berstad A, Kløw NE, Arnljot K, Moi KS, Valeur J. Abnormal accumulation of intestinal fluid following ingestion of an unabsorbable carbohydrate in patients with irritable bowel syndrome: an MRI study. Neurogastroenterol Motil 2014; 26:1686-93. [PMID: 25271767 DOI: 10.1111/nmo.12449] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 09/09/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postprandial discomfort following intake of poorly absorbable, but fermentable carbohydrates is a common complaint in patients with irritable bowel syndrome (IBS). We used lactulose as a model substance for this group of symptom triggering carbohydrates, aiming to visualize the intestinal response in IBS patients compared to healthy controls. METHODS Patients with IBS according to Rome III criteria (n = 52) and healthy controls (n = 16) underwent a lactulose challenge test. By using magnetic resonance imaging, we measured small bowel water content (SBWC), and distension (diameter) of the distal ileum and the colon, both in fasting state and 1 h after ingestion of 10 g lactulose. We recorded symptoms after lactulose ingestion. KEY RESULTS Lactulose provoked significantly more symptoms in IBS patients than in healthy controls (p < 0.0001). SBWC increased more in the patient group compared to the control group (p = 0.0005). The postprandial diameter of the terminal ileum was larger in patients with IBS and the postprandial diameter of the ascending colon was smaller in patients with diarrhea-predominant phenotype (IBS-D). Symptoms were not correlated with change in SBWC (r = 0.05; p = 0.11), nor to the diameters of the terminal ileum or the colon. CONCLUSIONS & INFERENCES Compared to healthy controls, IBS patients developed more symptoms and had an abnormal accumulation of fluid in the small bowel in response to ingestion of the unabsorbable carbohydrate lactulose. This may be due to impaired motor activity of the small intestine or impaired function of the ileocecal segment.
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Affiliation(s)
- R Undseth
- Department of Radiology, Lovisenberg Diakonale Hospital, Oslo, Norway
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Tuck CJ, Muir JG, Barrett JS, Gibson PR. Fermentable oligosaccharides, disaccharides, monosaccharides and polyols: role in irritable bowel syndrome. Expert Rev Gastroenterol Hepatol 2014; 8:819-34. [PMID: 24830318 DOI: 10.1586/17474124.2014.917956] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Irritable bowel syndrome (IBS) was previously left poorly treated despite its high prevalence and cost. Over the past decade, significant research has been conducted providing new dietary strategies for IBS management. The 'low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet' has shown symptom improvement in 68-76% of patients. Randomized, controlled trials have now proven its efficacy. The diet, low in poorly absorbed and fermentable carbohydrates, uses dietary restriction and re-challenge to determine individual tolerance to various short-chain carbohydrates. However there may be potential detrimental effects of the diet in the long term, due to potential changes to the gastrointestinal microbiota. Appropriate dietary education and management of the diet is imperative. Future research should focus on the relevance of changes to the microbiota and ways to liberalize the dietary restrictions.
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Affiliation(s)
- Caroline J Tuck
- Department of Gastroenterology, Monash University and Alfred Health, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, 3004 Australia
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Abstract
Breath tests are non-invasive tests and can detect H2 and CH4 gases which are produced by bacterial fermentation of unabsorbed intestinal carbohydrate and are excreted in the breath. These tests are used in the diagnosis of carbohydrate malabsorption, small intestinal bacterial overgrowth, and for measuring the orocecal transit time. Malabsorption of carbohydrates is a key trigger of irritable bowel syndrome (IBS)-type symptoms such as diarrhea and/or constipation, bloating, excess flatulence, headaches and lack of energy. Abdominal bloating is a common nonspecific symptom which can negatively impact quality of life. It may reflect dietary imbalance, such as excess fiber intake, or may be a manifestation of IBS. However, bloating may also represent small intestinal bacterial overgrowth. Patients with persistent symptoms of abdominal bloating and distension despite dietary interventions should be referred for H2 breath testing to determine the presence or absence of bacterial overgrowth. If bacterial overgrowth is identified, patients are typically treated with antibiotics. Evaluation of IBS generally includes testing of other disorders that cause similar symptoms. Carbohydrate malabsorption (lactose, fructose, sorbitol) can cause abdominal fullness, bloating, nausea, abdominal pain, flatulence, and diarrhea, which are similar to the symptoms of IBS. However, it is unclear if these digestive disorders contribute to or cause the symptoms of IBS. Research studies show that a proper diagnosis and effective dietary intervention significantly reduces the severity and frequency of gastrointestinal symptoms in IBS. Thus, diagnosis of malabsorption of these carbohydrates in IBS using a breath test is very important to guide the clinician in the proper treatment of IBS patients.
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Zhao J, Zheng X, Chu H, Zhao J, Cong Y, Fried M, Fox M, Dai N. A study of the methodological and clinical validity of the combined lactulose hydrogen breath test with scintigraphic oro-cecal transit test for diagnosing small intestinal bacterial overgrowth in IBS patients. Neurogastroenterol Motil 2014; 26:794-802. [PMID: 24641100 DOI: 10.1111/nmo.12331] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Accepted: 02/21/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Small intestinal bacterial overgrowth (SIBO) may be a cause of irritable bowel syndrome (IBS); however, current investigations have important limitations. We aimed to identify clinically relevant diagnostic criteria for SIBO based on lactulose hydrogen breath test (LHBT) alone and combined with scintigraphic measurement of oro-cecal transit (SOCT). METHODS Results of LHBT/SOCT investigation from 89 IBS patients and 13 healthy volunteers were included in a systematic analysis of six published criteria for SIBO diagnosis. Clinical relevance of competing criteria was determined by assessing (i) prevalence of SIBO in IBS patients and healthy volunteers (ii) if SIBO diagnosis predicted improvement in IBS symptoms in a prospective, pilot therapeutic trial of a non-absorbable antibiotic (rifaximin 600 mg b.d.) in IBS patients. KEY RESULTS Reproducibility of SIBO diagnosis by combined LHBT/SOCT was near perfect. A ≥5 ppm H2 increase prior to appearance of cecal contrast was detected in more IBS patients than healthy volunteers (35/89 vs 1/13; p = 0.026), but not for other diagnostic criteria. IBS patients with SIBO, compared to those without SIBO, reported significantly greater improvement in abdominal symptoms following rifaximin therapy (p < 0.002 overall IBS symptom severity). This improvement was most marked in D-IBS patients in whom all symptoms improved, including stool frequency and consistency (all p < 0.004). CONCLUSIONS & INFERENCES Combined LHBT/SOCT testing using a H2 5 ppm cutoff may identify a subgroup of IBS patients with SIBO. Pilot data examining the clinical response to rifaximin suggest that this subset of IBS patients may benefit more than those with a normal test.
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Affiliation(s)
- J Zhao
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Division of Gastroenterology & Hepatology, Tongde Hospital of Zhejiang Province, Hangzhou, China
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Yang J, Fox M, Cong Y, Chu H, Zheng X, Long Y, Fried M, Dai N. Lactose intolerance in irritable bowel syndrome patients with diarrhoea: the roles of anxiety, activation of the innate mucosal immune system and visceral sensitivity. Aliment Pharmacol Ther 2014; 39:302-11. [PMID: 24308871 DOI: 10.1111/apt.12582] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 09/14/2013] [Accepted: 11/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Irritable bowel syndrome patients with diarrhoea (IBS-D) often report intolerance to milk; however, the mechanism underlying these symptoms is unknown. AIM To assess the role of psychological factors, immune activation and visceral sensitivity on the development of lactose intolerance (LI) in IBS-D patients. METHODS Fifty-five IBS-D patients and 18 healthy controls (HCs) with lactase deficiency underwent a 20-g lactose hydrogen breath test (LHBT). Patients were categorised as lactose malabsorption (LM; malabsorption only) or LI [malabsorption plus increase in total symptom score (TSS). Measurements included (i) psychological status; (ii) enteric biopsies with quantification of mast cells (MCs), T-lymphocytes and enterochromaffin cells; (iii) serum cytokines; (iv) rectal sensitivity before and after lactose ingestion. RESULTS LI was more prevalent in IBS-D patients than HCs [25/55 (46%) vs. 3/18 (17%), P = 0.029]. IBS-D patients with LI had (i) higher levels of anxiety than those with LM (P = 0.017) or HCs (P = 0.006); (ii) increased mucosal MCs compared with LM (P = 0.006) and HCs (P < 0.001); (iii) raised serum TNF-α compared with LM (P = 0.034) and HCs (P < 0.001) and (iv) increased rectal sensitivity after lactose ingestion compared with LM (P < 0.001) or HCs (P < 0.001). Severity of abdominal symptoms after lactose ingestion was associated with the increase in visceral sensitivity after lactose intake (r = 0.629, P < 0.001), MCs (r = 0.650, P < 0.001) and anxiety (r = 0.519, P < 0.001). CONCLUSIONS IBS-D patients with lactose intolerence are characterised by anxiety, mucosal immune activation and increased visceral sensitivity after lactose ingestion. The presence of these biomarkers may indicate an IBS phenotype that responds to dietary therapy and/or mast cell stabilisers.
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Affiliation(s)
- J Yang
- Department of Gastroenterology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Department of Gastroenterology, The First People's Hospital of Hangzhou, Hangzhou, China
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