Splitting irritable bowel syndrome: from original Rome to Rome II criteria

Low FODMAP Diet and Probiotics in Irritable Bowel Syndrome: A Systematic Review With Network Meta-analysis

Background: Probiotic and low fermentable oligosaccharide, disaccharide, monosaccharide, and polyol (FODMAP) diet are two commonly used management approaches for patients with irritable bowel syndrome (IBS). We aimed to evaluate the most effective combinations and components among different probiotics or low FODMAP diet through component network meta-analysis (NMA).

Methods: We searched Embase, Ovid Medline, and Web of Science from inception to 21 January 2021. Randomized controlled trials (RCTs) examining the efficacy of probiotics and low FODMAP diet for IBS were included, with placebo, sham diet, or conventional treatments as controls. Binary outcomes were compared among treatments using the relative ratio (RR). A minimally contextualized framework recommended by the GRADE group was used to evaluate the certainty of evidence. The primary efficacy outcome was the relief of global IBS symptoms, and the secondary efficacy outcome was the reduction in IBS symptom scores or abdominal pain scores.

Key Results: We included 76 RCTs (n = 8058) after screening 1940 articles. Eight RCTs were classified as low risk of bias. Standard network meta-analysis (NMA) showed that Lactobacillus (RR 1.74, 95% CI 1.22–2.48) and Bifidobacterium (RR 1.76, 95% CI 1.01–3.07) were the most effective for the primary efficacy outcome (high certainty evidence); component NMA showed that Bacillus (RR 5.67, 95% CI 1.88 to 17.08, p = 0.002) and Lactobacillus (RR 1.42, 95% CI 1.07 to 1.91, p = 0.017) were among the most effective components. The results of standard NMA and CNMA analysis of the improvement of overall IBS symptom scores or abdominal pain scores were consistent with this finding.

Conclusion:Lactobacillus was the most effective component for the relief of IBS symptoms; Bifidobacterium and Bacillus were possibly effective and need further verification.

Systematic Review Registration: website, identifier registration number.

Validation of the Rome III criteria for the diagnosis of irritable bowel syndrome in secondary care

BACKGROUND & AIMS

There are few validation studies of existing diagnostic criteria for irritable bowel syndrome (IBS). We conducted a validation study of the Rome and Manning criteria in secondary care.

METHODS

We collected complete symptom, colonoscopy, and histology data from 1848 consecutive adult patients with gastrointestinal symptoms at 2 hospitals in Hamilton, Ontario; the subjects then underwent colonoscopy. Assessors were blinded to symptom status. Individuals with normal colonoscopy and histopathology results, and no evidence of celiac disease, were classified as having no organic gastrointestinal disease. The reference standard used to define the presence of true IBS was lower abdominal pain or discomfort in association with a change in bowel habit and no organic gastrointestinal disease. Sensitivity, specificity, and positive and negative likelihood ratios, with 95% confidence intervals, were calculated for each diagnostic criteria.

RESULTS

In identifying patients with IBS, sensitivities of the criteria ranged from 61.9% (Manning) to 95.8% (Rome I), and specificities from 70.6% (Rome I) to 81.8% (Manning). Positive likelihood ratios ranged from 3.19 (Rome II) to 3.39 (Manning), and negative likelihood ratios from 0.06 (Rome I) to 0.47 (Manning). The level of agreement between diagnostic criteria was greatest for Rome I and Rome II (κ = 0.95), and lowest for Manning and Rome III (κ = 0.59).

CONCLUSIONS

Existing diagnostic criteria perform modestly in distinguishing IBS from organic disease. There appears to be little difference in terms of accuracy. More accurate ways of diagnosing IBS, avoiding the need for investigation, are required.

Perspectives on irritable bowel syndrome: where have we been? Where are we now?

Irritable bowel syndrome is a chronic functional disorder with a complex etiology and multiple overlapping symptoms. Irritable bowel syndrome is characterized by long-lasting abdominal pain or discomfort, abnormal bowel habits and typically inadequate response to many of the available therapies.

Diagnostic criteria in IBS: useful or not?

There are a number of reasons to establish the accurate diagnosis of irritable bowel syndrome (IBS): to relieve patient uncertainty; to avoid adverse effects of unnecessary medications or treatments; to avoid unnecessary diagnostic procedures and surgeries; to conserve limited healthcare resources; and, of course, to initiate the most appropriate treatment. However, making the diagnosis of IBS remains difficult because it is clinically heterogeneous, no biological marker to detect it exists, many other diseases share the same clinical manifestations and it is often difficult for both physicians and patients to accept the uncertainty of a symptom-based diagnosis. Different diagnostic criteria have been developed during the last 4 decades but none have proved to be an ideal method of accurately diagnosing IBS. Just as importantly, physicians are frequently unaware of published guidelines or consciously ignore these diagnostic criteria. Most clinicians still believe IBS is a diagnosis of exclusion and not a positive diagnosis based on history, physical examination, use of published diagnostic criteria such as the Rome III criteria, and the absence of alarm features. In the sections to follow we will address the inherent difficulties of diagnosing IBS, highlight the importance of symptom-based diagnoses to help reign in soaring healthcare costs, and discuss future strategies that may enable a more cost-efficient diagnosis of IBS.

Epidemiology of IBS

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

The current prevalence of irritable bowel syndrome in Asia

Irritable bowel syndrome (IBS) has been one of the commonly presented gastrointestinal disorders. It is of interest how commonly it presents in the society. Western studies indicated that most population-based IBS prevalences range 10%-15%. It is believed that IBS is prevalent in both East and West countries without a significant prevalence difference. Most recently, the Asia IBS prevalence has a higher trend in the affluent cities compared to South Asia. Since many Asia IBS prevalence studies have been published in the recent decade, we could compare the IBS prevalence data divided by various criteria in looking whether they were also comparable to this of West community. Summarized together, most Asia community IBS prevalences based on various criteria are usually within the range 1%-10% and are apparently lower than these of selected populations. Within the same population, the prevalence orders are first higher based on Manning criteria, then followed by Rome I criteria and finally reported in Rome II criteria. Overall, the median value of Asia IBS prevalences defined by various criteria ranges 6.5%-10.1%. With regard to gender difference, female predominance is usually found but not uniquely existed. For the IBS subtypes, the proportions of diarrhea predominant-IBS distribute widely from 0.8% to 74.0%, while constipation predominant-IBS proportion ranges 12%-77%. In conclusions, current Asia IBS prevalence is at least equal to the Western countries. Female predominant prevalence in Asia is common but not uniquely existed, while the proportions of IBS subtypes are too variable to find a rule.

Societal costs for irritable bowel syndrome--a population based study

OBJECTIVE

Irritable bowel syndrome (IBS) is associated with increased use of health care services. This study aims to estimate the costs of IBS in relation to differing diagnostic criteria of IBS, duration of symptoms, gender, and age.

MATERIAL AND METHODS

A two-phase postal survey. Questionnaire I covering gastrointestinal (GI) symptoms by Manning and Rome II criteria was mailed to 5000 randomly selected adults. Questionnaire II, mailed to those fulfilling IBS criteria of Questionnaire I, recorded data on physician visits, medications, and diagnostic procedures performed.

RESULTS

Proportion of GI consulters was 48% (95% CI 41-55%) and 32% (95% CI 28-36%) for Rome II and Manning groups. Annual GI related individual costs were euro 497 (95% CI euro 382-621) and euro 295 (95% CI euro 246-347) by Rome II and Manning criteria. Societal GI costs were euro 82 million and euro 154 million by Rome II and Manning criteria. Direct non-GI costs amounted to euro 43 million and euro 126 million by Rome II and Manning criteria. Duration of GI symptoms, gender, or age had no impact on GI costs.

CONCLUSIONS

IBS incurs substantial GI and non-GI costs corresponding to a share of up to 5% of the national direct outpatient and medicine expenditures. The more restrictive Rome II criteria identify an IBS population incurring higher GI related individual costs than Manning criteria. Costs due to GI endoscopies are not lower for those with a long history of symptoms suggesting that guideline recommendations for avoiding repeated diagnostic procedures may not be followed.

The Differences in Prevalence and Sociodemographic Characteristics of Irritable Bowel Syndrome According to Rome II and Rome III

BACKGROUND/AIMS

Irritable bowel syndrome (IBS) is one of the most frequently observed disorders by primary care and practitioners. The aim of this study was to estimate the prevalence of IBS using the Rome II and III criteria in the general Korean population and also to compare sociodemographic differences between subjects diagnosed by these criteria.

METHODS

Telephone interview surveys were performed with a total of 1,009 individuals in Korea, 15 years of age or older. The questionnaire, based on the Rome II and III criteria, was validated.

RESULTS

Among the 1,009 subjects, the prevalence of IBS was 8.0% under the Rome II criteria (81 subjects; 6.4%, male; 9.6%, female), and 9.0% (91 subjects; 7.0%, male; 11.0%, female) under the Rome III criteria. The accordance rate of Rome II and III was 73.5%. Both groups showed highest frequency in the age of 30s (13.9% vs. 15.3% respectively). Female subjects showed a higher prevalence than male subjects under Rome III (91 subjects; 11.0% in female, 7.0% in male; p < 0.05), but not under Rome II criteria. Many patients older than 50 years were added when analyzed under the Rome III criteria, but not under the Rome II criteria (p = 0.017).

CONCLUSIONS

The Rome III criteria were less restrictive and showed good agreement with the Rome II criteria. The prevalence of IBS was increased in young women.

[Irritable bowel syndrome and inflammatory bowel disease: Is there a connection?]

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders and is that with the greatest socioeconomic impact worldwide. Diagnosis of IBS is based on clinical criteria that have been modified over time, the Rome II criteria being those that are currently followed. Some of the symptoms of IBS are similar to those in patients with inflammatory bowel disease (IBD), which can hamper or delay diagnosis. The use of inflammatory markers in stools (such as calprotectin) may help to distinguish between these two entities. A possible connection between IBS and IBD could be based on five points: (i) both disorders have similar symptoms; (ii) symptoms often overlap in the same patients; (iii) IBS and IBD have a common familial aggregation; (iv) some predisposing factors, such as a history of acute gastroenteritis, play a role in both disorders, and (v) importantly, signs of microinflammation are found in the bowels of patients with IBS. With regard to this latter point, an increase in inflammatory cells has been found in the intestinal mucosa of patients with IBS and, more specifically, mastocytes have been found to be increased in the jejunum and colon while CD3 and CD25 intraepithelial lymphocytes have be observed to be increased in the colon. Moreover, activated mastocytes are increased near to nerve endings in patients with IBS and this finding has been correlated with the intensity of both intestinal symptoms (abdominal pain) and psychological symptoms (depression and fatigue). A good model of microinflammation is post-infectious IBS, since the timing of the onset of the infectious process is known. In patients with post-infectious IBS, an increase in intraepithelial lymphocytes and enterochromaffin cells is initially found, which is reduced over time; consequently, although the symptoms of IBS persist, after 3 years no differences are detected in the number of inflammatory cells between IBS patients and controls. Among the various factors that can favor the development of IBS in these patients, two host-dependent mechanisms are most closely implicated in the physiopathology of IBS: polymorphism of the genes codifying pro- or anti-inflammatory cytokines and psychological factors such as anxiety, depression, somatization and neuroticism at the time of the acute infection. In view of all of the above, the similarities between IBS and IBD are probably more than mere coincidence and may reflect distinct manifestations of a broad spectrum of inflammation in the colon.

Efficient diagnosis of suspected functional bowel disorders

Functional bowel disorders (FBDs) are common disorders that are characterized by various combinations of abdominal pain and/or discomfort, bloating and changes in bowel habits. At present, diagnosing FBDs often incurs considerable health-care costs, partly because unnecessary investigations are performed. Patients are currently diagnosed as having an FBD on the basis of a combination of typical symptoms, normal physical examination and the absence of alarm features indicative of an organic gastrointestinal disease. Basic laboratory investigations, such as a complete blood count, measurement of the erythrocyte sedimentation rate and serological tests for celiac disease, are useful in the initial evaluation. No further investigations are needed for most patients who have typical symptoms and no alarm symptoms. The most important alarm symptoms include signs of gastrointestinal bleeding, symptom onset above 50 years of age, a family history of colorectal cancer, documented weight loss and nocturnal symptoms. The presence of alarm symptoms obviously does not exclude an FBD, but further investigation is needed before confirmation of the diagnosis. For patients with predominant and severe diarrhea, a more thorough diagnostic work-up should normally be considered, including colonoscopy with colonic biopsies and a test for bile-acid malabsorption.

Treatments for irritable bowel syndrome: patients' attitudes and acceptability

BACKGROUND

Irritable Bowel Syndrome, a highly prevalent chronic disorder, places significant burden on the health service and the individual. Symptomatic distress and reduced quality of life are compounded by few efficacious treatments available. As researchers continue to demonstrate the clinical efficacy of alternative therapies, it would be useful to gain a patient-perspective of treatment acceptability and identify patient's attitudes towards those modalities considered not acceptable.

METHODS

Six hundred and forty-five participants identified from an earlier IBS-prevalence study received a postal questionnaire to evaluate preferences and acceptability of nine forms of treatment. Proportions accepting each form of treatment were calculated and thematic analysis of qualitative data undertaken.

RESULTS

A total of 256 (39.7%) of 645 potential respondents completed the questionnaire (mean age 55.9 years, 73% female). Tablets were most acceptable (84%), followed by lifestyle changes (diet (82%), yoga (77%)). Acupuncture (59%) and suppositories (57%) were less acceptable. When explaining lack of acceptability, patient views fell into four broad categories: dislike treatment modality, do not perceive benefit, general barriers and insufficient knowledge. Scepticism, lack of scientific rationale and fear of CAM were mentioned, although others expressed a dislike of conventional medical treatments. Past experiences, age and health concerns, and need for proof of efficacy were reported.

CONCLUSION

Most patients were willing to accept various forms of treatment. However, the reservations expressed by this patient-population must be recognised with particular focus directed towards allaying fears and misconceptions, seeking further evidence base for certain therapies and incorporating physician support and advice.

Irritable bowel syndrome among patients attending General Outpatients' clinics in Jos, Nigeria

Irritable bowel syndrome (IBS) is a common disorder in the Western world. Its prevalence is yet to be fully determined in the African setting. This was a cross-sectional study of patients attending three General Outpatient clinics in Jos, Nigeria. Four hundred and eighteen randomly selected patients were interviewed using a structured questionnaire based on the Rome II diagnostic criteria for IBS. Excluded from the study were patients with established organic disease, memory problems, and pregnant women. Eighteen patients were excluded based on these criteria and 400 were analysed using Epi Info 2000 (Atlanta, Georgia, USA) statistical computer software. One hundred and thirty-two (33%) out of the 400 patients fulfilled the criteria for the diagnosis of IBS, the female to male ratio being 1.13 : 1. IBS was significantly associated with increasing age (P=0.03) and depression (P<0.001). The prevalence of IBS is high among patients attending primary care in the African setting with depression being the likely reason for seeking care.

Systematic review and meta-analysis: The incidence and prognosis of post-infectious irritable bowel syndrome

BACKGROUND

Individual studies suggest that post-infectious irritable bowel syndrome is common, but symptoms gradually improve.

AIM

To review evidence for an association between intestinal infection and development of irritable bowel syndrome, assess the prognosis of post-infectious irritable bowel syndrome and explore factors that increase the risk.

METHODS

MEDLINE (1966-2007) and EMBASE (1980-2007) databases were searched to identify the studies of post-infectious irritable bowel syndrome epidemiology. Data were extracted by two independent reviewers. Pooled odds ratios (POR) and corresponding 95% CI for incidence of irritable bowel syndrome were estimated among the exposed and unexposed groups.

RESULTS

Eighteen of 26 studies identified were eligible for inclusion. Intestinal infection was associated with increased odds of developing irritable bowel syndrome at study end (POR = 5.86; 95% CI: 3.60-9.54). In subgroup analysis, the odds of developing irritable bowel syndrome was increased at 3 months (POR = 7.58; 95% CI: 4.27-13.45), 6 months (POR = 5.18; 95% CI: 3.24-8.26), 12 months (POR = 6.37; 95% CI: 2.63-15.40) and 24-36 months (POR = 3.85; 95% CI: 2.95-5.02). Among all studies (controlled and uncontrolled), the pooled incidence of irritable bowel syndrome at study conclusion was 10% (95% CI: 9.4-85.6). Subjects with post-infectious irritable bowel syndrome were younger and more anxious and depressed than those without post-infectious irritable bowel syndrome.

CONCLUSION

The odds of developing irritable bowel syndrome are increased sixfold after acute gastrointestinal infection. Young age, prolonged fever, anxiety and depression are risk factors for post-infectious irritable bowel syndrome.

The effect of culture on symptom reporting: Hispanics and irritable bowel syndrome

PURPOSE

To explore whether the symptoms reported by Mexican-American patients with irritable bowel syndrome (IBS) meet the current diagnostic criteria.

DATA SOURCES

A retrospective review of charts of Mexican-American patients diagnosed with IBS at three large medical centers in central California was performed. Demographic information was extracted, and descriptive statistics were used to determine how symptoms were reported and whether the described symptoms met the Rome II criteria.

CONCLUSIONS

Only 63% of the Mexican-American patients in this study reported symptoms that met any of the nine Rome II criteria. There was no significant difference between patients who were English dominant and those who were monolingual Spanish in the concordance of their presenting complaint and the current diagnostic criteria. In addition, there was no significant gender difference in the rate at which symptoms met the Rome II criteria.

IMPLICATIONS FOR PRACTICE

Assessment of illness and its symptoms requires that the practitioner have a clear understanding of what the illness means to the patient in order to develop an accurate diagnosis and an appropriate and timely plan of treatment. This study highlights the necessity of revising the symptom-based criteria for diagnosing IBS to include a wider array of reported complaints, taking into account the impact of culture on the perception and description of symptoms.

Mechanisms of Disease: genetics of functional gastrointestinal disorders—searching the genes that matter

There is evidence to suggest that genetic factors contribute to the manifestation of functional gastrointestinal disorders (FGID). As such, it is important to note that FGID are heterogeneous; they have quite different clinical features and (probably) different underlying pathophysiologic mechanisms. Evidence from family and twin studies indicates that there is clustering of FGID in families and increased concordance in monozygotic compared with dizygotic twins. The clinical features of FGID implicate polymorphisms in the genes that encode adrenergic, opioidergic or serotonergic receptors, as well as in the G-protein beta3 subunit (GNB3) gene and serotonin-transporter genes, in their manifestations. As mediators or regulators of mucosal inflammation can trigger events that ultimately result in manifestations of FGID, polymorphisms in genes that encode proteins with immunomodulatory and/or neuromodulatory features (e.g. OPRM1, IL4, IL4R, TNF) might also have a role in the manifestation of FGID. A two-step model for the role of genetic factors in the manifestation of functional gastrointestinal pain can, therefore, be proposed. In the presence of specific hereditary factors, environmental factors that do not usually cause long-term functional alterations are linked to the manifestation of symptoms.

Symptom patterns and relative distribution of functional bowel disorders in 1,023 gastroenterology patients in Iran

BACKGROUND AND AIMS

There are scanty data on functional bowel disorder (FBD) patterns in Iran. This first-time study tried to provide preliminary data on relative distribution of different types of FBD and their symptom patterns in Iranian patients.

METHODS

A consecutive sample of 1,023 patients in an outpatient gastroenterology clinic in central Tehran was interviewed using two questionnaires based on Rome II criteria from December 2004 to May 2005 to detect FBD patients.

RESULTS

Of 1,023 gastroenterology patients, 410 met Rome II criteria for FBD; functional constipation, 115 (28%); irritable bowel syndrome (IBS), 110 (27%) [IBS-C, 29%; IBS-D, 11%; IBS-A, 60%]; functional bloating, 102 (25%); unspecified FBD, 76 (18%); and functional diarrhea, 7 (2%). FBD had no association with age or level of education, while it was more frequent in women (P=0.001). FBD was also more frequent among those with a history of abdominal/pelvic surgery (P=0.021). IBS patients had a lower mean of age compared with non-FBD group, while patients with constipation were older (Mann-Whitney U test, P=0.006). Constipation-related symptoms were the most frequent symptoms among IBS patients. Constipation (<3 defecations/week) was also the most frequent change in bowel habit in bloating and unspecified FBD patients. Fourteen percent of IBS consulters and 8.7% of functional constipation consulters met Rome II criteria for dyspepsia (disregarding the ruling out of upper gastrointestinal organic disease). Only 20% of patients with functional constipation were consulters.

CONCLUSIONS

Population-based studies at provincial levels are essential to clarify FBD patterns in each provincial district in the country.

Irritable bowel syndrome: the burden and unmet needs in Europe

Irritable bowel syndrome affects approximately 10-15% of the European population, although prevalence rates vary depending on the classification used and the country surveyed. This may be due to differences in patterns of medical care and diagnosis of the condition. Up to 70% of individuals with irritable bowel syndrome may not have been formally diagnosed. The disorder affects 1.5-3 times as many women as men and poses a significant economic burden in Europe, estimated at euro 700-euro 1600 per person per year. It also reduces quality of life and is associated with psychological distress, disturbed work and sleep, and sexual dysfunction. It is a chronic disorder, which affects many individuals for more than 10 years. Most patients are managed in primary care, although some are referred to gastroenterologists and other specialists. Patients with irritable bowel syndrome undergo more abdomino-pelvic surgery than the general population. We propose that a positive diagnosis of the condition may avoid the delay in diagnosis many patients experience. We conclude that, in Europe, there are significant unmet needs including lack of familiarity with irritable bowel syndrome, difficulties in diagnosis and lack of effective treatments for the multiple symptoms of the disorder. The development of pan-European guidelines for irritable bowel syndrome will benefit patients with this condition in Europe.

Sex differences in irritable bowel syndrome in Japanese university students

BACKGROUND

Epidemiological studies of irritable bowel syndrome (IBS) among young adults are few, especially in Asian countries. Our aim was to examine the prevalence of IBS, whether there was a sex difference, and whether allergic diseases were important risk factors for IBS in young adults.

METHODS

Newly enrolled university students completed health survey questionnaires regarding general health. Those with gastrointestinal symptoms completed the Gastrointestinal Symptom Rating Scale (GSRS) and an additional questionnaire covering the presence of allergic manifestations. IBS was diagnosed based on the Rome II criteria.

RESULTS

IBS was diagnosed in 268 of 2495 students [10.7%; constipation-predominant type (IBS-C), 128; diarrhea-predominant type (IBS-D), 117; unclassified, 23]. IBS-C was associated with female sex (odds ratio, 6.4; 95% confidence interval, 4.1-9.7; P < 0.001), whereas there was no sex difference in IBS-D. The proportions of subjects with food sensitivity were significantly different among the three groups (4.0%, subjects without IBS; 8.6%, IBS-C group; and 15.4%, IBS-D group) (P < 0.001). The median GSRS scores for pain (1.67 vs 1, P = 0.001), indigestion (1.75 vs 1.5, P < 0.001), and constipation (2.0 vs 1.33, P < 0.001) were higher, and the median diarrhea score was lower (1.33 vs 1.67) (P < 0.001), in women than in men. The median score for diarrhea (2.33 vs 1.67, P = 0.001) was significantly higher in subjects with food sensitivity than in those without.

CONCLUSIONS

There was a strong relationship between IBS-C and female sex, and food sensitivity seemed to be an exacerbating factor for IBS-D.

To "lump" or to "split" the functional somatic syndromes: can infectious and emotional risk factors differentiate between the onset of chronic fatigue syndrome and irritable bowel syndrome?

OBJECTIVES

Recent academic debate has centered on whether functional somatic syndromes should be defined as separate entities or as one syndrome. The aim of this study was to investigate whether there may be significant differences in the etiology or precipitating factors associated with two common functional syndromes, irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS).

METHODS

We prospectively studied 592 patients with an acute episode of Campylobacter gastroenteritis and 243 with an acute episode of infectious mononucleosis who had no previous history of CFS or IBS. At the time of infection, patients completed a baseline questionnaire that measured their levels of distress using the Hospital Anxiety and Depression scale. At 3- and 6-month follow-up, they completed questionnaires to determine whether they met published diagnostic criteria for chronic fatigue (CF), CFS, and/or IBS.

RESULTS

The odds of developing IBS were significantly greater post-Campylobacter than post-infectious mononucleosis at both 3- (odds ratio, 3.45 [95% confidence interval (CI), 1.75-6.67]) and 6- (2.22 [95% CI, 1.11-6.67]) month follow-up. In contrast, the odds for developing CF/CFS were significantly greater after infectious mononucleosis than after Campylobacter at 3 (2.77 [95% CI, 1.08-7.11]) but not 6 (1.48 [95% CI, 0.62-3.55]) months postinfection. Anxiety and depression were the strongest predictors of CF/CFS, whereas the nature of the infection was the strongest predictor of IBS.

CONCLUSIONS

These results support the argument to distinguish between postinfectious IBS and CFS. The nature of the precipitating infection appears to be important, and premorbid levels of distress appear to be more strongly associated with CFS than IBS, particularly levels of depression.

Prevalence of irritable bowel syndrome and depression in fibromyalgia

The purpose of this study was to determine the point prevalence of depressive symptoms, using the PRIME-MD questionnaire, and irritable bowel syndrome (IBS), while comparing the Rome II to the Rome I criteria, in patients with fibromyalgia (FM) and rheumatologic controls in an outpatient setting. The prevalence of IBS in FM patients (n = 105) was 63% by Rome I and 81% by Rome II criteria. The prevalence of IBS in controls (n = 62) was 15% by Rome I and 24% by Rome II criteria (FM vs. control; P < 0.001). Depressive symptoms were met in 40% of FM patients and 8% of controls (P < 0.001). The coexistence of IBS and depressive symptoms in the FM patients was 31% (Rome I) and 34% (Rome II). The prevalence of IBS and depressive symptoms was higher in FM patients compared to the control population. Identification of IBS and depressive symptoms in FM patients might enable clinicians to better meet the needs of this patient population.

A symptom-based approach to making a positive diagnosis of irritable bowel syndrome with constipation

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder. Characterised by abdominal pain or discomfort, bloating and altered bowel habit, IBS is a chronic recurring condition, typically affecting up to 15% of the Western population, IBS can be subclassified into IBS with constipation (IBS-C), IBS with diarrhoea (IBS-D), or IBS with alternating constipation or diarrhoea symptoms (IBS-A). Conventional clinical diagnosis focuses on excluding all potential organic causes of patient symptoms. However, a positive diagnosis of IBS may be established using published criteria such as the Manning and/or Rome criteria. While these methods are useful to identify patients with IBS who are suitable for enrollment into clinical trials, the criteria are relatively complex and not readily applicable to general practice. In this review we present an 'identify, eliminate, probe' algorithm that may be appropriate to establish a positive diagnosis of patients with IBS-C, as symptoms characteristic of patients in this IBS subgroup are least likely to be confused with symptoms reflecting serious organic disease.

Functional gastrointestinal disorders and mood disorders in patients with inactive inflammatory bowel disease: prevalence and impact on health

BACKGROUND

Symptoms of functional gastrointestinal disorders (FGID) associated with mood disorders (MD), such as depression and anxiety, occur in some patients with quiescent inflammatory bowel disease (IBD) and could be caused by changes in gut motility, visceral hypersensitivity, or psychological dysfunction. We assessed the prevalence of FGID symptoms and mood disorders in ambulatory patients with quiescent IBD and examined their impact on health-related quality of life (HRQOL) and use of health resources.

METHODS

Consecutive ambulatory patients with IBD completed a survey of Rome II criteria for FGID, the Hospital Anxiety and Depression Survey, HRQOL indices, and health resource utilization. Logistic and linear regression analyses tested for predictors of FGID and HRQOL.

RESULTS

Of 361 patients surveyed, 149 (44 ulcerative colitis [UC] and 105 Crohn's disease [CD]) had inactive IBD during the previous 12 months. Symptoms of at least 1 FGID occurred in 81.9%. Functional anorectal disorders were the most prevalent (53.7%) followed by functional bowel disorders (51.7%), and both were of greater prevalence than in the Canadian population (41.6% and 22.6%, respectively). Irritable bowel syndrome symptoms were more common in inactive CD than in UC (26% versus 9.1%, P = .01) and functional constipation was more common in inactive UC than in CD (26.2% versus 5.8%, P < .01). MD occurred in 27.3% of UC and 31.3% of CD patients. Age > or =40 years and anxiety independently predicted an FGID. Both FGID symptoms and MD were associated with impaired HRQOL and increased use of health services.

CONCLUSIONS

Many patients with inactive IBD have symptoms compatible with FGID. Both FGID-like symptoms and MD are associated with impaired HRQOL and increased health resource utilization. Recognition and treatment of FGID and MD could potentially improve daily functioning of IBD patients.

Spatial organization and composition of the mucosal flora in patients with inflammatory bowel disease

The composition and spatial organization of the mucosal flora in biopsy specimens from patients with inflammatory bowel disease (IBD; either Crohn's disease or ulcerative colitis), self-limiting colitis, irritable-bowel syndrome (IBS), and healthy controls were investigated by using a broad range of fluorescent bacterial group-specific rRNA-targeted oligonucleotide probes. Each group included 20 subjects. Ten patients who had IBD and who were being treated with antibiotics were also studied. Use of nonaqueous Carnoy fixative to preserve the mucus layer was crucial for detection of bacteria adherent to the mucosal surface (mucosal bacteria). No biofilm was detectable in formalin-fixed biopsy specimens. Mucosal bacteria were found at concentrations greater than 10(9)/ml in 90 to 95% of IBD patients, 95% of patients with self-limiting colitis, 65% of IBS patients, and 35% of healthy controls. The mean density of the mucosal biofilm was 2 powers higher in IBD patients than in patients with IBS or controls, and bacteria were mostly adherent. Bacteroides fragilis was responsible for >60% of the biofilm mass in patients with IBD but for only 30% of the biofilm mass in patients with self-limiting colitis and <15% of the biofilm mass in patients with IBS. In contrast, bacteria which positively hybridized with the probe specific for Eubacterium rectale-Clostridium coccoides accounted for >40% of the biofilm in IBS patients but for <15% of the biofilm in IBD patients. In patients treated with (5-ASA) or antibiotics, the biofilm could be detected with 4,6-diamidino-2-phenylindole but did not hybridize with fluorescence in situ hybridization probes. A Bacteroides fragilis biofilm is the main feature of IBD. This was not previously recognized due to a lack of appropriate tissue fixation. Both 5-ASA and antibiotics suppress but do not eliminate the adherent biofilm.

Prevalence of functional gastrointestinal disorders in women who report domestic violence to the police

BACKGROUND & AIMS

Retrospective studies found an association between past sexual, physical, or psychological abuse and functional gastrointestinal disorders (FGIDs). However, there are no studies evaluating such an association concurrently with the ongoing abuse. Our aim was to investigate the prevalence of the main FGIDs, functional dyspepsia and irritable bowel syndrome, in 70 women reporting a situation of domestic violence to the police and to evaluate the level of psychological distress and its relationship with the presence of FGID.

METHODS

Through an interview between a social worker and the woman reporting abuse, digestive symptoms, psychological status, and type of abuse were recorded. These data were matched against police records. Functional dyspepsia and irritable bowel syndrome were diagnosed according to Rome II criteria.

RESULTS

Seventy-one percent of the women had an FGID: 67% functional dyspepsia, 47% irritable bowel syndrome, and 43% both. In two thirds of the cases, FGID onset occurred simultaneously with or soon after abuse onset. Only 34% of the women had sought medical attention for FGID symptoms. No differences were found between women with or without FGID regarding age and type or duration of abuse; psychological distress tended to be more severe in the group of women with FGIDs.

CONCLUSIONS

Most women who suffer domestic violence (reported to the police) have functional dyspepsia and/or irritable bowel syndrome and also have elevated psychological distress. This has important implications, not only for comprehensive health care of women in a situation of abuse, but also for medical treatment of women with FGIDs.

Bowel habit subtypes and temporal patterns in irritable bowel syndrome: systematic review

Irritable bowel syndrome (IBS) is a heterogeneous condition characterized by the presence of abdominal discomfort or pain and bowel habit alterations: constipation (C-IBS), diarrhea (D-IBS), or alternating C and D (A-IBS). Its clinical course is poorly known.

OBJECTIVES

(i) To compare bowel habit subtypes distribution in IBS according to sample origin and diagnosis criteria; (ii) To evaluate IBS temporal patterns based on follow-up studies.

METHODS

A literature search (1966-2003) was conducted in the MEDLINE and EMBASE databases. A total of 72 studies were found and 22 were finally selected.

RESULTS

Population-based studies from the United States (Manning) found similar distribution among C-IBS, D-IBS, and A-IBS, while European studies (Rome I, Rome II, or self-reporting) showed either C-IBS or A-IBS as the most prevalent subtypes. Primary care office-based studies (Rome I or Rome II) showed A-IBS as the most prevalent group. Gastroenterology specialized office-based studies found either C-IBS or D-IBS as the most frequently reported subtype. Prospective follow-up investigations showed that the most frequent IBS temporal pattern profile consists of mild to moderate symptoms appearing in cluster in an intermittent way, about once a week, and lasting 2-5 days on average.

CONCLUSION

IBS clinical subtypes distribution differs depending on the population evaluated, the geographical location, and the criteria employed to define IBS and bowel habit subtypes. In most cases, clinical course is characterized by the presence of mild-to-moderate symptoms appearing sequentially. Prospective studies, using clear and stable diagnostic criteria and subtype definitions, and based on daily data collection should further characterize IBS clinical course.

Characterization of the alternating bowel habit subtype in patients with irritable bowel syndrome

BACKGROUND

Due to a wide range of symptom patterns, patients with irritable bowel syndrome (IBS) are often subgrouped by bowel habit. However, the IBS subgroup with alternating bowel habits (IBS-A) has been poorly characterized.

OBJECTIVES

(i) To determine a set of bowel habit symptom criteria, which most specifically identifies IBS patients with an alternating bowel habit, (ii) to describe IBS-A bowel symptom patterns, and (iii) to compare clinical characteristics among IBS-A, constipation-predominant (IBS-C), and diarrhea-predominant IBS (IBS-D).

METHODS

One thousand one hundred and two Rome I positive IBS patients were analyzed. Three sets of potential criteria for IBS-A were developed and compared by multirater Kappa test. Gastrointestinal, psychological, extraintestinal symptoms, and health-related quality of life were compared in IBS-A, IBS-C, and IBS-D using chi(2) test and analysis of variance (ANOVA).

RESULTS

Stool consistency was determined to be the most specific criteria for alternating bowel habits. IBS-A patients reported rapid fluctuations in bowel habits with short symptom flares and remissions. There was a greater prevalence of psychological and extraintestinal symptoms in the IBS-A subgroup compared to IBS-C and IBS-D. No differences were seen between bowel habit subtypes in health-related quality of life.

CONCLUSIONS

IBS-A patients have rapidly fluctuating symptoms and increased psychological comorbidity, which should be taken into account for clinical practice and clinical trials.

Prevalence of irritable bowel syndrome according to different diagnostic criteria in a non-selected adult population

BACKGROUND

Prevalence of irritable bowel syndrome shows great variation among epidemiological studies, which may be due to different diagnostic criteria.

AIM

To assess prevalence of irritable bowel syndrome according to various diagnostic criteria and to study differences in symptom severity, psychopathology, and use of health care resources between subjects fulfilling different diagnostic criteria.

METHODS

A questionnaire was mailed to 5000 randomly selected adults. Presence of irritable bowel syndrome was assessed by four diagnostic criteria: Manning 2 (at least two Manning symptoms), Manning 3 (at least three Manning symptoms), Rome I and Rome II.

RESULTS

Response rate was 73%. Prevalence of irritable bowel syndrome by Manning 2, Manning 3, Rome I and Rome II criteria was 16.2%, 9.7%, 5.6%, and 5.1% respectively. Of those fulfilling Rome II criteria, 97% fulfilled Manning 2. Severe or very severe abdominal pain was reported by 27-30% of Manning-positive subjects, and 44% of Rome-positives. Prevalence of depression in Manning 2, and Rome II groups was 30.6 and 39.3%.

CONCLUSIONS

Prevalence of irritable bowel syndrome by Rome II criteria is considerably lower than by Manning criteria. Subjects fulfilling Rome criteria form a subgroup of Manning-positive subjects with more severe abdominal symptoms, more psychopathology, and more frequent use of the health care system.