Bowel Disorders

Lactiplantibacillus plantarum (CECT7484 and CECT7485) and Pedioccoccus acidilactici (CECT7483) enhance actin cytoskeleton and CYP1A1 expression restoring epithelial permeability alterations induced by irritable bowel syndrome mediators

Irritable bowel syndrome (IBS) is a multifactorial condition with heterogeneous pathophysiology, including intestinal permeability alterations. The aim of the present study was to assess the ability of a probiotic blend (PB) consisting of two Lactiplantibacillus plantarum strains (CECT7484 and CECT7485) and one strain of Pediococcus acidilactici (CECT7483) to recover the permeability increase induced by mediators from IBS mucosal biopsies and to highlight the underlying molecular mechanisms. Twenty-one IBS patients diagnosed according to ROME IV criteria (11 IBS-D and 10 IBS-M) and 7 healthy controls were enrolled. Mucosal mediators spontaneously released by IBS and HC biopsies were collected and incubated with/without the PB (104 and 106 CFU/ml). Paracellular permeability was assessed by evaluating the amount of sulfonic-acid-conjugated to fluorescein passing through the Caco-2 monolayer. RNA was extracted from Caco-2 cells and used to perform qPCR analyses, to evaluate the expression of ZO-1 and β-actin, and RNAseq to evaluate the transcriptomic profile. Untargeted metabolomics was used to characterize metabolites produced by the PB. The PB significantly reduced paracellular permeability after 3 h of incubation. Both doses of the PB significantly recovered the increase in paracellular permeability induced by IBS mediators. qPCR analyses showed that both doses of the PB co-incubated with IBS mediators induced a significant increase in beta-actin expression compared to IBS mediators alone. Concerning IBS subtypes, the high dose of the PB recovered the increase of permeability induced by IBS-D mediators. Transcriptomic analyses, confirmed by qPCR, showed that the high dose of the PB significantly increased CYP1A1 compared to IBS mediators alone. The PB produced a high amount of indole-3-lactic acid. The PB recovers the permeability increase induced by IBS mediators inducing the up-regulation of β-actin. In addition, the PB up-regulates the expression of CYP1A1, known to be involved in the metabolism of xenobiotics, possibly through the production of the indole-3-lactic acid.

The role of gluten and wheat in irritable bowel syndrome and noncoeliac gluten or wheat sensitivity

PURPOSE OF REVIEW

The role of gluten and wheat in irritable bowel syndrome (IBS) is unclear, whereas it plays a key-role in the diagnosis and treatment of noncoeliac gluten or wheat sensitivity (NCGWS). This review aims to provide the most recent insights in pathophysiological mechanisms and to summarize the evidence for a gluten- or wheat-free diet in IBS and NCGWS.

RECENT FINDINGS

The exact role of gluten and wheat in IBS and NCGWS pathophysiological mechanisms remains complex. However, recent findings suggest a role for antigliadin antibodies to identify those IBS patients who may benefit from a gluten-free diet and low levels of fecal calprotectin to differentiate IBS and NCGWS. The importance of gut-brain interactions in self-reported gluten sensitive individuals was shown by a strong nocebo effect, although a role of gluten could not be excluded. Evidence for a gluten-free diet remains debatable in both conditions, whereas a wheat-free diet may have more potential, especially in NCGWS.

SUMMARY

IBS and NCGWS are two closely related conditions with a complex and largely unrevealed pathophysiology. The role of gluten may have been overestimated in the past, but it is likely that certain wheat components, along with gut-brain interactions, play a role in both conditions.

2025 Seoul Consensus on Clinical Practice Guidelines for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic, disabling, and functional bowel disorder that significantly affects social functioning and reduces quality of life and increases social costs. The Korean Society of Neurogastroenterology and Motility published clinical practice guidelines on the management of IBS based on a systematic review of the literature in 2017, and planned to revise these guidelines in light of new evidence on the pathophysiology, diagnosis, and management of IBS. The current revised version of the guidelines is consistent with the previous version and targets adults diagnosed with or suspected of having IBS. These guidelines were developed using a combination of de novo and adaptation methods, with analyses of existing guidelines and discussions within the committee, leading to the identification of key clinical questions. Finally, the guidelines consisted of 22 recommendations, including 3 concerning the definition and risk factors of IBS, 4 regarding diagnostic modalities and strategies, 2 regarding general management, and 13 regarding medical treatment. For each statement, the advantages, disadvantages, and precautions were thoroughly detailed. The modified Delphi method was used to achieve expert consensus to adopt the core recommendations of the guidelines. These guidelines serve as a reference for clinicians (including primary care physicians, general healthcare providers, medical students, residents, and other healthcare professionals) and patients, helping them to make informed decisions regarding IBS management.

Validation of the London Classification for Rectal Hyposensitivity in an Anorectal Manometry Database of 2540 Patients With Functional Defecatory Disorder

Background/Aims

Rectal hyposensitivity (RH), as defined by the London Classification, has been linked to sensory dysfunction caused by diabetes mellitus and Parkinson's disease (PD); however, its clinical interpretation has not been sufficiently validated. In this study, we aim to explore the correlations between rectal sensory thresholds and the clinical characteristics of patients with functional defecatory disorders.

Methods

We reviewed data from patients who underwent high-resolution anorectal manometry and acquired their clinical characteristics using a standardized questionnaire. The associations between RH based on either 1 (borderline RH) or 2 (RH) abnormal rectal sensory thresholds and patients' clinical and demographic characteristics were analyzed using linear and logistic regression models in the overall sex-stratified populations.

Results

We enrolled 2540 patients, of whom 1046 (41.2%) were men. Overall, 150 (5.9%) patients were diagnosed with RH, whereas 422 (16.6%) had borderline RH. Multivariate linear regression analysis revealed that the Cleveland Clinic Constipation Score (CCCS) increased linearly with the increase in the number of abnormal rectal sensory thresholds (effect per threshold: 0.900 [standard deviation: 0.188]). Upon stratification by sex, borderline RH was positively associated with diabetes mellitus, PD, and CCCS (adjusted odds ratio [aOR] = 2.11, 95% confidence interval [1.08, 4.15]; aOR = 1.49 [1.03, 2.14]; aOR = 1.03 [1.01, 1.05], respectively) in women. However, RH was positively associated with only the CCCS.

Conclusions

Defining RH based on 1 or more abnormal sensory thresholds showed better clinical correlation with patient characteristics. However, further prospective studies are needed to validate these findings before proposing revisions to the current London classification criteria.

Predictors of response to low-dose amitriptyline for irritable bowel syndrome and efficacy and tolerability according to subtype: post hoc analyses from the ATLANTIS trial

BACKGROUND

Low-dose amitriptyline, a tricyclic antidepressant (TCA), was superior to placebo for irritable bowel syndrome (IBS) in the AmitripTyline at Low-dose ANd Titrated for Irritable bowel syndrome as Second-line treatment (ATLANTIS) trial.

OBJECTIVE

To perform post hoc analyses of ATLANTIS for predictors of response to, and tolerability of, a TCA.

DESIGN

ATLANTIS randomised 463 adults with IBS to amitriptyline (232) or placebo (231). We examined the effect of baseline demographic and disease-related patient characteristics on response to amitriptyline and the effect of amitriptyline on individual symptoms and side effects by subtype.

RESULTS

There was a quantitative difference in amitriptyline effectiveness in those ≥50 years vs <50 on the IBS severity scoring system (IBS-SSS) (interaction p=0.048, mean difference in ≥50 years subgroup -46.5; 95% CI -74.2 to -18.8, p=0.0010), and subjective global assessment of relief (interaction p=0.068, OR in ≥50 years subgroup 2.59; 95% CI 1.47 to 4.55, p=0.0010), and those in the 70% most deprived areas of England compared with the 30% least deprived for a ≥30% improvement in abdominal pain (interaction p=0.021, OR in 70% most deprived subgroup 2.70; 95% CI 1.52 to 4.77, p=0.0007). Stronger treatment effects were seen in men, with higher Patient Health Questionnaire-12 scores, and with IBS with diarrhoea. Mean differences in individual IBS-SSS components favoured amitriptyline, and side effects were similar, across almost all IBS subtypes.

CONCLUSION

These exploratory analyses demonstrate there are unlikely to be deleterious effects of amitriptyline in any particular IBS subtype and could help identify patients in whom amitriptyline may be more effective.

TRIAL REGISTRATION NUMBER

ISRCTN48075063.

Digital Gut-Directed CBT May Improve Fecal Incontinence in IBS

INTRODUCTION

Fecal incontinence (FI) occurs in up to 20% of irritable bowel syndrome (IBS) patients, with a negative impact on quality of life, psychologic symptoms, and work impairment. We aimed to evaluate the impact of an app-based gut-directed cognitive behavioral therapy (CBT) program on IBS-associated fecal incontinence (FI) using real-world evidence from user data.

METHODS

The study population was selected from 1,383 Mahana™ IBS users who had completed a 3-month access period for a prescription CBT program between August 2021 and February 2024. Patients completed at least one of the 10-session program, completed ≥ 2 symptom log entries, reported ≥ 1 FI episode during the program, and completed assessments of symptom severity (IBS Symptom Severity Scoring System; IBS-SSS). Mixed-effects linear regression models analyzed the number of FI episodes/user during each session and changes in IBS-SSS as a function of session progression.

RESULTS

Sixty-six patients met inclusion criteria with mean age of 49 ± 18 years and a baseline IBS-SSS of 286 ± SD 104. IBS-SSS decreased to 206 ± 125 and 193 ± 129 at sessions 5 and 10, respectively (p < 0.0001). Mean FI episodes/user decreased from 5 ± 11 in session 1 to 0.5 ± 1.5 and 0.1 ± 0.3 in sessions 5 and 10, respectively (p < 0.0001). Responder analysis found that 100% of patients who completed 2 + sessions met the criteria of ≥ 50% reduction in FI episodes between their first and last session.

DISCUSSION

Our findings suggest that gut-directed digital CBT may reduce the frequency of IBS-associated FI. Future studies should evaluate how brain-gut behavioral therapies can affect anorectal mechanosensory phenomena.

Evaluating Equity in Clinical Trial Accessibility: An Analysis of Demographic, Socioeconomic, and Educational Disparities in Irritable Bowel Syndrome Drug Trials

INTRODUCTION

Irritable bowel syndrome (IBS), a disorder of gut-brain interaction, imposes a significant economic burden because of its high prevalence and the chronic nature of its symptoms. IBS currently has 7 United States Food and Drug Administration-approved treatments. Despite efforts to improve diversity in randomized controlled trials' participation, significant disparities remain in various medical fields; yet, these have not been thoroughly examined within the context of IBS. We aimed to investigate the demographic, socioeconomic, educational, and geographic disparities in IBS drug trials.

METHODS

We conducted a systematic review of phase 3 randomized controlled trials on United States Food and Drug Administration-approved drugs for the treatment of IBS with constipation and IBS with diarrhea in the United States. Data on participant demographics and trial site locations were extracted and analyzed to identify disparities.

RESULTS

Our analysis included 17 studies encompassing 21 trials with 17,428 participants. Approximately 77.3% of participants were female, with a mean age of 45.4 years. Race was reported in 95% of the trials, but only 35% disclosed ethnicity. White participants constituted the majority at 79.3%. Hispanics accounted for only 5.9%. Counties without trial sites had smaller average population sizes compared with trial and trial-adjacent counties. Socioeconomic indicators such as poverty rates, median household income, educational attainment, and broadband internet access were lower in counties without trial sites, with higher average Area Deprivation Index scores indicating greater deprivation.

DISCUSSION

The findings highlight significant disparities in IBS trial participation across race, ethnicity, gender, and socioeconomic backgrounds. This raises potential concerns about generalizability of trial outcomes and underscores the need for strategies to enhance inclusivity in clinical research.

Classification of Irritable Bowel Syndrome Using Brain Functional Connectivity Strength and Machine Learning

BACKGROUND

Irritable Bowel Syndrome (IBS) is a prevalent condition characterized by dysregulated brain-gut interactions. Despite its widespread impact, the brain mechanism of IBS remains incompletely understood, and there is a lack of objective diagnostic criteria and biomarkers. This study aims to investigate brain network alterations in IBS patients using the functional connectivity strength (FCS) method and to develop a support vector machine (SVM) classifier for distinguishing IBS patients from healthy controls (HCs).

METHODS

Thirty-one patients with IBS and thirty age and sex-matched HCs were enrolled in this study and underwent resting-state functional magnetic resonance imaging (fMRI) scans. We applied FCS to assess global brain functional connectivity changes in IBS patients. An SVM-based machine - learning approach was then used to evaluate whether the altered FCS regions could serve as fMRI-based markers for classifying IBS patients and HCs.

RESULTS

Compared to the HCs, patients with IBS showed significantly increased FCS in the left medial orbitofrontal cortex (mOFC) and decreased FCS in the bilateral cingulate cortex/precuneus (PCC/Pcu) and middle cingulate cortex (MCC). The machine-learning model achieved a classification accuracy of 91.9% in differentiating IBS patients from HCs.

CONCLUSION

These findings reveal a unique pattern of FCS alterations in brain areas governing pain regulation and emotional processing in IBS patients. The identified abnormal FCS features have the potential to serve as effective biomarkers for IBS classification. This study may contribute to a deeper understanding of the neural mechanisms of IBS and aid in its diagnosis in clinical practice.

Elevated Fecal Biomarkers of Colo-Rectal Epithelial Cell Activity in Irritable Bowel Syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common functional gastro-intestinal disorder characterized by discomfort with constipation and/or diarrhea with unclear pathophysiology. We aimed to determine the activities of colorectal eosinophils, neutrophils and epithelial cells by biomarkers in feces reflecting these activities.

METHODS

Fecal samples were collected from 185 patients with IBS before and after 8 weeks of placebo or mesalazine treatment and from 40 healthy subjects. Calprotectin, eosinophil derived neurotoxin (EDN), eosinophil cationic protein (ECP), human neutrophil lipocalin (HNL) (pab/765) or dimer, human phospholipase BII-precursor (HPLBII-P) and myeloperoxidase (MPO) were measured by ELISA. Symptom scores were evaluated by diaries.

RESULTS

HPLBII-P, HNL (pab/765) and EDN, proteins secreted by intestinal epithelial cells, were elevated in IBS patients as compared to healthy subjects (p < 0.0001-p = 0.008). In contrast, the neutrophil proteins calprotectin, MPO and HNL dimer were unaltered. The eosinophilic protein ECP was lower in IBS (p = 0.001). HNL (pab/765) (p = 0.01) and EDN (p = 0.004) increased in IBS patients after mesalazine treatment. Colo-rectal mucosa showed strong staining of HPLBII-P and western blotting of fecal extracts showed the presence of mainly monomeric, epithelial-associated HNL.

CONCLUSIONS

The absence of signs of involvement of neutrophils and eosinophils in IBS suggests that activity of local epithelial cells rather than inflammation may be a major determinant of the disease. The measurements of EDN, HNL (pab/765), and HPLBII-P may serve as potential fecal biomarkers in the study and monitoring of IBS.

Rome Foundation Working Team Report on overlap in disorders of gut-brain interaction

In patients with disorders of gut-brain interaction (DGBI), overlapping non-gastrointestinal conditions such as fibromyalgia, headaches, gynaecological and urological conditions, sleep disturbances and fatigue are common, as is overlap among DGBI in different regions of the gastrointestinal tract. These overlaps strongly influence patient management and outcome. Shared pathophysiology could explain this scenario, but details are not fully understood. This overlap has been shown to be of great relevance for DGBI. In addition, symptoms considered to be caused by a DGBI could have a detectable organic cause, and in patients with a diagnosed organic gastrointestinal disease, symptoms not clearly explained by the pathology defining this organic disease are common. Thus, the aims of this Rome Foundation Working Team Report were to review the literature on overlapping conditions among patients with paediatric and adult DGBI and, based on the available epidemiological and clinical evidence, make recommendations for the current diagnostic and therapeutic approach, and for future research. Specifically, we focused on other DGBI in the same or different gastrointestinal anatomical region(s), DGBI overlap with organic bowel diseases in remission, and DGBI overlap with non-gastrointestinal, non-structural conditions.

Impact of Positive Glucose, Lactose, and Fructose Hydrogen Breath Tests on Symptoms and Quality of Life in Irritable Bowel Syndrome

BACKGROUND

Gas production due to fermentation from fructose malabsorption (FM) or lactose malabsorption (LM) and small intestinal bacterial overgrowth (SIBO) contribute to the development of gastrointestinal symptoms in patients with irritable bowel syndrome (IBS). However, the impact of the carbohydrate malabsorption, unlike SIBO, is relatively unknown.

METHODOLOGY

A multicenter, prospective study of consecutive adults with IBS who underwent a hydrogen breath test (HBT) (glucose, 75 g; lactose, 25 g; or fructose, 25 g) was conducted. The proportion of patients who tested positive for glucose, fructose and lactose HBT were evaluated. The symptom severity, psychology, and quality of life of subjects with SIBO were compared with those having LM and/or FM. Independent factors associated with severe IBS (IBS-symptom severity scale: IBS-SSS > 300) were explored.

RESULTS

A total of 116 subjects were included (median age 56 years, male 35.3%). Of these, 23.3% (27/116), 85.7% (24/28), and 44.4% (16/36) of them tested positive for glucose, lactose, and fructose HBT, respectively. Among those with a positive HBT (n = 65), patients with SIBO were more likely to have the diarrhea-predominant subtype of IBS (77.8% vs. 47.4%, p = 0.014). Severe IBS was associated with SIBO, compared with LM/FM (SIBO: 36.4% vs. LM: 9.1%/FM 13.3%, p = 0.016). With multivariate analysis, SIBO (OR 5.25, p = 0.028) and depression (OR 5.59, p = 0.030) were independently associated with severe IBS.

CONCLUSION

Although LM and FM commonly co-exist in IBS, their clinical relevance appears to be less significant than that of SIBO. The connection between SIBO with depression reinforces the importance of the microbiome-gut-brain axis in IBS.

[Opioid-induced constipation: Update on management and treatment]

Opioids are effective for acute and chronic pain management and are therefore an important treatment option for supportive care, especially in patients with cancer. They often induce digestive adverse effects, the most frequent being opioid-induced constipation (OIC), which is related to their action on μ receptors in the gastro-intestinal tract. These receptors play a role in the regulation of the gut motility and secretions. OIC has frequently been overlooked, although it can impair patients' comfort and compromise their compliance with opioid treatment. The consensus definition of OIC was established in 2016, and targeted therapies, the peripherally acting μ-opioid receptor antagonist (PAMORA) can yet specifically treat OIC without compromising pain relief. This review aims to explore the definition, pathophysiology, epidemiology, and diagnostic criteria of OIC. Risk factors and the necessary testing for the diagnostic work-up will be detailed. Finally, the impact of OIC on opioid treatment will be explained, and the treatment options, including non-pharmacological treatments, and pharmacological first-line and second-line therapies will be developed. A summary of the current therapeutic recommendations will be provided.

Complex and Bidirectional Interplay Between Marital Quality, Catastrophizing, Psychological Dysfunction, and Quality of Life in Married Malay Women With Disorder of Gut-Brain Interactions

BACKGROUND

Disorders of gut-brain interactions (DGBI) affect more women, and marital quality may have been a factor that explains clinical manifestations of DGBI-however, the mechanism is unclear. This study aimed to elucidate supported relationships between DGBI with marital quality and clinical attributes in married Malay women.

METHODS

This cross-sectional study involved married Malay women with functional dyspepsia (FD), irritable bowel syndrome (IBS), and FD-IBS overlap per Rome IV criteria. Multivariate analysis of variance (MANOVA) and Pearson correlation analysis were performed to determine the association between DGBI, marital quality, and clinical attributes of catastrophizing, psychological dysfunction, and quality of life. Path analysis models were developed, tested, and fitted to elucidate relationships that satisfied significance testing and fit indices (termed supported relationship).

KEY RESULTS

Of 1130 screened participants, 513 were analyzed. The prevalence of FD, IBS, and FD-IBS overlap was 33.9% (n = 174), 29.5% (n = 151), and 36.6% (n = 188), respectively. Of 17 variables in MANOVA, significant differences in variables were observed for FD vs. FD-IBS overlap (10), IBS versus FD (10), and IBS versus FD-IBS overlap (5). Pearson correlation matrices found significant correlations for 15 of 17 variables. After testing and fitting, the third path model (Model 3) was deemed the final model. Model 3 suggested that relationships between DGBI and marital and clinical attributes were complex and bidirectional. The number of supported relationships were 50, 43, and 39 for FD-IBS overlap, FD, and IBS, respectively.

CONCLUSIONS AND INFERENCES

Relationships between DGBI, marital quality, and clinical attributes among married Malay women are complex and bidirectional.

Association between AHR in EGCs and IBS-D patients: the indole pathway of tryptophan metabolism

Background

The pathophysiological mechanisms of irritable bowel syndrome (IBS) are intricate, and associated with tryptophan metabolites. This study was designed to investigate the relationship between indole metabolites in the feces and intestinal function in patients with IBS.

Methods

In this study, 42 patients with diarrhea-predominant IBS (IBS-D) and 36 healthy controls were recruited. The symptom severity was evaluated using IBS-quality of life (IBS-QOL) and IBS symptom severity system (IBS-SSS). The levels of indole metabolite in fecal samples were determined by means of mass spectrometry. Colon mucosal tissues were collected during colonoscopy procedures. Immunohistochemistry or immunofluorescence techniques were employed to analyze the expressions of the aryl hydrocarbon receptor (AHR), cytochrome P450 1A1 (CYP1A1), glial fibrillary acidic protein (GFAP), S100 calcium-binding protein B (S100B), zonula occludens-1 (Zo-1), occludin, substance P (SP), nerve growth factor (NGF), NOD-like receptor family pyrin domain containing 3 (NLRP3), and nuclear factor kappa B (NF-κB) in the mucosal tissues.

Results

Compared with healthy controls, the concentrations of the main indole metabolites (p = 0.020), and the expressions of CYP1A1 (p < 0.001), and Zo-1 (p = 0.017) were decreased in patients with IBS-D, but the expressions of S100B (p < 0.001), NF-κB (p = 0.006), and NRLP3 (p = 0.041) were increased. Immunofluorescence analysis demonstrated the co-expression of AHR with GFAP or S100B. Moreover, the ratio of S100B/AHR (p = 0.011) was higher in IBS-D patients than in health controls. This ratio was positively correlated with IBS-SSS score (r = 0.47, p = 0.006), as well as with the expression levels of NRLP3 (r = 0.505, p = 0.019), NF-κB (r = 0.548, p = 0.01), and SP (r = 0.832, p < 0.01).

Conclusion

Patients with IBS-D exhibited low-grade inflammation in the colon mucosal tissues, compromised intestinal barrier function, and abnormal visceral sensation. This may be attributed to the decreased levels of tryptophan indole metabolites, the heightened activity of enteric glial cells (EGCs), and the inhibition of AHR/CPY1A1 signaling pathway.

Diet therapy (The 8×5 Diet) for adults living with bile acid diarrhoea: protocol for a feasibility randomised controlled trial

INTRODUCTION

A national research priority for people living with bile acid diarrhoea (BAD) is effective treatment options to improve their quality of life. This study aims to evaluate the feasibility of conducting a randomised controlled trial (RCT) of a novel healthy dietary pattern (The 8×5 Diet) to inform a future, larger trial.

METHODS AND ANALYSIS

We plan to enrol 76 UK adults living with BAD and ongoing diarrhoea using self-selection sampling and digital technologies. Eligible participants will be assigned to groups using permuted block randomisation using 1:1 allocation to receive either 8 weeks of usual care or The 8×5 Diet using one-to-one, dietitian counselling via a video-conferencing platform and developed digital resources. Randomisation, consent, recruitment, retention and acceptability will be evaluated using data from the RCT and post-trial interviews conducted with those in the intervention group. Secondary outcome exploratory assessment will include health-related quality of life, symptom relief, diarrhoea, diet quality, nutrient intakes and diet satisfaction.

ETHICS AND DISSEMINATION

Ethical approval was granted by the University of Manchester Research Ethics Committee (2024-19094-33261; V1.7, last updated: 24/02/2025).Findings will be disseminated through peer-reviewed publication, conference presentation and social media.

TRIAL REGISTRATION NUMBER

NCT06259396.

Colonic mucosal TRPA1 expression profiles in irritable bowel syndrome and its correlation to symptom severity: An exploratory study

INTRODUCTION

Visceral hypersensitivity is a hallmark of irritable bowel syndrome (IBS). A putative involvement of the Transient Receptor Potential Ankyrin-1 (TRPA1) cation channel has been suggested by several animal studies. Main objective of this study is to assess location-specific TRPA1 expression in the colonic mucosa and its correlation with symptom severity in IBS patients.

METHODS

Biopsies were obtained from the sigmoid of 30 IBS patients (Rome III; median age 39.0 years, 80 % female) and 23 healthy controls (median age 22.7 years, 43.5 % female). Additional biopsies of the proximal colon were obtained in 24 IBS patients. TRPA1 expression levels were measured in duplicate by quantitative reverse-transcriptase-polymerase-chain-reaction, normalized to GAPDH, and assessed as relative mRNA values using the -2ΔCt method. In IBS patients, symptoms were assessed and correlated with TRPA1 expression.

RESULTS

Relative TRPA1 expression in the sigmoid was significantly higher in IBS patients compared to healthy controls (P < 0.001). Within IBS patients TRPA1 expression of sigmoid biopsies was significantly higher compared to proximal colon samples (p < 0.001). No significant correlation was found between TRPA1 expression in sigmoid or proximal colon samples and the symptom severity (abdominal discomfort, abdominal pain and bloating).

CONCLUSION

These findings suggest a potential role for the TRPA1 related pathway as a target for IBS treatment in the future. Since there was no correlation found in the current exploratory study between TRPA1 expression and symptom severity, further research towards the clinical relevance of the increased TRPA1 expression in IBS-patients along with its location-specific expression is warranted.

Laxative Effect of Crataegus azarolus Leaves Decoction Extract Against Loperamide-Induced Constipation and Oxidative Stress in Rats

Constipation represents a common gastrointestinal disorder that has various adverse effects on the gastrointestinal tract. As a result, various civilizations have developed phytomedicines in order to treat and relieve its symptoms. In the current study, we evaluated the effect of Crataegus azarolus L. leaves decoction extract (CALDE) against loperamide (LOP)-induced constipation in rats. For 3 days, treated rats were administered LOP (3 mg/kg, b.w., p.o.) and CALDE (50, 100, and 200 mg/kg, b.w., p.o.) or yohimbine (2 mg/kg, b.w., p.o.). The gastric emptying test or intestinal transit time was calculated. The oxidative status was studied and evaluated using biochemical colorimetric methods. Results showed that CALDE administration improves gastric emptying and accelerates gastrointestinal transit. Pretreatment with LOP altered the defecation parameters and generated an oxidative status in healthy rats. In contrast, CALDE coadministration protected against the deregulation of intestinal motor function and frequency of defecation and significantly re-established oxidative marker levels. CALDE treatment demonstrated significant protection against experimental oxidative stress and constipation induced by LOP. Therefore, it can be considered a pharmacological drug to treat these gastrointestinal troubles.

Is there a sex difference in response to FODMAP diet group education for IBS? A clinical practice service evaluation

Background: While the low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet, low FODMAP diet (LFD) has demonstrated effectiveness in managing irritable bowel syndrome (IBS) symptoms, little is known about sex-specific responses to this dietary intervention. Aim: This study evaluates the role of sex differences in symptom improvement following a dietitian-led, group education session on the LFD for IBS patients. Methods: A total of 305 patients, including 249 with a diagnosis of IBS and 56 classified as having suspected IBS, were enrolled in this study (79.7% female). Patients attended two group education sessions on the LFD. Primary outcomes were measured using the IBS Symptom Severity Score (IBS-SSS) and the Global Symptom Question (GSQ). Secondary outcomes included stool frequency, stool consistency and individual symptoms assessed by the Gastrointestinal Symptom Rating Scale. Statistical analyses were performed to compare baseline and follow-up data within and between sexes. Results: Both male and female patients experienced significant reductions in IBS-SSS scores and improvements in GSQ satisfactory relief, stool frequency, stool consistency and individual gastrointestinal (GI) symptoms following the LFD (p < 0.05). There were no significant between-sex differences in the extent of symptom relief (p > 0.05). Conclusion: The study found no significant sex-based differences in symptom reduction or GI relief following the intervention. These findings suggest that, despite differing symptom profiles and IBS prevalence, both male and female patients achieve similar relief with the LFD group education.

Decoding Abdominal Pain in Constipation-predominant Irritable Bowel Syndrome and Functional Constipation: Mechanisms and Managements

PURPOSE OF REVIEW

Abdominal pain in constipation-predominant irritable bowel syndrome (IBS-C) and functional constipation (FC) remains a difficult clinical challenge due to unclear pathophysiological mechanisms and limited pain-targeted treatments. This review critically evaluates the evidence on the underlying pain mechanisms in IBS-C and/or FC and explores management strategies, their limitations, and future directions.

RECENT FINDINGS

Most research on constipation-related pain is based on IBS-C patients or animal models, with limited studies focusing on FC. Visceral hypersensitivity, serotonin dysregulation, gut-brain axis dysfunction, and central/peripheral nervous system alterations are implicated in IBS-C pain, while FC pain is less studied and may be primarily linked to colonic distension and motility dysfunction. Management strategies include 5-HT4 agonists, GC-C agonists, chloride channel activators, psychological therapies, probiotics and complementary medicine. Despite available treatment options, managing abdominal pain in IBS-C and FC remains challenging due to heterogeneous pathophysiology and limited targeted therapies. While some interventions provide symptomatic relief, there is no universally effective treatment for abdominal pain across all patients. Future research should focus on identifying pain-specific biomarkers, refining diagnostic criteria, and integrating multi-omics data and neuroimaging techniques to better distinguish pain mechanisms in IBS-C versus FC and develop more precise, patient-centered interventions.

A Probiotic Mixture of Lactobacillus rhamnosus LR 32, Bifidobacterium lactis BL 04, and Bifidobacterium longum BB 536 Counteracts the Increase in Permeability Induced by the Mucosal Mediators of Irritable Bowel Syndrome by Acting on Zonula Occludens 1

Irritable Bowel Syndrome (IBS) is a disorder of gut- brain interaction characterized by recurrent abdominal pain associated with altered bowel habits. The therapeutic options for IBS patients include the use of probiotics. The aim of this study was to assess the effect of a multi-strain probiotic made up by Lactobacillus rhamnosus LR 32, Bifidobacterium lactis BL 04, and Bifidobacterium longum BB 536 (Serobioma, Bromatech s.r.l., Milano, Italy) on an in vitro model of the intestinal epithelial barrier in the presence of mucosal mediators that are released by IBS patients. IBS (n = 28; IBS with predominant diarrhea, IBS-D = 10; IBS with predominant constipation, IBS-C = 9; and IBS with mixed bowel habits, IBS-M = 9) patients, diagnosed according to the Rome IV criteria, and asymptomatic controls (ACs, n = 7) were enrolled. Mucosal mediators that were spontaneously released by colonic biopsies were collected (supernatants). Two doses of Serobioma were tested with/without IBS/AC mediators. RNA was extracted from Caco-2 cells to evaluate the tight junction (TJ) expression. Serobioma (106 CFU/mL) significantly reinforced the Caco-2 monolayer compared to growth medium alone (p < 0.05). IBS supernatants significantly increased Caco-2 paracellular permeability compared to the AC supernatants. The co-incubation of Caco-2 cells with IBS supernatants and Serobioma (106 CFU/mL) avoided the paracellular permeability alterations that were induced by IBS supernatants alone (p < 0.001), and, in particular, IBS-D and IBS-M ones. The co-incubation of Serobioma (106 CFU/mL) and IBS-D supernatants significantly increased ZO-1 expression compared to Caco-2 cells incubated with supernatants alone (p < 0.05), as confirmed via qPCR analyses. Serobioma (106 CFU/mL) counteracts the paracellular permeability changes that are induced by IBS supernatants, in particular IBS-D and IBS-M supernatants, likely modulating ZO-1 expression.

Synthesis, Cytotoxic and Genotoxic Evaluation of Drug-Loaded Silver Nanoparticles with Mebeverine and Its Analog

Background: Irritable bowel syndrome (IBS) is a prevalent gastrointestinal disorder with a complex pathogenesis that necessitates innovative therapeutic approaches for effective management. Among the commonly used treatments, mebeverine (MBH), an antispasmodic, is widely prescribed to alleviate IBS symptoms. However, challenges in delivering the drug precisely to the colonic region often hinder its therapeutic effectiveness. To address this limitation, silver nanoparticles (AgNPs) have emerged as promising drug delivery systems, offering unique physicochemical properties that can enhance the precision and efficacy of IBS treatments. Objectives: This study aimed to synthesize AgNPs as drug delivery vehicles for MBH and a previously reported analog. The research focused on evaluating the cytotoxic and genotoxic effects of the AgNPs and forecasting their possibly harmful effects on future sustainable development. Methods: AgNPs were synthesized using a rapid method and functionalized with MBH and its analog. The nanoparticles were characterized using different techniques. Cytotoxicity and genotoxicity were evaluated in vitro. Additionally, in silico docking analyses were performed to explore their safety profile further. Results: In vitro assays revealed concentration-dependent cytotoxic effects and a lack of genotoxic effects with MBH-loaded AgNPs. A molecular docking simulation was performed to confirm this effect. Conclusions: The study underscores the potential of AgNPs as advanced drug delivery systems for safe and significant therapeutic implications for IBS. Future in vivo and preclinical investigations are essential to validate the safe range of exposure doses and evaluation standards for assessing AgNPs' safety in targeted and personalized medicine.

Etiologies of exocrine pancreatic insufficiency

Exocrine pancreatic insufficiency (EPI) is a major cause of maldigestion and malnutrition, resulting from primary pancreatic diseases or other conditions. As the prevalence of EPI continues to rise, accurate identification of its etiology has become critical for the diagnosis and treatment of pancreatic secretory insufficiency. EPI can result from both pancreatic and non-pancreatic disorders. Pancreatic disorders include acute and chronic pancreatitis, pancreatic tumors, cystic fibrosis, procedures that involve pancreatic resection, and other rare causes. Non-pancreatic disorders of EPI include diabetes mellitus, celiac disease, inflammatory bowel disease, gastrointestinal and esophagectomy surgery, as well as advanced patient age. This review aims to provide a comprehensive analysis of the literature on EPI etiology, with a thorough overview to support its consideration as a potential diagnosis.

Prevalence of Irritable Bowel Syndrome Based on Rome IV Criteria in Patients in Biochemical and Endoscopic Remission From Newly Diagnosed Inflammatory Bowel Disease: One- and Three-Year Results (the IBSEN III Cohort)

BACKGROUND

Distinguishing irritable bowel syndrome (IBS) from inflammatory bowel disease (IBD) flare-ups is challenging. This study used objective remission markers to accurately determine IBS prevalence in a population-based cohort of patients with IBD.

METHODS

Adults with ulcerative colitis and Crohn's disease were recruited from the IBD in South-Eastern Norway III cohort study. Irritable bowel-like symptoms were assessed using the Rome IV criteria for patients in remission from IBD at 1- and 3-year follow-ups. Remission was defined objectively using the biochemical marker fecal calprotectin (FC) ≤ 250 µg/g, and comparisons to remission based on endoscopic indices were made at 1-year follow-up.

RESULTS

Among patients with FC ≤ 250 µg/g, IBS prevalences were 21.9% (n = 62/283) and 16.1% (n = 49/304) at the 1- and 3-year follow-ups, respectively, which were higher than that in the Norwegian population (9.5%; P < .005). Of patients in endoscopic remission at 1-year follow-up, 19.2% (n = 43/224) reported IBS-like symptoms, which was not significantly different from IBS prevalence for patients with FC ≤ 250 µg/g. Irritable bowel syndrome was independently associated with substantial fatigue (odds ratio: 3.05 [95% CI, 1.48-6.27]) and female sex (odds ratio: 2.67 [95% CI, 1.34-5.32]) at the 1-year follow-up. Patients with IBS reported significantly reduced health-related quality of life (HRQoL) scores.

CONCLUSIONS

The prevalence of IBS among patients in remission from IBD was approximately twice as common as that in the Norwegian population. Irritable bowel syndrome was independently associated with substantial fatigue, female sex, and reduced HRQoL.

Functional Foods and Nutraceuticals in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction, with a multifactorial pathophysiology involving gut-brain axis dysregulation, visceral hypersensitivity, microbiota imbalance, and immune dysfunction. Traditional IBS management emphasizes dietary modifications and pharmacologic therapies. However, increasing attention has been directed toward functional foods, nutraceuticals, and herbal remedies due to their potential to target IBS pathophysiological mechanisms with favorable safety profiles. This clinical review explores the role of these adjunctive therapies, evaluating evidence from preclinical and clinical studies. Functional foods such as kiwifruit, prunes, and rye bread demonstrate benefits in bowel habit regulation through fiber content and microbiota modulation. Nutraceuticals like peppermint oil, palmitoylethanolamide, and herbal mixtures exhibit anti-inflammatory, antispasmodic, and analgesic effects. Prebiotics provide substrate-driven microbiota changes, although dosage is key, as given their fermentative properties, when used at high dosages, they can exacerbate symptoms in some individuals. Probiotics and postbiotics offer microbiota-based interventions with promising symptom relief in IBS subtypes, although factors for personalized treatment still need to be further elucidated. These strategies highlight a paradigm shift in IBS management, integrating diet-based therapies with evolving nutraceutical options to improve patient outcomes. Despite promising findings, challenges in standardizing definitions, mechanisms, and safety profiles still remain. Rigorous, large-scale trials to validate the therapeutic potential of these interventions are needed, to enhance the benefits of these compounds with an individualized treatment approach.

Quality of life, functional impairment and healthcare experiences of patients with irritable bowel syndrome in Norway: an online survey

BACKGROUND

The present study is an online survey to determine the quality of life and functional impairment caused by irritable bowel syndrome (IBS) and the healthcare experiences of IBS patients in Norway, which has not been done previously.

METHODS

An author-developed, online questionnaire using Microsoft Forms program was applied. The questionnaire comprised 52 questions. The questionnaire was posted from 1 March to 17 April (a 48-day period) on the Norwegian Gastrointestinal Association website and in its magazine and social media posts.

RESULTS

The questionnaire was completed by 2727 patients. Of these patients 327 were excluded because they have not been diagnosed by a medical doctor. IBS reduced the quality of life in 97% of affected patients, including the social life in 90% and the sexual life in 69%. The unemployment rate of IBS patients in Norway 38%, which is 10-fold higher than that of the general population, and 94% of IBS patients reported that IBS impaired their work/study performance. About half of the patients had to discuss their abdominal symptoms with their general practitioner (GP) more than 10 times and wait more than 1 years before being diagnosed. Only 34% and 48% were satisfied with the help they received from their GP and gastroenterologist, respectively. Only 18% and 43% of the IBS patients felt that their GP and gastroenterologist, respectively, were sufficiently knowledgeable about IBS. Only 21% of the IBS patients was satisfied with the treatment they received.

CONCLUSIONS

IBS markedly reduces the affected patient's quality of life and their working productivity. IBS patients are generally dissatisfied with the clinical management they receive from GPs and gastroenterologists.

Naloxegol for the Treatment of Opioid-Induced Constipation in Patients with Cancer Pain: A Pooled Analysis of Real-World Data

OBJECTIVE

The aim of the NALOPOOL project was to assess the efficacy and safety of naloxegol in patients with cancer pain who exhibited opioid-induced constipation (OIC) and were treated under real-world conditions.

METHODS

We pooled individual patient data from three multicenter observational studies conducted with naloxegol in patients with cancer who exhibited OIC and were prescribed naloxegol under real-world conditions. Efficacy outcomes were evaluated after 4 weeks of treatment. All analyses were performed via a visit-wise approach. Heterogeneity was assessed via Cochran's Q-test or Levene's test.

RESULTS

Spontaneous bowel movements (SBM) response (≥3 SBM per week and an increase of ≥1 from baseline; three studies) was reported in 223 of 314 evaluable patients (71%, 95% CI 66-76); clinically relevant improvement in the Patient Assessment of Constipation Quality-of-Life Questionnaire (>0.5 points; three studies) occurred in 179 of 299 evaluable patients (60%, 95% CI 56-74) and in the Patient Assessment of Constipation Symptoms (>0.5 points; two studies) was reported in 131 of 190 evaluable patients (69%, 95% CI 62-76); and clinically relevant improvement in the Bowel Function Index (score ≥ 12 points at the endpoint; two studies;) was reported in 133 of 195 evaluable patients (68%, 95% CI 62-75). No significant heterogeneity was found for any efficacy outcome. The pooled proportion of patients who discontinued the drug owing to adverse reactions was 6.1% (95% CI 3.8% to 8.4%).

CONCLUSIONS

Our results support the use of naloxegol for the management of OIC in patients with cancer pain who do not respond to laxative treatment.

Why Symptoms Linger in Quiescent Crohn's Disease: Investigating the Impact of Sulfidogenic Microbes and Sulfur Metabolic Pathways

INTRODUCTION

Even in the absence of inflammation, persistent symptoms in patients with Crohn's disease (CD) are prevalent and worsen quality of life. We previously demonstrated enrichment in sulfidogenic microbes in quiescent Crohn's disease patients with (qCD + S) vs without persistent GI symptoms (qCD-S). Thus, we hypothesized that sulfur metabolic pathways would be enriched in stool while differentially abundant microbes would be associated with important sulfur metabolic pathways in qCD + S.

METHODS

We performed a multicenter observational study nested within SPARC IBD. Quiescent inflammation was defined by fecal calprotectin level < 150 mcg/g. Persistent symptoms were defined by CD-PRO2. Active CD (aCD) and non-IBD diarrhea-predominant irritable bowel syndrome (IBS-D) were included as controls.

RESULTS

Thirty-nine patients with qCD + S, 274 qCD-S, 21 aCD, and 40 IBS-D underwent paired shotgun metagenomic sequencing and untargeted metabolomic profiling. The fecal metabolome in qCD + S was significantly different relative to qCD-S and IBS-D but not aCD. Patients with qCD + S were enriched in sulfur-containing amino acid pathways, including cysteine and methionine, as well as serine, glycine, and threonine. Glutathione and nicotinate/nicotinamide pathways were also enriched in qCD + S relative to qCD-S, suggestive of mitochondrial dysfunction, a downstream target of H2S signaling. Multi-omic integration demonstrated that enriched microbes in qCD + S were associated with important sulfur metabolic pathways. Bacterial sulfur metabolic genes, including CTH, isfD, sarD, and asrC, were dysregulated in qCD + S. Finally, sulfur metabolites with and without sulfidogenic microbes showed good accuracy in predicting the presence of qCD + S.

DISCUSSION

Microbial-derived sulfur pathways and downstream mitochondrial function are perturbed in qCD + S, which implicate H2S signaling in the pathogenesis of this condition. Future studies will determine whether targeting H2S pathways results in improved quality of life in qCD + S.

Safety of Naldemedine for Opioid-Induced Constipation - A Systematic Review and Meta-Analysis

Naldemedine is a peripheral acting µ-opioid receptor antagonist approved by the Food and Drug Administration to treat opioid-induced constipation. Concerns about side effects like opioid withdrawal prevent its widespread use, especially for cancer patients. We performed this systematic review and meta-analysis to evaluate existing safety data of naldemedine treating opioid-induced constipation following the PRISMA guidelines. We searched PubMed and the Cochrane Library on April 16th 2024 to identify studies evaluating naldemedine treatment among patients with opioid-induced constipation. Our analysis found no differences between groups comparing naldemedine therapy with placebo-control for treatment-emergent adverse events (OR = 1.06; 95%-CI: 0.91-1.24), serious adverse events (OR = 1.02; 95%-CI: 0.76-1.38). We found no increased risk for opioid withdrawal, while an increased risk for gastrointestinal disorders (OR = 2.08; 95%-CI: 1.72-2.51), particularly higher incidences of diarrhea (OR = 2.44; 95%-CI: 1.81-3.29) and abdominal pain (OR = 3.31; 95%-CI: 2.16-5.06) were found. In the cancer subgroup, treatment-emergent and serious adverse events were more frequent. However, no increased risk for opioid withdrawal was observed. This analysis confirms naldemedine's overall safety in treating opioid-induced constipation, with manageable gastrointestinal side effects. However, the higher adverse events in cancer patients require further investigation to ensure safe use in this population.

Intestinal Permeability in Disorders of Gut-Brain Interaction: From Bench to Bedside

Intestinal barrier function lies at a critical interface of a range of peripheral and central processes that influence disorders of gut-brain interactions (DGBI). Although rigorously tested, the role of barrier dysfunction in driving clinical phenotype of DGBI remains to be fully elucidated. In vitro, in vivo, and ex vivo strategies can test various aspects of the broader permeability and barrier mechanisms in the gut. Luminal mediators of host, bacterial, and dietary origin can influence the barrier function and a disrupted barrier can also influence the luminal milieu. Critical to our understanding is how barrier dysfunction is influenced by stress and other comorbidities that associate with DGBI and the crosstalk between barrier and neural, hormonal, and immune responses. Additionally, the microbiome's significant role in the communication between the brain and gut has led to the integrative model of a microbiome gut-brain axis with reciprocal interactions between brain networks and networks composed of multiple cells in the gut, including immune cells, enterochromaffin cells, gut microbiota and the derived luminal mediators. This review highlights the techniques for assessment of barrier function, appraises evidence for barrier dysfunction in DGBI including mechanistic studies in humans, as well as provides an overview of therapeutic strategies that can be used to directly or indirectly restore barrier function in DGBI patients.

Exploring Dietitians' Perspectives Toward Current Practices and Services in Relation to Irritable Bowel Syndrome Management in Clinical Settings Across the United Kingdom: A Qualitative Study

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic and relapsing gastrointestinal condition that negatively impacts quality of life. Dietary triggers are common and dietary management is central to the IBS treatment pathway, and dietitians are the main education providers for patients.

OBJECTIVE

The aim of this study was to explore dietitians' perspectives on current practices and services in relation to IBS management in clinical settings across the United Kingdom.

DESIGN

Qualitative semi-structured interviews were undertaken from May to October 2021 via videoconferencing software. Eligible participants were dietitians specializing in gastroenterology and working in National Health Service (NHS) Trusts in the United Kingdom. Interviews were audio recorded and transcribed following intelligent transcription. Template analysis guided by naïve realism and its underlying epistemological assumptions was used.

PARTICIPANTS/SETTING

Dietitians (N = 13) working in various NHS Trusts across the United Kingdom with at least 1 year of clinical experience in IBS management were included.

QUALITATIVE DATA ANALYSIS

Template analysis, a form of thematic analysis with hierarchical coding, was used to explore dietitians' perspectives of IBS practices.

RESULTS

Participating dietitians were mostly female (92.3%), of White race (84.6%), working in various NHS Trusts across the United Kingdom, and had more than 5 years of clinical experience (69.2%). The following 3 main themes emerged: 1) dietetics services as part of IBS referral pathways; 2) practices in relation to dietetics services; and 3) patients' expectations and feelings. Each main theme had subthemes to facilitate the description and interpretation of data. The increasing number of IBS referrals to dietitians and the need for accurate and timely IBS diagnosis and specialist dietitians were reported, along with the use of digital innovation to facilitate practice and access to dietetic care. The use of internet as a source of (mis)information by patients and the limited time available for educating patients were identified as potential barriers to dietetic practice. Dietitians follow a patient-centered approach to dietary counseling and recognize the negative implications of perceived IBS-related stigma by patients on their feelings and treatment expectations.

CONCLUSIONS

The study identified areas and practices that can facilitate access to dietetic services and patient-centered care in IBS management, as outlined in UK-based guidelines.

Functional constipation is associated with long-term clinical failure after gastric per-oral endoscopic myotomy for the treatment of gastroparesis

BACKGROUND

This study investigates the role of functional constipation (FC) in predicting the long-term success of Gastric Per-oral Endoscopic Myotomy (G-POEM) for treating gastroparesis.

METHODS

This was a retrospective observational study. Patients who underwent G-POEM between July 2015 and August 2022 with > 6-month follow-up were included. The primary objective was to evaluate the relationship between FC and G-POEM success. Secondary objectives included documenting the role of other digestive motility disorders, history of eating disorders, chronic opioid use, and cannabis use. Multivariate logistic regression analysis was used to evaluate the relationship between clinical success and various parameters, including FC.

RESULTS

80 patients were included, 58 women (72.5%) and 22 men (27.5%) with a mean age of 51.78 years. The mean follow-up was 3.4 years. Clinical success was observed in 52.5% of the patients' post-G-POEM. 42.5% had FC, 17.7% had esophageal motility disorders (EMD), and 13.9% had other motility disorders. In univariate analysis, FC and EMD were more frequent in patients with failure: 57.89 vs 28.57%, p = 0.015 and 28.95 vs 7.32%, p = 0.017, respectively. In multivariate analysis, the presence of FC (OR = 0.281 [0.105; 0.75], p = 0.0113) was the only predictive factor for success.

CONCLUSION

FC emerged as a significant predictor of lower clinical success rates after G-POEM. It suggests that an expanded gastrointestinal evaluation and treatment of other motility disorders may improve the outcomes for patients with gastroparesis treated with G-POEM.

Predictors of response to a dietary intervention in patients with irritable bowel syndrome

BACKGROUND

Different diets have emerged as potential therapeutic options for patients with irritable bowel syndrome (IBS).

OBJECTIVE

To identify predictors of improvement after a low-FODMAP, low-starch and low-sucrose diet among patients with IBS.

METHODS

We performed a descriptive cross-sectional study including patients with IBS according to Rome IV criteria undertaking a social-media based program with a two-week dietary intervention. Patients completed an online survey before and after the intervention including the presence of intestinal and extra-intestinal symptoms, the IBS-SSS (irritable bowel syndrome symptoms severity scale) and the PHQ-9 (patient health questionnaire-9). Clinical improvement was defined as a decrease of at least 50% in IBS-SSS post dietary intervention. Variables associated with symptomatic response were identified with logistic regression analysis. A clinical score to predict response was created and tested with a with a receiver operating characteristic (ROC) curve analysis.

RESULTS

A total of 3583 patients with IBS were included. Mean IBS-SSS before and after dietary intervention was 295.5±52.32 and 240±48.66, respectively (p=0.01); 1178 (32.8%) patients showed clinical improvement. A mean basal IBS-SSS >400 (OR 3.04), chronic headache (OR 1.96), and chronic fatigue (OR 1.81) were significantly associated with symptomatic response. Patients with arthralgia (OR 0.41) and/or fibromyalgia (OR 0.33) were less likely to improve. Each variable received the following individuals scores: IBS-SSS >400: +2, chronic headache: +1.5, chronic fatigue: +1, arthralgia: -1, and fibromyalgia: -1. The ROC curve analysis of the proposed score showed an area under the curve of 0.72 (95% CI 0.69-0.76). A score ≥3 had a sensitivity of 72.64% and specificity of 60.56% for predicting symptomatic improvement.

CONCLUSIONS

There are clinical variables that could serve as reliable predictors of response to a low-FODMAP, low-sucrose, low-starch diet among patients with IBS. Further research is needed to understand the link between the presence of extra-intestinal symptoms and clinical improvement after dietary interventions for IBS.

Clinical Trial: Study to Investigate the Efficacy and Safety of the Alpha-2-Delta Ligand PD-217,014 in Patients With Irritable Bowel Syndrome

INTRODUCTION

Despite the emergence of drugs to treat irritable bowel syndrome (IBS), improving abdominal pain can still be challenging. α2δ ligands, such as gabapentin and pregabalin, are sometimes used off-label to tackle this problem. However, evidence for efficacy is limited, and no large-scale studies have been published.

AIM

To study the efficacy of the α2δ ligand PD-217,014 in IBS.

METHODS

This multi-centre, double-blind, randomised, placebo-controlled, parallel group study randomised participants with Rome II-defined IBS to 150 or 300 mg b.d. of PD-217,014 or placebo b.d. for 4 weeks. The primary efficacy endpoint was responder, defined as having adequate relief of abdominal pain/discomfort for ≥ 50% of the active treatment period. Key secondary endpoints were change from baseline in abdominal pain, bloating, stool frequency/consistency, and global assessment of IBS symptoms.

RESULTS

We randomised 330 participants [aged 19-73 years; 209 (65%) female] satisfying Rome II criteria, 322 (98%) were treated, and of whom 271 (84%) completed the study. In this study, 321 satisfied Rome IV criteria. Neither dose of PD-217,014 improved the percentage of participants reporting adequate relief of abdominal pain/discomfort compared with placebo, either using the Rome II-defined total cohort or Rome II and IV IBS bowel habit sub-types. There were similar observations for secondary endpoints, and no association between abdominal pain or anxiety levels at baseline with participant improvement. PD-217,014 was generally well tolerated.

CONCLUSION

This first large, dose-ranging trial examining the efficacy of PD-217,014 showed no significant efficacy in participants with IBS or bowel habit sub-types, irrespective of their pain and anxiety levels.

Irritable bowel syndrome remains a complex disorder of gut-brain interaction: Too many actors on stage

The recent study published in the World Journal of Gastroenterology examines the interplay among the neuroendocrine axis, gut microbiota, inflammatory markers, and gastrointestinal symptoms in irritable bowel syndrome (IBS). By integrating all these factors into a single study, this approach reflects the modern concept of functional gastrointestinal disorders as disorders of the gut-brain interaction to be approached in a multiparametric manner, also incorporating non-gastroenterological elements and extending evaluations to parameters related to the neuroendocrine axis. This invited letter to the editor summarizes the main results of the aforementioned study and highlights its multiparametric approach, including variables not strictly gastroenterological, in the study of IBS, and discusses its strengths and limitations.

Ultrasonographic assessment of gastric and gallbladder dynamics in human health and disease

The diagnosis of functional disorders of the upper gastrointestinal tract relies on clinical evaluation after exclusion of most frequent organic diseases. Diagnostic techniques contribute to better characterization of disease, choice of specific therapy, and follow-up. Functional ultrasonography was introduced in the early '80 s for the non-invasive study of gastric and gallbladder emptying without ionizing radiation, during fasting and postprandially. This technique detects dysfunctional motility in several gastrointestinal and systemic conditions, and can be used along with the assessment of real-time satiety and gastrointestinal symptoms after food ingestion, and dosing of hormones involved in the modulation of gastrointestinal and metabolic homeostasis. Functional ultrasonography has been increasingly used to explore the gastrointestinal pathophysiology, the gut-brain interaction, the effects of drugs (such as antidiabetics), the response to specific dietary and feeding patterns, and to support the development of nutraceuticals. In this evolving scenario, ultrasonography stands as a widely available, highly sustainable, non-invasive, repeatable, safe and low-cost tool, as compared with more expensive, less sustainable or still scarcely standardized procedures to study gastric and gallbladder motility as scintigraphy, wireless motility capsule tests, 13C breath tests, or magnetic resonance imaging. Functional ultrasonography not only provides reliable data in experimental protocols, but also in the assessment of clinical conditions as dyspeptic symptoms, diabetes, gastroenteric and neurological diseases, critical illness, and as a benchmark to evaluate the gastrointestinal effects of innovative drugs.

Complex Probiotics Ameliorate Fecal Microbiota Transplantation-Induced IBS in Mice via Gut Microbiota and Metabolite Modulation

Background/Objectives: Irritable bowel syndrome (IBS) is a highly prevalent functional gastrointestinal disorder. Emerging evidence implicates gut microbiota dysbiosis in IBS pathogenesis, and probiotic interventions targeting microbial modulation hold therapeutic promise. Methods: this study used fecal microbiota transplantation to establish a mouse model of IBS before evaluating the effects of the complex probiotic by using metagenomics and targeted metabolomics to explore the potential mechanism. Results: After 14 days, the probiotic relieved constipation, reduced inflammation and intestinal permeability, lowered 5-HT levels and increased serotonin transporter (SERT) expression in tissues. Metagenomic analysis showed a reduced inflammation-related species abundance. It also decreased fecal butyric acid, acetic acid and tryptophan levels in IBS mice. Conclusions: The probiotic complex effectively alleviated IBS symptoms in mice by modulating gut microbiota and fecal metabolites, providing insights for future IBS research and treatment.

Brain activity during a public-speaking situation in virtual reality in patients with irritable bowel syndrome and functional dyspepsia

BACKGROUND

Psychosocial stress plays a central role in the pathophysiology of disorders of gut-brain interactions (DGBI), including functional dyspepsia (FD) and irritable bowel syndrome (IBS). Brain activity during psychosocial stress in patients with DGBI has not been adequately investigated. In this prospective study, we aimed to explore brain activity during psychosocial stress in patients with DGBI.

METHODS

Situations in an unmanned room, public space without attention, and public speaking were simulated in a virtual reality (VR) environment. Subjective stress, emotional state, and gastrointestinal (GI) symptoms were assessed using a visual analog scale, the State-Trait Anxiety Inventory, and the GI Symptom Rating Scale, respectively. Electrocardiograms were recorded to evaluate autonomic function. Activity in the prefrontal cortex (PFC) was examined using functional near-infrared spectroscopy (fNIRS).

RESULTS

Overall, 15 healthy controls, 15 patients with IBS, and 15 patients with FD were included. In the public-speaking scenario, subjective stress scores significantly decreased (indicating more stress) and sympathetic nervous activity increased equally among the three groups compared with those in an unmanned scene. Patients with IBS had higher activity in the left ventrolateral prefrontal cortex (VLPFC) and lower activity in the dorsolateral PFC (DLPFC) than those with FD and healthy controls.

CONCLUSIONS

Brain activity increased in the VLPFC and decreased in the DLPFC under stressful psychosocial situations created in the VR space in patients with IBS. Thus, the combination of VR and fNIRS is a viable option for evaluating brain activity under psychosocial stress in natural clinical settings.

Efficacy and safety of elobixibat in patients with chronic constipation-A randomized, multicenter, double-blind, placebo-controlled, parallel-group study from India

BACKGROUND

Elobixibat is a locally acting ileal bile acid transporter (IBAT) inhibitor that relieves functional constipation in patients by accelerating colonic transit. In this study, we aimed at determining the efficacy and safety of elobixibat for short-term treatment (two weeks) of chronic constipation in Indian patients.

METHODS

The present study was a randomized, double-blind, parallel-group, placebo-controlled, phase III study to evaluate efficacy and safety of elobixibat. The study planned to enroll patients with chronic constipation of at least six months' duration, satisfying Rome IV criteria for functional constipation. Following a run-in of approximately 14 days to confirm eligibility and determine baseline frequency of spontaneous bowel movements (SBMs), eligible patients were randomized 1:1 either to elobixibat or to placebo groups. The change in weekly frequency of spontaneous bowel movements (SBMs) at the end of treatment (week two) over baseline was the primary efficacy endpoint in this trial. Primary efficacy analyses were based on the modified intention-to-treat (mITT) population. This trial is registered at CTRI (Clinical Trial Registry of India).

RESULTS

Between April 2023 and December 2023, 150 patients were randomized into the two-week trial. In mITT population (n = 146 [elobixibat = 75 and placebo = 71]), the least square mean (LSM) difference between elobixibat (3.83) and placebo (2.68) was 1.15 (95% CI, 0.31, 1.99) demonstrating a statistically significant improvement (p = 0.008) in weekly frequency of SBMs (week two over baseline) with the use of elobixibat. The proportions of patients with a complete spontaneous bowel movement (CSBM) "response" was significantly higher with elobixibat (49.33%) compared to the placebo (26.76%) treatment (difference 22.57% [95% CI, 8.36%, 36.78%] [p = 0.005]). The most common adverse event (AE) was abdominal pain (elobixibat = 6 patients [7.89%] vs. placebo = 3 patients [4.05%]).

CONCLUSIONS

Elobixibat was well tolerated and improved bowel movement frequency within two weeks of treatment in Indian patient population with chronic constipation.

CLINICAL TRIAL REGISTRY NUMBER

CTRI/2022/10/046690.

The Study of Anorectal Function Using High-resolution Anorectal Manometry in Patients With Fecal Impaction

AIM

This study aims to evaluate anorectal function through high-resolution anorectal manometry (HRAM) in patients with constipation and fecal impaction, considering the limited information available on this subject.

MATERIALS AND METHODS

HRAM conducted between January 2021 and November 2023 (785 procedures) were reviewed. Patients were identified as individuals who experienced at least one episode of hard stools in the last year that were unable to evacuate. They were compared with constipated patients without fecal impaction episodes (control group). HRAM was performed using solid-state equipment (Medtronic). Logistic regression analysis was done to identify demographic-clinical factors and manometric variables associated with fecal impaction.

RESULTS

Fecal incontinence was independently associated with fecal impaction [adjusted odds ratio (aOR): 20.4, 95% CI: 2.5-167.8] after adjusting for demographic and clinical variables. Severe rectal hyposensitivity (no perception of urgency from a volume of 200 mL) was present in 38.2% of patients with fecal impaction and 5.9% of controls (P=0.001). Defecatory dyssynergia was diagnosed in 29.4% of patients with fecal impaction. Lower squeeze pressure and severe rectal hyposensitivity were independently associated with fecal impaction with an aOR of 0.98 (95% CI: 0.98-0.99) and aOR of 10.4 (2-54.1), respectively, and after adjusting for all manometric parameters. Hypotonia and hypo-contractility of the anal canal were found in 53.8% and 46.2% of patients with fecal impaction and incontinence, respectively.

CONCLUSION

Patients with fecal impaction often show rectal hyposensitivity and anal hypo-contractility, which are independent risk factors for impaction. Fecal incontinence is linked to fecal impaction, and their coexistence is associated with reduced anal canal pressures.

Irritable bowel syndrome, the gut microbiome, and diet

PURPOSE OF REVIEW

To provide an update of recent studies exploring the role of the gut microbiota and diet in the pathogenesis and treatment of irritable bowel syndrome (IBS).

RECENT FINDINGS

The human gut microbiome has been recognized as an important, active source of signaling molecules that explain in part the disorder of the gut brain interaction (DGBI) in IBS. Subsequent changes in the metabolome such as the production of short-chain fatty acids (SCFA) and serotonin are associated with IBS symptoms. Dietary components are recognized as important triggers of IBS symptoms and a diet low in fermentable oligo-, di-, monosaccharides, and polyols (FODMAPs) has been shown effective and safe, even when used long-term. Fecal microbiota transplantation (FMT) in IBS has not shown sustained and effective IBS symptom reduction in controlled clinical trials.

SUMMARY

This update elucidates recent developments in IBS as it relates to clinical trial results targeting dietary and gut microbiota interventions. The gut microbiome is metabolically active and affects the bi-directional signaling of the gut-brain axis.

Impact of Psychosocial and Neurodevelopmental Disorders on Pediatric Ulcerative Colitis: A Single-Center, Retrospective, Observational Study

BACKGROUND

This study aimed to evaluate the effects of psychosocial and neurodevelopmental disorders on pediatric ulcerative colitis management. Specifically, the relationships between these disorders and disease severity, as well as treatment strategies, were assessed through a single-center, retrospective, observational study.

METHODS

The study included pediatric patients with ulcerative colitis (UC) under 15 years of age diagnosed by colonoscopy and histological evaluation between January 2022 and May 2024. Data on comorbid functional gastrointestinal disorders and neurodevelopmental disorders were obtained from patients' electronic medical records, and their effects on disease severity and treatment choices were analyzed.

RESULTS

Of the 166 patients with UC, 21.4% had neurodevelopmental disorders, and 17.5% had functional gastrointestinal disorders. Patients with these comorbidities had significantly lower Pediatric Ulcerative Colitis Activity Index scores, with notable differences in parameters such as abdominal pain and stool consistency. In addition, these patients had more extensive disease and higher rates of immunomodulator (66.1%) and biologic use (46.4%) than those without these complications. The prevalence of functional gastrointestinal disorders was higher in patients with autism spectrum disorder, and specialized care at a developmental outpatient clinic was required in 23.2% of cases.

CONCLUSIONS

Psychosocial and neurodevelopmental disorders are prevalent in children with UC and significantly affect both disease severity and therapeutic approaches. The findings suggest that comprehensive management involving psychosocial interventions and multidisciplinary support is crucial for effectively treating these patients.

Positive Effect of Lecithin-Based Delivery Form of Curcuma and Boswellia Extracts on Irritable Bowel Syndrome After COVID-19 Infection

Background: Post-COVID-19 irritable bowel syndrome (PCIBS) is a frequent finding and is frequently associated with enteral dysbiosis. This pilot study compared the effects of extracts from curcuma and boswellia on PCIBS and irritable bowel syndrome (IBS) in individuals who had never had a COVID-19 infection (controls). Methods: A total of 16 subjects with PCIBS and 28 controls with evidence of IBS gastrointestinal symptoms and with enteral dysbiosis were recruited and supplemented for 30 days with sunflower-lecithin-based formulations of extracts of Curcuma longa (500 mg) and Boswellia serrata (150 mg) b.i.d. and with low-FODMAP diet. Abdominal bloating, abdominal pain, enteral dysbiosis (as increased urinary indican), and the global assessment of efficacy (GAE) were evaluated at the end of the study. Results: In both cohorts, intra-cohort changes revealed a statistically significant (p < 0.05) reduction in bloating and abdominal pain. The GAE showed similar and relevant satisfactory rates in both groups. On the contrary, urinary indican values showed a significant decrease only in the IBS group. Conclusions: Supplementation with Curcuma and Boswellia has favorable effects on abdominal bloating and abdominal pain of subjects with PCIBS and with IBS, while enteral dysbiosis is significantly decreased only in patients with IBS. Additional studies are needed to confirm these preliminary findings and to clarify the reasons for the persistence of dysbiosis in PCIBS.

Gastrointestinal symptoms and bowel habits in 53 046 healthy Danish blood donors: a nationwide cross-sectional study

OBJECTIVE

To characterise gastrointestinal symptoms and bowel habits in healthy blood donors and explore symptom phenotypes and their associated factors.

METHODS

Between November 2020 and March 2023, 53 046 participants in the nationwide Danish Blood Donor Study completed a questionnaire including 13 gastrointestinal symptoms, defaecation pattern regularity, stool frequency, and stool consistency. We used a data-driven approach to explore symptom phenotypes and investigated associated factors by multinomial logistic regression.

RESULTS

Among the 53 046 participants (52% women), 68% (95% CI 67.5% to 68.3%) reported at least one of 13 gastrointestinal symptoms. The most frequent symptoms were bloating (40%), abdominal rumbling (40%), abdominal pain (17%), acid regurgitation (13%), heartburn (12%), diarrhoea (12%), nausea (12%), and constipation (10%). Half of the participants (50%) had a regular defaecation pattern (defined as generally the same stool consistency and stool frequency) consisting of Bristol Stool Form Scale 4 stools 1-3 times per day. Symptom phenotypes and their prevalence among 51 820 near-complete case participants were as follows: (1) no gastrointestinal symptoms (32%); (2) bloating and/or rumbling only (21%); (3) acid regurgitation and/or heartburn only (4%); (4) any other one or two symptoms (14%); (5) any three or four symptoms (18%); (6) any five or six symptoms (7%); (7) at least seven symptoms (3%). The acid regurgitation and/or heartburn only phenotype associated with obesity, and the remaining symptomatic phenotypes were associated with female sex, decreasing age, and an irregular defaecation pattern, even after excluding individuals with self-reported irritable bowel syndrome, lactose intolerance, or gluten intolerance.

CONCLUSION

Most healthy adults, especially women younger than 50 years, experience gastrointestinal symptoms. Symptom phenotypes strongly correlate with sex, age, and bowel habits.

The Endocannabinoid System: Implications in Gastrointestinal Physiology and Pathology

The endocannabinoid system (ECS), composed of receptors, endocannabinoids, and enzymes that regulate biosynthesis and degradation, plays a fundamental role in the physiology and pathology of the gastrointestinal tract, particularly in the small and large intestine and liver. Specifically, cannabinoid receptor type 1 (CB1R) and cannabinoid receptor type 2 (CB2R), located principally in the nervous system and immune cells, orchestrate processes such as intestinal motility, intestinal and hepatic inflammation, and energy metabolism, respectively. The main endocannabinoids, anandamide (AEA) and 2-arachidonoylglycerol (2-AG), influence appetite, body weight regulation, and inflammatory states and thus have implications in obesity, non-alcoholic fatty liver disease (NAFLD) and irritable bowel syndrome (IBS). Recent studies have highlighted the therapeutic potential of targeting the ECS to modulate gastrointestinal and metabolic diseases. In particular, peripheral CB1R antagonists and CB2R agonists have shown efficacy in treating intestinal inflammation, reducing hepatic steatosis, and controlling IBS symptoms. Moreover, the ECS is emerging as a potential target for the treatment of colorectal cancer, acting on cell proliferation and apoptosis. This review highlights the opportunity to exploit the endocannabinoid system in the search for innovative therapeutic strategies, emphasizing the importance of a targeted approach to optimize treatment efficacy and minimize side effects.

Exploring the gut-brain axis in a large cohort of patients with irritable bowel syndrome: Is there a link between depression and intestinal and extra-intestinal symptoms?

OBJECTIVE

We aimed to determine the prevalence of intestinal and extra-intestinal symptoms according to depression severity in a large cohort of patients with irritable bowel syndrome (IBS).

PATIENTS AND METHODS

A consecutive series of patients with diagnosis of IBS according to Rome IV criteria undertaking a social-media based program (B15 program) were analyzed. The B15 program provides evidence-based dietary and non-pharmacological recommendations (i.e., mindfulness techniques and exercise) to improve gastrointestinal health. All patients completed the symptom-severity questionnaire (IBS-SSS) to determine severity of disease and the patient health questionnaire (PHQ9) to assess depressive symptoms. Patients' depression severity was stratified according to the PHQ9 score: none (0-4), mild (5-9), moderate (10-14), moderately severe (15-19), and severe (20-27). Demographics, IBS phenotype and prevalence of intestinal and extra-intestinal symptoms were compared among groups.

RESULTS

A total of 15,675 patients with IBS were included; 895 (12.1%) with none, 5709 (36.4%) with mild, 4279 (27.3%) with moderate, 2457 (15.7%) with moderately severe, and 1335 (8.5%) with severe depression. Mean IBS-SSS score was significantly higher in patients with depressive symptoms (none 256.5 vs. severe 324.1, p<0.0001). IBS-M (mixed bowel habits alternating constipation and diarrhea) was more frequent in those with depression (p<0.0001). The presence of bloating, heartburn, dyspepsia, and belching were significantly more common in patients with higher levels of depression (p<0.0001). The prevalence and number of extra-intestinal symptoms were also associated with the severity of depression (p<0.0001).

CONCLUSIONS

The presence and severity of depression are strongly associated with the prevalence of intestinal and extra-intestinal symptoms in patients with IBS. Stratifying patients based on both their symptomatic and psychological profile could help targeting therapy.

Alterations in the Tongue Coating Microbiome in Patients With Diarrhea-Predominant Irritable Bowel Syndrome: A Cross-Sectional Study

The gut microbiota plays a critical role in the occurrence and development of IBS-D, however, IBS-D-associated tongue coating microbiome dysbiosis has not yet been clearly defined. To address this, we analyzed the structure and composition of the tongue coating microbiome in 23 IBS-D patients and 12 healthy controls using 16S rRNA high-throughput sequencing analysis. The 16S rRNA sequencing results revealed that the overall observed OTUs of tongue coating microbiome in IBS-D patients exhibited a significant decrease compared with the healthy controls. Alpha diversity analysis showed that the diversity and community richness were significantly reduced in IBS-D patients, and PCoA revealed a distinct clustering of tongue coating microbiome between the IBS-D patients and healthy controls. Microbial comparisons at the genus level showed that the abundance of Veillonella, Prevotella in IBS-D patients was higher than those in healthy controls, while Streptococcus, Haemophilus, Granulicatella, and Rothia were significantly reduced compared with the healthy volunteers. Functional analysis results showed significant differences in 88 functional metabolic pathways between the IBS-D patients and the healthy controls, including fatty acid biosynthesis. These findings identified the structure, composition, functionality of tongue coating microbiome in IBS-D patients, and hold promise the potential for therapeutic targets during IBS-D management.

Comparative Efficacy and Safety of Lubiprostone and Osmotic Laxatives in Chronic Idiopathic Constipation: A Systematic Review and Network Meta-Analysis

OBJECTIVE

The objective of this study is to compare the efficacy and safety of lubiprostone (Lub) with osmotic laxatives in the treatment of chronic idiopathic constipation (CIC).

METHODS

A comprehensive literature search was conducted using PubMed, EMBASE, and the Cochrane Library in May 2024. Studies that met the inclusion criteria were manually searched by two independent reviewers. The efficacy was assessed by the proportion of patients with spontaneous bowel movements (SBMs) within 24 h after the first administration of the medication and SBMs in Weeks 1 and 4. Safety was evaluated based on adverse events including nausea, diarrhea, and abdominal distension. Optimal probability values and the surface under the cumulative ranking area (SUCRA) were also calculated for all interventions. Higher SUCRA values indicate better efficacy and safety of the intervention.

RESULTS

Following a thorough search and screening process, 25 articles were included. Among the selected trials, 8 compared Lub to placebo, 10 compared polyethylene glycol (PEG) to placebo, 4 compared lactulose (Lac) to placebo, and 3 compared PEG to Lac. The meta-analysis results indicated that Lub and osmotic laxatives were significantly more effective than placebo. According to the SUCRA results, the highest rank probabilities were for Lub in increasing the SBMs and reducing abdominal distension.

CONCLUSION

Lubiprostone is more effective than PEG and Lactulose for treating CIC, with comparable safety profiles. However, this conclusion requires further validation through large-scale, high-quality studies.

Comparison of Digitally Delivered Gut-Directed Hypnotherapy Program With an Active Control for Irritable Bowel Syndrome

INTRODUCTION

Gut-directed hypnotherapy (GDH) treats irritable bowel syndrome (IBS), but its accessibility is limited. This problem may be overcome by digital delivery. The aim of this study was to perform a randomized control trial comparing the efficacy of a digitally delivered program with and without GDH in IBS.

METHODS

Adults with IBS were randomized to a 42-session daily digital program with the GDH Program (Nerva) or without (Active Control). Questionnaires were completed to assess gastrointestinal symptoms through IBS Symptom Severity Scale (IBS-SSS), quality of life, and psychological symptoms (Depression Anxiety and Stress Scale-21) at regular intervals during the program and 6 months following the conclusion on the intervention. The primary end point was the proportion of participants with ≥50-point decrease in IBS-SSS between the interventions at the end of the program.

RESULTS

Of 240/244 randomized participants, 121 received GDH Program-the median age 38 (range 20-65) years, 90% female, IBS-SSS 321 (interquartile range 273-367)-and 119 Active Control-36 (21-65), 91% female, IBS-SSS 303 (255-360). At program completion, 81% met the primary end point with GDH Program vs 63% Active Control ( P = 0.002). IBS-SSS was median 208 (interquartile range 154-265) with GDH and 244 (190-308) with control ( P = 0.004), 30% reduction in pain was reported by 71% compared with 35% ( P < 0.001), and IBS quality of life improved by 14 (6-25) compared with 7 (1-15), respectively ( P < 0.001). Psychological status improved similarly in both groups.

DISCUSSION

A digitally delivered GDH Program provided to patients with IBS was superior to the active control, with greater improvement in both gastrointestinal symptoms and quality of life and provides an equitable alternative to face-to-face behavioral strategies.