Clinical assessment of irritable bowel syndrome

2-Amino-N-Phenethylbenzamides for Irritable Bowel Syndrome Treatment

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder characterized by abdominal pain or discomfort. Mebeverine is an antispasmodic that has been widely used in clinical practice to relieve the symptoms of IBS. However, its systemic use usually leads to side effects. Therefore, the current paper aimed to synthesize more effective medicines for IBS treatment. We used ring opening of isatoic anhydride for the synthesis in reaction with 2-phenylethylamine. In silico simulation predicted spasmolytic activity for 2-amino-N-phenethylbenzamides. The newly synthesized compounds demonstrated a relaxation effect similar to mebeverine but did not affect the serotonin or Ca2+-dependent signaling pathway of contractile activity (CA) in contrast. Having in mind the anti-inflammatory potential of antispasmodics, the synthesized molecules were tested in vitro and ex vivo for their anti-inflammatory effects. Four of the newly synthesized compounds demonstrated very good activity by preventing albumin denaturation compared to anti-inflammatory drugs/agents well-established in medicinal practice. The newly synthesized compounds also inhibited the expression of interleukin-1β and stimulated the expression of neuronal nitric oxide synthase (nNOS), and, consequently, nitric oxide (NO) synthesis by neurons of the myenteric plexus. This characterizes the newly synthesized compounds as biologically active relaxants, offering a cleaner and more precise application in pharmacological practice, thereby enhancing their potential therapeutic value.

The Validity of a New Structured Assessment of Gastrointestinal Symptoms Scale (SAGIS) for Evaluating Symptoms in the Clinical Setting

BACKGROUND

The clinical assessments of patients with gastrointestinal symptoms can be time-consuming, and the symptoms captured during the consultation may be influenced by a variety of patient and non-patient factors. To facilitate standardized symptom assessment in the routine clinical setting, we developed the Structured Assessment of Gastrointestinal Symptom (SAGIS) instrument to precisely characterize symptoms in a routine clinical setting.

AIMS

We aimed to validate SAGIS including its reliability, construct and discriminant validity, and utility in the clinical setting.

METHODS

Development of the SAGIS consisted of initial interviews with patients referred for the diagnostic work-up of digestive symptoms and relevant complaints identified. The final instrument consisted of 22 items as well as questions on extra intestinal symptoms and was given to 1120 consecutive patients attending a gastroenterology clinic randomly split into derivation (n = 596) and validation datasets (n = 551). Discriminant validity along with test-retest reliability was assessed. The time taken to perform a clinical assessment with and without the SAGIS was recorded along with doctor satisfaction with this tool.

RESULTS

Exploratory factor analysis conducted on the derivation sample suggested five symptom constructs labeled as abdominal pain/discomfort (seven items), gastroesophageal reflux disease/regurgitation symptoms (four items), nausea/vomiting (three items), diarrhea/incontinence (five items), and difficult defecation and constipation (2 items). Confirmatory factor analysis conducted on the validation sample supported the initially developed five-factor measurement model ([Formula: see text], p < 0.0001, χ ²/df = 4.6, CFI = 0.90, TLI = 0.88, RMSEA = 0.08). All symptom groups demonstrated differentiation between disease groups. The SAGIS was shown to be reliable over time and resulted in a 38% reduction of the time required for clinical assessment.

CONCLUSIONS

The SAGIS instrument has excellent psychometric properties and supports the clinical assessment of and symptom-based categorization of patients with a wide spectrum of gastrointestinal symptoms.

Managing irritable bowel syndrome

Irritable bowel syndrome (IBS), characterized by abdominal pain or discomfort associated with a change in bowel patterns, is one of the most common functional gastrointestinal disorders. Because no single drug effectively relieves all IBS symptoms, management relies on dietary and lifestyle modifications, as well as pharmacologic and nonpharmacologic therapies. The authors review current approaches to treatment and discuss nursing implications.

Outcome of biofeedback therapy in dyssynergic defecation patients with and without irritable bowel syndrome

AIM

The Rome II and III diagnostic criteria for dyssynergic defecation require the exclusion of irritable bowel syndrome (IBS). To prospectively study whether the presence of IBS affects the outcome of biofeedback therapy in dyssynergic defecation patients.

METHODS

Consecutive patients with dyssynergic defecation underwent biofeedback therapy. Dyssynergic defecation was diagnosed based on symptoms, anorectal manometries, balloon expulsion tests, and colonic transit studies. The defecation dynamics and balloon expulsion time were evaluated at the end of the biofeedback therapy in all patients. IBS symptoms were graded before and 4 weeks after the biofeedback therapy using a 4-point Likert scale. Failure of the biofeedback therapy was defined as <50% improvement of constipation symptoms, which were evaluated using a 10 cm long visual analog scale before and 4 weeks after biofeedback therapy.

RESULTS

Fifty patients completed the study. The biofeedback therapy was successful in 30 patients. Twenty-nine patients fulfilled the Rome II criteria for IBS. Patients with or without IBS demonstrated similar responses to the biofeedback therapy (16 of 29 vs. 14 of 21, P>0.05). The disappearance of IBS symptoms was observed more frequently in patients with an improved defecation index compared with those with no improvement (8 of 12 vs 4 of 17, P<0.05). A high pretreatment constipation symptom score, a high rectal sensory threshold, and a delayed colonic transit time were associated with a poor treatment outcome.

CONCLUSIONS

The presence of IBS in dyssynergic defecation did not affect the outcome of biofeedback therapy. In addition, treating dyssynergic defecation patients with IBS by biofeedback therapy improved both constipation and IBS symptoms.

Pilot study: a randomised, double blind, placebo controlled trial of pancrealipase for the treatment of postprandial irritable bowel syndrome-diarrhoea

OBJECTIVE: To evaluate the efficacy of pancrealipase (PEZ) compared with placebo in the reduction of postprandial irritable bowel syndrome-diarrhoea (IBS-D). DESIGN: An intention to treat, double blind, randomised, crossover trial comparing PEZ to placebo for reduction of postprandial IBS-D. Patients had to recognise at least two different triggering foods, be willing to consume six baseline 'trigger meals' and again blinded with PEZ and placebo. Patients then chose which drug they preferred for another 25 meals. SETTING: Outpatient internal medicine practice clinic. PATIENTS: 255 patients were screened; 83 met the criteria, including 5 years of symptoms, recognised 'food triggers', no other identifiable cause for the symptoms, either a normal colonoscopy or barium enema while symptomatic and able to discontinue all anticholinergic medications. 69 patients were enrolled, 20 withdrew before randomisation, leaving 49 patients: 14 men, 35 women, mean age 52 years (SD 15.3). Over 60% had experienced symptoms for 11-30 years and 16% for more than 40 years. INTERVENTIONS: After completing six baseline meals, patients were randomised in blocks of four to receive either identical PEZ or a placebo for another six meals, and after a washout period of time received the alternative drug. MAIN OUTCOME MEASURES: The primary analysis was number of patients who chose PEZ over placebo for the extended use. RESULTS: Overall, 30/49 (61%) would have chosen PEZ (p=0.078), with first drug preference for PEZ at 0.002. Among the PEZ subgroup, PEZ use compared with placebo, demonstrated improvement in all symptoms (p≤0.001) for cramping, bloating, borborygami, urge to defecate, global pain and decrease stooling with increase in stool firmness. CONCLUSIONS: PEZ was found in a small group of patients to reduce postprandial IBS-D symptoms and deserves further evaluation.

New clinical method for distinguishing D-IBS from other gastrointestinal conditions causing diarrhea: the LA/IBS diagnostic strategy

Modern methods of diagnosing diarrhea-predominant irritable bowel syndrome (D-IBS) require a "diagnosis of exclusion" approach. In this study we aim to test the diagnostic ability of using the fluctuation of frequency and consistency of bowel patterns in IBS to discriminate it from other causes of diarrhea. Eligible subjects were asked to complete a questionnaire on the changes in form and frequency of bowel habits by time. The primary endpoint was to evaluate the diagnostic effectiveness of having irregularly irregular bowel function and form as more characteristic of IBS versus non-IBS causes. Patients were prospectively recruited from a tertiary care GI clinic. Subjects had to have diarrhea as their primary complaint. In the case of IBS, D-IBS subjects were recruited. Subjects with celiac disease, Crohn's and ulcerative colitis were recruited for comparison and were categorically called "non-IBS." Non-IBS subjects could not have a recent history of blood in stool or a history of bowel surgery, fistulae or narcotic use. Sixty-two IBS and 37 non-IBS subjects were recruited. Among the 62 IBS subjects, 49 (79%) stated that their bowel habits varied in form and frequency on a daily basis compared to 35% in non-IBS subjects (OR = 8.9, CI = 3.5-22.5, P < 0.00001). When subjects were compared by the number of different stool forms they had witnessed in the prior week, IBS subjects noted 3.58 +/- 0.19 types and non-IBS reported 2.35 +/- 0.16 (P < 0.00001). Using > or = 3 stool forms per week as a method of discriminating IBS from non-IBS, 50 out of 62 subjects with IBS (81%) reported this greater number of forms compared to 15 out of 37 (41%) non-IBS subjects (sensitivity = 0.81; specificity = 0.60). The use of this simple tool that identifies an irregularly irregular bowel form and function is successful in separating D-IBS from non-IBS subjects.

Efficacy of dioctahedral smectite in treating patients of diarrhea-predominant irritable bowel syndrome

BACKGROUND AND AIM

Dioctahedral smectite (DS) is natural adsorbent clay useful in treating acute diarrhea. The aim of this study was to determine DS efficacy on patients with diarrhea-predominant irritable bowel syndrome (D-IBS in a phase III-, 8-week-randomized, double-blind, placebo-controlled trial.

METHODS

The 104 patients who met the D-IBS Rome II criteria were randomized to receive either DS (n = 52) or placebo (n = 52) treatment for 8 weeks (three sachets daily). The primary efficacy endpoint was the changes of the visual analog scale (VAS) score of IBS overall disorder and pain/discomfort-related symptoms after treatment on days 28 and 56, respectively. Other outcome measures included improvement of bowel movement disorders. The therapeutic global response was assessed by the patients and investigators at each visit, as was drug safety.

RESULTS

Both treatments diminished overall disorder at each visit (P < 0.01), with respect to primary efficacy. This effect was further observed in DS-treated patients on day 56 (P = 0.0167). Placebo had no effect on the VAS score of pain/discomfort at any visit, whereas DS improved this score on days 28 and 56, respectively (P < 0.05). DS and placebo similarly diminished bowel disorders at each visit; however, only DS improved abdominal bloating (P < 0.01). The global therapeutic responses evaluated by the patients and investigators were similarly distributed. The study drug was well tolerated during the 8-week period.

CONCLUSION

DS seems acceptable to treat D-IBS patients, particularly for pain-related symptoms.

Pharmacotherapy for fecal incontinence: a review

Fecal incontinence is a common clinical problem that often is frustrating to the patient and treating physician. Nonsurgical management for fecal incontinence includes dietary manipulation, Kegel exercises, perianal skin care, and biofeedback therapy. Pharmacotherapies often are used to assist in management of fecal incontinence. A variety of pharmacotherapies have been utilized for the management of fecal incontinence; limited data from randomized, placebo-controlled trials are available. This is a review of the existing literature on clinical trials of several classes of drugs and other medical therapies that may be beneficial for patients with fecal incontinence. The information in this article was obtained by a MEDLINE search for all clinical trials of drug therapy for fecal incontinence. These treatments and the existing data on their use are summarized. Treatments reviewed include stool bulking agents, with an emphasis on the most promising effect obtained with calcium polycarbophil, constipating agents, including loperamide, codeine, amitriptyline, atropine, and diphenoxylate agents injected into the anal sphincter, drugs to enhance anal sphincter function, including topical phenylepherine and oral sodium valproate, and trials of fecal disimpaction. A new classification to easily remember the treatment categories for this condition, based on the "ABCs of treatment for fecal incontinence," has been introduced into the structure of this review.

Irritable bowel syndrome in the 21st century: perspectives from Asia or South-east Asia

Asian irritable bowel syndrome (IBS) studies not only confirm the truth of this functional disorder but also describe the current disease situation of this continent, with its variable socioeconomic backgrounds. Most Asian community IBS prevalence is within 5-10%, regardless of gender or ethnic character. As well as meeting the main Rome II criteria, Asian IBS subjects also have many minor symptoms. Thus this recommendation remains useful to diagnose Asian IBS. Also, female patients commonly express constipation-predominant (C-) symptoms. Extra-colonic symptoms are common in Asia, for example dyspepsia, insomnia and irritable urinary bladder. Asian IBS subjects do experience psychological disturbances including anxiety, depression, agoraphobia and neuroticism. Accordingly, their quality of life is poor and there is absenteeism leading to excessive physician visits. Abnormal gut motor and sensory functions have been indicated among the Asian IBS subjects. Now, there is evidence of altered colonic neuroimmune function leading to gut hypersensitivity and dysmotility. An Asia-Pacific trial also confirmed tegaserod efficacy on female C-IBS subjects. More than 90% of nurses have very limited IBS knowledge, and are unable even to explain it clearly. In conclusion, Western recommended criteria clearly diagnose Asian IBS and many factors are mutual leading to IBS. Current IBS treatments remain useful but additional reeducation for medical professionals appears to be needed.

Histopathological alterations in irritable bowel syndrome

Irritable bowel syndrome is a common disorder defined by a symptom complex including abdominal pain and altered bowel habit. The etiopathogenesis appears to be multifactorial and to involve altered gastrointestinal motor function, enhanced perception of visceral stimuli and psychosocial factors. More recently a role for mucosal immune activation has been suggested. Routine histologic examination reveals no mucosal abnormality in the majority of cases but quantitative histological, immunohistochemical and ultrastructural analyses reveal subtle morphologic changes involving lymphocytes, mast cells, enterochromaffin cells and enteric nerves. The recent appreciation of these changes has led to new hypotheses linking central and enteric nervous systems to immune processes. This review highlights the spectrum of morphologic changes that occur in irritable bowel syndrome, examines their relationship to the pathophysiology of irritable bowel syndrome and considers their relevance to daily pathology practice.

Recognizing and managing patients with irritable bowel syndrome

PURPOSE

To address the diagnosis and clinical management of irritable bowel syndrome (IBS) and provide a discussion of the available serotonergic agents.

DATA SOURCES

Recent studies examining the pathophysiology of IBS.

CONCLUSIONS

Diagnostic testing may be required in the subset of patients with IBS who present with alarm symptoms, or "red flags," suggestive of underlying organic disease. An important role has been suggested for the neurotransmitter serotonin in both gut motility and visceral pain sensitivity.

IMPLICATIONS FOR PRACTICE

A diagnosis of IBS is largely based on symptoms; therefore, effective clinician-patient communication and careful attention to details of patient presentation, history, and physical examination are essential.

Irritable bowel syndrome in the United States: prevalence, symptom patterns and impact

BACKGROUND

The impact of irritable bowel syndrome, a gastrointestinal motility disorder, is underestimated and poorly quantified, as clinicians may see only a minority of sufferers.

AIM

To determine the prevalence, symptom patterns and impact of irritable bowel syndrome in the US.

METHODS

This two-phase community survey used quota sampling and random-digit telephone dialing (screening interview) to identify individuals with medically diagnosed irritable bowel syndrome or individuals not formally diagnosed, but fulfilling irritable bowel syndrome diagnostic criteria (Manning, Rome I or II). Information on irritable bowel syndrome symptoms, general health status, lifestyle and impact of symptoms on individuals' lives was collected using in-depth follow-up interviews. Data were also collected for healthy controls identified in the screening interviews.

RESULTS

The total prevalence of irritable bowel syndrome in 5009 screening interviews was 14.1% (medically diagnosed: 3.3%; undiagnosed, but meeting irritable bowel syndrome criteria: 10.8%). Abdominal pain/discomfort was the most common symptom prompting consultation. Most sufferers (74% medically diagnosed; 63% undiagnosed) reported alternating constipation and diarrhoea. Previously diagnosed gastrointestinal disorders occurred more often in sufferers than non-sufferers. Irritable bowel syndrome sufferers had more days off work (6.4 vs. 3.0) and days in bed, and reduced activities to a greater extent than non-sufferers.

CONCLUSIONS

Most (76.6%) irritable bowel syndrome sufferers in the US are undiagnosed. Irritable bowel syndrome has a substantial impact on sufferers' well-being and health, with considerable socioeconomic consequences.

Rationale for using serotonergic agents to treat irritable bowel syndrome

PURPOSE

The role of serotonin in gastrointestinal (GI)-tract functioning, the pharmacologic rationale for using serotonergic agents in the treatment of irritable bowel syndrome (IBS), and clinical experience with novel serotonergic agents are described.

SUMMARY

IBS is a common multisymptom disorder that is associated with a high socioeconomic burden. The goal of treatment is to provide rapid and sustained global relief of the multiple symptoms of IBS with a single, effective, well-tolerated agent. Traditional treatment options target single symptoms, and many patients are dissatisfied with the level of relief achieved and adverse effects. Research has revealed that serotonin is involved in three major actions in the gut: (1) mediating intestinal motility, (2) mediating intestinal secretion in the GI tract, and (3) modulating perception in the bowels. Serotonin is also a vital link in the brain-gut axis. Alterations in key elements of serotonin signaling have been demonstrated in patients with IBS. Tegaserod, a selective serotonin type 4 (5-HT(4))-receptor partial agonist, is indicated for use in women with IBS whose primary bowel symptom is constipation. Alosetron, a 5-HT(3)-receptor antagonist, is indicated for use in women with severe diarrhea-predominant IBS in whom traditional therapies have failed. The clinical usefulness of several other serotonergic agents for IBS is being investigated.

CONCLUSION

The use of serotonergic agents in patients with IBS is based on the critical role that serotonin plays in the maintenance of normal gut function and brain-gut communication. Pharmacologic therapies targeting specific serotonin receptors represent an important step in the management of IBS.

Clinical outcome of laparoscopic antireflux surgery for patients with irritable bowel syndrome

BACKGROUND

The prevalence of irritable bowel syndrome (IBS) is higher among subjects with gastroesophageal reflux disease (GERD). This study aimed to assess the effect of IBS on the postoperative outcome of antireflux surgery.

METHODS

For this study, 102 patients who underwent laparoscopic fundoplication were screened preoperatively for IBS with the Rome II criteria. There were 32 patients in the IBS group and 70 patients in the non-IBS group. Most of the patients (97%) (31 of 32 IBS and 68 of 70 non-IBS patients) had both pre- and postoperative IBS evaluation. A visual analog GERD-specific scoring scale was used to evaluate GERD symptoms prospectively.

RESULTS

In both groups, GERD symptom scores were statistically improved postoperatively. Of the 31 IBS patients 25 (80.6%) showed a reduction in their symptoms below the Rome II criteria for IBS diagnosis postoperatively.

CONCLUSION

Irritable bowel syndrome does not have a negative effect on the outcome of laparoscopic antireflux surgery. Surgical correction of GERD may improve the severity of irritable bowel symptoms.