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Camilleri M, Dilmaghani S. Update on treatment of abdominal pain in irritable bowel syndrome: A narrative review. Pharmacol Ther 2023; 245:108400. [PMID: 37001737 DOI: 10.1016/j.pharmthera.2023.108400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/22/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023]
Abstract
The objectives of this narrative review are to update readers on the current state-of-the-art regarding diverse approaches for the treatment of pain, global symptoms, or adequate relief in irritable bowel syndrome (IBS). The article appraises medications, dietary interventions including low fermentable oligosaccharides, disaccharides, and monosaccharides and polyols (FODMAP) diet, fecal microbial transplantation (FMT), electrical approaches, and behavioral therapies including cognitive behavioral therapy (CBT), gut-directed hypnotherapy (GDH), mindfulness, and open-label placebo. Current evidence demonstrates only modest benefit in global IBS symptoms and pain relief. A future approach that identifies pathophysiological mechanisms of IBS through validated biomarkers has the potential to individualize treatment of patients rather than sequential therapeutic trial and error approaches.
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Camilleri M. Electrical devices for functional visceral pain. Neurogastroenterol Motil 2023; 35:e14518. [PMID: 36520617 DOI: 10.1111/nmo.14518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/01/2022] [Accepted: 12/05/2022] [Indexed: 02/08/2023]
Abstract
Several studies have documented correction of dysmotility in several regions of the gastrointestinal tract based on electrical stimulation of extrinsic nerves supplying those regions. In this issue of Neurogastroenterology and Motility, Ma et al. (2023) document the effect of transcutaneous neuromodulation applied by acustimulation at ST36 for ineffective esophageal motility in patients with gastroesophageal reflux disease. In addition to motor effects, there were also significant effects on GERD symptoms, raising the question whether extrinsic electrical nerve stimulation of the gut can reduce symptoms through effects that target sensation. This brief review summarizes evidence regarding the application of electrical acustimulation, transauricular electrical stimulation, and sacral electrical or magnetic stimulation to reduce abdominal or pelvic pain.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Layer P, Andresen V, Allescher H, Bischoff SC, Claßen M, Elsenbruch S, Freitag M, Frieling T, Gebhard M, Goebel-Stengel M, Häuser W, Holtmann G, Keller J, Kreis ME, Kruis W, Langhorst J, Jansen PL, Madisch A, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Raithel M, Röhrig-Herzog G, Schemann M, Schmiedel S, Schwille-Kiuntke J, Storr M, Preiß JC, Andus T, Buderus S, Ehlert U, Engel M, Enninger A, Fischbach W, Gillessen A, Gschossmann J, Gundling F, Haag S, Helwig U, Hollerbach S, Karaus M, Katschinski M, Krammer H, Kuhlbusch-Zicklam R, Matthes H, Menge D, Miehlke S, Posovszky MC, Schaefert R, Schmidt-Choudhury A, Schwandner O, Schweinlin A, Seidl H, Stengel A, Tesarz J, van der Voort I, Voderholzer W, von Boyen G, von Schönfeld J, Wedel T. Update S3-Leitlinie Reizdarmsyndrom: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) – Juni 2021 – AWMF-Registriernummer: 021/016. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:1323-1415. [PMID: 34891206 DOI: 10.1055/a-1591-4794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - H Allescher
- Zentrum für Innere Medizin, Gastroent., Hepatologie u. Stoffwechsel, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Deutschland
| | - S C Bischoff
- Institut für Ernährungsmedizin, Universität Hohenheim, Stuttgart, Deutschland
| | - M Claßen
- Klinik für Kinder- und Jugendmedizin, Klinikum Links der Weser, Bremen, Deutschland
| | - S Elsenbruch
- Klinik für Neurologie, Translational Pain Research Unit, Universitätsklinikum Essen, Essen, Deutschland.,Abteilung für Medizinische Psychologie und Medizinische Soziologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - M Freitag
- Abteilung Allgemeinmedizin Department für Versorgungsforschung, Universität Oldenburg, Oldenburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - M Gebhard
- Gemeinschaftspraxis Pathologie-Hamburg, Hamburg, Deutschland
| | - M Goebel-Stengel
- Innere Medizin II, Helios Klinik Rottweil, Rottweil, und Innere Medizin VI, Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - W Häuser
- Innere Medizin I mit Schwerpunkt Gastroenterologie, Klinikum Saarbrücken, Saarbrücken, Deutschland
| | - G Holtmann
- Faculty of Medicine & Faculty of Health & Behavioural Sciences, Princess Alexandra Hospital, Brisbane, Australien
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Deutschland
| | - P Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah, Klinikum Region Hannover, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - B Niesler
- Abteilung Molekulare Humangenetik Institut für Humangenetik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
| | - D Pohl
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - M Raithel
- Medizinische Klinik II m.S. Gastroenterologie und Onkologie, Waldkrankenhaus St. Marien, Erlangen, Deutschland
| | | | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Deutschland
| | - S Schmiedel
- I. Medizinische Klinik und Poliklinik Gastroenterologie, Universitätsklinikum Hamburg-Eppendorf, Deutschland
| | - J Schwille-Kiuntke
- Abteilung für Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg, Deutschland
| | - J C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Berlin, Deutschland
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Woodroffe RW, Pearson AC, Pearlman AM, Howard MA, Nauta HJW, Nagel SJ, Hori YS, Machado AG, Almeida Frizon L, Helland L, Holland MT, Gillies GT, Wilson S. Spinal Cord Stimulation for Visceral Pain: Present Approaches and Future Strategies. PAIN MEDICINE 2020; 21:2298-2309. [PMID: 32719876 DOI: 10.1093/pm/pnaa108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The introduction of successful neuromodulation strategies for managing chronic visceral pain lag behind what is now treatment of choice in refractory chronic back and extremity pain for many providers in the United States and Europe. Changes in public policy and monetary support to identify nonopioid treatments for chronic pain have sparked interest in alternative options. In this review, we discuss the scope of spinal cord stimulation (SCS) for visceral pain, its limitations, and the potential role for new intradural devices of the type that we are developing in our laboratories, which may be able to overcome existing challenges. METHODS A review of the available literature relevant to this topic was performed, with particular focus on the pertinent neuroanatomy and uses of spinal cord stimulation systems in the treatment of malignant and nonmalignant gastrointestinal, genitourinary, and chronic pelvic pain. RESULTS To date, there have been multiple off-label reports testing SCS for refractory gastrointestinal and genitourinary conditions. Though some findings have been favorable for these organs and systems, there is insufficient evidence to make this practice routine. The unique configuration and layout of the pelvic pain pathways may not be ideally treated using traditional SCS implantation techniques, and intradural stimulation may be a viable alternative. CONCLUSIONS Despite the prevalence of visceral pain, the application of neuromodulation therapies, a standard approach for other painful conditions, has received far too little attention, despite promising outcomes from uncontrolled trials. Detailed descriptions of visceral pain pathways may offer several clues that could be used to implement devices tailored to this unique anatomy.
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Affiliation(s)
- Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy C Pearson
- Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy M Pearlman
- Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Matthew A Howard
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Haring J W Nauta
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky
| | - S J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Y S Hori
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre G Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Logan Helland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Marshall T Holland
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - George T Gillies
- Department of Mechanical and Aerospace Engineering, University of Virginia, Charlottesville, Virginia, USA
| | - Saul Wilson
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Fassov J, Lundby L, Laurberg S, Krogh K. Sacral nerve modulation for irritable bowel syndrome: A randomized, double-blinded, placebo-controlled crossover study. Neurogastroenterol Motil 2019; 31:e13570. [PMID: 30793441 DOI: 10.1111/nmo.13570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/07/2019] [Accepted: 01/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Irritable bowel syndrome (IBS) is among the most common gastrointestinal disorders, and a substantial proportion of patients have an insufficient response to treatment. In a single-blinded study, sacral nerve modulation (SNM) significantly reduced symptoms of IBS. The aim of the present double-blinded, randomized, placebo-controlled study was to evaluate the effect of SNM for IBS. METHODS We included patients with diarrhea-predominant or mixed IBS and a minimum baseline IBS-specific symptom score of 40 points (Gastrointestinal Symptom Rating Scale-IBS version). Patients underwent a 6-week period of SNM. In the first 4 weeks, the patients were randomized 1:1 to have the neurostimulator set subsensory or OFF for 2 weeks and then the opposite for another 2 weeks. Patients and investigators were blinded to settings. In the remaining 2 weeks, the stimulation was set suprasensory. IBS-specific symptoms and quality of life were assessed with validated questionnaires and bowel diaries. KEY RESULTS Twenty-one patients were randomized and eligible for analysis. The IBS-specific symptom score was reduced with borderline significance during stimulation (subsensory-OFF median change -1 (-26, 9), OFF-subsensory median change 8 (-11, 36); P = 0.0572). Pain was significantly reduced during stimulation (subsensory-OFF median change -1.5 (-4, 1), OFF-subsensory median change 1 (-4, 3); P = 0.0188), along with the number of daily bowel movements (subsensory-OFF median change 0 (-1.8, 0.2), OFF-subsensory median change 0.2 (-0.5, 1.1); P = 0.0373). The median placebo effect was 14% (0, 55). CONCLUSION AND INFERENCES Sacral nerve modulation for IBS seems promising but should be considered experimental until larger multicenter studies have been performed.
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Affiliation(s)
- Janne Fassov
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Lilli Lundby
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Laurberg
- Department of Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
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Wortman MSH, Lokkerbol J, van der Wouden JC, Visser B, van der Horst HE, olde Hartman TC. Cost-effectiveness of interventions for medically unexplained symptoms: A systematic review. PLoS One 2018; 13:e0205278. [PMID: 30321193 PMCID: PMC6188754 DOI: 10.1371/journal.pone.0205278] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/22/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In primary and secondary care medically unexplained symptoms (MUS) or functional somatic syndromes (FSS) constitute a major burden for patients and society with high healthcare costs and societal costs. Objectives were to provide an overview of the evidence regarding the cost-effectiveness of interventions for MUS or FSS, and to assess the quality of these studies. METHODS We searched the databases PubMed, PsycINFO, the National Health Service Economic Evaluation Database (NHS-EED) and the CEA registry to conduct a systematic review. Articles with full economic evaluations on interventions focusing on adult patients with undifferentiated MUS or fibromyalgia (FM), irritable bowel syndrome (IBS) and chronic fatigue syndrome (CFS), with no restrictions on comparators, published until 15 June 2018, were included. We excluded preventive interventions. Two reviewers independently extracted study characteristics and cost-effectiveness data and used the Consensus on Health Economic Criteria Checklist to appraise the methodological quality. RESULTS A total of 39 studies out of 1,613 articles met the inclusion criteria. Twenty-two studies reported costs per quality-adjusted life year (QALY) gained and cost-utility analyses (CUAs). In 13 CUAs the intervention conditions dominated the control conditions or had an incremental cost-effectiveness ratio below the willingness-to-pay threshold of € 50,000 per QALY, meaning that the interventions were (on average) cost-effective in comparison with the control condition. Group interventions focusing on MUS (n = 3) or FM (n = 4) might be more cost-effective than individual interventions. The included studies were heterogeneous with regard to the included patients, interventions, study design, and outcomes. CONCLUSION This review provides an overview of 39 included studies of interventions for patients with MUS and FSS and the methodological quality of these studies. Considering the limited comparability due to the heterogeneity of the studies, group interventions might be more cost-effective than individual interventions. REGISTRATION Study methods were documented in an international prospective register of systematic reviews (PROSPERO) protocol, registration number: CRD42017060424.
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Affiliation(s)
- Margreet S. H. Wortman
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- * E-mail:
| | - Joran Lokkerbol
- Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Johannes C. van der Wouden
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Bart Visser
- ACHIEVE – Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Henriëtte E. van der Horst
- Department of General Practice and Elderly Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Tim C. olde Hartman
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
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Fassov J, Lundby L, Laurberg S, Buntzen S, Krogh K. Three-year follow-up of sacral nerve stimulation for patients with diarrhoea-predominant and mixed irritable bowel syndrome. Colorectal Dis 2017; 19:188-193. [PMID: 27328645 DOI: 10.1111/codi.13428] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/04/2016] [Indexed: 01/03/2023]
Abstract
AIM Our unit has recently shown that sacral nerve stimulation (SNS) has a significantly positive short-term effect on selected patients with diarrhoea-predominant or mixed irritable bowel syndrome (IBS). The aim of the present prospective study was to evaluate the medium-term efficacy of SNS for IBS to establish whether SNS could have a future role in the treatment of IBS. METHOD Patients with IBS who had previously been implanted with a permanent neurostimulator as part of a randomized, controlled, crossover study, were assessed for medium-term follow-up. The primary end-point was change in the IBS-specific symptom score (Gastrointestinal Symptom Rating Scale-Irritable Bowel Syndrome version questionnaire) from baseline to 3-year follow-up. The secondary end-point was a change in the IBS-specific quality of life score (Irritable Bowel Syndrome-Impact Scale questionnaire) from baseline to 3-year follow-up. RESULTS Of 26 patients, 20 were eligible for 3-year follow-up. The median IBS-specific symptom score was significantly lower at 3-year follow-up (30, range 13-71) than at baseline (62, 45-80) (P = 0.0001). The effect was observed in all symptom clusters within the score. Also, the median IBS-specific quality of life score was significantly improved at 3-year follow-up (52, 26-169) compared with baseline (135, 82-180, P = 0.0002). The effect was observed in all domains of the score. As per the protocol, 75% of patients were judged therapeutic successes. Seventy per cent of patients had a more than 50% reduction in daily IBS symptoms. CONCLUSION At medium-term follow-up, SNS continues to be an effective treatment for highly selected patients with diarrhoea-predominant or mixed IBS.
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Affiliation(s)
- J Fassov
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark.,Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark
| | - L Lundby
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Laurberg
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - S Buntzen
- Surgical Research Unit, Department of Surgery P, Aarhus University Hospital, Aarhus, Denmark
| | - K Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology V, Aarhus University Hospital, Aarhus, Denmark
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