Complementary and alternative medicines in irritable bowel syndrome: An integrative view

Exploring manual therapy in the management of irritable bowel syndrome in adults: A scoping review

INTRODUCTION

IBS is a prevalent gut-brain interaction disorder characterized by abdominal pain and altered bowel habits, significantly affecting quality of life (QoL). IBS contributes to substantial work absenteeism and economic burdens and often coexists with other somatic and psychiatric conditions, with psychological well-being being a critical determinant of QoL. IBS sufferers often turn to MT due to dissatisfaction with conventional treatments. However, no comprehensive review has assessed the evidence for MT in treating IBS.

OBJECTIVE

The objective of this review is to identify and map the available evidence on the effects of various manual therapy (MT) techniques on the biopsychosocial functioning, well-being, and QoL of individuals with irritable bowel syndrome (IBS).

METHODS

A comprehensive search was conducted in PubMed, Embase, and Scopus. Studies involving adults with IBS and investigating the effects of MT on biological, psychological, and social outcomes, well-being, or QoL were included. A scoping review was conducted following PRISMA-ScR guidelines. Study quality was assessed using The National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tools. The protocol for this review was registered with the Open Science Framework and is available at https://doi.org/10.17605/OSF.IO/QN4WU.

RESULTS

Of 730 records identified, 30 studies met the inclusion criteria (9 trials, 21 reviews). The interventions reviewed included osteopathic manipulative treatment (OMT), acupuncture, acupressure, reflexology, traditional Chinese spinal orthopaedic manipulation, and Tuina. The most frequently assessed outcomes were biological and psychological variables, as well as QoL, with well-being being the least commonly examined.

CONCLUSIONS

Although the results suggest potential benefits of MT in IBS treatment, they should be interpreted with caution due to the lack of robust trials, inconsistent findings, and occasional adverse events. High-quality randomized controlled trials and standardized outcome measures are necessary to validate these therapies and improve IBS management.

Pharmacologic treatment of irritable bowel syndrome. Position statement of the Asociación Mexicana de Gastroenterología, 2024

INTRODUCTION

The aim of this position statement is to provide health professionals with an updated and evidence-based guideline for the pharmacologic management of irritable bowel syndrome (IBS) in Mexico.

MATERIAL AND METHODS

A literature review was conducted that included relevant guidelines and studies, up to the date of its publication. The mechanism of action, specific indications in IBS, safety profile, and availability of each therapeutic class were evaluated. The recommendations were developed by 14 experts, considering the clinical reality of IBS patients in Mexico.

RESULTS

Specific recommendations were issued for each class. Antispasmodics (alone or combined) are used as first-line therapy for pain management, whereas antidiarrheals, such as loperamide, are used for reducing diarrhea in diarrhea-predominant IBS (IBS-D) and laxatives are used for constipation in constipation-predominant IBS (IBS-C). 5-HT4 agonists (prucalopride and mosapride) are recommended in IBS-C and 5-HT3 antagonists (ondansetron) are recommended in IBS-D. Linaclotide is the only secretagogue available in Mexico and is used in IBS-C. Rifaximin-alpha stands out for its efficacy in a subgroup of patients with IBS-D or mixed IBS. Probiotics are conditionally recommended as adjuvant therapy due to heterogeneous evidence. Neuromodulators (tricyclic antidepressants, selective serotonin reuptake inhibitors, etc.) are recommended as second-line treatment for pain management. Mesalazine can be used in IBS-D, but the corresponding evidence is weak.

CONCLUSION

Overall, these recommendations provide a solid framework for personalizing treatment, based on the clinical characteristics of the Mexican patient with IBS.

A comprehensive metabolome profiling of Terminalia chebula, Terminalia bellerica, and Phyllanthus emblica to explore the medicinal potential of Triphala

Triphala is a traditional Ayurvedic herbal formulation composed of three fruits: amla (Phyllanthus emblica), bibhitaki (Terminalia bellerica), and haritaki (Terminalia chebula). Triphala is a potent Ayurvedic remedy that promotes digestion, detoxification, and overall wellness, while also providing antioxidant benefits through its trio of nutrient-rich fruits. In order to elucidate the individual contributions of the three ingredients of Triphala from molecular perspective, the individual ingredients were used for the untargeted LCMS/MS analysis. Fresh fruits (PE, TC, and TB) were collected, processed into coarse powders, and sequentially extracted {hexane, chloroform, and ethyl acetate}. LCMS/MS data analysis was performed on the resultant metabolites, with bioinformatics tools employed for pathway enrichment, target prediction, and classification of identified compounds. Additionally, polyphenols were identified as key compounds with potential health benefits. LCMS analysis of the individual extracts identified a total of 10227 features, resulting in 2515 annotated metabolites, with PE contributing the highest number at 1286. Comparative analysis revealed 408 non-redundant metabolites, with 74.2% being unique to individual fruits, underscoring the complementary phytochemical profiles. Pathway enrichment analysis highlighted dominant phenylpropanoid biosynthesis pathways across all extracts, while a comprehensive polyphenol classification identified 71 polyphenols, with significant interactions predicted between polyphenols and gut microbiota. Additionally, five common polyphenols showed potential human targets related to antioxidant activity. These findings provide a deeper understanding of the phytochemical diversity and potential health benefits of Triphala, supporting its traditional use in promoting health.

Symptom bothersomeness and life interference support Rome clinical criteria as clinically relevant indicators of DGBI

BACKGROUND

Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are common disorders of gut-brain interaction (DGBI). The Rome IV criteria are the gold standard for research when diagnosing DGBI. However, bothersomeness, or the degree to which symptoms are distressing or disruptive to a person's daily life, is a potential treatment-seeking motivator that is not assessed by the Rome criteria. The Rome Foundation developed and published diagnostic criteria for clinical practice that include bothersomeness. We aimed to evaluate these constructs via patient focus groups to determine what prompts healthcare-seeking as a means to assess its value in the Rome clinical criteria.

METHODS

Adults meeting Rome IV criteria for IBS, FD, or both participated in focus groups in Australia and the United States. Semi-structured interview transcripts were analyzed using Template Thematic Analysis, with three a priori and other a posteriori themes refined iteratively through team discussion and consensus.

KEY RESULTS

Participants confirmed the frequency and duration of symptoms was not sufficient to reflect illness experience. Four major themes emerged: (1) Bothersomeness should be included in assessments of IBS and FD; (2) Patients find many DGBI symptoms bothersome; (3) Bothersomeness traverses multiple domains of quality of life; (4) Patients may hesitate to seek medical advice due to past negative experiences.

CONCLUSIONS AND INFERENCES

These findings support the value of the Rome Clinical Criteria. They emphasize the importance of expanding assessments of patients with DGBI to include how bothersome they perceive symptoms to be, how much symptoms interfere with their daily life, and what may moderate their decisions to seek treatment.

Health Resource Utilization and Cost Impact of Integrative Medicine Services for Newly Diagnosed Chronic Pain Patients

Background: Integrative medicine (IM) is the healing-oriented practice of medicine that emphasizes the relationship between practitioner and patient. It considers the whole person, their environment, lifestyle, and social and cultural factors. It is evidence based and makes use of all appropriate therapies, conventional and complimentary. Objective: To evaluate the impact of IM services on health outcomes and care costs of chronic pain management patients compared with standard care. Methods: This article uses University of New Mexico hospital billing data from 10/2016 to 09/2019 to identify patients with nervous system or musculoskeletal pain. A total of 1,304 patients were matched using propensity scores into IM services (treatment: 652) and standard care (control: 652) cohorts for difference-in-differences analysis. The patients were matched based on age, sex, race, zip code, insurance type, ICD-10s, prescriptions, health care events, and medical claim costs. Results: Patients who used IM services had better health outcomes and lower costs at 3-month, 6-month, and 12-month follow-up. At the 12-month follow-up, the IM group showed a 19% decrease in utilization of inpatient care, a 37% decrease in Emergency Department utilization, and an 11.3% reduction in claim costs compared with the control group. Conclusion: Patients who utilize IM services as part of chronic pain management have overall lower health care costs and better health outcomes. Unfortunately, in the health system studied, less than 3% of patients utilize these services. Promotion of and education about IM services should be aimed at both patients and their providers.

Effects of Physical Exercise on the Microbiota in Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a prevalent functional gastrointestinal disorder characterized by abdominal pain, bloating, diarrhea, and constipation. Recent studies have underscored the significant role of the gut microbiota in the pathogenesis of IBS. Physical exercise, as a non-pharmacological intervention, has been proposed to alleviate IBS symptoms by modulating the gut microbiota. Aerobic exercise, such as running, swimming, and cycling, has been shown to enhance the diversity and abundance of beneficial gut bacteria, including Lactobacillus and Bifidobacterium. These bacteria produce short-chain fatty acids that possess anti-inflammatory properties and support gut barrier integrity. Studies involving IBS patients participating in structured aerobic exercise programs have reported significant improvements in their gut microbiota's composition and diversity, alongside an alleviation of symptoms like abdominal pain and bloating. Additionally, exercise positively influences mental health by reducing stress and improving mood, which can further relieve IBS symptoms via the gut-brain axis. Long-term exercise interventions provide sustained benefits, maintaining the gut microbiota's diversity and stability, supporting immune functions, and reducing systemic inflammation. However, exercise programs must be tailored to individual needs to avoid exacerbating IBS symptoms. Personalized exercise plans starting with low-to-moderate intensity and gradually increasing in intensity can maximize the benefits and minimize risks. This review examines the impact of various types and intensities of physical exercise on the gut microbiota in IBS patients, highlighting the need for further studies to explore optimal exercise protocols. Future research should include larger sample sizes, longer follow-up periods, and examine the synergistic effects of exercise and other lifestyle modifications. Integrating physical exercise into comprehensive IBS management plans can enhance symptom control and improve patients' quality of life.

Double-blind, randomized, 8-week multicenter study of the efficacy and safety of STW 5-IIversus placebo in functional dyspepsia

Background and Aim

Herbal products are widely used to treat patients with disorders of gut brain interaction but clinical efficacy and safety data for treatments lasting >4 weeks are widely lacking. We evaluated the efficacy and safety of 8 weeks of treatment with the herbal combination product STW 5-II for patients with functional dyspepsia (FD) meeting Rome II criteria. We also conducted a post hoc analysis including patients meeting Rome IV criteria for FD and evaluated the effect of the G-protein beta 3 (GNB3) subunit polymorphism (C825T) on therapeutic response.

Methods

This multicenter, placebo-controlled, double-blind study included 272 FD patients meeting Rome II criteria in the intention-to-treat cohort and 266 meeting Rome IV criteria. We used the validated Gastrointestinal Symptom Score (GIS) to assess GI symptoms, defining response rate as the proportion of patients with ≥50% GIS improvement in at least three of four assessments.

Results

After 8 weeks, the response rate was significantly higher in the STW 5-II group versus placebo (61.2% vs 45.1%, P = 0.008). Mean GIS non-significantly improved with STW 5-II treatment (7.9 ± 4.41 vs 6.7 ± 4.91 with placebo; P = 0.07). In the Rome IV subgroup analysis, STW 5-II yielded a better response rate (P = 0.01) versus placebo and greater postprandial distress symptom improvement (P = 0.04) versus placebo. Safety parameters did not differ between groups, and GNB3 status was not linked with therapeutic response.

Conclusion

STW 5-II is efficacious, with no observed safety signals at up to 8 weeks of treatment in patients with FD meeting Rome II or IV criteria.

Modified Gwakjeongtang for Diarrhea-Predominant Irritable Bowel Syndrome: Study Protocol for a Randomized, Double-Blind, Placebo-Controlled, Pilot Clinical Trial

Introduction

Irritable bowel syndrome (IBS) is a chronic condition characterized by recurrent abdominal pain associated with bowel movements. Modified Gwakjeongtang (MGT), an herbal prescription rooted in traditional East Asian medicine, consists of thirteen botanical drugs known for their potential to enhance intestinal barrier function, regulate gastrointestinal motility, and exhibit anti-inflammatory and antioxidant properties. Despite a few previous clinical trials highlighting MGT's potential for IBS symptom management, limited evidence exists with placebo control.

Methods and Analysis

In this pilot randomized clinical trial protocol, we aim to exploratively evaluate the efficacy and safety of MGT in patients with diarrhea-predominant IBS (IBS-D) by comparing it with a placebo. A total of 60 IBS-D patients will be enrolled, and eligible participants will be randomly allocated to either the MGT or placebo groups. Over a 4-week period, they will receive MGT or placebo granules three times a day. The primary endpoint will be the overall response rate post-treatment, determined through daily assessments of abdominal pain intensity and stool consistency.

Ethics and Dissemination

This clinical trial protocol has received approval from the Korean Ministry of Food and Drug Safety for an investigational new drug application and Institutional Review Board of the Kyung Hee University Korean Medicine Hospital. The research findings will be submitted and published in international peer-reviewed journal.

Trial Registration

Clinical research information service (registration number: KCT0008523).

Development and Validation of a High-Performance Liquid Chromatography Method to Quantify Marker Compounds in Lysimachia vulgaris var. davurica and Its Effects in Diarrhea-Predominant Irritable Bowel Syndrome

Irritable bowel syndrome (IBS), a common gastrointestinal disorder worldwide, is characterized by chronic abdominal pain, bloating, and disordered defecation. IBS is associated with several factors, including visceral hypersensitivity, gut motility, and gut-brain interaction disorders. Because currently available pharmacological treatments cannot adequately improve symptoms and may cause adverse effects, the use of herbal therapies for managing IBS is increasing. Lysimachia vulgaris var. davurica (LV) is a medicinal plant used in traditional medicine to treat diarrhea. However, information on whether LV can effectively improve diarrhea-predominant IBS (IBS-D) remains limited. In this study, using an experimental mouse model of IBS-D, we elucidated the effects of the LV extract. The methanol extract of LV decreased fecal pellet output in the restraint stress- or 5-hydroxytryptamine (5-HT)-induced IBS mouse model and inhibited 5-HT-mediated [Ca2+]i increase in a dose-dependent manner. Furthermore, we developed and validated a high-performance liquid chromatography method using two marker compounds, namely, chlorogenic acid and rutin, for quality control analysis. Our study results suggest the feasibility of the methanol extract of LV for developing therapeutic agents to treat IBS-D by acting as a 5-HT3 receptor antagonist.

The Multisystem effects of Long COVID Syndrome and Potential Benefits of Massage Therapy in Long COVID Care

Background

A major complication of infection with Severe Acute Respiratory Coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, is the potential for Long COVID Syndrome. While the pathophysiology of Long COVID Syndrome has yet to be described, the disease presentation is characterized by long-term symptoms with debilitating effects on human health. A better understanding of Long COVID symptomology may open up new avenues for patient treatment such as massage therapy.

Methods

From the PubMed database, cohort studies that examined post-infection COVID sequelae published between January 1st, 2021 and April 30th, 2021 were selected to investigate patient demographics and symptoms. A review of massage therapy literature since 2000 in conjunction with identified Long COVID symptoms was performed.

Results

This systematic review identified 17 cohort studies across the world that investigated the symptomatology of patients suffering from post-COVID sequelae in multiple organ systems. We identified the pulmonary and nervous systems to be the organ systems most affected with post-COVID sequelae, with PTSD, fatigue, dyspnea, cough, sleep disturbances, loss of smell, abdominal pain, and decreased appetite as the most common symptoms reported by >20% of Long COVID patients. Massage therapy was historically found to provide benefits to patients experiencing similar symptoms to those identified in Long COVID.

Conclusions

Recognizing the need for new approaches to treatment for Long COVID Syndrome, we identify massage therapy as a potential therapeutic treatment to positively impact the organ systems affected by Long COVID, especially the high-incident symptoms, and improve patient quality of life.

Effectiveness of Group Emotional Schema Therapy on Psychological Distress, Severity and Frequency of Symptoms in Women with Irritable Bowel Syndrome

Background

This study aimed to evaluate the effectiveness of emotional schema therapy on psychological distress, severity and frequency of symptoms in women with irritable bowel syndrome (IBS).

Materials and Methods

This semi-experimental two-group three-stage (pre and post-test and two-month follow-up) study was done on 30 women of 18-50 years old with IBS. They were randomly assigned to two groups (experimental and control). Psychological distress and Bowel symptoms severity and frequency in the three stages were measured. The emotional schema therapy group was treated for 8 sessions and the control group remained on the waiting list.

Results

The mean score of pre-test, post-test and follow-up of emotional therapy schema group in psychological distress were 21.23 ± 8.18, 16.08 ± 6.05 and 14.69 ± 4.05; in symptom intensity 7.46 ± 1.98, 5.23 ± 1.30 and 6.46 ± 1.33 and in symptom frequency 7.46 ± 1.98, 6.08 ± 1.66 and 7.54 ± 2.18 respectively. In the control group, there was no difference between the scores of different tests; in the pre-test, post-test and follow-up, the scores of psychological distress were 20.23 ± 5.39, 20.08 ± 5.59, and 20.38 ± 4.75, in the symptoms severity 7.69 ± 1.49, 7.62 ± 1.33, and 7.69 ± 1.80, and in the symptoms frequency 6.92 ± 2.75, 6.54 ± 2.40 and 6.62 ± 2.63 respectively. In the control group, there was no difference between the scores in different tests. In the pre-test, post-test and follow-up, in psychological distress, the scores were 20.23 ± 5.39, 20.08 ± 5.59, and 20.38 ± 4.75 in the symptom severity 7.69 ± 1.49, 7.62 ± 1.33, and 7.69. ±1.80 and in the symptoms frequency 6.92 ± 2.75, 6.54 ± 2.40 and 6.92 ± 2.75 respectively (P < 0.05).

Conclusion

Emotional schema therapy can be used as a complementary psychological treatment to reduce psychological distress and severity and frequency of symptoms in women with IBS.

A Study to Evaluate the Effectiveness of "Mindfulness-Based Stress Reduction Therapy(MBSRT)" in Reducing Symptom Severity and Improving Quality of Life in Patients Suffering From Irritable Bowel Syndrome

INTRODUCTION

Irritable bowel syndrome (IBS) is a functional gastrointestinal disease with a high prevalence. IBS is considered a disorder of brain-gut interaction. Mindfulness-Based Stress Reduction Therapy (MBSRT) is a form of treatment that uses meditation and relaxation to foster awareness and acceptance of the present moment. This kind of therapy requires individuals to practice noticing and observing details about their surroundings without passing judgment or reacting to triggers in the environment.

MATERIAL AND METHODS

After making the diagnosis of IBS, 30 patients were subjected to concomitant MBSRT in addition to pharmacological therapy(Case Group) while the remaining were given only pharmacotherapy (Control Group). MBSRT was performed by a Clinical Psychologist. Seventeen patients were given only pharmacological therapy (Control Group). Scores were assessed using the IBS Symptom Severity Scale (IBS-SSS), Five Facets of Mindfulness Questionnaire(FFMQ), and World Health Organisation Quality Of Life-BREF (WHO-QOL-BREF) before and after the completion of MBSRT sessions.

RESULTS

The study included 47 patients (30 in the case group and 17 in the control group) who presented to Medicine OPD and were diagnosed with IBS. Kendall tau correlation test was applied for IBS-SSS scores, which showed significant improvement in IBS-SSS scores postmindfulness therapy in the case group with P value of <0.001. McNemar test was applied for FFMQ scores, which showed significant improvement in FFMQ scores postmindfulness therapy in the case group with a P value of <0.001. A logistic regression model was also generated, which showed a significant change in QOL scores after MBSRT.

CONCLUSION

IBS patients who received MBSRT had a greater improvement in the quality of life and mindfulness components and reduced IBS symptoms as compared with the control group.

Gut microbiota plays a role in irritable bowel syndrome by regulating 5-HT metabolism

Irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder. Brain-gut-microbiota axis dysfunction is an important pathogenic factor for IBS, in which neurotransmitters and gut microbes play key roles. The gastrointestinal tract contains large amounts of serotonin (5-hydroxytryptamine, 5-HT), a neurotransmitter that has been strongly linked to IBS-related symptoms. More than 90% of serotonin is synthesized in the gut by enterochromaffin cells (ECs), and certain intestinal flora can affect the occurrence and development of IBS by regulating 5-HT and its metabolism. In this review, we will discuss the role of gut microbiota in IBS by regulating 5-HT.

Intestinal anti-inflammatory and visceral analgesic effects of a Serpylli herba extract in an experimental model of irritable bowel syndrome in rats

Ethnopharmacological relevance:Serpylli herba extract (SHE), composed of the aerial parts of wild thyme (Thymus serpyllum L.) (Lamiaceae family), is traditionally used in Europe and North Africa to treat diarrhea, gastric ulcers, intestinal parasites and upper respiratory tract infections. Recently, SHE has generated a great interest for irritable bowel syndrome (IBS) management, probably due to its intestinal anti-inflammatory properties shown in experimental colitis and the fact that its active components could preserve the intestinal barrier integrity, which is altered in patients with IBS.

Aim of study: We aimed to test the effects of a SHE in a rat experimental model resembling human IBS.

Materials and methods: IBS was provoked by deoxycholic acid (DCA). Rats were then treated with SHE (100 mg/kg) or gabapentin (70 mg/kg) and different inflammatory and gut barrier integrity markers were evaluated. Moreover, several gut hypersensitivity and hyperalgesia determinations were performed.

Results: SHE improved referred pain and visceral hypersensitivity. Additionally, SHE enhanced immune status by downregulating of the expression of the pro-inflammatory mediators Il-1β, Il-6, Ifn-γ, Tlr-4, and the inducible enzyme Cox-2, thus inducing visceral analgesia, and promoting the restore of the gut barrier function by upregulating the mucins Muc-2 and Muc-3. These anti-inflammatory effects could be related to its action on mast cells since it significantly inhibited the β-Hexosaminidase production in RBL-2H3 cells. Lastly, SHE also seems to modulate the serotonin pathway by restoring the altered expression of the 5-HT receptors Htr-3 and Htr-4.

Conclusion: SHE could be considered a potential new treatment for IBS, since it ameliorates hypersensitivity, visceral hyperalgesia, and inflammation. These beneficial effects may be due to the inhibition of mast cells degranulation and serotonin pathway.

Effects and Mechanisms of Acupuncture on Diarrhea-Predominant Irritable Bowel Syndrome: A Systematic Review

Background

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction with challenging treatment. According to evidence-based studies, acupuncture is likely to be a promising therapy and subservient adjunct for IBS. Mechanism study of acupuncture based on related clinical trials of high quality, nevertheless, is still vacant.

Aim

This study aims to assess the results and qualities of current clinical evidence and conclude the relevant pathophysiological mechanisms and therapeutic effects of acupuncture on IBS with diarrhea (IBS-D).

Methods

Literature from four databases, namely, PubMed, Cochrane Library, EMBASE, and Web of Science, was systematically searched to obtain eligible randomized controlled trials (RCTs), which contained mechanism research of acupuncture treatment in IBS-D patients. Two independent reviewers completed data extraction and quality evaluation using the RevMan 5.4.1 software.

Results

Ten trials that covered 19 items related to mechanism research were included in this review. Acupuncture was reported to improve IBS-D symptoms and quality of life, with positive effects in regulating brain-gut peptides, cerebral activities, neuroendocrine functions, psychological state, and inflammatory GI and hypersensitive intestinal tracts.

Conclusion

Acupuncture has potential influence on pathophysiology alterations such as regulating brain-gut peptides, altering cerebral connectivity and activity, promoting neuroendocrine functions and mental state, and mitigating inflammation as well as hypersensitivity of bowels in IBS-D patients, but further studies of high quality are still necessary.

Systematic Review Registration

[https://www.crd.york.ac.uk/PROSPERO], identifier [CRD42022320331].

Acupuncture and Moxibustion in the Treatment of Adult Diarrhea Irritable Bowel Syndrome: A Network Meta-analysis

Objective

This study was aimed at comparing the clinical efficacy of acupuncture and moxibustion on irritable bowel syndrome complicated with diarrhea (IBS-D) in adults and providing guidance for clinical treatment.

Methods

PubMed, The Cochrane Library, Embase, CBM, CNKI, and VIP and Wanfang databases were searched to obtain clinical randomized controlled trials (RCTs) on acupuncture and moxibustion in the treatment of IBS-D published from establishment of the database to August 5, 2021. Relevant data were extracted to assess the risk of bias in the included studies, and statistical software Stata 16.0 was used for meta-analysis.

Results

Twenty-one studies were eventually included in the network meta-analysis (NMA), including 1626 patients with IBS-D and 8 therapeutic measures. NMA showed that acupuncture [OR = 0.35, 95%CI (0.25, 0.49), P < 0.05], warming needle moxibustion [OR = 6.34, 95%CI (2.83, 14.21), P < 0.05], acupuncture+sandwiched moxibustion [OR = 12.83, 95%CI (4.49, 36.64), P < 0.05], acupuncture+heat-sensitive moxibustion [OR = 9.86, 95%CI (1.77, 55.00), P < 0.05] were more effective than pinaverium bromide in the treatment of IBS-D. Cumulative ranking probability (SUCRA) showed that the comprehensive efficacy of acupuncture and moxibustion (86.8%) and quality of life (QOL) (70.4%) was the best, while the comprehensive efficacy of pinaverium bromide (2.1%) and QOL (16.3%) was the worst. GV20, GV29, ST 25, ST37, ST36, SP6, LR3, and CV12 were used frequently.

Conclusion

Acupuncture+sandwiched moxibustion has the best effect on improving the efficacy and QOL of IBS-D patients. Limited by the number and quality of studies, we still need a large sample, multicenter, and high-quality clinical trials to confirm our findings.

Efficacy and safety of Qinghua Zhixie Decoction against diarrhea-predominate irritable bowel syndrome: A protocol for a randomized controlled trial

BACKGROUND

Diarrhea-predominant irritable bowel syndrome (D-IBS) is the main subtypes of irritable bowel syndrome (IBS). In recent years, more than half of IBS patients have received complementary and alternative medicine. Traditional Chinese herbal formula is widely used in Asia, and clinical studies have also found that Chinese herbal formula could significantly improve abdominal pain and diarrhea. We plan to carry out a randomized, controlled, double blind, clinical studies to observe the clinical efficacy of Qinghua Zhixie decoction in the treatment of D-IBS.

METHODS

Four hundred sixty-four participants will be randomly assigned to the treatment group and control group. Patients in both groups would take medications and stimulations simultaneously. The outcomes of IBS symptom severity score, quality of life, psychological states, and recurrence rate will be recorded. Statistics will be analyzed with the SPSS 22.0.

CONCLUSIONS

The findings of the study will identify the safety and efficacy of Qinghua Zhixie decoction in the treatment of D-IBS.

TRIAL REGISTRATION OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/C8MHW.

The prevalence of irritable bowel syndrome among Saudi population in Riyadh by use of Rome IV criteria and self-reported dietary restriction

BACKGROUND

Irritable bowel syndrome (IBS) is the most prevalent functional gastrointestinal disorder. Diet may play a role in triggering the symptoms. We aimed to measure the prevalence of IBS and its types, and its association with food restrictions among the Saudi population, using the Rome IV criteria.

METHODS

A cross-sectional study was conducted in the outpatient clinics of three major hospitals in Riyadh in conjunction with an electronic survey which was shared on social media. A total of 1,319 subjects (706 males and 613 females) completed a questionnaire of four domains (sociodemography, Rome IV, food restriction, and herbs) between Nov 2019 and February 2020. Convenience sampling was used.

RESULTS

IBS was diagnosed in 104 subjects (7.9%) and, of these, 52% were IBS-M (mixed) type. The prevalence was higher in women than in men (4.9% vs. 3.0%; P = 0.006). A significant association was found between the presence of IBS symptoms and low income (P = 0.010), and not working (P < 0.0001). Most of the IBS patients showed food restriction related to milk (P < 0.0001) and legumes (P = 0.0029), besides other types of food and drinks.

CONCLUSIONS

IBS is less common among the Saudi population. A female gender, low family income, and working status, have the highest association with IBS. The foods most often restricted were legumes and milk. Future community studies may present an opportunity to relate with cultural differences and food preferences.

Why use nutraceutical strategies for the Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a chronic functional bowel disorder, often stress-related, identified by many abdominal symptoms, the most important of which is the chronic visceral abdominal pain. Therefore, IBS commonly impairs the quality of life of patients, moreover it is frequently linked to depressive and anxiety symptoms. The treatment of IBS primarily focuses on symptoms relief. Unfortunately, up to now, no efficacious therapies have been found. Therefore, it would be important to develop new anti-IBS interventions. The aim of this brief review is to summarize the current evidence of nutraceutical supplementation in IBS treatment, with probiotics, prebiotics, synbiotics, butyrate, palmitoylethanolamide and colostrum. Since nutraceutics are over the counter products, the review has the purpose to better inform the medicinal chemist and the practitioner about the possible benefit mechanisms and the many advantages that these therapies offer. All of these compounds present multiple mechanisms of action, such as restoring the physiological microbiota, potentiating gastrointestinal barrier's function, immunomodulatory, anti-inflammatory and antinociceptive activities. From the literature data it results that these compounds are not only capable to improve IBS symptomatology, but mainly display an optimal safety and tolerability profile. Although extensive studies must be carried out to reinforce the evidences from the so far limited clinical trials, the supplementation with these compounds may be useful considering the warnings of prescription medicines for special populations of patients, such as elders, youngsters, or patients who need a combination therapy. Finally, the nutraceutical approach may improve adherence to treatment, given its better acceptance by the patients compared to pharmacological therapy.

Gwakhyangjeonggi-san for irritable bowel syndrome: A protocol for systematic review and meta-analysis

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic functional bowel disorder characterized by abdominal pain or discomfort, stool irregularities, and bloating. Owing to its atypical symptoms and various mechanisms, there is no standard treatment for IBS. Gwakhyangjeonggi-san (GJS), a traditional Korean herbal medicine, has been used to treat lower intestinal abnormalities in Asia. We will systematically review randomized controlled trials (RCTs) to evaluate the efficacy and safety of GJS as a complementary treatment for IBS.

METHODS AND ANALYSIS

Four English databases, namely, Medline (via PubMed), EMBASE, the Cochrane Central Register of Controlled Trials, and the Allied and Complementary Medicine Database, will be searched for entries up to May, 2021. Additional databases will include 5 Korean databases, 1 Chinese database, and 1 Japanese database. RCTs and quasi-RCTs will be searched for to assess the effectiveness and safety of GJS. The primary outcome measure will be the overall efficacy rate, and the secondary outcome will include data such as global symptom scores, IBS Quality of Life measurements, and adverse events. Data analysis will be performed using Review Manager Version 5.3, and the risk of bias will be assessed using the Cochrane Collaboration's risk-of-bias tool. The quality of the results will be evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

CONCLUSION

This systematic review will provide evidence for the efficacy and safety of GJS for IBS.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/V93JN (https://osf.io/v93jn).

Mechanism of Colonic Slow Wave Rhythm Regulated by Electro-acupuncture Determined using Calcium-Sensitive Receptor

The calcium-sensitive receptor (CaSR) plays a role in several biological processes. However, its role in intestinal motility remains unclear. In this study, we aimed to determine the effect of electro-acupuncture (EA) at Shangjuxu (ST37) on CaSR in colonic dysplasia mice, and to explore the possible mechanism of EA regulating colonic movement. The mice were injected with nicardipine or hexamethonium bromide to induce colonic dysplasia. Intestinal transit function was assessed by twelve hours fecal granules and fecal water content percentage, while colonic slow wave was assessed by multi-channel physiological signal acquisition system, immunofluorescence and laser confocal microscopy were used to examine CaSR expression in the gastrointestinal (GI) tract of the mice. We found that the number of fecal particles, the frequency and amplitude of colonic slow wave were disrupted after nicardipine or hexamethonium bromide injection. In addition, CaSR expression in control group was mainly distributed in intestinal epithelial cells, and the morphological structure of mucosal layer was regular. Compared with control group, the structure of mucosal layer in nicardipine group and hexamethonium bromide group were all disorderly, the expression and fluorescence intensity of CaSR in nicardipine group were visible, but in hexamethonium bromide group were weakened. After EA intervention, these disorders were ameliorated, which suggested that EA at ST37 could therefore regulate colonic motility disorders via the involvement of CaSR.

Importance of Non-pharmacological Approaches for Treating Irritable Bowel Syndrome: Mechanisms and Clinical Relevance

Chronic visceral pain represents a major unmet clinical need with the severity of pain ranging from mild to so severe as to prevent individuals from participating in day-to-day activities and detrimentally affecting their quality of life. Although chronic visceral pain can be multifactorial with many different biological and psychological systems contributing to the onset and severity of symptoms, one of the major triggers for visceral pain is the exposure to emotional and physical stress. Chronic visceral pain that is worsened by stress is a hallmark feature of functional gastrointestinal disorders such as irritable bowel syndrome (IBS). Current pharmacological interventions for patients with chronic visceral pain generally lack efficacy and many are fraught with unwanted side effects. Cognitive behavioral therapy (CBT) has emerged as a psychotherapy that shows efficacy at ameliorating stress-induced chronic visceral pain; however, the molecular mechanisms underlying CBT remain incompletely understood. Preclinical studies in experimental models of stress-induced visceral pain employing environmental enrichment (EE) as an animal model surrogate for CBT are unraveling the mechanism by which environmental signals can lead to long-lasting changes in gene expression and behavior. Evidence suggests that EE signaling interacts with stress and nociceptive signaling. This review will (1) critically evaluate the behavioral and molecular changes that lead to chronic pain in IBS, (2) summarize the pharmacological and non-pharmacological approaches used to treat IBS patients, and (3) provide experimental evidence supporting the potential mechanisms by which CBT ameliorates stress-induced visceral pain.

Alternative Treatment Approaches to Small Intestinal Bacterial Overgrowth: A Systematic Review

Background: Broad-spectrum antibiotics are the first-line treatment for small intestinal bacterial overgrowth (SIBO). However, many antibiotics have a considerable side-effect profile and SIBO commonly reoccurs after successful eradication with antibiotics. Alternative therapies such as probiotics, therapeutic diets, and herbal medicines have been used to individualize SIBO management, particularly in recalcitrant cases. Objectives: The objective of this review is to evaluate the role of alternative therapies in SIBO treatment. Data Sources: EMBASE, MEDLINE, and the Cochrane Central Register were systematically searched for clinical studies evaluating alternative therapies in the management of SIBO. Study Eligibility Criteria: Human studies in which an alternative intervention was used to treat SIBO were included. Alternative interventions were defined as an intervention that included a probiotic supplement, herbal preparation, or a dietary change. Randomized controlled trials (RCTs), nonrandomized clinical trials with or without a control, and crossover studies were included. Study Appraisal: The following information was extracted from the selected studies: study type, study participants, SIBO subtype, intervention, comparison, outcome measures, relevant results, relevant side effects, and Jadad score. Results: Eight studies met inclusion criteria. The studies evaluated probiotics (n = 5), therapeutic diet (n = 1), and herbal medicines (n = 2). Among these studies, there were four RCTs, two open-label single-arm studies, one randomized, double-blind crossover study, and one two-arm open-label study with crossover. Main results are summarized. Limitations: There may be studies not captured by the defined search criteria. Additionally, studies used different methodologies in both breath testing and measurement of clinical symptoms, making it difficult to draw conclusions on SIBO eradication and symptom improvement across studies. Conclusions and Implications: Our findings suggest preliminary evidence for a role of alternative therapies in the treatment of SIBO. However, robust clinical trials are generally lacking. Existing studies tend to be small and lack standardized formulations of treatment. Breath testing protocols and clinical symptom measurement greatly varied between studies. Large-scale, randomized, placebo-controlled trials are needed to further evaluate the best way to utilize alternative therapies in the treatment of SIBO.

Assessment of Polygonum odoratum Lour. Leaf Extract on Rat's Ileum Contraction and the Mechanisms Involved

Vietnamese coriander (Polygonum odoratum Lour.) is a plant native to northern Thailand. The biological activities of P. odoratum Lour. extract (POE) include antibacterial, antiviral, and expectorant. However, the effect of POE on intestinal smooth muscle motility is unclear. The aim of this study was to evaluate the relaxant effects of POE on isolated rat ileum. Propranolol (1 μM), calcium chloride (1-20 mM), and Nω-nitro-l-arginine methylester (l-NAME, 100 μM) were used to investigate the mechanisms of action. The results showed that POE (0.01-5 mg/mL) reduced KCl-induced contraction. In addition, POE (1 mg/mL) reduced the contraction by propranolol and l-NAME and attenuated CaCl₂-induced contractions. Our results indicate that the relaxation effect of POE on ileum contractions seems to involve nitric oxide and β-adrenergic pathways, and blockade of calcium influx. These findings provide a pharmacological basis for the traditional use of POE to treat gastrointestinal disorders such as irritable bowel syndrome or diarrhea.

Treating Chronic Abdominal Pain in Patients with Chronic Abdominal Pain and/or Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is probably the most common diagnosis in gastroenterology involving the brain-gut axis. By definition, pain is the most frequent symptom experienced by patients. It is important to understand the biopsychosocial and physiologic aspects of the disease when discussing treatment of IBS. Such therapies as lifestyle modifications, changes in diet, and cognitive behavioral therapy should be used in conjunction with pharmacotherapy rather than pharmacotherapy alone. The pathophysiologic mechanisms are reviewed in this article along with the current treatments available, in the era of growing demand for more effective treatments for the pain component of IBS.

A Qualitative Study of the Experiences of Complementary and Alternative Medicine of Patients With IBS-C

The aim of this study was to examine the complementary and alternative medicine (CAM) experiences of patients with constipation irritable bowel syndrome (IBS-C). This qualitative study consisted of a total of 30 patients, who were admitted to a university hospital in Turkey. Data were collected using a descriptive questionnaire and a semistructured interview. Data analysis identified 5 main themes: (1) constipation-related difficulties experienced due to IBS, (2) the feeling that the CAM use is natural and useful, (3) the effect of the environmental stimuli in preferring the use of CAM, (4) the feeling that CAM is not negative and relieves, and (5) suggesting the CAM use. In conclusion, it was determined that all the patients with constipation IBS used various CAM methods. It may be recommended to raise the awareness of the patients by health care professionals about the CAM methods that may be useful.

The Impact of an Individual Educational Program on the Quality of Life and Severity of Symptoms of Patients with Irritable Bowel Syndrome

Background: Irritable bowel syndrome (IBS) is one of the most common functional diseases of the gastrointestinal tract. A typical symptom is changed bowel patterns: diarrhea, constipation, or alternation of the two. Abdominal pains vary in intensity and location, with periods of exacerbation and remission, causing disorganization in everyday life and work. Educational intervention could be one strategy to improve the well-being of IBS patients. Only a few trials have examined this hypothesis. The aim of this study was to examine the effect of an educational program combined with elements of behavioral therapy, individualized for each patient, on quality of life (QOL) and severity of pain of patients with IBS. Methods: In total, 150 IBS patients and 100 healthy persons in the control group were included. QOL (36-Item Short Form Health Survey, SF-36) and pain severity (Visual Analogue Scale) were measured at baseline and six months after education of IBS patients. Results: At baseline, patients with IBS showed highly significantly worse QOL. In the IBS group, significantly higher physical component summary (PCS) and mental component summary (MCS) scores were noted for 35- to 50-year-old patients compared to other patients. Six months after education and behavioral therapy, significant improvement in QOL and a significant decrease in the subjective perception of pain severity were noted compared to values before therapeutic education. Conclusion: An educational program combined with elements of behavioral therapy, individualized for patients with IBS, is an important part of therapy for these patients.

A Qualitative Study of the Experiences of Complementary and Alternative Medicine Use in Patients With IBS-C

The aim of this study was to explore the experiences of complementary and alternative medicine (CAM) among patients with constipation irritable bowel syndrome (IBS-C). This qualitative study consisted of a total of 30 patients who were admitted to a university hospital in Turkey. Data were collected using a descriptive questionnaire and a semistructured interview. Data analysis identified 5 main themes: (1) the constipation-associated difficulties experienced because of IBS; (2) the feeling that CAM is natural and useful; (3) the effect of environmental stimuli in preferring the use of CAM; (4) the feeling that CAM is not negative and relieves symptoms; and (5) suggesting the use of CAM. In conclusion, it was determined that all the patients with IBS-C used various CAM methods. It may be recommended that health care professionals should raise awareness among patients about CAM methods that may be useful.

Shared Decision Making in Gastroenterology: Challenges and Opportunities

This article reviews the current uses of shared decision making in gastroenterology and discusses additional areas of opportunity for shared decision making, especially in the area of functional gastrointestinal disorders. PubMed, MEDLINE, and Cochrane library databases were searched for articles published during a 10-year period from January 1, 2007, through December 31, 2017. Search terms included shared decision making and gastroenterology, shared decision making in gastrointestinal disease, shared decision making in functional GI disorders, and shared decision making and irritable bowel syndrome. Studies were not included in this review when a health care professional other than a gastroenterologist was involved, eg, an article that reported shared decision making regarding the use of radiation therapy in a patient with advanced rectal cancer in which the health care professional helping to make the decision was an oncologist.

European society of neurogastroenterology and motility guidelines on functional constipation in adults

INTRODUCTION

Chronic constipation is a common disorder with a reported prevalence ranging from 3% to 27% in the general population. Several management strategies, including diagnostic tests, empiric treatments, and specific treatments, have been developed. Our aim was to develop European guidelines for the clinical management of constipation.

DESIGN

After a thorough review of the literature by experts in relevant fields, including gastroenterologists, surgeons, general practitioners, radiologists, and experts in gastrointestinal motility testing from various European countries, a Delphi consensus process was used to produce statements and practical algorithms for the management of chronic constipation.

KEY RESULTS

Seventy-three final statements were agreed upon after the Delphi process. The level of evidence for most statements was low or very low. A high level of evidence was agreed only for anorectal manometry as a comprehensive evaluation of anorectal function and for treatment with osmotic laxatives, especially polyethylene glycol, the prokinetic drug prucalopride, secretagogues, such as linaclotide and lubiprostone and PAMORAs for the treatment of opioid-induced constipation. However, the level of agreement between the authors was good for most statements (80% or more of the authors). The greatest disagreement was related to the surgical management of constipation.

CONCLUSIONS AND INFERENCES

European guidelines on chronic constipation, with recommendations and algorithms, were developed by experts. Despite the high level of agreement between the different experts, the level of scientific evidence for most recommendations was low, highlighting the need for future research to increase the evidence and improve treatment outcomes in these patients.

FUNCTIONAL CHANGES IN BRAIN ACTIVITY AFTER HYPNOSIS: Neurobiological Mechanisms and Application to Patients with a Specific Phobia-Limitations and Future Directions

Studies of brain-plasticity changes in hypnosis using functional magnetic resonance imaging (fMRI), positron-emission-tomography (PET) and electroencephalography (EEG) were reviewed. The authors found evidence in those studies that hypnosis is a powerful and successful method for inhibiting the reaction of the fear circuitry structures. Limitations of the studies were critically discussed, and implications for future research were made. The authors are currently using a portable fNIRS apparatus to integrate the scanning device into real life situations in medical practice. Their aim is to disentangle the neuronal mechanisms and physiological correlates in patients with severe fear of medical treatments when directly confronted with anxiety-provoking stimuli and to assess the effects of a brief hypnosis. Drawing on evidence from several technological modalities, neuroimaging and physiological studies pave the road to a better scientific understanding of neural mechanisms of hypnosis.

Homeopathy for treatment of irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a common, chronic disorder that leads to decreased health-related quality of life and work productivity. A previous version of this review was not able to draw firm conclusions about the effectiveness of homeopathic treatment for IBS and recommended that further high quality RCTs were conducted to explore the clinical and cost effectiveness of homeopathic treatment for IBS. Two types of homeopathic treatment were evaluated in this systematic review: 1. Clinical homeopathy where a specific remedy is prescribed for a specific condition; 2. Individualised homeopathic treatment, where a homeopathic remedy based on a person's individual symptoms is prescribed after a detailed consultation.

OBJECTIVES

To assess the effectiveness and safety of homeopathic treatment for IBS.

SEARCH METHODS

For this update we searched MEDLINE, CENTRAL, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), the Cochrane IBD Group Specialised Register and trials registers from inception to 31 August 2018.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cohort and case-control studies that compared homeopathic treatment with placebo, other control treatments, or usual care, in adults with IBS were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias and extracted data. The primary outcome was global improvement in IBS as measured by an IBS symptom severity score. Secondary outcomes included quality of life, abdominal pain, stool frequency, stool consistency, and adverse events. The overall certainty of the evidence supporting the primary and secondary outcomes was assessed using the GRADE criteria. We used the Cochrane risk of bias tool to assess risk of bias. We calculated the mean difference (MD) and 95% confidence interval (CI) for continuous outcomes and the risk ratio (RR) and 95% CI for dichotomous outcomes.

MAIN RESULTS

Four RCTs (307 participants) were included. Two studies compared clinical homeopathy (homeopathic remedy, asafoetida or asafoetida plus nux vomica) to placebo for IBS with constipation (IBS-C). One study compared individualised homeopathic treatment (consultation plus remedy) to usual care for the treatment of IBS in female patients. One study was a three armed RCT comparing individualised homeopathic treatment to supportive listening or usual care. The risk of bias in three studies (the two studies assessing clinical homeopathy and the study comparing individualised homeopathic treatment to usual care) was unclear on most criteria and high for selective reporting in one of the clinical homeopathy studies. The three armed study comparing individualised homeopathic treatment to usual care and supportive listening was at low risk of bias in four of the domains and high risk of bias in two (performance bias and detection bias).A meta-analysis of the studies assessing clinical homeopathy, (171 participants with IBS-C) was conducted. At short-term follow-up of two weeks, global improvement in symptoms was experienced by 73% (46/63) of asafoetida participants compared to 45% (30/66) of placebo participants (RR 1.61, 95% CI 1.18 to 2.18; 2 studies, very low certainty evidence). In the other clinical homeopathy study at two weeks, 68% (13/19) of those in the asafoetida plus nux vomica arm and 52% (12/23) of those in the placebo arm experienced a global improvement in symptoms (RR 1.31, 95% CI 0.80 to 2.15; very low certainty evidence). In the study comparing individualised homeopathic treatment to usual care (N = 20), the mean global improvement score (feeling unwell) at 12 weeks was 1.44 + 4.55 (n = 9) in the individualised homeopathic treatment arm compared to 1.41 + 1.97 (n=11) in the usual care arm (MD 0.03; 95% CI -3.16 to 3.22; very low certainty evidence).In the study comparing individualised homeopathic treatment to usual care, the mean IBS symptom severity score at 6 months was 210.44 + 112.4 (n = 16) in the individualised homeopathic treatment arm compared to 237.3 + 110.22 (n = 60) in the usual care arm (MD -26.86, 95% CI -88.59 to 34.87; low certainty evidence). The mean quality of life score (EQ-5D) at 6 months in homeopathy participants was 69.07 (SD 17.35) compared to 63.41 (SD 23.31) in usual care participants (MD 5.66, 95% CI -4.69 to 16.01; low certainty evidence).For In the study comparing individualised homeopathic treatment to supportive listening, the mean IBS symptom severity score at 6 months was 210.44 + 112.4 (n = 16) in the individualised homeopathic treatment arm compared to 262 + 120.72 (n = 18) in the supportive listening arm (MD -51.56, 95% CI -129.94 to 26.82; very low certainty evidence). The mean quality of life score at 6 months in homeopathy participants was 69.07 (SD 17.35) compared to 63.09 (SD 24.38) in supportive listening participants (MD 5.98, 95% CI -8.13 to 20.09; very low certainty evidence).None of the included studies reported on abdominal pain, stool frequency, stool consistency, or adverse events.

AUTHORS' CONCLUSIONS

The results for the outcomes assessed in this review are uncertain. Thus no firm conclusions regarding the effectiveness and safety of homeopathy for the treatment of IBS can be drawn. Further high quality, adequately powered RCTs are required to assess the efficacy and safety of clinical and individualised homeopathy for IBS compared to placebo or usual care.

An examination of naturopathic treatment of non-specific gastrointestinal complaints: comparative analysis of two cases

BACKGROUND

Functional gastrointestinal disorders (FGID) affect more than one-third of the general population and contribute a considerable burden on the health and wellbeing of the community and the economy. This study aims to examine the treatment approaches and outcomes of naturopathic management of individuals presenting with a non-specific FGID.

METHODS

We report a comparison of two clinical case studies of patients being treated by a naturopath for a functional gastrointestinal disorder. The care was provided by two different student practitioners under the supervision of an industry qualified mentor within a multidisciplinary academic clinic at the Endeavour College of Natural Health. A student practitioner and student observer conduct consultations under the supervision of an industry qualified mentor. The outcomes of care were measured by the Gastrointestinal Symptom Rating Scale.

RESULTS

Clinical notations partially correlate to Jane's outcomes measured by gastrointestinal rating scale scores, which remain stable. Significant changes in Rona's gastrointestinal rating scale scores equate to only generalizable minimal clinical notations.

CONCLUSIONS

The holistic and individualised approach core to naturopathic medicine practice is also informed by traditional methods, research evidence and the pragmatic needs of the patient. The emphasis within naturopathic treatment approaches on dietary changes and lifestyle prescription alongside other ingestive therapies such as herbal and nutritional medicine underscores the need for clinical research designs which support evaluation of complex interventions in real-world settings.

Expression and clinical significance of 5-HT and 5-HT3R in the intestinal mucosa of patient with diarrhea-type irritable bowel syndrome

Expression levels and clinical significance of 5-HT and 5-HT₃R in the intestinal mucosa tissue of patients with diarrhea-type irritable bowel syndrome (D-IBS) were investigated. A retrospective analysis was performed on 46 tissue specimens (observation group) of the intestinal mucosa of patients with D-IBS, who were diagnosed in the Tongde Hospital of Zhejiang Province and received colonoscopy from March 2016 to December 2017, and 18 tissue specimens (control group) of the intestinal mucosa of healthy subjects who received physical examinations. The expression levels of 5-HT and 5-HT₃R in the intestinal mucosa tissue of patients in the observation and control group were detected by ELISA, and the relationship between 5-HT, 5-HT₃R and the clinicopathological parameters of patients with D-IBS was analyzed. Pearson's correlation analysis was used to analyze the correlation of 5-HT and 5-HT₃R in the intestinal mucosa tissue of patients with D-IBS. The expression levels of 5-HT and 5-HT₃R in the intestinal mucosa tissue of patients in the observation group were significantly higher than those of the patients in the control group (344.86±67.52 ng/ml and 13.04±8.34 pg/ml) (P<0.001). There was a positive correlation between the expression level of 5-HT and the expression level of 5-HT₃R in the intestinal mucosa tissue of patients with D-IBS (r=0.725, P<0.001). The expression levels of 5-HT and 5-HT₃R in the intestinal mucosa tissue of patients with D-IBS were both significantly higher than those of the healthy subjects. The expression levels of 5-HT and 5-HT₃R in patients with D-IBS were correlated with age, sex and the history of gastrointestinal infection. 5-HT and 5-HT₃R may be involved in the pathogenesis of D-IBS, and potentially used for clinical treatment.

Use of Complementary and Alternative Medicine by Patients with Irritable Bowel Syndrome According to the Roma IV Criteria: A Single-Center Italian Survey

Aim: This study was conducted to evaluate the impact of complementary and alternative medicine (CAM) in patients with irritable bowel syndrome (IBS) as assessed by the Rome IV criteria. Methods: Consecutive patients referring for IBS were re-evaluated according to the Rome IV criteria. Demographic features and characteristics potentially associated with the use of CAM were collected. A validated, self-administered, survey questionnaire dealing with CAM and patients’ level of knowledge, motivation, perception, and information seeking-behavior toward the use of CAM was analyzed. Multivariate logistic regression analysis was performed in order to identify predictors of CAM use among participants. Results: Among 156 patients claiming IBS, 137 (88%) met the Rome IV criteria, and 62 of them (45%) were CAM users. Biologically based therapy was the most chosen CAM (78%). Significant risk factors (adjusted odds ratio, 95% confidence interval) for the use of CAM were female gender (7.22, 2.31–22.51), a higher BMI (1.16, 1.02–1.33), and a good knowledge of CAM (4.46, 1.73–11.45), while having children was a protective factor (0.25, 0.07–0.95). Only 19% of patients used CAM due to medical advice and over half (51%) thought it was a “more natural” approach. Although a minority of patients (16%) had full satisfaction from CAM, 81% of users would repeat the CAM experience for their IBS symptoms. Conclusions: The widespread use of CAM in IBS, the patients’ belief in its safety, and their willingness to re-use it suggest that knowledge of health-care providers and patient education should be improved.

Acupuncture and related therapies for treating irritable bowel syndrome: overview of systematic reviews and network meta-analysis

BACKGROUND

An overview of systematic reviews (SRs) and a network meta-analysis (NMA) were conducted to evaluate the comparative effectiveness of acupuncture and related therapies used either alone, or as an add-on to other irritable bowel syndrome (IBS) treatments.

METHODS

A total of eight international and Chinese databases were searched for SRs of randomized controlled trials (RCTs). The methodological quality of SRs was appraised using the AMSTAR instrument. From the included SRs, data from RCTs were extracted for the random-effect pairwise meta-analyses. An NMA was used to evaluate the comparative effectiveness of different treatment options. The risk of bias among included RCTs was assessed using the Cochrane risk of bias tool.

RESULTS

From 15 SRs of mediocre quality, 27 eligible RCTs (n = 2141) were included but none performed proper blinding. Results from pairwise meta-analysis showed that both needle acupuncture and electroacupuncture were superior in improving global IBS symptoms when compared with pinaverium bromide. NMA results showed needle acupuncture plus Geshanxiaoyao formula had the highest probability of being the best option for improving global IBS symptoms among 14 included treatment options, but a slight inconsistency exists.

CONCLUSION

The risk of bias and NMA inconsistency among included trials limited the trustworthiness of the conclusion. Patients who did not respond well to first-line conventional therapies or antidepressants may consider acupuncture as an alternative. Future trials should investigate the potential of (1) acupuncture as an add-on to antidepressants and (2) the combined effect of Chinese herbs and acupuncture, which is the norm of routine Chinese medicine practice.

Gastrointestinal symptom improvement from fiber, STW 5, peppermint oil, and probiotics use-Results from an online survey

OBJECTIVES

Several common supplements are used by a significant number of patients affected by gastrointestinal (GI) disorders to improve symptoms and quality of life. We investigated the impact of GI symptom improvement with the use of fiber, STW 5, probiotics, and peppermint oil in relation to overall GI pain and quality of life via an online survey.

DESIGN

We used a cross-sectional, descriptive, correlation design. A Qualtrics online survey was utilized to collect data from January to June 2013 through various websites. Areas evaluated included participant demographics, use of supplements, and gastrointestinal symptom severity.

RESULTS

The rate of supplement use among patients with GI disorders was high (90% in past year) and consultation with healthcare providers was reported by 80%. Participants who completed the survey (n = 68) reported a strong correlation between GI symptom severity and overall quality of life (r2 = 0.8682, p < 0.001). The use of fiber improved GI symptom severity while both STW 5 and probiotics were linked to specific improvements.

CONCLUSIONS

Persons with chronic GI disorders often choose the complementary use of common supplements to mitigate GI symptoms and consult with their healthcare providers frequently. The use of STW 5 and probiotics specifically is linked to overall reduction in GI symptoms and improvement of quality of life.

An integrative review of dietetic and naturopathic approaches to functional bowel disorders

OBJECTIVES

Naturopathy and dietetics have evolved as two separate but parallel professions that use diet to promote optimal health and manage many illnesses and diseases. Given the increasing recognition of the influence of diet on health outcomes, there is increasing demand for the services of both professions. The aim of this research was to investigate similarities and differences between naturopathic and dietetic approaches to functional bowel disorders (FBDs).

DESIGN

For this integrative review AMED, CINAHL, the Cochrane Database of Systematic Reviews, EMBASE, Medline and PubMed databases were searched for articles that focused on dietetic or naturopathic diagnosis and treatment of food intolerance expressing as a FBD in adults. (Registration: PROSPERO 2016 CRD42016049469).

RESULTS

Of the 55 papers in the final review, 10 discussed complementary medicine approaches to FBDs. Both dietitians and naturopaths used similar holistic approaches to diagnosis and treatment, adjusted diets as a primary treatment approach, and individualised treatment for their patients. The professions differed in their use of vitamin, mineral and herbal supplements and in their willingness to recommend other treatments like osteopathy and acupuncture.

CONCLUSIONS

There is much overlap between dietetic and naturopathic approaches to assessment and treatment of FBDs. Further publications that describe naturopathic treatments for FBDs are needed to confirm these results and to provide opportunities for increased recognition and scrutiny of any distinctively naturopathic approaches. Without doing so, naturopathic practices are likely to remain marginalised and poorly understood. Moreover, the opportunity to fully contribute to the management of lifestyle-related diseases will be missed.

Effect of electroacupuncture at homotopic and heterotopic acupoints on abdominal pain in patients with irritable bowel syndrome: study protocol for a randomized controlled trial

BACKGROUND

Acupuncture has been widely applied in the clinic to treat irritable bowel syndrome (IBS), but the underlying mechanism remains unknown. Diffuse noxious inhibitory control (DNIC) is deficient in patients with IBS, which attenuates the systemic analgesic effect elicited by noxious stimulation that is remote from pain areas. Therefore, the aim of this study is to investigate the analgesic effect of electroacupuncture (EA) at homotopic or heterotopic acupoints on abdominal pain in patients with IBS.

METHODS/DESIGN

This study is a randomized, single-blinded, controlled, four-arm parallel trial. A total of 144 patients will be randomly assigned to four groups: a homotopic noxious stimulation group (group A), a homotopic innocuous stimulation group (group B), a heterotopic noxious stimulation group (group C), and a heterotopic innocuous stimulation group (group D). Each patient will receive 14 sessions of treatment, twice per week for 7 weeks. The primary outcome will be pain intensity measured with the visual analog scale. The secondary outcomes will include the IBS Symptom Severity Scale, IBS Quality of Life questionnaire, pain threshold (PT), and the Symptom Checklist-90 for psychological distress. The PT will be measured before and after every treatment. All other outcomes will be evaluated before the 1st treatment, after 7th and 14th treatment, and 3 months later during follow-up.

DISCUSSION

The aim of this study is to assess the analgesic effect of EA at homotopic (abdomen) acupoints and heterotopic (lower limb) acupoints on abdominal pain in patients with IBS, as well as the difference in analgesic effects between noxious and innocuous stimulation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IPR-15006879 . Registered on 5 August 2015.

Relaxant effects of Azadirachta indica A. Juss var. siamensis Valeton flower extract on isolated rat ileum contractions and the mechanisms of action

Azadirachta indica A. Juss var. siamensis Valeton or commonly known as Siamese neem is one of the most well-known plant in traditional Ayurvedic medicine. The aim of the present study was to investigate the relaxant effects of A. indica on isolated rat ileum contractions and its potential underlying mechanisms involved. The isometric contractions of ileum segments were investigated in organ baths for spontaneous activity and response to aqueous extract of Siamese neem flower (SNF). The spasmolytic action of the extract was also assessed on contraction induced by acetylcholine and high potassium. Our findings indicate that cumulative concentrations of SNF aqueous extract induced relaxant effect on spontaneous rat ileum contractions. The extract has also suppressed the cumulative concentration response curve for acetylcholine and pottasium ions-induced contraction. The presence and absence of propranol (antagonist of β-adrenergic receptor) and l-Name (antagonist of nitric oxide synthase) in SNF aqeous extract co-treatment demonstrated no significant different in term of contraction activity when compared to SNF extract treatment alone. The treatment of SNF extract caused a significant inhibition in tissue contraction stimulated by accumulation of calcium ions. Our results showed the relaxant effect of SNF aqueous extract on the isolated rat ileum. In short, the SNF aqueous extract exhibited an inhibitory effect on the spontaneous ileum contactions particularly on the contraction stimulated by acetylcholine and high potassium. The observed effect might acted through the modulation of calcium channels. This findings provide a pharmacological basis for the traditional use of SNF for the treatment of gastrointestinal spasms.

Fecal incontinence in people with self-reported irritable bowel syndrome: Prevalence and quality of life

Irritable bowel syndrome (IBS) is a common functional gastrointestinal (GI) disorder characterized by recurrent abdominal pain and altered bowel habits. IBS is a risk factor for fecal incontinence (FI), the unintentional passage of solid or liquid stool. FI can substantially interfere with health related quality of life (HRQL), leading to heightened anxiety and avoidance behavior. Nevertheless, relatively little research has been conducted on the prevalence of FI in IBS patients. This study evaluated the prevalence of FI in people with self-reported IBS and the relationship between FI and HRQL. 703 people who reported a diagnosis of IBS completed questionnaires on IBS symptom severity, FI symptom severity, HRQL, fear of food, anxiety about visceral sensations, and GI specific catastrophizing. Overall, 60% of people with IBS reported experiencing at least one lifetime episode of FI. In a subsample of 360 people who met strict Rome IV criteria and reported no other GI related co-morbidities, 62% reported experiencing at least one lifetime episode. While people who experienced FI more frequently had worse HRQL statistically, the differences in HRQL between people who had experienced FI and those who had not were not clinically significant. Rather than frequency of FI or physical symptom severity, quality of life was mostly determined by psychological variables, such as fear of food, anxiety, and catastrophizing. This study suggests that FI is quite prevalent in IBS patients, but that the best way to improve HRQL for IBS patients with FI may be to focus on reducing anxiety, catastrophizing and avoidance.

Review article: an analysis of safety profiles of treatments for diarrhoea-predominant irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is multifactorial in nature, and a wide range of therapies is available to manage symptoms of this common disorder.

AIM

To provide an overview of the safety of interventions that may be used to manage patients with diarrhoea-predominant IBS (IBS-D).

METHODS

Medline and Embase database searches (through 02 May 2018) to identify clinical studies that evaluated treatment safety and/or efficacy in adults with IBS-D.

RESULTS

IBS-D treatments include dietary modification, probiotics, serotonin receptor antagonists, opioid receptor agonists and antagonists, nonsystemic antibiotics, bile acid sequestrants, antidepressants, and complementary and alternative therapies. These treatments vary in administration frequency (eg, daily; short-course therapy) and target various pathophysiologic factors. Safety profiles vary considerably by treatment among IBS-D therapies. The number needed to harm (defined as the number of patients treated to encounter an adverse event) was lowest (worse) for antidepressants (8.5) and highest (best) for probiotics (35), and the number needed to harm (defined as the number of patients who discontinued due to an adverse event) was lowest for tricyclic antidepressants (9) and highest for rifaximin (8971). Notable safety concerns with IBS-D treatments include pancreatitis with eluxadoline, ischaemic colitis and serious complications of constipation with alosetron, and cardiac adverse events with loperamide and tricyclic antidepressants. Treatment decisions need to account for medication risks and adverse events for each patient.

CONCLUSIONS

Multiple treatment options are now available for patients with IBS-D. However, the safety profiles of these agents vary widely by number needed to harm value. Providers should consider both safety and efficacy of a specific intervention when determining how best to manage patients' IBS-D symptoms.

Triphala: current applications and new perspectives on the treatment of functional gastrointestinal disorders

Background

Ayurvedic medicine is based on natural healing methods that use herbal medicine to cleanse the body of toxins and to attain physical and mental regeneration. Triphala (TLP) is one of the most important ayurvedic supplements and is believed to have a beneficial effect on the entire gastrointestinal (GI) tract.

Purpose

We aim to summarize available literature focused on the components of TLP (Terminalia chebula, Terminalia bellerica and Phyllanthus emblica) and discusse their effectiveness and therapeutic value for improving lower GI symptoms in functional GI disorders, particularly irritable bowel syndrome (IBS).

Methods

This study is based on pertinent papers that were retrieved by a selective search using relevant keywords in PubMed and ScienceDirect databases.

Results

The components of TLP are believed to cause restoration of the epithelium lining of the digestive tract, and by exhibiting mild laxative properties facilitate passage of stool in the colon. TLP is rich in polyphenols, vitamin C and flavonoids, which provide antioxidant and anti-inflammatory effects. It also contains various types of acids, such as gallic, chebulagic and chebulinic, which additionally possess cytoprotective and antifungal properties.

Conclusion

Triphala holds potential in improving lower GI symptoms and may be a valuable and effective addition to standard treatment of IBS. Supplementation of TLP herbal formulations alone or along with other probiotics can be recommended in ongoing clinical studies.

Efficacy and indication optimization of Chinese medicine (Tiao-Chang Ke-Min granules) for diarrhea-predominant irritable bowel syndrome: study protocol for a randomized controlled trial

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic, recurring condition, prevalent in the general population. Current medication treatments usually leave patients undertreated. Nowadays, Chinese medicine (CM) is being considered as a promising treatment approach for IBS. However, due to methodological limitations, there is no strong evidence to support CM. Although IBS relapses are common, the relapse assessment has always been neglected in CM study designs. Meanwhile, in clinical practice and studies, it has been found that certain CM formulas can only benefit certain kinds of patients. Discovering what population and illness characteristics likely respond to outcomes may help improve the effectiveness of CM. The aims of this study are to evaluate the efficacy and safety of Tiao-Chang Ke-Min (TCKM) granules for IBS, especially in reducing IBS symptoms' relapse, by a high-quality randomized controlled trial and then to optimize the indication of the TCKM granules.

METHODS/DESIGN

This is a parallel-group, randomized, double-blind, placebo-controlled trial embedded with outcome predictive factors. Eligible patients with diarrhea-predominant IBS will be randomized into either a TCKM granule group or a placebo group. Patients from both groups will receive health education. The treatment duration is 4 weeks and the follow-up is 12 weeks. The primary outcome is global improvement measured with adequate relief (AR). The second outcome measures include time until relief, time until first relapse, total relapse times, long-term effectiveness, individual symptoms, IBS-Symptom Severity Score (IBS-SSS), IBS-Quality of Life Questionnaire (IBS-QOL), and Hospital Anxiety and Depression Scale (HADS). Predictive factors associated with patient and illness characteristics have been widely collected. These factors will be embedded in this trial for further identification.

DISCUSSION

This trial may provide high-quality evidence on the efficacy and safety of TCKM granules for IBS and a more accurate indication. Importantly, this trial will provide a new research method for improving the therapeutic effects of CM for clinicians and researchers. To address IBS relapse assessment, a series of special definitions of relapse incidents has been made for this trial.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ID: ChiCTR-IOR-17010600 . Registered on 9 February 2017.

Neuromuscular electrical stimulation as an adjunctive therapy to drotaverine hydrochloride for treating patients with diarrhea-predominant irritable bowel syndrome: A retrospective study

This retrospective study investigated the effectiveness and safety of neuromuscular electrical stimulation (NMES) as an adjunctive therapy to drotaverine hydrochloride (DHC) in patients with diarrhea-predominant irritable bowel syndrome (BP-IBS).A total of 108 patient cases with BP-IBS were included in this study. Of these, 54 cases were assigned to a treatment group and received NMES and DHC, whereas the other 54 subjects were assigned to a control group and underwent DHC alone. All patients were treated for a total of 4 weeks. Primary outcomes were measured by the visual analog scale (VAS), and average weekly stool frequency. Secondary outcome was measured by the Bristol scale. In addition, adverse events were documented. All outcome measurements were analyzed before and after 4-week treatment.Patients in the treatment group did not show better effectiveness in VAS (P = .14), and average weekly stool frequency (P = .42), as well as the Bristol scale (P = .71), compared with the patients in the control group. Moreover, no significant differences in adverse events were found between 2 groups.The results of this study showed that NMES as an adjunctive therapy to DHC may be not efficacious for patients with BP-IBS after 4-week treatment.