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Contributions of suggestion, desire, and expectation to placebo effects in irritable bowel syndrome patients
Lene Vase a, Michael E. Robinson b * merobin@uf1.edu , G. Nicholas Verne c and Donald D. Price d,e
PAIN®, Vol. 105 (1-2) (2003) pp. 17-25
© 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
PII: S0304-3959(03)00073-3
Abstract
In order to investigate external factors that may influence the magnitude of placebo analgesia as well as psychological factors that mediate placebo analgesia, 13 irritable bowl syndrome (IBS) patients rated evoked rectal distension and cutaneous heat pain under the conditions of natural history (NH), rectal placebo (RP), rectal nocebo (RN), rectal lidocaine (RL) and oral lidocaine (OL). Patients were given verbal suggestions for pain relief and rated expected pain levels and desire for pain relief for both evoked visceral and cutaneous pain, respectively. Large reductions in pain intensity and pain unpleasantness ratings were found in the RP, RL and OL condition as compared to the natural history condition, whereas no significant difference in pain reduction between the three treatment conditions was found. Ratings during RN and NH were not statistically different. Compared to a previous study, which shows that rectal lidocaine reverses visceral and cutaneous hyperalgesia, these results suggest that adding a verbal suggestion for pain relief can increase the magnitude of placebo analgesia to that of an active agent. Since IBS patients rate these stimuli as much higher than do normal control subjects and since placebo effects were very large, they probably reflect anti-hyperalgesic mechanisms to a major extent. Expected pain levels and desire for pain relief accounted for large amounts of the variance in visceral pain intensity in the RP, RL, and OL condition (up to 81%), and for lower amounts of the variance in cutaneous pain intensity. Hence, the combination of expected pain levels and desire for pain relief may offer an alternative means of assessing the contribution of placebo factors during analgesia.
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Constipation and its management
BMJ 2003;327:459-460 (30 August)
Options go beyond laxatives and include behavioural treatment as well as new drugs
Although slow to emerge, major advances have occurred in understanding the causes and management of constipation. It now receives the attention deserved of a symptom that affects a quarter of the population at some time. Most important is the recognition that different pathophysiological processes can result in the final common symptoms of decreased bowel frequency or impaired rectal evacuation. Different clinical syndromes require different therapeutic approaches.
Bowel frequency is influenced by several factors including intake of dietary fibre, emotional make up, and psychological morbidity. Introspective individuals have a lower bowel frequency and produce less stool than extroverts. Infrequent bowel actions in the absence of symptoms can be regarded as part of the normal spectrum of bowel frequency. Low bowel frequency is more common in women.
Controlled cross sectional studies have shown that psychological morbidity is commonly associated with severe constipation.1 In some patients it is the key causative factor. Other factors include childhood problems such as sexual or physical abuse, loss of a parent through death or separation, or disturbed toileting behaviour. Underlying depression is another cause. For some the gut is their "outlet valve" for the normal stresses of living. The pathways between brain and gut that link emotions to bowel function have been largely characterised and shown to involve cerebral corticotrophin releasing factor and efferent autonomic pathways. Although psychological factors should be sought at initial assessment, in some patients they are less important. Not all patients have a psychological "skeleton."
The distinction as to whether a patient has a normal diameter or dilated large bowel is of practical importance. Severe intractable constipation with resistance to laxatives in the presence of an apparently normal (non-dilated) colon is seen most commonly in women of reproductive age. When transit is slow the key physiological abnormality is diminished colonic propulsive activity. There are associated changes in upper gut transit and sensory function. Although neural abnormalities can be shown in the colon, such as changes in the pacemaker cells of Cajal, these may be secondary to chronic ingestion of laxatives. The reversibility of impaired function by behavioural treatment2 implies that neural changes are often secondary.
Constipation is now recognised as an important symptom in a range of patients' groups with other primary pathology. Almost all patients with spinal injury experience constipation; lack of bowel control is one of their most distressing symptoms.3 It is also common in patients with multiple sclerosis. Patients with mild disease can be helped by behavioural treatment, which shows that in patients with neurological disease bowel dysfunction often has a reversible component.
Patients with a dilated bowel constitute a different clinical problem. Those with a dilated rectum and faecal impaction—so called idiopathic megarectum—are usually teenagers or young adults of either sex.4 They have often soiled since childhood. In some the problem has a behavioural basis, whereas in others there may be subtle neuromuscular abnormalities of the gut. Constipation with faecal impaction is also seen in elderly patients, especially those in care. Poor general health, impaired mobility, inadequate toilet facilities, and drugs may all contribute. Patients with dilation throughout the gut are rare and they usually have a discrete abnormality of enteric nerves or muscle, leading to impaired propulsion. In such patients with chronic intestinal pseudo-obstruction, constipation is only part of a complex mix of symptoms including pain, vomiting, and nutritional impairment.
For people with mild longstanding constipation investigations are not required, and dietary management is usually sufficient to relieve symptoms. When chronic constipation is more severe, detailed consideration of likely causes and other treatments is warranted.
Many patients with mild constipation can be managed with simple bulking agents or laxatives. After thousands of years of empirical use of such agents, prescribing can now be based on evidence from controlled trials. In elderly patients with resistant constipation, a stimulant such as senna, possibly combined with a bulking agent, is more effective and cheaper than lactulose.5 Polyethylene glycol based laxatives have recently been shown to provide long term benefit in patients with idiopathic constipation and faecal impaction.
For many patients, however, laxatives do not provide sustained relief of symptoms. In addition increasing dietary fibre has been shown to worsen symptoms in many patients by causing increased bloating without an improvement in bowel function.6
Behaviour therapy, including biofeedback (teaching the patient to normalise pelvic floor function while watching real time feedback about sphincter function) and habit training, has become established as the most effective form of treatment for patients with either slow transit or impaired evacuation, when traditional treatments have failed.2 Behavioural treatments comprise a "package" of care, including exercises focused on the gut, help in coming off laxatives, and psychological support. Such treatment has been shown to improve symptoms, transit time through the gut, psychological wellbeing, and quality of life, as well as leading to reduced use of laxatives.2 7 8 It has been shown to be effective in patients with slow gut transit, impaired rectal emptying, constipation after childbirth or pelvic surgery such as hysterectomy, solitary rectal ulcer from the trauma of straining, rectocele (anterior rectal wall bulge from repeated straining), and in patients with mild degrees of neurological disease such as multiple sclerosis. Long term follow up of cohorts of patients has shown that for most of these conditions about two thirds of patients are helped.7
For those who do not benefit from simple bulking agents, laxatives, or behavioural treatments, new pharmacological approaches may offer help. The neurochemical basis for peristalsis is now better appreciated and known to involve 5-hydroxytryptamine4 (serotonin type 4) receptors.9 In contrast to laxatives, which work via a luminal mechanism, the newly developed 5-hydroxytryptamine4 agonists are absorbed in the small intestine and induce peristalsis through a systemic mechanism. Tegaserod and prucalopride are two such drugs; the former is licensed in the United States but not in the United Kingdom or most of Europe. The latter is still under development.
Patients with idiopathic megarectum should have their bowel emptied completely before titrating an osmotic laxative.4 Such a laxative may be required in the long term, although behavioural treatment seems also to help some of these patients.
Surgery was commonly used in the past to treat patients with intractable constipation, such as young women with severe idiopathic constipation. The variable and unpredictable results of colectomy,10 together with the success of conservative treatments, has made this necessary only rarely. When surgery is being considered, new techniques, such as sacral nerve stimulation, may modify bowel neuromuscular control while avoiding irreversible bowel resection.11 This treatment involves chronic neural stimulation via percutaneously placed fine sacral electrodes.
The paradigm of a drug or operation for every condition needs broadening when treating constipation. When simple treatments have failed and specialist treatment is sought, broadly based multidisciplinary teams need to be able to offer more than laxatives and surgery. It might be argued that such a trivial symptom is not deserving of such use of resources. However, patients with functional gut symptoms have impaired quality of life and consume a large amount of healthcare resources. While relieving symptoms, effective treatments are also likely to be cost effective.
Michael A Kamm, professor of gastroenterology
St Mark's Hospital, Harrow HA1 3UJ (kamm@imperial.ac.uk)
--------------------------------------------------------------------------------
Competing interests: MK has been an adviser to Abbott, Johnson and Johnson, Medtronic, and Novartis.
References
Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological morbidity in women with idiopathic constipation. Am J Gastroenterol 2000;95: 2852-7.[CrossRef][ISI][Medline]
Chiotakakou-Faliakou E, Kamm MA, Roy AJ, Storrie JB, Turner IC. Biofeedback provides long term benefit for patients with intractable, slow and normal transit constipation. Gut 1998;42: 517-21.[Abstract/Free Full Text]
Glickman S, Kamm MA. Bowel dysfunction in spinal cord injury patients. Lancet 1996;347: 1651-3.[ISI][Medline]
Gattuso JM, Kamm MA. Clinical features of idiopathic megarectum and idiopathic megacolon. Gut 1997;41: 93-9.[Abstract/Free Full Text]
Passmore AP, Wilson-Davies K, Stoker C, Scott ME. Chronic constipation in long stay elderly patients: a comparison of lactulose and a senna-fibre combination. BMJ 1993;307: 769-71.[ISI][Medline]
Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet 1994;344: 39-40.[ISI][Medline]
Emmanuel AV, Kamm MA. Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation. Gut 2001;49: 214-9.[Abstract/Free Full Text]
Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological state and quality of life in patients treated by behavioral treatment (biofeedback) for intractable constipation. Am J Gastroenterol 2002;97: 3154-9.[CrossRef][ISI][Medline]
Grider JR, Foxx-Orenstein AE, Jin JG. 5-Hydroxytryptamine4 receptor agonists initiate the peristaltic reflex in human, rat, and guinea pig intestine. Gastroenterology 1998;115: 370-80.[ISI][Medline]
Kamm MA, Hawley PR, Lennard-Jones JE. Outcome of colectomy for severe idiopathic constipation. Gut 1988;29: 969-73.[Abstract]
Kenefick NJ, Nicholls RJ, Cohen RG, Kamm MA. Permanent sacral nerve stimulation for treatment of idiopathic constipation. Br J Surg 2002;89: 882-8.[CrossRef][ISI][Medline]
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Gastroenterology, August 2003 Journal Scan
From
The American Journal of Gastroenterology
August 2003 (Volume 98, Number 8)
Association Between Pain Episodes and High Amplitude Propagated Pressure Waves in Patients With Irritable Bowel Syndrome
Clemens CH, Samsom M, Roelofs JM, van Berge Henegouwen GP, Smout AJ
The American Journal of Gastroenterology. 2003;98(8):1838-1843
The underlying pathogenesis of irritable bowel syndrome (IBS) appears to involve both increased visceral sensitivity and altered colonic motility. In healthy individuals, colonic motility patterns known as high amplitude propagated pressure waves (HAPPWs) occur approximately 6 times daily. These waves are believed to be the driving force in the colon that generates transit of colonic content over long distances; they appear essential for maintenance of physiologic bowel activity.
In the normal, healthy individual, HAPPWs occur more often in the postprandial period or after awakening, and infrequently occur at night. However, as might be expected, in patients with IBS with diarrhea, there is generally a trend toward an increased number of HAPPWs, whereas in those patients with IBS with constipation, a decreased number of propagated contractions are observed.
Recently, an association was demonstrated between the occurrence of HAPPWs and abdominal cramps in patients with IBS, but these propagated waves were induced by cholecystokinin and a high-calorie meal in a laboratory setting. So, under physiologic conditions, do patients with IBS perceive HAPPWs as painful?
To address this question and determine the temporal relationship between occurrence of pain and HAPPWs, Clemens and colleagues recorded abdominal pain and HAPPWs during a prolonged, fully ambulatory manometric study of the left colon in patients with IBS with the predominant nonconstipation pattern (n = 11) vs controls (n = 10). The link between episodes of abdominal pain and occurrence of HAPPWs was assessed by using a modification of the symptom association probability (SAP). An SAP > 95% was considered to indicate that the observed association did not occur by chance.
This represents the first study using techniques of objective analysis to demonstrate an association between HAPPWs and pain in a subset of patients with IBS studied under physiologic conditions. The study authors found that for 4 of 7 patients reporting pain on day 2, the SAP was > 95%. HAPPWs that were associated with episodes of abdominal pain originated at a more proximal level (P = .026) and occurred earlier (P = .007) than HAPPWs that were not associated with pain. The duration of a pain period was correlated with the number of pain-related HAPPWs occurring in that period (r = 0.906, P = .013). Two of the 10 control patients experienced pain, but these pain episodes were not related to occurrence of HAPPWs.
As these investigators pointed out, it was interesting to note that HAPPWs related to pain (in patients with SAP>95%) did not appear to show any major differences from those not associated with pain, except for occurring more proximally in the left colon and earlier in the day. Therefore, it was suggested that pain induced by a stimulus that does not normally produce pain, rather than hyperalgesia, may actually be important in pain generation in patients with IBS with SAP > 95%.
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Infectious Gastroenteritis Linked to Irritable Bowel Syndrome
Laurie Barclay, MD
Sept. 25, 2003 — Infectious gastroenteritis is associated with the development of irritable bowel syndrome (IBS), according to the results of a prospective, community-based study published in the September issue of the American Journal of Gastroenterology.
"IBS might develop after gastroenteritis," write Sally D. Parry, from the University of Newcastle in the U.K., and colleagues. "Most previous studies of this relationship have been uncontrolled, and little is known regarding other functional gastrointestinal disorders (FGIDs) after gastroenteritis."
In this case-control study, cases had proven bacterial gastroenteritis, and control patients were community-based. Self-administered Rome II modular questionnaires diagnosed FGIDs at baseline, three, and six months. Subjects with prior FGIDs were excluded from the study. Of 500 identified cases, 265 patients (53%) consented to take part in the study, as did 705 control patients, of whom 219 were eligible. Six-month questionnaire data were available for 108 cases and 206 controls.
The primary end point, defined as the presence of one of the three specific FGIDs at six months, occurred in significantly more cases than in controls (27 [25%] vs. 6 [2.9%]; OR = 11.11; 95% confidence interval [CI], 4.42 - 27.92). At three months, 29% of cases and 2.9% of controls had an FGID.
Although functional dyspepsia was uncommon in both case and control patients, IBS was diagnosed in 18 cases (16.7%) and four controls (1.9%; OR = 10.1; 95% CI, 3.32 - 30.69), and functional diarrhea was diagnosed in six cases (5.6%) and in no control patients.
Study limitations include very low participation rate, exclusion of a significant proportion of potential subjects because of a pre-existing FGID, fairly high drop-out rate, and lack of endoscopic data.
"Symptoms consistent with IBS and functional diarrhea occur more frequently in people after bacterial gastroenteritis compared with controls, even after careful exclusion of people with pre-existing FGIDs," the authors write. "The proportion of patients with an FGID was maintained between 3 and 6 months, which suggests that the symptoms are likely to be long-lasting. Clearly, more needs to be known about the natural history of FGIDs after bacterial gastroenteritis, and the field of postinfectious IBS is rich in possibilities for discovering more about the pathoetiology of these common gut disorders."
Northumbria NHS Healthcare Trust funded this study.
Am J Gastroenterol. 2003;98 (9):1970-1975
Reviewed by Gary D. Vogin, MD
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Three in Four People With IBS Also Have Functional Dyspepsia
Charlene Laino
Oct. 14, 2003 (Baltimore) — More patients than thought may suffer from multiple functional gastrointestinal disorders, according to researchers who found that nearly three quarters of people who suffer from irritable bowel syndrome (IBS) also have functional dyspepsia.
"Physicians need to realize that many patients seeking care for gastrointestinal symptoms are likely to have more than one clinical disorder," said lead researcher Ashok K. Tuteja, MD, from the Department of Gastroenterology at the University of Utah in Salt Lake City.
Dr. Tuteja presented the findings here on Monday at the 68th annual scientific meeting of the American College of Gastroenterology. About 1 in 10 American suffer from IBS and even more from dyspepsia, he said.
It has been suggested that dyspepsia and IBS represent the same disease entity — the so-called irritable gut, Dr. Tuteja said. As a result, he and colleagues undertook a study to determine how common each syndrome is and how much the two overlap.
The researchers followed 723 people who filled out questionnaires asking about their upper and lower gastrointestinal symptoms. Their ages ranged from 24 to 77 years (median, 47 years).
IBS was defined as having continuous or recurrent symptoms for three months or more in the previous 12 months. Symptoms included abdominal pain or discomfort that is relieved with defecation or associated with changes in stool, hard or loose stool, straining or urgency, and bloating.
Functional dyspepsia was defined as having upper abdominal pain or discomfort six months or more in the previous year.
Nearly 15% of the patients reported symptoms of dyspepsia: 6.2% reported ulcer-like dyspepsia, 6.1% reported dysmotility-like dyspepsia, and 9.4% reported reflux dyspepsia. Also, 8.9% of patients had IBS symptoms, and 6.2% reported both dyspepsia and IBS.
Of the patients with IBS, 70% also had functional dyspepsia and of subjects with dyspepsia, 43% also had IBS, the study showed.
The association between the two syndromes was much greater than that expected by chance (kappa = 0.48), Dr. Tuteja reported.
Both IBS and the overlap syndrome were more common in women, but these differences were not statistically significant (P > .27). There was no association between any of the disorders and alcohol or aspirin use (P > .19), the study showed.
The people who reported symptoms of both disorders or symptoms of IBS were much more likely to consult a physician about their problems than those with dyspepsia alone, Dr. Tuteja reported. Thirty-three percent of those with both dyspepsia and IBS symptoms visited a physician in the previous year compared with 17% of patients with dyspepsia alone and 31% with IBS alone.
Richard G. Locke, III, MD, associate professor of medicine at the Mayo Clinic in Rochester, Minnesota, said that physicians are increasingly recognizing that many patients will have symptoms of more than one gastric disorder.
The question, he said, is "should we be rearranging the deck? Are people who have IBS and dyspepsia somehow different than those who have only one or the other?"
As drugs targeting the molecular aberrations that cause gastric disorders are developed, knowing the answer to that question will become increasingly important, he said.
Kevin W. Olden, MD, associate professor of medicine in the Division of Gastroenterology at the Mayo Clinic in Scottsdale, Arizona, agreed. "Each person has different molecular changes. The patient with both IBS and dyspepsia will have a different molecular change than the person with just IBS or dyspepsia."
Understanding these molecular changes is the wave of the future, he said.
ACG 68th Annual Scientific Meeting: Abstract 301. Presented Oct. 13, 2003.
Reviewed by Gary D. Vogin, MD
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Date: 2003-10-15
Researchers Identify Molecular Alterations In Patients With Irritable Bowel Syndrome
BALTIMORE, Md. – Novel research shows that alterations in serotonin signaling in the gastrointestinal (GI) tract are present in patients with Irritable Bowel Syndrome (IBS). These data shed light on the alterations in gut motility, secretion, sensation, as well as the clinical manifestations of IBS, which include abdominal discomfort, pain, bloating, constipation and/or diarrhea.
The study findings were presented today by two lead investigators from the University of Vermont, Peter Moses, M.D., Associate Professor of Medicine and Director of Clinical Research in the Digestive Diseases, and Gary Mawe, Ph.D., Professor of Anatomy and Neurobiology, in an oral presentation during the plenary session at the 68th Annual Scientific Meeting of the American College of Gastroenterology in Baltimore.
"Serotonin is a critical signaling molecule necessary for normal gut function – when released, it causes gut motility and secretion, and triggers signals to the brain and spinal cord," said Moses. "Our finding that key elements of serotonin signaling are changed in IBS lends credibility to the notion that IBS is not simply a psychological or social disorder as was once thought, but instead due to altered gut biochemistry and interactions between the gut and the brain."
Serotonin (5-HT) is a naturally occurring neurotransmitter and signaling molecule. Ninety-five percent of all serotonin is localized in the GI tract where it plays a key role in the motor, sensory and secretory functions of the gut. For some time, scientists have suspected that alterations in serotonin may contribute to abnormal conditions in the GI tract.
"Now we have a perspective on molecular changes in the intestines of individuals with IBS that we did not have before," said Mawe. "We identified a significant decrease in the serotonin transporter in cells that form the inner lining of the bowel – the same serotonin transporter that is located in cells in the brain. In the gut, this transporter acts as a sponge to remove serotonin once it is released, and therefore stops its actions. Because the transporter is diminished in IBS, serotonin stays around longer, and this can lead to changes in motility, secretion and sensitivity."
The study examined tissue obtained from 43 healthy controls and 32 patients with IBS and 22 patients with inflammatory bowel disease (IBD). IBS patients were defined strictly using ROME II criteria. Each biopsy was evaluated by five parameters: immunohistochemical staining, histological assessment, serotonin content, serotonin release and the measurement of mRNA encoding. The study also examined the molecular components of serotonin signaling, including the serotonin re-uptake system.
Specifically, the investigators measured serotonin content, the endocrine cell number, serotonin release and presence of serotonin transporters (SERT). Serotonin transporters are regulatory molecules that control the activity of serotonin within nerve endings in the GI tract to coordinate motility, visceral sensitivity and intestinal secretion.
In patients with IBS, the study found a significant decrease in serotonin content and significantly higher endocrine cell (EC) populations in patients with IBS compared to controls, while the release of serotonin from EC cells was not significantly different. In terms of the way the body inactivates serotonin signaling, or the serotonin re-uptake system, SERT mRNA and SERT immunoreactivity were markedly reduced. This reduction led to a decrease in the capacity to remove serotonin from intracellular space once it was released, thus increasing serotonin availability.
The study was sponsored through a research grant from Novartis Pharmaceuticals, maker of Zelnorm® (tegaserod maleate) for IBS-C. In addition to Moses and Mawe, members of the study team included Matthew Coates, Christine Mahoney, David Linden, Joanna Sampson and Eric Newton of the University of Vermont; Michael Gershon and Jason Chen of the Department of Anatomy and Cell Biology at Columbia University; Keith Sharkey of the Department of Physiology and Biophysics at the University of Calgary, and Michael Crowell of the Clinical Research department at Novartis Pharmaceuticals.
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Mind-Body Technique Eases Kids' Gut Pain
Kids Have Fewer Days of Abdominal Pain When Using Relaxation Technique
By Jeanie Lerche Davis
WebMD Medical News
Reviewed By Brunilda Nazario, MD
Aug. 5, 2003 -- For kids with chronic abdominal pain, relaxation techniques can help them cope.
Some 20% of school-age children suffer from recurrent abdominal pain -- and for 10% of them, there is a real problem in the gut. But for the rest, the pain is often unexplained -- yet persists, sometimes into adulthood.
It's a big problem that upsets their quality of life. "Not only are these children in pain, they are missing school, making frequent doctor visits and may suffer from anxiety and depression," says lead researcher Thomas M. Ball, MD, MPH, professor of clinical pediatrics at the University of Arizona, in a news release.
His report is published in the July/August issue of Clinical Pediatrics.
In it, he describes using guided imagery therapy -- which combines relaxation, imagery, and hypnosis -- to help children gain control over their pain. Other studies have shown that the technique helps kids with other types of pain, says Ball.
The technique affects the autonomic nervous system -- the nerves that are involved in involuntary functions in the body, such as digestion. In essence, it taps the body's own healing power, he says.
Each child was trained in relaxation and guided imagery during four weekly sessions. Each filled out a daily "pain diary" three times a day to track the effectiveness of the technique.
During the month of training, the children had 36% fewer days with pain.
In the second month, "pain days" decreased an additional 50%.
Total decrease in pain days was 67% less within two months of starting therapy.
Of the 10 children, seven showed improvement by the end of therapy and nine showed results one month later. Only one child showed no improvement.
The intensity of abdominal pain did not change during the period, but there were far fewer pain days, Ball reports.
SOURCES: Clinical Pediatrics, July/August 2003.
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Travelers' Diarrhoea Can Trigger Irritable Bowel
By M.M. Pennell
SAN DIEGO, CA -- October 22, 2003 -- About 10% of people who report cases of travelers' diarrhoea are at risk for developing chronic gastrointestinal disorders, including irritable bowel syndrome (IBS).
This news comes as a result of a study presented October 11th at the 41st Annual Meeting of the Infectious Diseases Society of America.
Lead investigator, Pablo Okhuysen, MD, associate professor of medicine, Division of Infectious Diseases, University of Texas Health Sciences Center, Houston, United States, prospectively followed 146 students who traveled to Mexico. Said Dr. Okhuysen, "Having diarrhoea while they were in Mexico -- and having more than one episode while traveling -- correlated with the likelihood of developing IBS. This confirms that there is probably a relationship between infectious gastroenteritis and IBS."
Dr. Okhuysen said that many IBS patients report onset of chronic symptoms after an initial attack of gastroenteritis. Published studies suggest that 7% to 33% of patients with bacterial gastroenteritis develop post-infection IBS.
Dr. Okhuysen and colleagues recruited 146 students who were followed prospectively for 4 weeks after arrival in Mexico. Students who developed diarrhoea were assessed for the presence of enteric pathogens. Assessment of chronic gastrointestinal symptoms was performed by questionnaire, which was mailed to the students 6 months after their return to the United States. Symptoms were evaluated according to the Rome II criteria to determine the presence of post-infection IBS.
Sixty-two students developed diarrhoea while traveling in Mexico, and a total of 98 students completed the 6-month follow-up, Dr. Okhuysen said.
Before travel, only 1 student met the criteria for IBS, but, after travel, seven students met IBS criteria, said Dr. Okhuysen. Additionally, at the 6-month follow-up 17 students reported chronic abdominal pain compared to five students before the trip, and 17 reported chronic diarrhoea, defined as diarrhea lasting 2 weeks or longer, while one student reported chronic diarrhoea before traveling to Mexico, he said.
All students who reported post-travel IBS experienced diarrhoea while in Mexico, while none of the students who were asymptomatic while in Mexico met the definition of IBS 6 months after travel. Dr. Okhuysen said the risk of post-travel IBS or post-travel gastrointestinal symptoms correlated with the severity of traveler's diarrhoea while in Mexico. Typically students who reported chronic gastrointestinal complaints experienced at least two episodes of diarrhoea while traveling, Dr. Okhuysen noted.
[Study Title: Frequency and Characteristics of Post Infectious Irritable Bowel Syndrome in Travelers to Mexico: Abstract 876]
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BBC News World Edition
The distress and discomfort of irritable bowel syndrome (IBS) earns little sympathy from many doctors, according to a survey.
The majority of US doctors interviewed believed that IBS, while unpleasant, was not a serious medical condition, while four out of five admitted that they did not follow established treatment guidelines.
Nearly a third of the doctors said that IBS was mainly a psychological problems, instead of a genuine physical complaint.
Even in the UK, support groups say that some doctors still have little time for patients complaining of IBS symptoms.
The condition, which affects thousands of women and men in the UK, is characterized by chronic abdominal pain and irregular bowel movements.
It can leave sufferers afraid to leave the house in case they urgently need to go to the toilet.
The root causes of IBS are still unknown, although attacks are thought to be made worse or triggered by stress.
It is suggested that the nerves lining the lower bowel are more sensitive than normal to bowel contractions and the passage of gas and fluid, leading to painful spasms.
Some patients have found that eating certain foods, such as dairy products or fatty foods, makes their condition worse.
The survey of three thousand sufferers and ordinary people found that IBS sufferers took many more days off work through sickness - 13.4 compared to 4.9 days.
Almost half the IBS patients said the condition limited their social life, holidays and travel.
Two out of five reported pain that was intolerable without painkillers, with nearly 70% saying they had experienced pain for more than three months in the past year.
Penny Nunn, a development worker at the UK support group IBS Network, said: "Some UK doctors are sympathetic and some are not. It's certainly a difficult condition to treat.
"Many of the women who come to us have already been through the mill as regards GPs, gastroenterologists and the like, and they are looking for a cure.
"But there are no quick fixes."
Doctors are currently working on guidelines for both patients and GPs on how to treat IBS.
http://news.bbc.co.uk/1/hi/health/459884.stm
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BBC News World Edition
Outlook affects bowel disorder patients
People's perception of their bowel disorder affects how they cope with the condition, researchers have found.
If they believe their Irritable Bowel Syndrome (IBS) is due to an external factor, such as a virus and that it can be controlled, they cope well.
But if they believe it is caused by psychological factors, they are less likely to cope with IBS.
Researchers from the University of Kent interviewed over 200 patients with IBS.
They were asked about their symptoms and what they believed about the causes and the severity of the disorder.
Patients were also asked to what extent people believed their IBS can be controlled or cured, how they coped with it and how anxious or depressed they were.
It was found that those who believed it could be controlled or cured were likely to accept their IBS and have a better quality of life.
But those who thought IBS was a very serious illness with potentially serious consequences suffered more anxiety and depression.
They also had a lower quality of life.
But Drs Claire and Derek Rutter, who carried out the research, said these people were more likely to try to avoid thinking or dealing with their IBS, which meant they were likely to fare less well.
They said therapy may help IBS patients to feel better.
Writing in the British Journal of Health Psychology, they said: "The effectiveness of psychological therapy for IBS patients may improve if therapists challenge patients' perceptions of serious consequences and may offer alternatives to behavioural disengagement and venting emotions.
"Therapists might also try to increase control beliefs and acceptance of the illness."
IBS varies between patients, but it usually includes cramping discomfort, a feeling of fullness or bloating, constipation and diarrhoea.
Women are affected more than men.
Sufferers often desperately need to go to the toilet with little warning, which severely limits their lifestyle.
No-one knows what causes the condition, although it is suggested that stress can make it worse.
Most people are advised to try to manage the condition by changing their diet and trying to reduce stress levels, as well as taking other medication.
http://news.bbc.co.uk/1/hi/health/2385631.stm
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Heather is the Administrator of the IBS Message Boards. She is the author of Eating for IBS and The First Year: IBS, and the CEO of Heather's Tummy Care. Join her IBS Newsletter. Meet Heather on Facebook!
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