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Hi there,thanks for the post. She probably does eat quite a bit of insoluble fibre. This is her third day of not going, she will go sometime today - if she doesn't go every day she goes every second or third day. We have tried fibre supplements, obviously haven't bought any from Heather yet, and both psyllium and normacol made her so sore and gassy she was doubled up in pain. I will try the suggestion of lying on left side with legs bent and deep breathing, I have done variants of this over the months :-) I have cut down her fruit consumption considerably, especially when I read that bananas can cause gas.
I know I don't know what I'm talking about but all this seems to be treating the symptoms and nothing getting to the bottom of what actually causes irritable bowel syndrome, I have read articles on the SIBO small intestine bacteria overgrowth and this makes sense to my untrained brain. These bacteria feed on partially digested foods in particular carbs and sugars causing gas and cramping. I know there are other articles that dispute this theory.
I guess I just can't get my head around a kid who was healthy on Thursday 4 Feb 2005 and then in pain etc on Friday 5 February 2005 and has continued like this for the year. How intolerances can just 'show up' 'out of the blue' I just don't know. I had at least been intolerant to cow's milk as a baby and still have problems with dairy products, but to suddenly become gluten and lactose intolerant in a day or there abouts like she has???????????
I can't fathom why there is no pain during the day (believe me I am thankful), but only pain at night, it seems to me that there is a gas build up of what she has eaten throughout the day, and this is causing the colicky crampy pain and gas at night. She has a very windy butt. :-)
Please excuse my ramblings, just a tired and desperate mother.
Thanks for listening Pauline
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Thanks Maile - I'll see what I can find out.
Pauline
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Its extremely unlikely its SIBO, she doesn't match the symptoms for one. Of course you could get a test for it, but I think its unlikely the problem.
IBS and SIBO are also two different conditions. Despite some of the controversy lately about it, although its possible for them to overlap. I could explain if you wish.
She does match IBS if anything and her age is also more the likelyhood its IBS.
Gas can cause pain because of sensitive nerves linig the gi tract in IBS.
The chemical the gut releases to signal to the brain sensations in the gut is serotonin and they know there is a problem with that in IBSers.
All pain is processed in the brain. There is an impairment in IBS in a particular part of the brain called the Anteior Cinculate Cortex, so the signals coming from the gut can be not working right.
I might have missed something, but what testys has she had done.
Bloodwork stool tests (three) colonoscopy?
You might also want to read this.
http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&organ=6&disease=43&lang_id=1
and this
with permission
Frequent stomachaches in children: a reason for concern? By Miranda Van Tilburg, PhD Assistant Professor of Medicine Division of Gastroenterology and Hepatology School of Medicine The University of North Carolina at Chapel Hill Most children will complain of a stomachache once in a while, because it is one of the most common childhood pain experiences. Complaints can range from a vague queasy feeling in the stomach to doubling over in pain accompanied by vomiting, diarrhea or constipation. Fortunately, in a majority of cases, the reasons for a stomachache are minor and relatively benign. Most often, the complaint settles without a specific diagnosis, even when a doctor is consulted. However, some children are more prone to developing abdominal pain than others. These children experience frequent stomachaches over a period of several months to several years, which can be very disrupting in the child's life. Due to (a fear of developing) stomachaches, these children often miss out on family events, social outings with friends, and attending school. Stepping out of normal life in this way makes these children vulnerable to loneliness, anxiety, depression and low self-esteem. In the late 1950's, the English pediatrician John Apley was one of the first to systematically study and describe this phenomenon of childhood stomachaches, which he named Recurrent Abdominal Pain (RAP). In his first monologue on RAP, Apley describes the typical situation of a child who complains of frequent stomachaches. This child has been sent home from school and may even have vomited however, by the time he arrives at the doctor's office, the pain is usually gone and upon examination nothing but indefinite tenderness in the abdomen is found. The doctor usually does not find anything definitive on which to base a diagnosis. Most likely, the child has had the stomach pain before » » » » as well as somebody in his immediate family. The pediatrician feels he or she can wait for further developments with the child but has doubts about having missed something. Was (s)he right to express only reassurances or should further investigations have been carried out? This description of the pain-prone family and doubtful physician is still true today. What is RAP? Apley defined RAP as at least three episodes of pain occurring within three months that are severe enough to affect the child's activities. This diagnosis is still widely used in clinical practice and research. Sometimes, Rome classification is used, with the most common diagnoses being Functional Dyspepsia (FD) or Irritable Bowel Syndrome (IBS). FD is diagnosed when there has been at least 12 weeks of persistent or recurrent pain in the upper abdomen, without evidence of organic disease and no relief with defecation or change in stool form or frequency. IBS is diagnosed when there has been at least 12 weeks of abdominal pain, without structural or metabolic abnormalities and at least two of the following three features -- relief with defecation, change in stool frequency, or change in stool consistency. Upon careful review of RAP patients, it is found that pediatric IBS is very common – 45 to 70% of RAP patients meet Rome criteria for IBS and about 16% are ascertained to suffer from functional dyspepsia. Nobody is in as much pain as my child RAP patients and their parents often believe their symptoms are unlike "normal" stomachaches reported by other children. Pediatricians and gastroenterologists, on the other hand, perceive RAP as a problem that is overflowing their practices. The truth lies somewhere in between these two perspectives. RAP is one of the most common chronic pain complaints in childhood, but only 10 to 25% of children are affected. Symptoms often wane with time and spontaneous remission of RAP is likely. Yet, more than half of RAP children will continue to suffer from frequent somatic or psychological symptoms into adulthood. For example, Christensen and Mortensen reported that 11 out of the 18 RAP patients in their study suffered from abdominal pain 29 years later. Frequent stomachaches in children: a reason for concern? Miranda Van Tilburg 3 out as early as possible. Depending on the symptoms, a physician can order blood, urine and stool tests to rule out some common conditions. But, the use of X-rays, CTscans and endoscopies are usually restricted to cases in which the history or physical exam raises questions as to the diagnosis. Even with extensive testing, the odds are against finding an organic cause for a child who meets symptom criteria for RAP. In only one out of 10 cases, an organic cause can be identified and misdiagnosis is extremely rare. Even up to 20 years after an initial diagnosis of RAP, the chance of identifying an initially undiagnosed organic disorder is very low. Is it all in your head? Apley believed that if there is no organic cause for the pain, then the stomachaches are psychogenic. In other words, RAP patients suffer from an emotional disorder. He came to this conclusion because stress seemed to exaggerate or precede pain attacks and psychotherapy was usually effective in relieving attacks. In trying to explain the absence of abnormal physiological findings, many have followed Apley's lead and suggested these children suffer from psychological problems. RAP patients have been described as fussy, perfectionistic, high strung and anxious, and several studies have shown they suffer from more psychological problems than healthy children. However, the landmark work of Walker & Greene has shown that anxiousness is a consequence of the presence of abdominal pain rather than a cause. RAP patients are not necessarily more anxious or depressed than patients suffering from peptic ulcer or IBD, in which the abdominal pain is caused by inflammation of the GI tract. These findings suggest that chronic abdominal pain affects patients in similar ways regardless of etiology, and the notion that RAP is a psychogenic disorder has now fallen largely out of favor. Psychosocial factors are assumed to influence GI functioning and can exaggerate symptoms, but they play only a limited causal role. Suffering from abdominal pain does, however, generate psychological distress. It can produce not only anxiety but also increased depressive symptoms, somatization and lower self-esteem. Now it is understood that the cause of RAP is neither organic nor psychogenic, but there is close interplay between physiology and psychology. What is causing RAP? Although no structural abnormalities or diseases may be found, RAP patients do show some abnormal physiological characteristics. There is growing evidence that a disruption in the functioning of the GI tract is one of the major causes of RAP. This basically means that the Frequent stomachaches in children: a reason for concern? In other words, RAP patients suffer from an emotional disorder. He came to this conclusion because stress seemed to exaggerate or precede pain attacks and psychotherapy was usually effective in relieving attacks. Are RAP stomachaches real, imagined or faked? Since stomachaches are notoriously used as an excuse for skipping school, they have gotten a bad reputation. A child with RAP is often thought of as a whiner who uses his bellyaches to get attention or get out of things, especially when a physiological cause for the pain cannot be identified. RAP children and their families face this type of prejudice almost daily, even among many health care professionals. However, it is important to understand that the pain of RAP is real and not faked or imagined. Even abdominal pain caused by stress or worry about going to school is usually real. Most children never think about faking it. Acknowledging the validity of RAP stomachaches is the right thing to do, but keeping a child who suffers from RAP out of school every time he or she complains is not necessary. If no other symptom, such as vomiting or fever is present, it is usually safe for the child to go to school. Has a serious disease been overlooked? Both parents and physicians are often doubtful about the diagnosis of RAP. There is no marker or test to identify RAP; the diagnosis is made purely on the basis of symptom characteristics. Common organic causes of abdominal pain are usually ruled out before giving a diagnosis of RAP. The list of disorders that can cause abdominal pain is lengthy and, generally, it is neither ethically nor financially possible to test every child for all possibilities. Serious illnesses can sometimes explain recurrent stomachaches and it is important to rule these When RAP persists into adulthood, these patients are most likely to develop IBS. There are striking similarities between adulthood IBS and childhood RAP in terms of prevalence, course, medical and psychiatric co-morbidity, family medical and psychiatric history, and stressful life events. There is data to suggest that the prognosis is worse for children who have a parent who suffers from recurrent pain and for children who experience more negative life events. Therefore, although it is true that some children will eventually grow out of their stomachaches, there is a good chance that abdominal or other somatic symptoms will reoccur later in life. 4 bodies of children with RAP work somewhat differently. This etiological model has been adapted largely from research findings on adulthood IBS. As discussed earlier, childhood RAP has many similarities with adulthood IBS and many young RAP patients will have or develop abdominal pain in their adult life. RAP is therefore often seen as a precursor to adulthood IBS and identical etiological mechanisms have been suggested. It is important to realize, however, that few studies to date have focused on etiological mechanisms of childhood RAP compared to the extensive literature on adult IBS, and findings have not always been identical. It has been suggested that the Autonomic Nervous System (ANS) is disrupted in RAP. The ANS consists of neurons that run between the central nervous system (e.g., the brain) and various internal organs, such as the bowels and stomach. The ANS is responsible for monitoring conditions in the internal environment and bringing about appropriate changes in them. For example, after eating, the ANS acts to ensure the stomach and bowel contract to move the food through the digestive tract. This happens largely involuntary, although we do have some control over our bowels as is shown by people practicing yoga or under hypnosis. It has been suggested that the ANS in RAP is weak -- it does not adapt to changes as effectively as in healthy children. For example, after stimulation of the rectum, RAP patients show slower recovery than children who do not suffer from RAP. A second mechanism that could explain RAP is disruptions in motility (the speed with which food moves through the digestive system). In many cases, RAP is associated with either diarrhea or constipation. This seems to suggest that food is either moving too quickly or too slowly through the bowels and that this motility problem could account for the pain. Some studies have observed increased transit time in RAP patients, but these findings have not been found in all studies. Furthermore, adding fiber to the diet to slow transit time has been found to benefit only a subgroup of RAP patients. Lately, visceral hypersensitivity has received considerable attention as one of the major pathways that causes RAP symptoms. Visceral hypersensitivity means that nerves in the gut are very sensitive: RAP patients feel pain in areas of the GI tract much more easily. Because of this heightened sensitivity, RAP children perceive 'normal' gastrointestinal events -- such as small increases in motility or gas -- as painful. There is convincing evidence of visceral hypersensitivity in many adult IBS patients and it has been reported in children with RAP, as well. This abnormal perception of pain (low pain threshold) can be due to changes in both the central (brain) and enteric (gut) nervous system. Nerves in the gut can become overly sensitive and start reacting to events that would otherwise be ignored. The brain, on the other hand, can overreact by not inhibiting as much information coming from the gut as usual, thereby enabling more pain stimuli to pass through into our awareness. Psychological distress can augment these processes. It should be emphasized that there might be different etiologies explaining RAP. In some children abdominal pain might be caused by disruptions in the ANS, while for others the pain is due to an increase in motility or visceral hypersensitivity, and for a third group the pain may be largely psychogenic. It is very likely that in most RAP patients multiple mechanisms can be identified that influence each other. For example, frequent severe pain due to increased motility may eventually lead to hypersensitivity for motility which, in turn, generates more pain due to heightened sensitivity to changes in motility. What about stress? Many parents, children and physicians understand that stress can exacerbate the pain. However, most studies so far have failed to find a clear relationship between major stressors (such as death or illness in the family, a divorce, or a move) and the occurrence of RAP. It might be possible that minor chronic stresses or daily hassles -- such as having to wait in line at the store, quarrels with siblings, constantly stopping for bathroom visits, or vigilantly monitoring what one's eating -- may be far more significant than the stress of major life events. Unfortunately, there is still little research on the effects of minor chronic stress. Effectiveness in coping may be even more important in explaining RAP than exposure to stress. When a child is an effective coper, even high levels of stress might not affect him or her very much. By contrast, an ineffective coper is likely to become distressed when faced with only minor setbacks in life. Coping with abdominal pain and other stresses is often difficult for children who suffer from RAP. Many RAP children use avoidance strategies such as denial, avoiding thinking about it and wishful thinking which, in turn, can result in elevated levels of pain, somatic symptoms and distress. By contrast, effectively adapting to (coping with) the pain by regulating attention and cognitions (e.g., distraction, acceptance of the pain or positive thinking) are associated with less pain, fewer somatic symptoms and Frequent stomachaches in children: a reason for concern? 5 less distress. Acting directly on the pain in an attempt to change the environment or one's emotions (e.g., taking medications, visiting a physician, reducing stress in one's life) can be somewhat helpful, but these actions do not appear to influence the pain very much. Are non-GI symptoms related to RAP? Children with RAP can present with a multitude of other unexplained symptoms (co-morbidity), and the physician may wonder if these are related to the stomachaches. Co-morbid symptoms are important since they may be indicative of: (1) psychological problems that could either drive the GI symptoms or be a consequence of coping with multiple pains, or (2) more severe or longer duration of pain which can trigger pain in other areas. Relatively little is known about co-morbid somatic symptoms in RAP. About half the children who report stomach pain indicate more than one pain location. Multiple pain sites are more commonly reported by girls than boys, and they increase with age. The most common combination is headache and abdominal pain and is reported in 25% of cases with two sites of chronic pain. In a study of RAP patients consulting a physician, the number of co-morbid symptoms was found to increase with the duration of RAP. In other words, one pain might initiate other pain. But, it could also be possible that only those patients who have multiple symptoms are seen by a doctor over a longer period of time. Another study did not find a relationship between the duration of stomachaches and the occurrence of other symptoms during a three-month follow-up of patients. However, three months might have been too short a period of time to see an effect. More research into associated symptoms, who is at increased risk, and what is causing the co-morbidity is needed. Do more severe symptoms result in more disability? RAP has a large impact on suffering, health care costs and functional disability. School absences are one of the most common and obvious effects of RAP, and often one of the first goals in therapy is to resume school attendance. The RAP child who misses school also tends to use more health care services. Health care resource use is particularly high among RAP patients, but not all children who suffer from RAP consult a doctor or miss school. Currently, there is little research-based insight into the characteristics of the child who is most likely to miss school and consult a physician for stomachaches. In a study by Hyams and colleagues, only 9% to10% of middle and high school students with RAP reported they had seen a doctor for abdominal pain within the last year. But, students who did visit a doctor for abdominal pain reported increased pain severity, frequency and duration and more disruption of their lives. In a study by Venepalli and colleagues, health care consulting and school attendance of middle school children could not be predicted by pain intensity or psychosocial distress of either the mother or the child. Identification of children who show high levels of functional disability is important, because this would allow for targeting (preventive) interventions, determining cost-effectiveness of care, and preventing poor academic performance due to school absences. Are the parents to blame? Physicians confronted with an anxious parent of a child with RAP often feel these parents play a major role in the maintenance and exacerbation of the symptoms. Parents for RAP children, on the other hand, feel they have no control over the situation and do not appreciate being 'blamed' for their child's symptoms. It is important to understand that a disorder seldom affects only the patient. People around the person in pain are affected, as well -- they can be stressed about the pain and its meaning. In fact, many parents of children who suffer from abdominal pain show increased levels of anxiety and somatization themselves. This is a normal reaction and does not imply that parents cause RAP. However, parental beliefs, stress, and coping strategies are of great influence on the child's pain perception of pain. Children are still developing their coping repertoires and look to adults for guidance about when to get anxious or worried and how to deal with symptoms. When a child is sick, in pain or discomfort, parents have the difficult task of interpreting the seriousness of the symptoms and deciding how to take action. Any parental action or reaction will influence how their children approach future illness and health. How can a doctor help a child who suffers from RAP? Standard medical care for RAP consists of (1) limited medical tests to rule out organic diseases, (2) acknowledgment that the pain is real, (3) reassurance that there is no illness causing the pain, and (4) advice on how to cope with the symptoms. Parents and children need to be partners with their physician in their health and health care. Since most patients visit a physician in search of a 'cure,' it is important for physicians to explain that RAP is a chronic condition and that returning to normal life as much as possible is the goal, rather than complete pain relief. Medications can be given to treat accompanying symptoms, such as constipation. 6 Frequent stomachaches in children: a reason for concern? Many RAP patients may come to the doctor's office with questions about diet. In fact, most of them will have changed their eating behavior before seeing a doctor. They may propose that food sensitivities, unhealthy diets or dysfunctional eating patterns are possible causes of the symptoms. At this time, there is only limited data on the effects of diet on RAP symptoms. The most extensively studied are the influence of lactose malabsorption and lack of sufficient fiber in the diet. Many parents will have placed their children on a lactose-free diet, but the majority of patients do not report benefits from this dietary restriction. Even lactoseintolerant children do not necessarily see a significant improvement in their RAP symptoms, suggesting that lactose intolerance might be an additional dysfunction the child is dealing with but it is not a major cause for the stomachaches. As mentioned above, fiber therapy can be helpful in some cases, but the currently limited research data is conflicting with regard to its benefit. Nevertheless, some suggest that because of its low cost and low risk, it might be worthwhile to try high fiber therapy in children presenting with RAP. Although standard medical care can result in significant improvements, many RAP patients need additional therapy. Psychological therapies such as Cognitive Behavioral Therapy (CBT) have been found to be effective in treating RAP. CBT teaches children and/or their parents to change unhelpful thoughts about the disorder and learn effective coping skills, and it is often combined with relaxation exercises. CBT has been shown to produce significant improvements in pain, health care utilization and school attendance. Unfortunately, these therapies are not available to a majority of the RAP patients. They require multiple meetings with a highly trained therapist, insurance often does not necessarily cover these costs, and most physician offices lack the time and resources to implement such a program. There is a need for effective psychological treatments for RAP that are more accessible. There is no quick fix for RAP and the road to recovery can be bumpy and challenging for all parties. Patients and their families may feel misunderstood and discouraged by relapses. Physicians might feel they are not able to convey their message to the family or lack the time to give adequate coping advice. Although RAP is a very challenging disorder, there are many ways in which children, their parents and physicians can help to ease the pain. No one approach will work in every child, but the right combination of understanding the disorder and its causes, medications, reduction of stress, changes in eating and bowel movement patterns, coping advice, and encouragement to fully participate in school and social life can be of great benefit in managing, reducing and controlling the pain. For many children, the care and encouragement of a good physician will be sufficient to take control over the symptoms. However, for children needing additional care, it can be challenging to find the right therapist or therapies. This gap is recognized and more research is being done in developing behavioral interventions. For example, the UNC Center for Functional GI & Motility Disorders is currently partnering with Dr. Rona Levy at the University of Washington to test a short Cognitive Behavioral Therapy for RAP in which both the children and parents are involved. At UNC, we are also in the process of developing a hypnosis program for RAP that can be used by any health care professionals without extensive training, making it more widely available to many patients. Some pediatric gastroenterologists are already teaming up with therapists who have specialized in pediatric GI disorders. In sum, the most important intervention for children who suffer from recurrent abdominal pain is to reassure them that we understand their pain is real but also that it can be managed with appropriate medical care and/or psychological therapy. Selected reading (a complete reference list can be obtained from the author) Apley J, Naish N. Recurrent abdominal pain: A field study of 1000 school children with recurrent abdominal pain. Archives of Diseases of Childhood 1958;46:337-340. Scharff L. Recurrent abdominal pain in children: a review of psychological factors and treatment. Clin Psychol Rev 1997;17:145- 166. Christensen MF, Mortensen O. Long-term prognosis in children with recurrent abdominal pain. Arch Dis Child 1975;50:110-114. Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a communitybased study. J Pediatr 1996;129:220-226. Venepalli N, Van Tilburg MAL, Whitehead WE. Recurrent Abdominal Pain (RAP): The relationship between illness behaviors and health services consulting? American Journal of Gastroenterology 2004;126:A372. Walker LS, Greene JW. Children with recurrent abdominal pain and their parents: More somatic complaints, anxiety, and depression than other families? Journal of Pediatric Psychology 1989;14:231-243. Walker LS, Garber J, Greeene JW. Psychosocial correlates of recurrent childhood pain: A comparison of pediatric patients with Recurrent Abdominal Pain, organic illness and psychiatric disorders. Journal of Abnormal Psychology 1993;102:248-258. Walker LS, Claar RL, Garber J. Social consequences of children's pain: when do they encourage symptom maintenance? J Pediatr Psychol 2002;27:689-698. • • • • • • • • 7 Frequent stomachaches in children: a reason for concern?
-------------------- My website on IBS is www.ibshealth.com
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here is another
with permission
Parent's Thoughts and Worries about Recurrent Abdominal Pain Miranda van Tilburg, PhD and William E. Whitehead, PhD UNC Center for Functional GI & Motility Disorders Abdominal pain is common in children and adults alike. As many as 9 to 25% of schoolaged children suffer from recurring episodes of moderate to severe abdominal pain (RAP)(1). In addition to the distress that is associated with the anticipation of pain or actual pain, increased school absence is a significant worry in these children. Spontaneous recovery is common, but many children continue to suffer even into adulthood(2-4). Despite the risk for lifetime suffering and the effects on academic and social functioning, RAP has received relatively little attention in the medical literature in comparison to the adult functional bowel disorders. Children, especially at younger ages, are still developing their coping skills and are, therefore, often ill-equipped to deal with functional abdominal pain. Parents – as the major caregivers -- are confronted with the difficult tasks of relieving their child's suffering and teaching better coping skills. Considering the irregularity and uncontrollability of functional abdominal pain, coping with its occurrence is a daunting task that even adults may struggle with. Because of the desire of any parent to ease their child's pain, it is understandable that many parents feel very frustrated and incapable of dealing with their child's stomachaches. Nevertheless, some parents seem to be doing better than others. Some families feel less need for treatment and diagnosis by a physician than others do, and not every child that suffers from recurrent abdominal pain misses many days out of school. One could argue that patients with more severe pain have an increased likelihood of seeing a doctor or missing school, but this is not necessarily the case. In adults suffering from Irritable Bowel Syndrome (IBS), consulting a doctor is associated with more psychological distress independent of symptom severity(5), and in high school students with RAP, more distress caused by pain was associated with seeing a physician(6). In younger children, the decision to visit a doctor or stay out of school is usually made by the parent rather than the child. Thus, parental thoughts and worries about their child's illness are of greater significance in these decisions than the child's cognitions. In fact, we have found that parents who have IBS themselves are far more likely to take their child to a doctor for gastrointestinal symptoms than parents who do not suffer from IBS(7). Research has shown that only a small proportion of people experiencing symptoms consult a doctor for them(8). Reasons for going to a doctor are "symptoms getting worse' or the fear that symptoms are caused by internal physical causes. High users of medical care perceive themselves as ill and vulnerable to illness, and believe their physician can be helpful. Low users, on the other hand, feel that they are more able to treat themselves(8). There are no data on the specific parental fears and worries associated with RAP, but concern about a disease is most likely an important factor. In a study among 98 mothers of children with unexplained abdominal pain, 65.3% believed physical factors were causing their children's symptoms(9). Fear of a severe illness is also a common health belief in adult patients with IBS(10,11). Worry about an illness might be common, but it is unlikely to be the only belief that contributes to consulting behavior and school absences. To learn more about these beliefs, we conducted in-depth interviews with 15 parents of children with RAP (age 5 to 13 years) visiting GI clinics(12). From these interviews, a model of parental cognitions was developed (Figure 1) that includes the following categories: (a) Pain concerns, i.e., worrying about pain and the consequences of the pain (such as, missing school). (b) Pain threshold, i.e., children were NOT perceived as complaining very easily of pain or faking pain. (c) Thoughts about physicians, i.e., parents reported a desire for relief and care, plus frustration with doctors and reluctance to give medications. (d) Thoughts about coping, i.e. parents felt unable to cope or decide what to do and were afraid to ignore the pain. (e) Exacerbating factors: these included stress, eating habits and modeling (similarity to parents); and (f) Fear of disease, i.e., worrying that the child has cancer or a structural abnormality. Parental cognitions about RAP revolved around the fear of disease and a desire for diagnosis and effective treatment. Many parents felt their children did not complain easily and they felt helpless to know how to deal with the child's suffering. Having identified in a preliminary way the types of worries parents of children with RAP have, it was important to study which of these worries are associated with seeing a physician and with school absences. A 51-item questionnaire was developed on the basis of the indepth interviews: the Parental Worry of RAP Questionnaire (PWRQ)(13). Parents of children with RAP were recruited online through the UNC Center for Functional GI & Motility Disorders web page. The PWRQ was completed by 233 parents (child age range 3-18 years old). Internal consistency of the entire scale (Cronbach's = 0.83) as well as the subscales was moderate to good (.62 d• d".87), which means that the items on the scale tend to measure the same thing. All questions were easily understood, as shown by the fact that mean subject-rated understandability on a 5-point scale was between 4.22 and 4.87. Cognitions of the 167 parents who consulted a doctor for their child's stomachaches differed significantly from the 66 parents who did not consult. Consulting parents worried more about their child's pain, were more likely to think their child might be suffering from a disease, and had a larger need for diagnosis and treatment by doctors. There was also a trend for non-consulting parents to feel more capable of coping with their child's stomachaches. Pearson correlations revealed that the longer the child suffered, the more likely the parents were to worry about pain, feared a disease, felt their child had a high complaint threshold, and felt it was less likely the child faked pain. In addition, increasing child age was associated with more pain worries, feeling better able to cope, and thinking that the child does not complain easily or fakes the pain, and more influence of exacerbating factors (such as stress) was acknowledged. The questionnaire appeared to work well to identify parental worries and concerns about abdominal pain in the first study. However, concerns that there could have been something unusual about the parents who participated through the web site, we then carried out a new study in a different group of families who were identified by surveying fourth grade students in three school districts in North Carolina. One-hundred and seventeen mothers completed the PWRQ. Internal consistency of the whole scale (Cronbach's = 0.95) as well as the subscales was moderate to good (.60 d• d".94). Parents were divided into three groups: 1) Healthy controls included 36 families in which the child did not suffer from stomachaches in the past three months, 2) RAP non-consulters consisted of 40 families with children suffering from stomachaches at least three days out of the past three months, but who did not consult a doctor for the stomachaches, and 3) RAP consulters were 41 families where the child suffered from stomachaches at least threedays out of the past three months and consulted a doctor for the stomachaches. Significant differences between groups were found on most subscales. In comparison to the healthy control group, parents of RAP children worried more about pain, felt their child complained less easily or was less likely to fake pain, felt less able to cope with stomachaches, and cited more exacerbating factors like stress. Consulters differed from non-consulters on pain worries, which were higher in the consulters. Furthermore, healthy controls and RAP non-consulters felt less need for diagnosis, car, and relief than RAP consulters. Interestingly, the three groups did not differ on the fear of disease subscale. We concluded that the PWRQ has very good internal consistency in both studies and can validly distinguish between consulting and non-consulting families. The previously reported subscales were developed based on our theory of how the questions should be grouped together, rather than examining how people actually answer the questions. Therefore, the scales may not necessarily include the items that best discriminate consulters from nonconsulters. We performed further statistical analyses (stepwise discriminant analyses) on the combined data of study 2 and 3 to see which individual items separated the consulters from the non-consulters. Table 1 shows the four items that contributed significantly to the discrimination of consulters from non-consulters. Based on these four items, 76.6% of the non-consulting groups could be correctly classified and 77.5% of the consulting group. TABLE 1 ITEMS THAT DISTINGUISH CONSULTERS FROM NON-CONSULTERS 1) I am frustrated with my child's doctor for failing to tell me what is wrong with my child 2) I would like doctors to suggest a treatment 3) I worry about my child missing things because of his/her stomachaches 4) It is okay to dismiss my child's stomachaches To confirm these results, we performed similar analyses predicting school absences for stomachaches. School absence data was only collected in the last study. Healthy controls were not included in this analysis. In the RAP groups, 56% reported that their child missed school one day or less in the last three months, and 35% reported that their child missed more than one day because of stomachaches. In a stepwise discriminant analysis, school absence was predicted by 9 items which correctly classified 84.2% of the children missing one day or less of school and 76.5% of those who missed more than one day of school. TABLE 2 ITEMS DISTINGUISHING CHILDREN WITH >1 DAY OF SCHOOL ABSENCE IN LAST 3 MONTHS 1) My child complains about stomachaches easily 2) I am afraid to ignore things that should be checked by a doctor 3) I worry that my child will have stomachaches for the rest of his/her life 4) I worry what to do when my child has stomachaches 5) I worry that my doctor does not understand my child's stomachaches 6) I believe my child exaggerates or fakes stomachaches 7) I feel frustrated with my child's doctor for suggesting that my child is faking the stomachaches 8) I believe a lack of exercise might be related to my child's stomachaches 9) I worry about my child's stomachaches affecting his/her school performances. These data indicate that it might be possible to shorten the questionnaire considerably. The current studies are limited by size, which means that we could obtain somewhat different results if we studied larger numbers of families or families recruited in a different way. Therefore, we need to confirm our findings in a larger sample before deciding to shorten the 51-items questionnaire to a smaller scale that can be reliably used as a screening tool. Ultimately, our goal is to understand the fears and worries of parents that are associated with consulting a doctor for RAP and with keeping the child out of school. This will give us important information on the types of cognitions that we need to address in order to help parents cope more effectively with their child's abdominal pain as well as to prevent lifelong disabling stomach aches in children. We would like to thank all the parents that have taken the time to participate in our studies and give us very valuable information on their thoughts and feelings about RAP. Readers interested in participating and completing the questionnaire should go to our Center's website (www.med.unc.edu/ibs) and click 'Research Subjects Needed". References: (1) Scharff L. Recurrent abdominal pain in children: a review of psychological factors and treatment. Clin Psychol Rev. 1997;17:145-66. (2) Magni G, Pierri M, Donzelli F. Recurrent abdominal pain in children: a long term follow-up. Eur J Pediatr. 1987;146:72-74. (3) Stickler GB, Murphy DB. Recurrent abdominal pain. Am J Dis Child. 1979;133:486-89. (4) Apley J, Hale B. Children with recurrent abdominal pain: how do they grow up? Br Med J. 1973;3:7- 9. (5) Burke P, Elliott M, Fleissner R. Irritable bowel syndrome and recurrent abdominal pain. A comparative review. Psychosomatics. 1999;40:277-85. (6) Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal pain and irritable bowel syndrome in adolescents: a community-based study. J Pediatr. 1996;129:220-226. (7) Levy RL, Whitehead WE, Von Korff MR, Feld AD. Intergenerational transmission of gastrointestinal illness behavior. Am J Gastroenterol. 2000;95:451-56. (8) Campbell S, Roland MO. Why do people consult a doctor? Fam Practice. 1996;13:75-83. (9) Claar RL, Walker LS. Maternal attributions for the causes and remedies of their children's abdominal pain. J Pediatr Psychol. 1999;24:345-54. (10) Drossman DA, Mckee DC, Sandler RS, Mitchell CM, Cramer EM, Lowman BC et al. Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome. Gastroenterol. 1988;95:701-8. (11) Gomborone J, Dewsnap P, Libby G, Farthing MJ. Abnormal illness attitudes in patients with Irritable Bowel Syndrome. J Psychosom Res. 1995;39:227-30. (12) van Tilburg MAL, Venepalli NK, Freeman KL, Whitehead W, Ulshen M, Levy RL. Parents' fears and worries about RAP. Gastroenterol. 2003;124:A-528. (13) Whitehead WE, van Tilburg MAL, Palsson O. Development of the Parental Worry of RAP Questionnaire. Am J Gastroenterol. 2003;98:S273.
-------------------- My website on IBS is www.ibshealth.com
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Can I ask what type of GF bread you buy that has flax? I don't think that would be safe to use without eating some SF beforehand, which is my problem. I like to use bread as my SF...so how would I do the sandwich on flax bread?
As far as me having to be GF...I tried eating GF for a year and it didn't help. Only made me go from D to C...but the pain and constipation and cramps and gas were still there. I've talked to a few GI docs, and none of them think I need to eat gluten free. One told me to do whatever I wanted and one said I must eat gluten free...but the other 3 told me that there is no reason to eat GF. I have gone back and forth with this dilemma for some time now. I do not have the celiac gene...so I know I don't have celiac disease. But the gluten or wheat intolerance remains a mystery.
-------------------- ~ Beth
Constipation, pain prodominent,cramps, spasms and bloat!
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Hi there, it is a brand of gluten free bread called Venerdi, available here in NZ. Yes it is predominantly brown rice, flaxseed etc. You are probably right it is too high in insoluble fibre, but like you said the white rice bread just bungs her up shockingly. It's a dilema. The ibs thing is hard enough to deal with, without all the intolerances. I will rethink what I have been and will be doing, thanks for pointing this out. Pauline
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Carbohydrates break down in the gut into tryptofan and then to serotonin and serotonin is a real problem in IBS.
You can also have a problem with wheat and not have full blown celiac.
also did you see this by any chance?
IBS
Bette Bischoff Background Prior to medical school when I was a practicing dietician, I had the privilege of working with many patients who had irritable bowel syndrome (IBS). I found the subject of nutritional intervention related to IBS to be very rewarding and often challenging because there is no "perfect" diet for this syndrome. In light of the different etiologies potentially at work in each patient with IBS, nutrition therapy should be carefully and thoughtfully tailored to each person. This can be likened to times past when a cobbler hand-made each person's shoes. Since each IBS patient can differ dramatically, careful documentation of exacerbating factors listed in the IBS diary maintained by patients may yield important clues to an effective approach to diet and nutrition. One of the issues is that patients with IBS may have a lower threshold to stressors compared to people without IBS. An example of this is patients with carbohydrate intolerances as well as a diagnosis of IBS, who experience an even greater response to problematic carbohydrates such as lactose or fructose as compared to someone who does not have IBS. Another important issue is being alert to unnecessary food aversions. Individuals may experience abdominal discomfort and associate this with eating a certain food, so they decide to avoid eating that particular item, even for life. This may lead to excessive food restriction and the potential for a full-blown eating disorder. What must be kept in mind is that IBS is characterized by increased gut and central nervous system (CNS) reactivity to stressors, and that these stressors can include any dietary excesses as well as chain fatty acids. Good sources of soluble fiber include oats, psyllium seed, pectin, and guar gum. Insoluble fibers consist of the outer husk of the grain and generally tend to decrease transit time. The national nutrition guidelines recommend an intake of 20-30 grams of fiber per day, yet the typical American consumes less than 10 grams of fiber per day. Fiber intake should be increased gradually in IBS patients with constipation, with an emphasis on including adequate water consumption (5). The overall fiber picture can become a bit more confusing than a simple recommendation to increase fiber intake. Insoluble fiber may have a high content of cereal bran, which is the outer husk of the grain. A recent paper investigated the effects of adding or omitting bran and found conflicting results. It appears the primary care provider may see a greater benefit from patients adding fiber to their diet than the gastroenterologist, possibly because primary care physicians see mostly milder forms of IBS and gastroenterologists see patients with more severe IBS. Whorwell studied 100 patients in a primary care setting that were encouraged to increase cereal bran. The results in the primary care provider scenario produced a "mixed" picture -- 22% reported worsening of IBS symptoms while 27% who showed improvement. This may be the result of visceral hypersensitivity triggered by bran consumption. Whorwell recommends that patients identified with IBS and visceral hypersensitivity should be counseled to exclude cereal (insoluble) fibers for a brief period to see if symptoms improve, especially if this is within the care of a specialty clinic. Another study found that cereal fibers were associated with a 55% worsening of symptoms (6, 7). Thus, if the goal is to increase transit rate and increase the frequency of bowel movements (for IBS-C), one could add insoluble fiber to the diet; however, since IBS is also associated with visceral hypersensitivity, if discomfort/pain or bloating occurs, the patient may need to switch solely to soluble fiber. Caffeine is a gastrointestinal stimulant. For IBS patients with diarrhea, a period of caffeine sensitivities to particular foods that are unique to the individual rather than to the IBS condition. This article reviews some of the literature in this area and then presents some treatment options to be considered in the nutritional management of IBS. It should be noted that the research and peer-reviewed published literature regarding IBS and diet is still very limited and, therefore, some of the resources cited in this article will date back several years. Nutritional Factors Influencing Motility: Fiber, Fat and Caffeine IBS is the most common of the functional GI disorder, affecting approximately 10-15% of the US population (1). IBS is a multifactorial illness with several different emerging pathophysiologies, including disorders of motility, visceral hypersensitivity, central processing dysfunctions, psychological factors, and post-infectious inflammation. Fiber: A recent survey reported that close to 95% of general practitioners believe that fiber deficiency is the main cause of IBS. In fact, the most common dietary advice offered to patients with IBS is for them to increase their intake of fiber, primarily to address the constipation that may be associated with IBS. However, since IBS is also associated with visceral hypersensitivity, luminal distension -- as might be caused by the bacterial fermentation of insoluble fiber -- can also produce discomfort (2). Dietary fiber is a non- starch polysaccharide derived from plant foods that are poorly digested by human enzymes. A fiber-enriched diet can relieve constipation, accelerate intestinal transit time, and may reduce intracolonic pressure. Furthermore, the intake of fiber is associated with a reduction in the intraluminal concentration of bile acids, which may reduce the contractile activity of the colon (3, 4). There are two types of fiber -- soluble and insoluble. Soluble fiber is derived from fruits and grains, and is fermented in the colon to form short
exclusion may prove beneficial. The total intake of caffeine-containing beverages by many adults and children often reaches levels that can induce pharmacological effects. Evidence associating caffeine with GI symptoms suffered by patients with IBS is limited in the current literature, but one study revealed that caffeinated coffee stimulated colonic motor activity in a magnitude similar to that of an entire meal and had a 60% stronger effect than ingesting water (. Dietary fat is also a potent modulator of gut motor function. This macronutrient delays gastric emptying time and accelerates small bowel transit rates. Symptoms of bloating are commonly reported after consuming a high-fat meal. Serra et al. found that after an infusion of enteral fat, the volume of retained gas increased from 298 to 505 ml (9, 10). For patients who need to limit their fat intake, counting actual fat grams in the diet can be an excellent way to identify high-fat food sources. In general, IBS patients should aim for only 40-50 grams of fat per day. If weight loss becomes an issue with fat restriction, medium chain triglycerides (MCT) are an excellent source of calories. Unfortunately, MCT oils are expensive and, due to taste issues, are generally not wellreceived by patients. Food Allergy, Hypersensitivity and Intolerance Although up to 45% of the population reports adverse reactions to food, the actual prevalence of immune-mediated food allergy is unknown. Symptoms are more common in atopic individuals who often have allergies to non-food antigens as well, such as pollens, and in young children who tend to outgrow an allergy. The role of food allergy in IBS has not been studied well. Surveys indicate that 40-70% of food-allergic patients report GI symptoms including nausea, vomiting, abdominal pain, bloating, and diarrhea. Stefanini et al. conducted a 4-week multi-center study comparing the efficacy of the mast cell stabilizing agent sodium cromoglycate at 1500 mg per day with an elimination diet, and 67% of the patients reported improvement in their symptoms (11). Attempts to "test" for food hypersensitivity in IBS have largely focused on the classic food allergy, which is based on the presence of IgE -- immunoglobulins of the "immediate type". These antibodies attach to certain cells in the body that release chemicals that cause anaphylaxis. Present speculation in the literature suggests that adverse reactions to food in patients with IBS might be due to forms of immunological mechanisms other than a dietary allergy, namely IgG antibodies. These tend to have a delayed response following exposure to a particular antigen and have been implicated in some cases of food hypersensitivity. IgG studies surfacing in the IBS literature are promising, but the issue of the validation of serum IgG testing is often raised. Atkinson et al. observed significant improvement in IBS symptoms in elimination diets using Elisa IgG antibody testing. Their results suggest that IgG antibodies may have a role in helping patients identify candidate foods for elimination (12). Collins et al. also found significant change in patients receiving the IgG exclusion diet. The foods that were most frequently associated with elevated IgG levels were yeast, milk, eggs, wheat, cashew nuts, peas, almonds, and barley. The mechanism by which the IgG antibodies have a detrimental effect is unclear, but most likely is associated with low-grade inflammation (12,13). For the most part, most patients with IBS do not have immune-mediated allergies to food and, more likely, have increased sensitivity to the direct effects of food on digestive function including increased food volume ingestion and the addition of fats, caffeine, carbohydrates, alcohol, etc. Food Intolerance and Exclusion Diets Niec recently summarized the literature on clinical trials using food elimination diets followed by rechallenge. Of the seven studies included in their review, positive response rates varied from 15 to 75 percent. A higher rate of response was correlated with diarrhea-predominant IBS. Milk, wheat and eggs were the most frequently implicated foods (14). Although the principle of food elimination or exclusion appears straightforward, it can be very demanding for the patient. If the patient appears hesitant or confused about food choices, physician referral to a registered dietitian may be helpful. With the exclusion of entire food groups, such as dairy products, the risk of developing a nutritional deficiency must be considered. Carbohydrate Malabsorption Carbohydrate intolerance can be seen in many
patients with IBS. Fructose, lactose and sorbitol malabsorption are common among patients who have IBS, and dietary restriction of these sugars may improve symptoms (15,16). One study found that 42% of IBS patients developed symptoms from sorbitol-fructose mixtures compared to 3.5 % in the control group (1. This could be an important factor when patients are consuming large amounts of weight-loss products or have diarrhea-predominant IBS. Lactose malabsorption occurs when lactose, the primary sugar in dairy products, is not completely digested and absorbed in the small bowel. Lactase, the enzyme required to hydrolyze lactose for intestinal absorption, is found primarily in the tips of the jejunum. When unabsorbed lactose reaches the colon, colonic bacteria uses this substrate for fermentation, producing gas and short chain fatty acids. The unabsorbed lactose also affects osmolality, causing water to be drawn into the bowel and accelerating the intestinal transit time. If lactose intolerance is suspected, it can be confirmed with a hydrogen breath test. Lactose intolerance appears to be dose dependant. This means that many patients can tolerate small amounts of dairy products throughout the day, such as ½ cup of milk, but not larger amounts. Although it may seem obvious which foods contain lactose, some sources may be difficult to discern. Patients should look for hidden sources in baked goods, salad dressings, and powdered mixes. Labels with the following words contain lactose: nonfat dry milk, milk powder, dry milk solids, whey curds, and caseinate milk sugar. Contrary to popular belief, acidophilus milk does not have the lactose sugar digested and is, therefore, a poor substitute for regular milk. Soymilk and rice milk do not contain lactose and are, therefore, good dairy substitutes. However, these products are often low in calcium and vitamin D. Hard cheeses and cultured yogurt are usually acceptable alternatives. For patients who do not tolerate lactose but want to consume dairy products, supplemental lactase enzymes are available. Several studies have shown that patients with lactose intolerance have significantly less calcium intake than those who tolerate lactose. In one study, patients who were lactose intolerant had a calcium intake of approximately 300 mg per day (1, which is only 20-40% of the recommended calcium intake for adults. Patients with lactose intolerance have also exhibited decreased bone mass density (19). In light of the potential for compromised calcium and vitamin D intake, it would be prudent to evaluate all patients with lactose intolerance for a calcium supplement if needed. Fructose is a hexose sugar that is highly utilized in the western diet. In the past 20 years, there has been a 10-fold increase due to its use in highly processed food products. It is often used as high fructose corn syrup in soda, fruit juices, cookies, baked goods, jellies, and candy. Unlike glucose, which is completely absorbed, fructose absorption capacity is limited. Therefore, when ingested in small quantities, dietary fructose will probably not be an issue. However, when consumed in larger amounts, fructose may serve to osmotically draw fluid into the intestinal lumen. This may cause distension of the small intestine and produce symptoms such as abdominal pain, bloating and discomfort. Furthermore, after reaching the colon, unabsorbed fructose may be fermented by colonic bacteria, producing excessive gas (20). Probiotics Several studies now exist defining the potential role of probiotics in IBS. These papers have exhibited a great degree of variability, possibly due to the use of different probiotic strains, their ability to adhere and colonize in the GI tract, and the number of colony-forming units actually ingested by the individual. The probiotics most often studied are lactobacillus, bidifobacterium, and some non-pathogenic forms of e-coli. In a recent study, bifidobacterium 35624 significantly alleviated symptoms of abdominal pain and discomfort, bloating, and distension. There was also a normalization of IL-10/IL-12 ratios (this skewed cytokine ratio may be indicative of a proinflammatory Th-1 state). The bifidobacterium used in this study is currently unavailable in the US marketplace in the concentrations used in this study (21,22). Food products that are high in probiotics include fermented milk, pourable yogurt, and yogurt with live active cultures. Currently, there is no federal agency in the US that routinely tests or "polices" the market to ensure standardization and quality of probiotic products. Independent tests have
revealed that up to 30% of probiotics on the market are "laced" with reasonably adequate live bacteria. One study used DNA extraction to test five probiotic products at a local health food store. The PCR analysis revealed that 2 of the 5 products did not contain the bifidobacterium claimed on the label (23). I called a well-known dairy in the Midwest several years ago. The technician responsible for mixing the probiotic in the yogurt explained that the bacteria are added to a very large vat of product. The yogurt is then packaged in individual cartons and there is no final definitive measurement to ensure that the amount of probiotic stated on the label is actually in each individual container. Putting It All Together Due to the complex underlying pathophysiologies in patients with IBS, nutritional intervention will vary with each patient. The following general IBS categories attempt to help "map" an approach for dietary manipulation in the patient with IBS. For individuals with diarrhea predominant IBS, consider limiting nutrients that exacerbate GI motility or intestinal secretion -- caffeine, fat and some carbohydrates (fructose, lactose and alcohol sugars). Probiotics can also be of benefit, especially if post-infectious IBS or bacterial overgrowth is suspected, or the patient has had numerous antibiotic therapies in the past. If constipation is the main issue, make sure the patient has had an adequate trial of increased insoluble fiber. This usually means that the patient needs to count fiber grams and seek to attain 20 grams of fiber per day. When visceral hypersensitivity is suspected, ask the patient to limit the amount of food eaten in one session and instead to eat three small meals per day with snacks. A low-fat diet and avoidance of insoluble fiber may also be helpful for these patients. Targeting nutritional intervention in the patient with IBS can be challenging due to the many different etiologies of this syndrome and the fact that some patients have heightened responses to different foods. A food diary kept by IBS patients can be a particularly helpful way to ascertain which foods may be problematic. It is recommended that the clinician look for food "trends" in the journal, with the goal of steering the patient away from excessive food restriction behaviors. References Drossman DA, Camilleri M, Mayer EA, et al. AGA Technical Review on Irritable Bowel Syndrome. Gastroenterology 2002;123(6):2108-2131. Bijkerk CJ, de Wit NJ, Stalman WA, et al. Irritable Bowel Syndrome in Primary Care: the Patient and Doctors Views on Symptoms, Etiology, and Management. Can J Gastroenterology 2003;17(6):363-368. Muller-Lissner SA. Effect of Wheat Bran on Weight of Stool and Gastrointestinal Transit Time: A Meta Analysis. Br Med J 1988;296:615- 617. Villaneva A, Dominguez-Munoz J, Mearin F. Update in the Therapeutic Management of Irritable Bowel Syndrome. Dig Dis 2001;19:244-250. Floch MH, Narayan R. Diet in Irritable Bowel Syndrome. J Clin Gastroenterol 2002;35:S48. Francis CY, Whorwell P. Bran and Irritable Bowel Syndrome: Time for Reappraisal. Lancet 1994;344(8914):39-40. Lea R, M Bch B, Whorwell P. The Role of Food Intolerance in Irritable Bowel Syndrome. Gastroenterol Clin N Am 2005;34:247-255. Rao S, Welcher K, Zimmerman B, et al. Is Coffee a Colonic Stimulant? Eur J Gastroenterol Hepatol 1998;10:113-118. Serra J, Salvioli B, Azpiroz F, et al. Lipid Induced Intestinal Gas Retention in Irritable Bowel Syndrome. Gastroenterology 2002;123(3):700-706. Jones VA, McLaughlin P, Shorthouse M, et al. Food Intolerance: a Major Factor in the Pathogenesis of Irritable Bowel Syndrome. Lancet 1982;2(8308):1115-1117. Stefanini GF, Saggioro A, Alvisi V, et al. Oral Cromolyn Sodium in Comparison with Elimination Diet in Irritable Bowel Syndrome, Diarrheic Type. Muti Center Study of 428 patients. Scand J Gastroenterol 1995;30(6):535-541. Atkinson W, Sheldon T, Shaath N, et al. IgG Antibodies to Food: a Role in Irritable Bowel syndrome. Gut 2004;53: 1459-1464. Collins SM, Vallance B, Barabra G, et al. Putative Inflammatory and Immunological Mechanisms in Functional Bowel Disorders. Bailleres Best Pract Res Clin Gastroenterol 1999;13(3):429-436. Niec AM, Frankum B, Talley NJ. Are Adverse Food Reactions Linked to Irritable Bowel Syndrome? Am J Gastroenterol 1998;93(11):2184-2190. Fernadez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar Malabsorption in Functional Bowel Disease: Clinical Implications. Am J Gastroenterol 1993;88(12): 2044-2050. Nelis GF, Vermeeren MA, Jansen W. Role of Fructose-sorbitol Malabsorption in the Irritable Bowel Syndrome. Gastroenterology 1990; 99(4):1016-1020. Symons P, Jones MP, Kellow J. Symptom Provocation in Irritable Bowel Syndrome. Effects of Differing Doses of Fructose-sorbitol. Scand J Gastroenterol 1992;27:940-944. Carroccio A, Montalto G, Cavera G, et al. Lactose Intolerance and Selfreported Milk Intolerance: Relationship with Lactose Maldigestion and Nutrient Intake. Lactase Deficiency Study Group J Am Coll Nutr 1998;17:631-636. Di Stefano MD, Veneto G, Malservis S, et al. Lactose Malabsorption and Intolerance and Peak Bone Mass. Gastroenterology 2002;122:1793- 1799. Choi YK, Johlin F, Summers R, et al. Fructose Intolerance: An Underrecognized Problem. Am J Gastroenterol 2003;98:1348-1353. O'Sullivan MA, O'Morain CA. Bacterial Supplementation in the Irritable Bowel Syndrome. A Randomized Double-blind Placebo Controlled Crossover Study. Dig Liver Dis 2000;32(4):294-301. Mahoney L, McCarthy J, Kelly P, et al. Lactobacillus and Bifidobacterium in Irritable Bowel Syndrome: Symptom Responses and Relationship to Cytokine Profiles. Gastroenterology 2005; 128(3):541-551. Drisko J, Bischoff B, Giles C, et al. Evaluation of Five Probiotic Products for Label Claims by DNA Extraction and Polymerase Chain Reaction Analysis. Digestive Disease and Sciences 2005;50: 1113-1117.
http://www.med.unc.edu/wrkunits/2depts/medicine/fgidc/collateral/digest/fall_2005_digest.pdf
-------------------- My website on IBS is www.ibshealth.com
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Pauline
#244094 - 02/04/06 07:57 AM
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Augie
Reged: 10/27/04
Posts: 5807
Loc: Illinois
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How do you test for wheat intolerance and gluten intolerance separately? So that you can determine if it's all gluten that's a problem...or just the wheat?
-------------------- ~ Beth
Constipation, pain prodominent,cramps, spasms and bloat!
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Thanks again for posting great info seaneric. There is a lot for me to 'digest'. I will read fully over the weekend. Thanks again, Pauline
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Hi there, gluten is the protein in wheat, barley, rye. You can have IgG gliadin tests done to see if you are sensitive to gluten. There is a specialist here in NZ, do a search for Dr Rodney Ford, Christchurch, NZ. He is a paediatric gastroenterologist who has helped us find out about the gluten intolerance - he is doing ground breaking research in this area and also his findings are medically proven but they are not medically accepted in this country yet. He lives many hundreds of miles away so going to him for consultations was not an option and he had helped us all he could via email.
If you are not a coeliac but have a problem eating normal bread etc, go for the wheat free bread i.e. rice and rye etc, eat barley etc, if there is no problem then maybe your problem is with the wheat rather than the gluten. You may also be able to eat oats, oats are questionable as to whether they contain gluten, the main reason they are not included in a gluten free diet is because they can often come into contact with wheat at harvesting or production time and thus causes contamination with gluten.
The gene testing our specialist is doing supposedly shows whether or not she has antibodies (I think this is how it works, but we visit him again on Tuesday, so I should know more then). If she has got the antibodies it means it is not the gluten that is causing the problem but probably the wheat.
Does any of this make sense? I hope so.
Take care Pauline
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