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Bacterial Overgrowth Apparently Not Important in IBS
By David Douglas
NEW YORK (Reuters Health) Jun 04 - An abnormally high number of bacteria in the small intestine does not appear to be a major factor underlying symptoms of irritable bowel syndrome (IBS), Swedish researchers report in the June issue of Gut.
"The data," senior investigator Dr. Magnus Simren told Reuters Health, "do not support an important role for small intestinal bacterial overgrowth, according to commonly used clinical definitions, in IBS."
Dr. Simren and colleagues at Sahlgrenska University Hospital, Gothenburg note that a high prevalence of small intestinal bacterial overgrowth has been reported in patients with IBS, but those results were based on indirect determination using hydrogen breath tests.
They therefore assessed small intestinal bacterial overgrowth by a direct test -- bacterial culture of small-bowel aspirates -- among 162 patients with IBS and 26 healthy controls. Cultures revealed small intestinal bacterial overgrowth in 4% of patients and 4% of controls.
Signs of enteric dysmotility were seen in 86% of patients with overgrowth and in 39% of patients without. Nevertheless, say the investigators, motility alterations could not reliably predict altered small-bowel bacterial flora.
"However," said Dr. Simren, "mildly increased counts of small-bowel bacteria seem to be more common in IBS," but "its clinical relevance remains unclear."
Gut 2007;56:802-808.
http://www.medscape.com/viewarticle/557698
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Am J Gastroenterol. 2003 Nov;98(11):2454-9.
Am J Gastroenterol. 2004 Jun;99(6):1191; author reply 1192.
Overlapping upper and lower gastrointestinal symptoms in irritable bowel syndrome patients with constipation or diarrhea.
Talley NJ, Dennis EH, Schettler-Duncan VA, Lacy BE, Olden KW, Crowell MD.
Mayo Foundation, Mayo Medical School, Rochester, Minnesota 55905, USA.
OBJECTIVES: Distinguishing between irritable bowel syndrome (IBS) and functional dyspepsia can be challenging because of the variations in symptom patterns, which commonly overlap. However, the overlap is poorly quantified, and it is equally uncertain whether symptom patterns differ in subgroups of IBS arbitrarily defined by primary bowel patterns of constipation (IBS-C) and diarrhea (IBS-D). We aimed to determine and to compare the distribution of GI symptoms, both, upper and lower, among IBS-C and IBS-D patients.
METHODS: A total of 121 consecutive patients presenting with a diagnosis of IBS were grouped according to primary bowel symptoms as IBS-C (58 women and 18 men, mean age 47 +/- 17 yr) or IBS-D (26 women and 19 men, mean age 47 +/- 15 yr). The Hopkins Bowel Symptom Questionnaire, which includes a brief Quality of Life assessment, and the Hopkins Symptom Checklist 90-Revised were completed by all patients at intake.
RESULTS: IBS-C patients reported significantly more overall GI symptoms when compared to patients with IBS-D (6.67 vs 4.62, respectively, p<0.001). Abdominal pain patterns differed in patients with IBS-C versus IBS-D (lower abdominal pain: 40.8% vs 24.4% p=0.05 and upper abdominal pain: 36.8% vs 24.4%, respectively). Bloating was substantially more common in IBS-C patients (75%) than in IBS-D (40.9%). There were no significant differences in personality subscales by IBS subgroup; however, somatization was positively associated with multiple symptom reports and was negatively correlated with quality of life.
CONCLUSIONS: Upper GI symptoms consistent with functional dyspepsia were more frequent in IBS-C. Although there was considerable overlap of upper and lower GI symptoms in patients with IBS-C and IBS-D, the former had more frequent lower abdominal pain and bloating.
PMID: 14638348 [PubMed - indexed for MEDLINE]
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IBS And Restless Legs Syndrome Linked
By Jeff Minerd, Contributing Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
May 24, 2007
WASHINGTON, May 24 -- Bacterial overgrowth in the gut, a factor in irritable bowel syndrome, may also be at work in restless legs syndrome and antibiotics can help both conditions, one small study suggests. Action Points
In 13 patients suffering from both conditions, all saw improvement in IBS symptoms and 10 found marked relief from restless legs symptoms after a 10-day course of antibiotics, said Leonard Weinstock, M.D., of Washington University in St. Louis.
Dr. Weinstock hypothesized a connection between IBS and restless legs syndrome when his cousin came down with both conditions after contracting a case of travelers' diarrhea, Dr. Weinstock told attendees at Digestive Disease Week here.
He said he'd also heard reports of IBS being linked with fibromyalgia, which in turn has been linked with restless legs syndrome. He hypothesized that bacterial overgrowth in the gut could be causing the problems and that antibiotic therapy targeting the small intestine might be the solution.
He tested his idea in a pilot study during which participants received a 10-day course of rifaximin (1,200 mg/day), which specifically destroys bacterial overgrowth in the small intestine. This short-term antibiotic therapy was followed by long-term tegaserod, and a one-month course of zinc and probiotic therapy, Dr. Weinstock said. The patients were followed for an average of 107 days.
Results became apparent, however, by day 11, he said. Abdominal pain improved by 74%, diarrhea by 73%, bloating by 70%, constipation by 64%, and flatulence by 47% from baseline. These improvements were maintained long-term, the study found.
Overall, IBS symptoms were rated as greatly improved by six patients, moderately improved by five, and mildly improved by two.
Restless legs syndrome symptoms improved as well: 10 of the 13 patients experienced an 80% improvement or greater from baseline after the antibiotic treatment. Five of them achieved and maintained 100% improvement in symptoms, Dr. Weinstock said.
Previous studies have shown that bacterial overgrowth in the small intestine causes inflammatory cells to increase production of IL-6, he noted. This cytokine, in turn, is known to boost levels of hepcidin, a protein that decreases iron absorption and transport. Because iron deficiency has been linked with restless legs syndrome, this process could account for the apparent link between IBS and restless legs, Dr. Weinstock speculated.
"Comprehensive bacterial overgrowth therapy may provide long-term improvement in symptoms of both IBS and restless legs syndrome, and further research on extra-gastrointestinal manifestations of bacterial overgrowth are warranted," Dr. Weinstock said.
"Our study provides the basis for a potential curative treatment for some patients, whereas current therapies only partially alleviate symptoms," he noted.
Dr. Weinstock and colleagues are undertaking a multi-center study with more than 600 patients to see if the pilot study results hold up.
The current study was supported by Salix pharmaceuticals, marketer of rifaximin. Dr. Weinstock is a consultant and speaker for Salix and has received grant/research support from the company. He is also a speaker for Novartis Pharmaceuticals.
Primary source: Digestive Disease Week
Source reference:
Leonard Weinstock et al. "Restless leg syndrome in patients with irritable bowel syndrome: response to bacterial overgrowth therapy." Abstract M2140. Presented at Digestive Disease Week 2007, Washington, D.C., May 19-21.
http://www.medpagetoday.com/MeetingCoverage/DDWMeeting/dh/5762
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1: Best Pract Res Clin Gastroenterol. 2007;21(4):689-707.
Irritable bowel syndrome and bloating.
Hasler WL.
Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, MI, USA.
Gaseous symptoms in irritable bowel syndrome (IBS) including eructation, flatulence, and bloating occur as a consequence of excess gas production, altered gas transit, abnormal perception of normal amounts of gas within the gastrointestinal tract, or dysfunctional somatic muscle activity in the abdominal wall. Because of the prominence of gaseous complaints in IBS, recent investigations have focussed on new insights into pathogenesis and novel therapies of bloating. The evaluation of the IBS patient with unexplained gas and bloating relies on careful exclusion of organic disease with further characterisation of the underlying condition with directed functional testing. Treatment of gaseous symptomatology in IBS should be targeted to pathophysiologic defects whenever possible. Available therapies include lifestyle alterations, dietary modifications, enzyme preparations, adsorbents and agents which reduce surface tension, treatments that alter gut flora, and drugs that modulate gut transit.
PMID: 17643909 [PubMed - in process]
http://www.mdlinx.com/GILinx/news/news2.cfm/0
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Gastroenterology. 2007 Jul;133(1):24-33. Epub 2007 Apr 14.
The fecal microbiota of irritable bowel syndrome patients differs significantly from that of healthy subjects.
Kassinen A, Krogius-Kurikka L, Mäkivuokko H, Rinttilä T, Paulin L, Corander J, Malinen E, Apajalahti J, Palva A.
Department of Basic Veterinary Sciences, Division of Microbiology and Epidemiology, University of Helsinki, Helsinki, Finland.
BACKGROUND & AIMS: Irritable bowel syndrome (IBS) is a significant gastrointestinal disorder with unknown etiology. The symptoms can greatly weaken patients' quality of life and account for notable economical costs for society. Contribution of the gastrointestinal microbiota in IBS has been suggested. Our objective was to characterize putative differences in gastrointestinal microbiota between patients with IBS and control subjects. These differences could potentially have a causal relationship with the syndrome.
METHODS: Microbial genomes from fecal samples of 24 patients with IBS and 23 controls were collected, pooled in a groupwise manner, and fractionated according to their guanine cytosine content. Selected fractions were analyzed by extensive high-throughput 16S ribosomal RNA gene cloning and sequencing of 3753 clones. Some of the revealed phylogenetic differences were further confirmed by quantitative polymerase chain reaction assays on individual samples.
RESULTS: The coverage of the clone libraries of IBS subtypes and control subjects differed significantly (P < .0253). The samples were also distinguishable by the Bayesian analysis of bacterial population structure. Moreover, significant (P < .05) differences between the clone libraries were found in several bacterial genera, which could be verified by quantitative polymerase chain reaction assays of phylotypes belonging to the genera Coprococcus, Collinsella, and Coprobacillus.
CONCLUSIONS: The study showed that fecal microbiota is significantly altered in IBS. Further studies on molecular mechanisms underlying these alterations are needed to elucidate the exact role of intestinal bacteria in IBS.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17631127&ordinalpos=18&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
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Am J Gastroenterol. 2006 Aug 4;
Quality of Life in Patients With Inflammatory Bowel Disease and Irritable Bowel Syndrome Differs Between Subjects Recruited from Clinic or the Internet.
Jones MP, Bratten J, Keefer L.
Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA.
INTRODUCTION: The Internet is used increasingly to recruit patients for studies of gastroenterological disorders. The Internet allows access to potentially large study populations but no data exist comparing Internet-based populations with patients recruited from a clinical setting. We conducted an assessment of the quality of life (QOL) in patients with active inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) recruited from a gastroenterology clinic and the Internet.
METHODS: Patients were recruited from a university gastroenterology clinic and several condition-specific support group web sites. The diagnosis of IBD and IBS was confirmed for clinic patients while Internet respondents were self-identified. Subjects completed both general (SF-36) and condition specific (IBS-QOL) measures.
RESULTS: Subjects with IBD included 47 recruited from clinic and 96 recruited from the Internet. The IBS group included 147 patients recruited from clinic and 84 recruited from the Internet. Both IBS and IBD clinic and Internet IBD groups did not differ by. IBD Internet respondents were more likely to be women (clinic: 28F/19M, online: 80F/16M, P= 0.002) while IBS Internet respondents were more likely to be male (123F/24M) than IBS clinic patients (62F/22M) (P= 0.09). Compared with patients seen in clinic, both IBS and IBD Internet respondents had significantly poorer QOL as measured by both SF-36 and IBS-QOL. The greatest decrements in QOL occurred on SF-36 scales for physical and emotional roles and social functioning. On the IBS-QOL, the greatest decrement was seen on scales for dysphoria and life interference. Significant differences were maintained after controlling for gender.
CONCLUSIONS: For both IBS and IBD, Internet-respondents had significantly poorer QOL than subjects recruited from clinic. These data demonstrate that subjects recruited from the Internet may represent a clinically distinct population and data obtained from online surveys may not generalize to broader clinical populations. Further study is needed to determine whether these differences reflect psychosocial characteristics of Internet responders or simply self-report behaviors in a relatively anonymous environment.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17680842&ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
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Eur J Gastroenterol Hepatol. 2007 Jun;19(6):437-9.
Irritable bowel syndrome and the Rome III criteria: for better or for worse?
Gwee KA.
National University of Singapore, Singapore.
The paper by Sperber et al. in this issue is an early evaluation of the Rome III criteria against the Rome II criteria for irritable bowel syndrome that throws up several important observations.
A three to four-fold increase was observed in irritable bowel syndrome prevalence with the Rome III criteria. Individuals with the Rome II criteria had more doctor visits, perception of stress and a negative global feeling.
There could be a shift of individuals between irritable bowel syndrome and other functional bowel disorder diagnostic groups such as functional constipation and functional bloating. In this review, it is suggested that rigid application of the symptom frequency and duration requirements of the older Rome criteria could have introduced a selection bias for patients with greater psychological disturbance, and that this could have impacted negatively on our perception and management of irritable bowel syndrome.
The findings of Sperber et al. suggest that the new Rome III criteria may enable us to pay more attention to the average irritable bowel syndrome patient we see in our clinics as opposed to the chronically severe patient. It is proposed that improved management of our average patient may translate into better outcomes in terms of reduction in specialist referral, unnecessary surgery and potentially harmful alternative treatments.
PMID: 17489052 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17489052&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus
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Alimentary Pharmacology & Therapeutics
Systematic Review and Meta-Analysis: The Incidence and Prognosis of Post-Infectious Irritable Bowel Syndrome
M. Thabane; D. T. Kottachchi; J. K. Marshall
Background: Individual studies suggest that post-infectious irritable bowel syndrome is common, but symptoms gradually improve.
Aim: To review evidence for an association between intestinal infection and development of irritable bowel syndrome, assess the prognosis of post-infectious irritable bowel syndrome and explore factors that increase the risk.
Methods: MEDLINE (1966-2007) and EMBASE (1980-2007) databases were searched to identify the studies of post-infectious irritable bowel syndrome epidemiology. Data were extracted by two independent reviewers. Pooled odds ratios (POR) and corresponding 95% CI for incidence of irritable bowel syndrome were estimated among the exposed and unexposed groups.
Results: Eighteen of 26 studies identified were eligible for inclusion. Intestinal infection was associated with increased odds of developing irritable bowel syndrome at study end (POR = 5.86; 95% CI: 3.60-9.54). In subgroup analysis, the odds of developing irritable bowel syndrome was increased at 3 months (POR = 7.58; 95% CI: 4.27-13.45), 6 months (POR = 5.18; 95% CI: 3.24-8.26), 12 months (POR = 6.37; 95% CI: 2.63-15.40) and 24-36 months (POR = 3.85; 95% CI: 2.95-5.02). Among all studies (controlled and uncontrolled), the pooled incidence of irritable bowel syndrome at study conclusion was 10% (95% CI: 9.4-85.6). Subjects with post-infectious irritable bowel syndrome were younger and more anxious and depressed than those without post-infectious irritable bowel syndrome.
Conclusion: The odds of developing irritable bowel syndrome are increased sixfold after acute gastrointestinal infection. Young age, prolonged fever, anxiety and depression are risk factors for post-infectious irritable bowel syndrome.
http://www.medscape.com/viewarticle/561853?src=mp
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Neuroscience. 2007 Sep 8;
Neural mechanisms of pelvic organ cross-sensitization.
Malykhina AP.
Department of Physiology, University of Oklahoma Health Sciences Center, 940 Stanton L. Young Boulevard, Oklahoma City, OK 73104, USA.
Clinical observations of viscerovisceral referred pain in patients with gastrointestinal and genitourinary disorders suggest an overlap of neurohumoral mechanisms underlying both bowel and urinary bladder dysfunctions. Close proximity of visceral organs within the abdominal cavity complicates identification of the exact source of chronic pelvic pain, where it originates, and how it relocates with time.
Cross-sensitization among pelvic structures may contribute to chronic pelvic pain of unknown etiology and involves convergent neural pathways of noxious stimulus transmission from two or more organs.
Convergence of sensory information from discrete pelvic structures occurs at different levels of nervous system hierarchy including dorsal root ganglia, the spinal cord and the brain. The cell bodies of sensory neurons projecting to the colon, urinary bladder and male/female reproductive organs express a wide range of membrane receptors and synthesize many neurotransmitters and regulatory peptides.
These substances are released from nerve terminals following enhanced neuronal excitability and may lead to the occurrence of neurogenic inflammation in the pelvis. Multiple factors including inflammation, nerve injury, ischemia, peripheral hyperalgesia, metabolic disorders and other pathological conditions dramatically alter the function of directly affected pelvic structures as well as organs located next to a damaged domain.
Defining precise mechanisms of viscerovisceral cross-sensitization would have implications for the development of effective pharmacological therapies for the treatment of functional disorders with chronic pelvic pain such as irritable bowel syndrome and painful bladder syndrome.
The complexity of overlapping neural pathways and possible mechanisms underlying pelvic organ crosstalk are analyzed in this review at both systemic and cellular levels.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17920206&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
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From Nature Clinical Practice Gastroenterology & Hepatology
Do Physicians Follow Evidence-Based Guidelines in the Diagnostic Work-up of IBS?
Brennan MR Spiegel
Why do clinicians continue to order tests for suspected IBS despite data that show that these tests generally have a low diagnostic yield? In light of the medical–legal interface in the US, one possibility is that some clinicians believe that diagnostic testing is a form of inoculation against litigation.
Clearly this is an inappropriate reason to pursue diagnostic testing, especially as data indicate that the quality of the physician–patient relationship is a critical predictor of outcomes, and probably a more important predictor of litigation than testing proclivity.
A second possibility is the belief that even negative diagnostic tests are useful because they can allay patient concerns about serious illness and provide reassurance. We have shown, however, that a negative colonoscopy, in particular, is not associated with reassurance or improved quality of life in young IBS patients.
In fact, we found a nonsignificant trend towards less reassurance in patients who received a negative colonoscopy versus no colonoscopy at all. A third possibility is that IBS patients with multiple unexplained somatic complaints and physical illnesses potentially related to their underlying psychosocial distress are sometimes misclassified as having several underlying organic conditions, and subsequently undergo diagnostic tests to chase these symptoms.
We found a linear and highly significant relationship between levels of such somatization and the amount of diagnostic testing in IBS, which suggests that clinicians should be aware of somatization in patients with IBS, and aggressively treat or refer such patients in lieu of performing potentially unnecessary tests.
The most common reason for diagnostic testing in IBS, however, might be that the Rome criteria have a 98%, rather than a 100%, positive predictive value, therefore, no matter how strong the evidence is that diagnostic testing has a low yield, a real possibility of underlying organic disease remains.
This argument is simply not debatable, particularly in light of growing evidence that patients diagnosed with IBS are a heterogeneous population with a core of pure IBS patients surrounded by small subsets who have alternative diagnoses such as celiac sprue and bacterial overgrowth.
http://www.medscape.com/viewarticle/558644
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