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Intolerance to visceral distension in functional dyspepsia or irritable bowel syndrome new
      #92819 - 07/24/04 02:17 PM
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Neurogastroenterology and Motility

Official Journal of the European Society of Neurogastroenterology and Motility and the American Motility Society

Edited by:


Michael Camilleri and Michael Schemann


Print ISSN: 1350-1925
Online ISSN: 1365-2982
Frequency: Bi-monthly
Current Volume: 16

ISI Journal Citation Reports® Ranking: 2003: 16/47 (Gastroenterology & Hepatology); 35/135 (Clinical Neurology); 83/198 (Neurosciences)
Impact Factor: 2.500



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Table of Contents > Issue > Abstract

Volume 16: Issue 3

Intolerance to visceral distension in functional dyspepsia or irritable bowel syndrome: an organ specific defect or a pan intestinal dysregulation?

M. Bouin
F. Lupien
M. Riberdy
M. Boivin
V. Plourde
P. Poitras




Abstract

Functional gastrointestinal disorders (FGID) are characterized by visceral hypersensitivity that could be specific to a region of the gut or reflect a diffuse pan-intestinal disorder. Sensory thresholds to distension at two visceral sites in patients with different FGIDs were determined. According to Rome II criteria, 30 patients from three groups were studied: patients with (i) functional dyspepsia (FD) or (ii) irritable bowel syndrome (IBS), and (iii) patients with concomitant symptoms of FD and IBS. Pain thresholds to balloon distension were determined in stomach and rectum. In FD patients, gastric intolerance to balloon distension was found in 91% patients; rectal hypersensitivity was documented in 18% patients. In IBS patients, rectal hypersensitivity was seen in 75% patients; while gastric hypersensitivity was never found. In patients with concomitant symptoms of FD + IBS, gastric and rectal intolerance to distension were present respectively in 82 and 91% patients. In the whole group, visceral intolerance to distension was documented at one site in 90% patients and at both sites, i.e. stomach and rectum, in 33% patients. Visceral intolerance to distension can be pan-intestinal in patients with multiple sites of symptoms, but appears organ-specific in patients exhibiting a specific site of symptoms.

http://www.blackwellpublishing.com/abstract.asp?ref=1350-1925&vid=16&iid=3&aid=7&s=&site=1

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Irritable Bowel Can Follow Dysentery new
      #96555 - 08/08/04 02:37 PM
HeatherAdministrator

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Posts: 7795
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Tue Jul 27, 2004
NEW YORK (Reuters Health)

In some cases, irritable bowel syndrome can result from a bout of dysentery caused by acute intestinal infection with Shigella bacteria, according to a report from China.

Irritable bowel syndrome, or IBS, is an often-mysterious ailment, with no obvious explanation for sufferers' bloating, pain, diarrhea and constipation. Previous studies have suggested that a history of dysentery triples the risk of IBS, the researchers explain in the medical journal Gut.

Despite this clue, it's not known how often IBS or the similar condition known as functional bowel disorder (FBD) occurs after Shigella-related dysentery.

Dr. G-Z Pan and colleagues from Peking Union Medical College Hospital, Beijing, looked into this question by studying 295 subjects with so-called bacillary dysentery and 243 matched "controls" without the intestinal infection.

After bacillary dysentery, 22 percent of patients had FBD and 8 percent had IBS, the authors report -- significantly higher than the corresponding rates (7 percent and 1 percent, respectively) among controls.

The duration of infection was an important risk factor for FBD.

Compared with controls, the researchers note, patients with IBS had higher inflammatory factors in the lining and nerves of the intestines.

"Our study provides new evidence in support of bacillary dysentery as a causative factor of post-infectious IBS," the authors conclude.

They say their findings indicate "that the immune system and the nervous system both play important roles in the (cause) of post-infectious IBS."

"There is increasing recognition of the importance of infection" in IBS, Dr. S. M. Collins from McMaster University Medical Center, Hamilton, Ontario, and Dr. G. Barbara from the University of Bologna, Italy, write in a related commentary.

They add, "With emerging evidence supporting a role for inflammation and immune activation in IBS, studies are encouraged to address the influence of the microbial environment on the epidemiology and clinical expression of IBS across the globe."

SOURCE: Gut, August 2004.

© Reuters 2004. All Rights Reserved.

http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=5788617

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Prevalence of IBS according to different diagnostic criteria new
      #96561 - 08/08/04 02:50 PM
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Reged: 12/09/02
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Prevalence of irritable bowel syndrome according to different diagnostic criteria in a non-selected adult population

Alimentary Pharmacology and Therapeutics

Edited by:
R.E. Pounder and W.L. Peterson

Print ISSN: 0269-2813
Online ISSN: 1365-2036
Frequency: Fortnightly
Current Volume: 19
ISI Journal Citation Reports® Ranking: 2003: 8/47 (Gastroenterology & Hepatology); 32/184 (Pharmacology & Pharmacy)
Impact Factor: 3.529

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Volume 20: Issue 3

Prevalence of irritable bowel syndrome according to different diagnostic criteria in a non-selected adult population

M. T. Hillilä
M. A. Färkkilä
Background

Prevalence of irritable bowel syndrome shows great variation among epidemiological studies, which may be due to different diagnostic criteria.

Aim

To assess prevalence of irritable bowel syndrome according to various diagnostic criteria and to study differences in symptom severity, psychopathology, and use of health care resources between subjects fulfilling different diagnostic criteria.

Methods

A questionnaire was mailed to 5000 randomly selected adults. Presence of irritable bowel syndrome was assessed by four diagnostic criteria: Manning 2 (at least two Manning symptoms), Manning 3 (at least three Manning symptoms), Rome I and Rome II.

Results

Response rate was 73%. Prevalence of irritable bowel syndrome by Manning 2, Manning 3, Rome I and Rome II criteria was 16.2%, 9.7%, 5.6%, and 5.1% respectively. Of those fulfilling Rome II criteria, 97% fulfilled Manning 2. Severe or very severe abdominal pain was reported by 27–30% of Manning-positive subjects, and 44% of Rome-positives. Prevalence of depression in Manning 2, and Rome II groups was 30.6 and 39.3%.

Conclusions

Prevalence of irritable bowel syndrome by Rome II criteria is considerably lower than by Manning criteria. Subjects fulfilling Rome criteria form a subgroup of Manning-positive subjects with more severe abdominal symptoms, more psychopathology, and more frequent use of the health care system.



Article Type: Original Article
Page range: 339 - 345


http://www.mdlinx.com/GILinx/thearts.cfm?artid=1016068&specid=13&ok=yes


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Categorization of dysmotility in patients with chronic constipation new
      #96563 - 08/08/04 02:54 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7795
Loc: Seattle, WA

Chinese Journal of Digestive Diseases

Official Journal of the Chinese Society of Gastroenterology and the Chinese Medical Association Shanghai Branch

Edited by:
Xiao Shudong

Print ISSN: 1443-9611
Online ISSN: 1443-9573
Frequency: Quarterly
Current Volume: 5

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Table of Contents > Issue > Abstract

Volume 5: Issue 3
Categorization of dysmotility in patients with chronic constipation and its significance for management

Xiao Feng GUO
Mei Yun KE
Zhi Feng WANG
Xiu Cai FANG
Bing WU
Yin Ping TU

Abstract

BACKGROUND:
Chronic constipation is a common gastrointestinal symptom with different patterns of dysmotility for which there is not one simple and effective diagnostic method for categorization. The present study assessed the diagnostic method used in patients with chronic constipation and its significance for clinical management.

METHODS:
The study group comprised 210 consecutive patients with chronic constipation who underwent history, digital anorectal examination (DARE), gastrointestinal transit test (GITT) and anorectal manometry (ARM) to determine the pattern of dysmotility. Symptoms and the examinations were summarized for establishing the diagnostic method and evaluation of the role of the examinations.

RESULTS:
Outlet obstructive constipation (OOC), slow transit constipation (STC) and mixed constipation (MC) accounted for 50.8%, 10.2% and 39.0% of cases, respectively. The stool was harder in STC or MC than in OOC (P = 0.036). The presence of a paradoxical inverse contraction of anal sphincter when straining to defecate during DARE or ARM was significant for the diagnosis of OOC (P < 0.001). The distribution of the residual markers on abdominal plain film after 48 h GITT was significant for the diagnosis of STC (P < 0.001). The sensitivity of DARE, GITT and ARM was 82.5%, 89.1% and 94.4%, and specificity was 95.2%, 87.9% and 82.6%, respectively. Clinical management was modified in 69.5% of patients after categorizing the constipation pattern.

CONCLUSIONS:
The symptoms, DARE, GITT and ARM are effective methods of evaluating the dysmotility patterns in patients with chronic constipation. DARE and ARM could improve the diagnostic rate of OOC, and GITT assists in diagnosis of STC. Proper categorization of the dysmotility pattern is important for the clinical management of chronic constipation.



Article Type: Original Article
Page range: 98 - 102

http://www.blackwellpublishing.com/abstract.asp?ref=1443-9611&vid=5&iid=3&aid=3&s=&site=1



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New views - and some respect - for IBS new
      #102639 - 08/30/04 01:25 PM
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Revised guidelines and targeted therapies are leading to a new view of the condition

From the September ACP Observer, copyright © 2003 by the American College of Physicians.

By Margie Patlak

Long disparaged as a "wastebasket disease," irritable bowel syndrome (IBS) appears to be gaining newfound respect among researchers, drug makers and gastroenterologists. The question now: Will other physicians begin to recognize IBS as a treatable condition, or will they continue to view it as a largely psychosomatic illness?

Researchers have made major strides in detecting the physiologic underpinnings of IBS as well as the nature of patients' "gut-brain" interactions. At the same time, drug makers now offer treatments that specifically target a broad range of IBS symptoms.

And gastroenterologists have identified the signs of IBS that can lead to a definitive diagnosis, crafting guidelines to help physicians distinguish IBS from other conditions.

But as many gastroenterologists are quick to point out, much of the progress being made on IBS has been lost on general practitioners. Rapid advances have created a "very big gap between primary care and gastroenterology," said Douglas A. Drossman, FACP, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders at Chapel Hill. "Primary care doctors are not up to speed."

To help close that gap, here is an overview of the latest developments in IBS research and treatment.

Help with the diagnosis

Until recently, physicians lacked a clear definition of what exactly constituted an IBS diagnosis. The condition required a diagnosis of exclusion, frustrating physicians and patients alike—and generally hampering treatment.

Even worse, arriving at an IBS diagnosis made many physicians fear they had missed a more dangerous condition such as colon cancer. Without any real guidance, it was difficult to feel sure that an IBS diagnosis didn't mean you were overlooking something more serious.

With the advent of new guidelines, known as the "Rome criteria," however, diagnosing irritable bowel syndrome has become more straightforward. The latest version of the criteria—Rome II—was developed by international experts and published in 2000. The criteria point to IBS as a genuine, treatable disorder.

The guidelines "give physicians something to hang a diagnosis on," said gastroenterologist Brian Lacy, MD, PhD, director of the Marvin M. Schuster Center for Digestive and Motility Disorders at Johns Hopkins Bayview Medical Center in Baltimore.

According to the Rome II criteria, patients suffering from IBS have experienced several specific symptoms for at least 12 weeks during the previous year. The guidelines emphasize that IBS is a multifaceted condition that involves not only a faulty defecation pattern, but pain. (For more on the Rome criteria, see "The Rome II diagnostic criteria for irritable bowel syndrome," below.)

"If they don't have pain, they don't have IBS," Dr. Lacy said, "even if they have diarrhea 15 times a day or go to the bathroom only once a month."

While the guidelines still require physicians to rule out other conditions such as functional diarrhea or pelvic floor disorders, both of which are similar to IBS, experts say the criteria reduce much of the diagnostic uncertainty by limiting the range of other possible conditions. You don't need to run most patients through an extensive battery of tests to reach a diagnosis.

Last year, both the American Gastroenterological Association and the American College of Gastroenterology (ACG) issued position statements that agree with that diagnostic approach. The organizations identified key "alarm signals" that should alert you to other potential diagnoses when working with possible IBS patients.

Those signals include blood in the stool, unexplained weight loss, anemia, chronic severe diarrhea, recurring fever and a family history of colon cancer. In the absence of such red flags, however, the statements claimed that the Rome II criteria are nearly 100% specific in diagnosing IBS—and that the risk of missing another disease is negligible.

While you may feel compelled to list several problems like pain, bloating and constipation when treating IBS patients, Dr. Lacy said that approach is unnecessary. "These patients have one unifying diagnosis—IBS—that should make it easier to treat them," he explained. "You need to think about treating this whole constellation of symptoms."

Performing fewer tests to make an IBS diagnosis benefits not only health plans, but patients themselves. Excessive testing can distress patients, noted gastroenterologist George F. Longstreth, MD, chief of gastroenterology at Kaiser Permanente Medical Care Program in San Diego.

"Too many tests sometimes create more anxiety," he said, a factor that can be a real liability when research suggests that IBS patients may have more pronounced intestinal reactions to stress than other patients. (For more on the "gut-brain" connection, see "IBS: An anatomy of what goes wrong in the body," below.)

And while internists instinctively worry about missing another disease, they need to guard against making the opposite mistake: confusing IBS symptoms for those of other medical conditions.

Studies have shown, for example, that IBS patients are more likely to have their gallbladders removed or to have a hysterectomy. "IBS patients shouldn't automatically have their gallbladders taken out," Dr. Longstreth said. "Their pain may be due to IBS."

New breed of drugs

Along with new diagnostic guidelines, physicians can now offer new treatments. What's remarkable about the latest drugs to treat IBS—alosetron and tegaserod—is that they treat several IBS symptoms, not just a single complaint.

Tegaserod. Tegaserod, which targets a serotonin receptor subtype in the intestines, has been shown to relieve IBS patients' bloating, abdominal discomfort and constipation significantly more than placebo. But because subjects in the studies' control groups experienced a significant placebo effect, the drug outperformed the placebo by only 10% to 15%.

"To say this drug is a breakthrough is an exaggeration," said Dr. Longstreth. "Some patients don't respond, and it is quite expensive."

The drug costs more than $2 a pill, and patients must take it twice a day. (Dr. Drossman noted, however, that patients who regularly take laxatives can spend up to $100 a month. He also added that laxatives do not address the pain of IBS.)

Tegaserod's main side effect, however, is diarrhea, which causes 1% to 2% of patients to stop taking it. Nevertheless, Dr. Drossman said he considers the drug safe enough to prescribe it even to patients with mild to moderate IBS.

While Dr. Lacy agreed that he doesn't consider tegaserod a "magic bullet," he said he considers it to a good, safe drug. He added that it will likely be years until researchers develop a miracle drug for a condition like IBS. "We have been spoiled by drugs like Prilosec that give a 90% response rate," he said. "You'll never see that for IBS."

One other note: Because tegaserod was tested primarily on women who suffer from an IBS-related form of constipation, the FDA approved the drug only for those patients.

However, a study published in the May 2003 issue of Gut suggested that the drug can relieve symptoms in IBS patients who alternate between diarrhea and constipation. Another study published in the May 2002 American Journal of Gastroenterology found that tegaserod does not worsen diarrhea symptoms in IBS patients.

And both Drs. Drossman and Lacy said they have had male patients who benefited from taking the drug.

Alosetron. Alosetron has a more checkered history than tegaserod. The FDA originally approved the drug in February 2000 for women with diarrhea-predominant IBS after alosetron was shown to relieve pain and discomfort, urgency and diarrhea. When several patients taking the drug developed serious complications due to severe constipation or ischemic colitis, however, the agency pulled the drug from the market.

To meet patient demand, the FDA re-approved it in June of 2002—with some new conditions. The agency restricted the drug to treating only women with "severe, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy." The agency also cut the recommended starting dose in half.

Physicians prescribing alosetron must register with the drug's manufacturer and educate patients about its risks and benefits. They must also have patients sign a consent form before using the drug.

But much of the anxiety over alosetron's serious side effects is unwarranted, Dr. Drossman said. If given to the right subgroup of IBS patients—those with diarrhea but not with constipation, he explained—the drug is generally safe.

Recent studies have found that alosetron used at the current recommended starting dose of 1 mg per day produced a 10% to 35% improvement in symptoms when compared to placebo. About 10% of patients, however, stop taking the drug because of constipation.

Most experts recommend prescribing alosetron for women who have moderate to severe IBS and no other options. "I've had a few patients who definitely thought alosetron was the best thing they've ever tried," noted Dr. Longstreth.

For most patients with milder forms of IBS, he added, physicians should "focus on the symptoms that are the biggest problem and do what they can for that." Many symptoms can be effectively treated with antidiarrheal agents such as loperamide. If constipation is the main complaint, fiber or laxatives are usually effective.

Low-dose tricyclic antidepressants. Thanks to a better understanding of what causes IBS pain, treatment options to relieve IBS symptoms now include low-dose tricyclic antidepressants.

While no good controlled studies have yet validated the effectiveness of these drugs for relieving IBS pain, most IBS experts swear by them. "Low-dose tricyclics relieve abdominal pain," Dr. Lacy said, "and they're safe."

(The ACG position paper did note, however, that these drugs may cause constipation and urged physicians to use caution when prescribing them for IBS patients who present with this as their main complaint.)

In theory, selective serotonin reuptake inhibitors (SSRIs) should also help relieve pain and constipation caused by IBS, as well as any concomitant anxiety and depression. Only a handful of clinical trials, however, have examined the drugs' effectiveness in relieving IBS symptoms. As a result, many gastroenterologists say they reserve SSRIs for IBS patients who also have excessive anxiety or depression.

Nondrug treatments

While drug therapies are more successfully targeting IBS, novel treatments like cognitive behavioral therapy are receiving more attention.

A small study by British researchers found that the symptoms of three-quarters of IBS patients who had not benefited from dietary or drug therapy significantly improved after just six sessions of cognitive behavioral therapy.

Another British study found cognitive behavioral therapy to be significantly more effective than psychotherapy in relieving IBS symptoms. Even more impressive, most of the patients successfully treated in the study found their IBS symptoms hadn't returned more than a year later.

While Dr. Lacy said these results are promising, he pointed out that very few people know how to do cognitive behavioral therapy properly. In addition, most insurers won't pay for it.

Research into other nondrug therapies has also been encouraging. A study led by Dr. Drossman and published in the July 2003 issue of Gastroenterology found that 70% of IBS patients improved when they received cognitive behavioral therapy directed toward bowel symptoms from a psychotherapist. By comparison, only 37% of subjects in the control group who received only IBS education reported improvement.

Although an accompanying editorial in the issue lauded the study's findings, it pointed to some of the same challenges that may stop cognitive behavioral therapy from being widely accepted. Patients tend to prefer pills over psychotherapy, and insurance companies may not pay for treatments. In addition, few psychotherapists have trained in strategies to manage IBS or pain.

While many patients may not yet be ready for cutting-edge treatments, IBS experts stress the importance of taking time to educate patients about IBS. One goal should be reassuring them that they don't have a more deadly condition such as ulcerative colitis or colon cancer.

"A lot of the improvement IBS patients experience probably comes as a result of them being reassured and having their symptoms explained to them," said Dr. Longstreth. "The doctor is functioning as the placebo."

With that in mind, Dr. Lacy said, don't expect any quick cures when working with IBS patients. "Doctors really want to cure things,s but this is not something you can cure," he explained. "You need to take a nice deep breath, realize it's going to be a chronic problem, and don't get discouraged or let your patients get discouraged."

Margie Patlak is a freelance science writer in Elkins Park, Pa.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.



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Top

The Rome II diagnostic criteria for irritable bowel syndrome

The Rome II criteria define irritable bowel syndrome (IBS) as abdominal discomfort or pain for at least 12 weeks (not necessarily consecutive) in the preceding 12 months, with two of the three following features:

The pain is relieved with defecation.
Onset is associated with a change in frequency of stool.
Onset is associated with a change in form (appearance) of stool.
The Rome II criteria state that the following symptoms cumulatively support an IBS diagnosis:

Abnormal stool frequency (for research purposes, "abnormal" may be defined as greater than three bowel movements per day and less than three bowel movements per week);
Abnormal stool form (lumpy/hard or loose/watery stool);
Abnormal stool passage (straining, urgency or feeling of incomplete evacuation);
Passage of mucus; and
Bloating or feeling of abdominal distention.
Source: December 2002 Gastroenterology.



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Top

IBS: An anatomy of what goes wrong in the body

Although the precise trigger of irritable bowel syndrome (IBS) remains unknown, researchers in the last decade have made substantial progress in understanding what goes awry in patients who suffer from the condition.

Studies have shown that many IBS sufferers are hypersensitive to stimuli in the gut. Their brains process those stimuli differently, and many also have heightened gut-immune responses.

As a result, researchers are beginning to look at IBS as an explainable disease rather than as a mysterious disorder. "As more of these abnormalities are being found in IBS, the distinction between a functional disorder and an organic disorder is being blurred," noted George F. Longstreth, MD, chief of gastroenterology at Kaiser Permanente Medical Care Program in San Diego.

Researchers at the University of California, Los Angeles, for example, found that when they used an inflatable balloon to distend the rectum and lower colon of IBS patients, PET scans of the brain showed greater activity in the brain's emotion and attention processing centers than in those of normal control subjects given the same stimulus. Those findings were confirmed by researchers at Vanderbilt University who used MRI studies instead of PET scans.

"Patients with IBS are hypervigilant," explained Brian Lacy, MD, director of the Marvin M. Schuster Center for Digestive and Motility Disorders at Johns Hopkins Bayview Medical Center in Baltimore. "They listen to their guts too carefully and hear every little contraction, gurgle and peristaltic wave."

Other studies have shown that IBS patients have lower visceral pain thresholds and greater gut reactions to psychological stress than control subjects. Those data have led some to hypothesize that a visceral hypersensitivity causes many IBS symptoms.

Whether that hypersensitivity originates in the brain or in the nervous system of the gut is unclear. Regardless of its origin, treatments that target the region of the brain shown to be hyperactive in IBS patients can effectively relieve symptoms. That's why therapies like cognitive behavioral therapy, alosetron, low-dose tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and cognitive therapy all work.

Although abnormalities in brain processing are thought to play a role in IBS, researchers have also found how some symptoms stem from the actions of nerves in the gut. The role of the "gut-brain" connection has recently gained more prominence as researchers continue to uncover its extensive influence on bowel motility, secretion, immune responses and signaling to the central nervous system.

Much of that influence gets carried out via the neurotransmitter serotonin. Remarkably, about 95% of the body's serotonin is found in the gut. Two serotonin receptor subtypes, 5-HT3 and 5-HT4, are thought to be responsible for the majority of the neurotransmitter's intestinal effects.

It's no surprise, then, that alosetron and tegaserod, the first two drugs shown to affect the broad spectrum of IBS symptoms, target 5-HT3 and 4. SSRIs may also act on the bowel's nervous system, although they are thought to have a greater effect on the brain.

There's also preliminary evidence that many IBS patients have a heightened immune response in the gut that includes a boosted number of mast cells, natural killer cells, lymphocytes and serotonin-laden enterochromaffin cells. Interestingly, between 10% and 30% of patients who recover from food poisoning develop IBS, especially if they were under undue psychological stress at the time they developed acute gastroenteritis.

"There's one theory that the infection and stress alter the permeability of the gut mucosa so that bacteria or viruses invade the gut where they don't belong," Dr. Lacy said. "This leads to chronic inflammation that could result in disordered motility and sensation by injuring nerves in the gut." The excessive numbers of enterochromaffin cells in some IBS patients could cause many IBS symptoms just by releasing their granules of serotonin.

The popular media have given a lot of play to a recent study by Mark Pimentel, MD, a gastroenterologist at Cedars-Sinai Medical Center in Los Angeles. He found that IBS patients were more likely to have an overgrowth of small intestinal bacteria as indicated by a breath test. After seven days of treatment with neomycin, their lactulose breath testing normalized.

Experts, however, question the validity of the study, citing several methodological shortcomings like short-term follow-up. "If these patients improved after one week," Dr. Longstreth said, "that's hardly good enough, since IBS naturally waxes and wanes."

All the basic research on IBS suggests that in the future, patients with the disorder may be subdivided based on the underlying mechanisms of their symptoms.

"We're starting to understand IBS not as a single entity but as a collection of pathophysiological subgroups," said gastroenterologist Douglas A. Drossman, FACP, co-director of the University of North Carolina Center for Functional Gastrointestinal and Motility Disorders at Chapel Hill. "Each subgroup might require different treatment."

http://www.acponline.org/journals/news/sep03/ibs.htm

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Small Intestinal Bacterial Overgrowth - A Framework for Understanding IBS new
      #102644 - 08/30/04 01:46 PM
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Vol. 292 No. 7, August 18, 2004

CLINICIAN'S CORNER
Small Intestinal Bacterial Overgrowth

A Framework for Understanding Irritable Bowel Syndrome

Henry C. Lin, MD


JAMA. 2004;292:852-858.

Context: Irritable bowel syndrome (IBS), which affects 11% to 14% of the population, is a puzzling condition with multiple models of pathophysiology including altered motility, visceral hypersensitivity, abnormal brain-gut interaction, autonomic dysfunction, and immune activation. Although no conceptual framework accounts for all the symptoms and observations in IBS, a unifying explanation may exist since 92% of these patients share the symptom of bloating regardless of their predominant complaint.

Evidence:Acquisition: Ovid MEDLINE was searched through May 2004 for relevant English-language articles beginning with those related to bloating, gas, and IBS. Bibliographies of pertinent articles and books were also scanned for additional suitable citations.

Evidence Synthesis: The possibility that small intestinal bacterial overgrowth (SIBO) may explain bloating in IBS is supported by greater total hydrogen excretion after lactulose ingestion, a correlation between the pattern of bowel movement and the type of excreted gas, a prevalence of abnormal lactulose breath test in 84% of IBS patients, and a 75% improvement of IBS symptoms after eradication of SIBO. Altered gastrointestinal motility and sensation, changed activity of the central nervous system, and increased sympathetic drive and immune activation may be understood as consequences of the host response to SIBO.

Conclusions: The gastrointestinal and immune effects of SIBO provide a possible unifying framework for understanding frequent observations in IBS, including postprandial bloating and distension, altered motility, visceral hypersensitivity, abnormal brain-gut interaction, autonomic dysfunction, and immune activation.


Author Affiliation: Division of Gastrointestinal and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles.





RELATED ARTICLES IN JAMA


This Week in JAMA
JAMA. 2004;292:773.


http://jama.ama-assn.org/cgi/content/abstract/292/7/852

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Dyssynergic Defecation: Demographics, Symptoms, Stool Patterns, and Quality of Life new
      #105355 - 09/12/04 03:35 PM
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Dyssynergic Defecation: Demographics, Symptoms, Stool Patterns, and Quality of Life.

Journal of Clinical Gastroenterology. 38(8):680-685, September 2004.

Rao, Satish S. C MD, PhD, FRCP(L) *; Tuteja, Ashok K MD *+; Vellema, Tony BS *; Kempf, Joan RN *; Stessman, Mary RN *

Abstract:
To understand the nature of bowel disturbance in patients with dyssynergia (chronic constipation due to a failure of coordination between the pelvic floor muscles and the anal sphincter, characterized by difficulty or inability to expel stool from the anorectum), we prospectively examined demographics, stool patterns, and quality of life by administering a 31-item questionnaire to 120 patients who fulfilled symptomatic and manometric criteria for dyssynergia (Rome II). Data from 118 subjects (M/F = 27/91) was analyzed.

Eighty four percent of patients reported excessive straining, and 76% reported feeling of incomplete evacuation; 9.7% had no urge to defecate. Abdominal bloating was reported by 74%. More women than men reported infrequent bowel movements and need to strain excessively (P < 0.05). Forty eight percent of patients, more women (P < 0.05) than men used digital maneuvers to evacuate. Hard stools was reported by 60% of women and 41% of men.

Sexual abuse was reported by 22%; 21% were women (P = 0.02). Physical abuse was reported by 32%. Bowel problem adversely affected family life in 33%, sexual life in 56%, work life in 69% and social life in 76% of patients. Most patients with dyssynergia reported an excessive need to strain, feeling of incomplete evacuation and abdominal bloating and one half used digital maneuvers. It significantly affected quality of life, particularly in women.

(C) 2004 Lippincott Williams & Wilkins, Inc.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1041743&specid=13&ok=yes

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Diagnostic approach to suspected irritable bowel syndrome new
      #105356 - 09/12/04 03:38 PM
HeatherAdministrator

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Diagnostic approach to suspected irritable bowel syndrome

J. G. Hatlebakk MD, PhD, Associate Professor, and M. V. Hatlebakk MD, MHA, Researcher

Institute of Medicine, Haukeland University Hospital, University of Bergen, Bergen, Norway

18 August 2004.

Abstract
Diagnostic activity in patients with suspected irritable bowel syndrome (IBS) should be brief and focused, limited to investigations that are likely to exclude serious alternative diagnoses and when negative support a positive diagnosis of IBS. The diagnosis of IBS is clinical, and is robust over time, although other symptoms may add to the clinical picture and other symptoms of functional disorders are common. The most important differential diagnoses are celiac disease, colorectal carcinoma and colitis. 'Red Flag' symptoms and signs should be considered indications for full colonoscopy, which should be performed with a low threshold in patients above 50 years of age. Serologic markers are useful to exclude celiac disease, but positive tests must be confirmed with duodenal biopsies.

Corresponding author. Tel.: +47-55-97-70; Fax: +47-55-97-29-50

Best Practice & Research Clinical Gastroenterology
Volume 18, Issue 4 , August 2004, Pages 735-746

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1041729&specid=13&ok=yes

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Treatment options in irritable bowel syndrome new
      #108480 - 09/26/04 02:57 PM
HeatherAdministrator

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Treatment options in irritable bowel syndrome

doi:10.1016/j.bpg.2004.04.008

Michael J. G. Farthing DSc (Med), MD, FRCP, FMedSci, Professor of Medicine,

St George's Hospital Medical School, Cranmer Terrace, Tooting, London SW17 0RE, UK

Available online 18 August 2004.




Abstract
The irritable bowel syndrome (IBS) is part of the spectrum of functional bowel disorders characterised by a diverse consortium of abdominal symptoms including abdominal pain, altered bowel function (bowel frequency and/or constipation), bloating, abdominal distension, the sensation of incomplete evacuation and the increased passage of mucus. It is not surprising therefore that no single, unifying mechanism has as yet been put forward to explain symptom production in IBS. The currently favoured model includes both central and end-organ components which may be combined to create an integrated hypothesis incorporating psychological factors (stress, distress, affective disorder) with end-organ dysfunction (motility disorder, visceral hypersensitivity) possibly aggravated by sub-clinical inflammation as a residuum of an intestinal infection.

There is currently no universally effective therapy for IBS. Standard therapy generally involves a symptom-directed approach; anti-diarrhoeal agents for bowel frequency, soluble fibre or laxatives for constipation and smooth muscle relaxants and anti-spasmodics for pain. New drug development has focused predominantly on agents that modify the effects of 5-hydroxytryptamine (5-HT) in the gut, principally the 5-HT3 receptor antagonists for painful diarrhoea predominant IBS and 5-HT4 agonists for constipation predominant IBS. More speculative new therapeutic approaches include anti-inflammatory agents, antibiotics, probiotics, antagonists of CCK1 receptors, tachykinins and other novel neuronal receptors.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1041731&specid=13&ok=yes



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What Differentiates Chronic Constipation From IBS With Constipation?
      #108487 - 09/26/04 03:25 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7795
Loc: Seattle, WA

Update on the Management of Chronic Constipation: What Differentiates Chronic Constipation From IBS With Constipation

Authors: Brooks Cash, MD, FACP; William D. Chey, MD, FACG, FACP


Release Date: August 26, 2004;

The irritable bowel syndrome (IBS) and chronic constipation (CC) are 2 of the most common conditions seen in primary care offices and are among the most common reasons for gastroenterology referral in the United States. IBS is a functional gastrointestinal disorder in which altered motility, abnormal visceral sensation, and psychosocial factors interplay to cause symptoms. Because of the overlap in symptoms reported by patients with IBS and a predominant bowel complaint of constipation (IBS-C) and CC, clinicians often find it challenging to differentiate between these 2 disorders. This Clinical Update will focus on the epidemiology, clinical and economic impact, and diagnosis and management of patients with chronic constipation. Important differences between CC and IBS-C will be highlighted in order to emphasize the differential diagnostic and management approaches to the 2 conditions.

Presentation, Epidemiology, and Clinical Impact of Chronic Constipation
The meaning of the word constipation varies widely among physicians and patients. While physicians generally equate constipation with reduced stool frequency, patients often use this term to describe a variety of defecatory complaints. Generally speaking, constipation refers to unsatisfactory defecation characterized by some combination of infrequent stools, straining, incomplete evacuation, hard/lumpy stools, increased time to stool, use of manual maneuvers to stool, or sense of difficulty passing stool.

These points speak to the difficulty in estimating the prevalence of constipation in the general population. Most population-based studies from North America suggest that the prevalence of CC is approximately 15%.[1] Studies indicate that prevalence estimates derived from self-reported constipation differ significantly from estimates based upon the Rome criteria for functional constipation. As is also the case with IBS, the Rome criteria for functional constipation undoubtedly fail to identify a large population of patients who feel that they are constipated. This point was recently borne out by a population-based study from Canada that found a prevalence of self-reported constipation of 27% as opposed to a prevalence of 15% using the Rome II criteria.[2]

Not unlike IBS, observational studies indicate that CC occurs more commonly in women than men. There is also evidence to suggest that the elderly, non-whites, and persons of lower socioeconomic status are more likely to report CC.[1] Almost a third of children with severe constipation will continue to suffer with symptoms beyond puberty.[3]

Only a minority of symptomatic patients seek care for constipation. Despite this, constipation accounts for 2.5 million physician visits and over 90,000 hospitalizations per year in the United States.[4] Although the vast majority of patients are cared for in the primary care setting, CC still remains one of the most commonly recorded diagnoses rendered by gastroenterologists.[5] It has been estimated that hundreds of millions of dollars are spent on an annual basis for laxative therapies.


Article continues at link below...
http://www.medscape.com/viewprogram/3375

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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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