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General IBS / Bowel Dysfunction
      #13954 - 07/14/03 01:56 PM
HeatherAdministrator

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All general research regarding IBS and bowel dysfunction / dysmotility that does not fit into one of the specific library category topics should be posted here.



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Inflammatory bowel disease and irritable bowel syndrome: separate or unified? new
      #13963 - 07/14/03 02:32 PM
HeatherAdministrator

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Current Opinion in Gastroenterology 2003; 19(4):336-342

Inflammatory bowel disease and irritable bowel syndrome: separate or unified?

Sylvie Bradesi, PhD *; James A. McRoberts, Ph.D *; Peter A. Anton, MD *; Emeran A. Mayer, MD *†‡

Both irritable bowel syndrome and inflammatory bowel diseases share symptoms of altered bowel habits associated with abdominal pain or discomfort. Irritable bowel syndrome has been referred to as a functional bowel disorder, which is diagnosed by a characteristic cluster of symptoms in the absence of detectable structural abnormalities. Inflammatory bowel disease is a heterogeneous group of disorders characterized by various forms of chronic mucosal and/or transmural inflammation of the intestine. In this review, the authors discuss recent evidence suggesting several potential mechanisms that might play a pathophysiologic role in both syndromes. Possible shared pathophysiologic mechanisms include altered mucosal permeability, an altered interaction of luminal flora with the mucosal immune system, persistent mucosal immune activation, alterations in gut motility, and a role of severe, sustained life stressors in symptom modulation. It is proposed that similarities and differences between the two syndromes can best be addressed within the framework of interactions between the central nervous system and the gut immune system. Based on recent reports of low-grade mucosal inflammation in subpopulations of patients meeting current diagnostic criteria for irritable bowel syndrome, therapeutic approaches shown to be effective in inflammatory bowel disease, such as probiotics, antibiotics, and antiinflammatory agents, have been suggested as possible therapies for certain patients with irritable bowel syndrome.

Abbreviations
HPA hypothalamic-pituitary-adrenal

IBD inflammatory bowel diseases

IBS irritable bowel syndrome

IELs intraepithelial lymphocytes

iNOS inducible nitric oxide synthase

MAPK mitogen-activated protein kinase

PI-IBS postinfectious irritable bowel syndrome

Th1 T helper 1

TNF-α tumor necrosis factor- α

CNS: Center of Neurovisceral Sciences & Women's Health, Division of Digestive Diseases and Brain Research Institute, Departments of Medicine*, Physiology†, and Psychiatry & Biobehavioral Sciences‡, David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, USA.

Correspondence to: Emeran A. Mayer, MD, CNS: Center of Neurovisceral Sciences and Women's Health, VAGLAHS, Bldg.115/CURE, Room 223, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; e-mail: emayer@ucla.edu

Current Opinion in Gastroenterology 2003; 19(4):336-342
Copyright © 2003 Lippincott Williams & Wilkins
All rights reserved

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Irritable bowel syndrome in primary care: The patients’ and doctors’ views new
      #13968 - 07/14/03 02:43 PM
HeatherAdministrator

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The Canadian Journal of Gastroenterology May 2003, Volume 17, Number 5 : 363-368

Irritable bowel syndrome in primary care: The patients' and doctors' views on symptoms, etiology and management

CJ Bijkerk, NJ de Wit, WAB Stalman, JA Knottnerus, AW Hoes, JWM Muris

BACKGROUND: To facilitate the development of clinical guidelines and to direct future irritable bowel syndrome (IBS) research, insight into the perceptions of patients and general practitioners (GPs) regarding IBS is required.

OBJECTIVES: To compare patients' and GPs' views on the symptomatology, etiology and treatment of IBS.

METHODS: One hundred forty-two IBS patients and 100 GPs were requested to complete a structured questionnaire.

RESULTS: The response rates of the patients and GPs were 80% and 47%, respectively. Abdominal pain and bloating were considered to be the most bothersome symptoms in IBS, by both patients and GPs. Although all patients were diagnosed by their GP as having IBS, and 62% met the Manning criteria, only 18% fulfilled the Rome II criteria for IBS. Patients consider food intolerance and GPs regard lack of fibre as the main etiologic dietary factor. Many IBS patients expect a diagnostic work-up, but GPs generally restrict this to elderly patients. GPs start IBS management with dietary advice (94%), counselling (77%) and drug therapy (55%). Patients expect reassurance (47%) and drug treatment (37%), but dietary interventions are less appreciated (9%).

CONCLUSIONS: Patients and GPs have different perceptions of the efficacy of diagnostic and dietary interventions in IBS. GPs should explore the patients expectations and incorporate these in their approach to IBS patients.

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Update on Treatment of Functional Gastrointestinal Disorders new
      #13970 - 07/14/03 02:55 PM
HeatherAdministrator

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Posts: 7788
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Digestive Disease Week 2003
IBS/Other Functional GI Disorders CME
May 18 - 21, 2003, Orlando; Florida

The Brain, the Gut, the Food, and the Bacteria? Update on Treatment of Functional Gastrointestinal Disorders

Yehuda Ringel, MD Douglas A. Drossman, MD

Introduction
Despite being the most prevalent gastrointestinal (GI) disorders seen in gastroenterology practice, functional gastrointestinal disorders (FGIDs) continue to be difficult conditions to understand and manage, for both clinicians and patients. The latter relates to the complex, multifactorial nature of these disorders, the limited understanding of the pathophysiologic mechanisms that underlie them, and the lack of effective comprehensive treatments. Given these circumstances, it has not been surprising to note the ongoing increase in interest in FGIDs, as reflected by the number of high-quality abstracts submitted and presented at this year's Digestive Disease Week (DDW) meeting, as well as by the number of attendees at sessions focusing on these disorders.

Presentations during this year's meeting proceedings covered the wide spectrum of intensive research that is ongoing in the field, and provided interesting new data about various aspects of these disorders. The latter included discussion of new data on the epidemiology, clinical characteristics, possible pathophysiologic mechanisms, diagnosis, and management of FGIDs.

This overview focuses on those key presentations that provided updates and new information about the effect and efficacy of available and commonly used treatment options for functional GI and motility disorders.

The Brain
Antidepressants have been commonly used for the treatment of irritable bowel syndrome (IBS) and other FGIDs, and recently published American Gastroenterological Association guidelines recommended their use for the pain associated with FGIDs, particularly when first-line therapies fail.[1] However, despite this recommendation and their long-standing availability and use in clinical settings, the evidence for efficacy of antidepressants in the treatment of FGIDs has been relatively weak. This has been, in part, due to the quality of the trials and the small sample sizes.

During DDW 2003, Drossman and colleagues[2,3] presented the results of a 7-year, 2-site, randomized, double-blind, placebo-controlled, treatment trial in patients with moderate-to-severe functional bowel disorders (FBDs; ie, chronic functional abdominal pain, IBS, painful constipation, and unspecified FBD). The investigators from the University of North Carolina and the University of Toronto randomized 431 patients into 2 treatment arms: medication (antidepressants vs placebo)[2] and psychological (cognitive behavioral therapy vs education).[3]

Medication Approach
In the medication arm,[2] 216 patients were randomized to receive either desipramine* up to 150 mg/day, and averaging 100 mg/day (dosage adjustment was based on side effects), or placebo. Responders were determined by an averaged satisfaction with treatment score of > 3.5 on a 0-5 scale range. The results on the intention-to-treat analysis (includes all patients who started the medication treatment) showed no statistically significant difference between the active and placebo groups (response rate of 60% vs 47%, respectively; P = .128). However, in the per protocol analysis of study completers (excluding 25% [30% desipramine, 17% placebo] drop outs and 12 subjects with nondetectable desipramine blood levels), there was a significant effect (response rate of 73% vs 49%, respectively; P = .006) and a number needed to treat of 4.3. It is interesting to note that desipramine was found to be more effective in nondepressed patients, as well as in those with moderate disease severity, predominant diarrhea, and a history of abuse.

Psychological Approach
The other arm of this study was presented in poster form. In this psychological treatment arm,[3] 215 patients were randomized to receive either cognitive behavioral treatment (CBT) or education for 12 weeks. Responder rates were determined, similar to the medication arm, by an averaged satisfaction with treatment score of > 3.5 on a 0-5 scale range. In the intention-to-treat analysis, CBT was found to be more effective than education (P = .0001), with a response rate of 70% vs 37% (P < .0001) and a number needed to treat of 3.1. These results held also in per protocol analysis after 21% (18% on CBT, 29% on education) dropped out. CBT was found to be effective for patients with moderate or severe FBD and for individuals with or without abuse history, but was not different from EDU in efficacy for patients with severe depression.

Commentary. The study authors concluded that CBT is statistically and clinically effective for treatment of FBD (including IBS) and that desipramine, although not significant in the intention-to-treat analysis, appears effective for patients who stay on treatment and who can tolerate the side effects (if present). However, certain clinically meaningful subgroups (eg, patients with depression, patients who appear less responsive) may be amenable to combination treatments using both modalities.

The Gut
Very few medications have been specifically approved for treatment of FGIDs. Therefore, it is not surprising that the US Food and Drug Administration-approved serotonin active agent, tegaserod, has gained noticeable interest during this year's meeting. Tegaserod, a 5-HT4 partial agonist, has been shown to be more effective than placebo in alleviating IBS global and associated symptoms in women with IBS with constipation. Because of its promotility/prokinetic effects on various parts of the GI tract, clinicians have been prompted to use this medication for various non-IBS-related GI motility disorders as well. Several studies were presented during DDW 2003 that offered new information about the use of tegaserod in these settings.

Dyspepsia and Gastroparesis
Tougas and colleagues[4] investigated the effect of different doses of tegaserod* in 163 patients with dyspeptic symptoms who also had delayed gastric emptying. Subjects were randomized to receive tegaserod at 6 mg twice daily (n = 38), 6 mg thrice daily (n = 24), 12 mg twice daily (n = 38), or placebo (n = 63), and gastric emptying was quantitated by scintigraphy before and after treatment. The investigators reported statistically significant improvement in gastric emptying with the 18 mg and 24 mg per day dosages of tegaserod.

Commentary. Several limitations of this study make it difficult to assess the clinical significance and relevance of these findings, such as that the currently approved dose of 12 mg daily did not show a significant effect; the patient population did not meet criteria for dyspepsia or other defined disorders; and information was not available about the symptom response or patients' quality of life (QOL) with this treatment. This is particularly important since it is well known that the correlation between dyspeptic symptoms and gastroparesis is poor. Therefore, at this time, the role of tegaserod in the treatment of dyspepsia and gastroparesis is not yet defined and additional investigation is warranted.

Chronic Constipation
Johansen and colleagues[5] reported the results of a double-blind, placebo-controlled multicenter study that examined the efficacy of tegaserod* 2 mg twice daily (n = 450), 6 mg twice daily (n = 451), or placebo (n = 447) in patients with chronic constipation. They found that tegaserod, 2 mg twice daily and 6 mg twice daily, given for 12 weeks, was superior to placebo in increasing spontaneous bowel movements per week (response was defined as an increase of > 1 spontaneous bowel movements/week compared with baseline), either after 4 weeks (response rate, 41.4%, 43.2%, and 24.9%, respectively; P < .0001 vs placebo) and 12 weeks (40.3%, 44.8%, and 26.9%, respectively; P < .0001 vs placebo). This response was also associated with improvement in other functional GI symptoms.

Commentary. The study authors concluded that tegaserod (2 mg twice daily and 6 mg twice daily) is effective in the treatment of chronic constipation and its related symptoms. However, it should be noted that patients with IBS whose predominant symptom was constipation were not excluded from this study. Patients with IBS with constipation are already known to benefit from tegaserod; therefore, not identifying this subgroup in the study population may have made it difficult to assess the efficacy of this agent in this setting. It would have been helpful to divide the patients in this study into 2 treatment groups -- those with chronic constipation with IBS and those with chronic constipation without IBS -- and to have looked at the treatment response rate in each subgroup. Thus, although these data are encouraging, additional investigation is warranted to assess the efficacy of tegaserod in treating chronic functional constipation.

The Food
Nutritional factors have been suspected to contribute to the symptoms and clinical presentation of FGIDs. Exacerbation of symptoms such as diarrhea, dyspepsia, and nausea are commonly reported postprandially. Many patients attribute some of their symptoms to certain types of food, and therefore avoid those food items. However, recommendations for elimination of specific food items in FGIDs is usually done in variable ways. That is, there are no available guidelines' evidence for the efficacy of this approach to managing these disorders.

Atkinson and colleagues[6] presented an interesting approach to this issue by assessing the efficacy of an exclusion diet based on testing for the presence of IgG food antibodies in unselected (all subtypes) patients with IBS. Patients (n = 150) were tested for the presence of IgG antibodies in a variety of food items and were then blindly randomized to receive either a diet excluding all foods to which they were found to be sensitive (IgG antibody titers >/= 3:1) or a sham diet excluding the same number of foods, but not those to which they were sensitive.

They found that the true diet was significantly more effective than the sham diet in reducing symptom severity scores (average reduction, 34; 95% confidence interval [CI]: 17.3, 68.6; P = .049) in the intention-to-treat analysis (considering all patients who were offered the treatment). When accounting for the patients' adherence to the number of foods to which they were sensitive, the reduction in symptom scores was even higher (average reduction, 89; 95% CI: 41, 137; P < .001). The adherence to the diet affected the response observed in patients on the true diet, but not patients on the sham diet (P = .038). These findings further supported the potential clinical benefit of food-elimination diets based on IgG food antibodies in patients with IBS.

The Bacteria
Several studies have suggested a potential beneficial effect of certain probiotics in reducing some of the symptoms of IBS.[7]

Probiotics vs Antibiotics
In a small (n = 44) study, Faber[8] examined the effect of probiotics* alone (n = 20) and in combination with antibiotics (n = 24) on GI symptoms and QOL in an uncontrolled trial of unselected (all subtypes) patients with IBS. Antibiotic treatment included ciprofloxacin* 500 mg twice daily per week, and probiotic treatment included Lactobacillus acidophilus NCFM (10 billion/g) and Bifidobacteria infantis (10 billion/g) daily for 4 weeks. Both groups showed significant improvement following treatment: In the probiotic/antibiotic group, a decrease in symptom frequency index scores from 35 to 18 (P < .001) and an increase in IBS-QOL scores from 67.6 to 87.8 (P < .001) were seen; in the probiotic-only group, a decrease in symptom frequency index scores from 39 to 17 (P < .001) and an increase in IBS-QOL scores from 69.3 to 86.4 (P < .001) were seen. The predominant IBS type did not alter the response to therapy.

Commentary. As a small uncontrolled study, these results may reflect, at least in part, a placebo response. Nevertheless, the findings emphasize the need for additional clinical studies to evaluate the role of probiotics and antibiotics in IBS patients.

Mechanisms of Probiotics
Although the efficacy and role of probiotics in the treatment of IBS remain uncertain and require confirmation, several studies presented during this year's meeting examined possible mechanisms for their effects on GI motor, sensory, and immune function.

Lamine and colleagues[9] investigated the effect of treatment with Lactobacillus farciminis bacteria on the nociceptive response to colorectal distension in basal conditions and after TNBS (2,4,6-trinitrobenzene sulfonic acid)-induced colonic inflammation in rats. They found that L farciminis treatment significantly reduced (P < .05) abdominal nociceptive response for all distending pressures in both the noninflamed-treated group compared with the noninflamed controls and in the TNBS-induced inflamed hypersensitivity treated group compared with the nontreated group. These researchers attributed this antinociceptive effect to the known ability of L farciminis to produce nitric oxide (NO). Indeed, hemoglobin (an NO scavenger) infusion resulted in reversing this organism's antinociceptive effect. These investigators concluded that a 3-week treatment with L farciminis can reduce visceral pain induced by colorectal distension in basal and inflammatory conditions, and that this effect depends on the NO released by these bacterial strains into the colonic lumen.

In another study, the same group of investigators reported a protective effect of the NO producing-L farciminis against TNBS-induced colitis in rats.[10] Rats that were treated with this organism for 3 weeks prior to induction of colitis showed significantly lower inflammation, as expressed by reduction in macroscopic damage score, MPO (myeloperoxidase) activity, and inducible NO synthase activities. As with the previous study, hemoglobin reversed the beneficial effect of L farciminis on the inflammation activity in the colitic rats.

Commentary. These studies suggest a role for NO-producing bacteria in protecting against inflammatory and hypersensitivity conditions. However, these findings in animal models deserve additional investigation in humans in order to confirm beneficial effects.

Another possible mechanism mediating the effects of probiotic bacteria on GI function has been proposed by Verdu and colleagues.[11] They investigated the effects of probiotics on intestinal muscle dysfunction in a mouse model of postinfective Trichinella spiralis IBS. Study mice groups were treated with Lactobacillus paracasei, Lactobacillus johnsonii, Bifidobacterium longum, or B lactis. Additional mice received heat-inactivated L paracasei or bacteria-free L paracasei spent culture medium (SCM). At 21 days post infection, L paracasei, but not L johnsonii, showed significant attenuation of hypercontractility to carbachol stimulation, compared with the control group (P = .01). The 2 bifidobacteria strains tended to decrease the hypercontractility; however, this trend did not reach statistical significance (P = .09). The attenuation of muscle hypercontractility was paralleled by a 2-fold decrease in the secretion of interleukin-4 (P < .0001), mRNA for transforming growth factor-beta (P = .0001), and cyclooxygenase-2 (P = .001) in longitudinal myenteric plexus preparation and by modulation of genes involved in innate defenses such as RANTES and cryptdin, as evaluated by gene array analysis.

Commentary. It is interesting that the normalization of the postinfection contractility was independent of L paracasei presence in the mucosa-associated flora -- thus indicating that the improvement in intestinal muscle dysfunction by L paracasei and free-L paracasei SCM is likely due to attenuation of cytokine and inflammatory mediator production in the muscularis externa and modulation of innate defense genes in the small intestine. In addition, this effect is strain-dependent.

The importance of the strain-specific effect has also been suggested by findings from other studies.[12] The clinical implication for this strain-specific effect has been shown in an interesting abstract presented by Drisko and colleagues.[13] These investigators examined 5 commercially, commonly available probiotic products. They used polymerase chain reaction (PCR) gel electrophoresis and amplicon excision with DNA sequencing to determine the bacterial strain content of these 5 products and compared their findings against what was reported in the respective product labeling information.

These investigators found that with a single exception, all bacterial species that were tested were detected in the probiotic samples by PCR analysis and confirmed by DNA sequencing. Bifidobacterium bifidum was not detected in 2 of the 5 samples reporting its presence. In contrast, Lactobacillus spp. were detected in 2 of the 5 product samples for which the species was not listed as an "ingredient."

Commentary. Although cultures of commercially available probiotics closely resemble their labeling information overall, there are some differences. Because emerging data suggest that the beneficial effect of probiotics is strain-dependent, a better regulation of dietary supplements may be necessary to ensure proper preparation and marketing standards.

Concluding Remarks
The above discussion is intended to bring to the fore the current state of knowledge regarding the multifactorial nature of FGIDs. Within this context, new insight may be gained with respect to the clinical and therapeutic implications for patients with these disorders, with a view toward the effect and effectiveness of available and commonly used treatment options.

* The United States Food and Drug Administration has not approved this medication for this use.

References
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.
Drossman DA, Diamant N, Toner B, et al. A multi-center randomized trial of despiramine (DES) vs placebo (PLA) in moderate to severe functional bowel disorder (FBD). Gastroenterology. 2003;124:A-30. [Abstract #199]
Drossman DA, Toner B, Whitehead W, et al. A mutli-center randomized trial of cognitive-behavioral treatment (CBT) vs education (EDU) in moderate to severe functiona; bowel disorder. Gastroenterology. 2003;124:A-530. [Poster #T1422]
Tougas G, Chen Y, Luo D, et al. Tegaserod improves gastric emptying in patients with gastroparesis and dyspeptic symptoms. Gastroenterology. 2003;124:A-54. [Abstract #432]
Johansen JF, Tougas G, Chey WD, et al. Tegaserod provides rapid and sustained relief of constipation, abdominal bloating/distension, and abdominal discomfort/pain in patients with chronic constipation. Gastroenterology. 2003;124:A-47. [Abstract #371]
Atkinson W, Gurney R, Sheldon TA, Whorwell PJ. Do food elimination diets improve irritable bowel syndrome? A double blind trial based on IgG antibodies to food. Gastroenterology. 2003;124:A-29. [Abstract #198]
Kim HJ, Camilleri M, McKinzie S, et al.A randomized controlled trial of a probiotic, VSL#3, on gut transit and symptoms in diarrhoea-predominant irritable bowel syndrome. Aliment Pharmacol Ther. 2003;17:895-904.
Faber S. Comparison of probiotics with antibiotics alone in treatment of diarrhea-predominant IBS (D-IBS), alternating (A-IBS), and constipation (C-IBS) patients. Gastroenterology. 2003;124:A-687. [Poster #W1523]
Lamine F, Cauquil E, Eutamene H, et al. Lactobacillus farciminis reduces sensitivity to rectal distension in rats: Involvement of nitric oxide. Gastroenterology. 2003;124:A-476. [Poster #T1060]
Lamine F, Cauquil E, Nepveu F, et al. Nitric oxide released by Lactobacillus farciminis protects rat colon against TNBS-induced inflammation. Gastroenterology, 2003;124:A-113. [Abstract #828]
Verdu EF, Bercik P, Blennerhassett P, et al. Strain-dependent effects of probiotics on intestinal muscle dysfunction in an animal model of post-infective irritable bowel syndrome. Gastroenterology. 2003;124:A-29. [Abstract # 197]
Ringel Y, Drossman DA. Inflammation, infection, and irritable bowel syndrome. Medscape Conference Coverage based on selected sessions at Digestive Disease Week, 2002. Medscape Gastroenterology 2002. Available at:
http://www.medscape.com/viewarticle/434527 Accessed June 3, 2003.
Drisko JA, Bischoff B, Giles C, et al. Evaluation of 5 probiotic products for bacteria by PCR. Gastroenterology. 2003;124:A-687. [Poster #W1522]

Copyright © 2003 Medscape.

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The Irritable Bowel Syndrome-Fibromyalgia Connection new
      #13979 - 07/14/03 03:19 PM
HeatherAdministrator

Reged: 12/09/02
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The Irritable Bowel Syndrome-Fibromyalgia Connection

Is there a connection between these two functional disorders?


As many as one-third of irritable bowel syndrome (IBS) patients have described extra intestinal symptoms such as rashes, tension headaches, and muscle aches and pains. Research has shown that as many as 60% of IBS patients also suffer from fibromyalgia syndrome (FMS). Conversely, as many as 70% of FMS patients have reported experiencing symptoms of IBS.(1) Could there be a common cause for the two conditions?

Fibromyalgia. FMS is a disorder of the musculoskeletal system that is associated with symptoms of general muscle aches, stiffness, overall fatigue, and poor sleeping habits (see Fibromyalgia Basics for a complete list of fibromyalgia symptoms). Symptoms can vary in both severity and duration; the pain may be dull or knife-like, linger persistently, or be intermittent. Like IBS, FMS is a functional disorder, therefore tests to find the origins of the pain often come back negative (see Table below for the diagnostic criteria for FMS). Approximately 3.4% of women, and 5% of men suffer from FMS.

The IBS-FMS connection. Given the co-existence of IBS and FM in so many people, it is reasonable to consider a connection between them. Even though IBS affects the gastrointestinal tract and FMS the musculoskeletal system, there are striking similarities. Neither condition can be explained by organic disease; they are considered functional disorders. At least in Western society, both occur frequently in women and the onset may be during a stressful event in life. Cognitive behavior therapy and certain types of prescription drugs are effective in both IBS and FMS.

Research has been suggested that people with IBS or FMS respond to pain differently than other persons. However, IBS patients have an altered response to visceral (intestinal) pain, while persons with FMS have an altered response to somatic (skin and muscle) pain. Not surprisingly, further studies have shown that people with both IBS and FMS have an altered response to both types of pain. Additionally, persons with severe cases of IBS were more likely to have FMS than those with less acute symptoms.(2)

Although researchers have suggested a common mechanism for both disorders, its origins are still unknown. Relatively speaking, the medical community has only just recognized both IBS and FMS as legitimate disorders and not psychosomatic problems. Therefore, research on either condition is still in its infancy, and studies connecting the two are rare. However, there is hope for sufferers from both conditions, as researchers are taking new interest in discovering why IBS and FMS seem to be connected.

Diagnosing fibromyalgia

In 1990, criteria for the diagnosis of fibromyalgia were established by the American College of Rheumatology (ACR).(3) These are:
A history of widespread pain, which is identified by pain being present:
In the left side of the body.
In the right side of the body.
Above the waist.
Below the waist.
Shoulder and buttock pain are taken into account as pain in the side of the body. Additionally, axial skeletal pain must also be established, which is defined by pain in one of the following:
Cervical spine.
Anterior chest.
Thoracic spine.
Low back (lower segment).
Pain must also be present in 11 of 18 pre-defined sites on the body when palpated (touched with the fingers) by a physician. The more technical ACR definitions of the sites are in parentheses.
1-2:The base of the skull, right and left sides (occiput: bilateral, at the suboccipital muscle insertions).
3-4: The lower neck, right and left sides (low cervical: bilateral, at the anterior aspects of the intertransverse spaces at C5-C7).
5-6: The midpoint between the neck and shoulder, right and left sides (trapezius: bilateral, at the midpoint of the upper border).
7-8: Muscles over the shoulder blades, right and left sides (supraspinatus: bilateral, at origins, above the scapula spine near the medial border).
9-10: The upper edge of the breastbone, right and left sides (second rib: bilateral, at he second costochondral junctions, just lateral to the junctions on upper surfaces).
11-12: Two centimeters towards the wrist from either elbow (lateral epicondyle: bilateral, 2 cm distal to the epicondyles).
13-14: The outer buttock muscles, right and left sides (gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle).
15-16: Upper buttock muscle where the buttocks meet the back, right and left sides (greater trochanter: bilateral, posterior to the trochanteric prominence).
17-18: Just inside and above either kneecap (knee: bilateral, at the medial fat pad proximal to the joint line).




1. Veale D, Kavanagh G, Fielding JF, Fitzgerald O. Primary fibromyalgia and the irritable bowel syndrome. Br J Rheumatol. 1991;30:220-222.
2. Lubrano E, Iovino P, Tremolaterra F, et al. Fibromyalgia in patients with irritable bowel syndrome. An association with the severity of the intestinal disorder. Int J Colorectal Dis. 2001;16:211-215.
3. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 Criteria for the Classification of Fibromyalgia. Report of the Multicenter Criteria Committee. Arthritis Rheum. 1990;33:160-172.

Copyright © 2003 About, Inc

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New and Important Insights Into IBS new
      #13981 - 07/14/03 03:24 PM
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New and Important Insights Into IBS: From Epidemiology to Treatment

Nicholas J. Talley, MD, PhD

Introduction
Disorders of gastrointestinal dysfunction, including irritable bowel syndrome (IBS), continue to attract increasing attention as our understanding of them accelerates. At this year's meeting of the American College of Gastroenterology, a number of important new findings in IBS emerged regarding epidemiology, impact, diagnosis, prognosis, potential mechanisms, and treatment. This summary discusses this new knowledge and places it in appropriate clinical context.

Epidemiology
It is well known that IBS is highly prevalent in the general population, but national US data are limited and previous studies have often focused on self-reported diagnosis of IBS data rather than applying standard diagnostic criteria (eg, Rome).[1]

Hungin and colleagues[2] applied random-digit-dialing technology to conduct telephone interviews in more than 5000 subjects 18 years and older in the United States. Using a structured questionnaire to obtain information on IBS, they identified the overall prevalence of this disorder to be 14%, with a female-male ratio of approximately 2:1. More women than men had typical IBS symptoms, but overall only about one fourth had been formally diagnosed as having IBS; 34% had symptoms for more than 10 years, and 48% had symptoms for more than 5 years. Approximately 60% of subjects used over-the-counter medications, and 20% used nothing to treat their IBS. These investigators reported that abdominal pain was the major reason patients visited healthcare professionals. They also observed that there was a higher rate of cholecystectomy and hysterectomy among those with IBS in the population. These findings are consistent with other high-quality US epidemiologic studies.[3] Similar results have also been observed in Europe[4] and Australia.[5]

In another epidemiologic study of 1069 employees of the Veterans' Affairs Health Care System in Utah, Tuteja and colleagues[6] evaluated potential risk factors for IBS. They recruited a total of 723 subjects, obtaining a response rate of 72%, and observed that 9% had IBS, as expected. Adjusting for age and sex, IBS was not associated with smoking, aspirin use, alcohol consumption, or education level. However, unmarried patients and those taking acetaminophen were at a significantly higher risk for IBS. Being unmarried may be of relevance because there is a lack of social support and therefore a potential increased vulnerability to stress. On the other hand, acetaminophen use may reflect the need for this medication for abdominal pain or extraintestinal pain, although there is no evidence that acetaminophen effectively relieves pain in this condition.

Impairment of quality of life is considered by many to be an important prerequisite if a condition not associated with mortality is to be labeled a disease.[1,7] Hungin and associates[8] reported that despite substantial nonconsulting, IBS had a significant impact on patients' day-to-day life: 25% were working fewer hours and 20% had changed their work schedule because of the disease. Although IBS has a confirmed predominance among women, it is still not known whether there are sex-specific differences that predict health-related quality of life in IBS.[1] Sach and associates[9] evaluated this issue. They found that IBS in both women and men had a similar overall gastrointestinal symptom severity score. They also noted that IBS patients in this study had more impaired mental and physical quality of life and worse vital exhaustion scores than controls. It appeared that in women physical factors may predominately predict impaired quality of life, whereas in men cognitive factors appear to be stronger predictors of impaired quality of life.

Thus, sex differences do matter in IBS, as exemplified by the not-yet-explained superior efficacy of the new peripherally acting serotonin-modulating drugs in IBS, which appear to be more efficacious in women (although admittedly there are fewer data in men).[1,7] Additional work is required to interpret the sex-specific impact of IBS and explore the mechanisms underlying the sex-specific differences in this disease.

Diagnosis
Symptomatic Differentiation
There is increasing interest in evaluating the utility of symptoms for distinguishing IBS from other functional and organic diseases.[1] One of the major issues that often faces clinicians is the challenge of differentiating IBS with constipation from functional constipation due to slow colonic transit or pelvic floor dysfunction.

Crowell and colleagues[10] evaluated patients seen in a tertiary referral center who fulfilled the Rome I criteria for either IBS or functional constipation. They applied a standardized bowel symptom questionnaire to determine which symptoms might differentiate IBS from functional constipation. They observed significant symptom overlap for the 2 conditions. However, they were able, applying discriminate analysis, to correctly classify the majority of patients (73%), although the model appeared to lack clinical utility and requires prospective testing. At this stage, differentiating IBS from other functional bowel diseases based on symptoms is arbitrary; more work is needed to determine if meaningful groupings can be identified with more careful attention to specific symptoms and pathophysiologic abnormalities in constipated patients.

IBD and IBS: Common Link?
A key issue that continues to be controversial is whether IBS and inflammatory bowel disease (IBD) have a common link. A small increased risk of IBD among individuals with IBS has been identified in 1 prospective cohort study.[11] Furthermore, it is well recognized that typical IBS-like symptoms may occur in IBD in remission.[1] Therefore, it may be difficult to distinguish these diseases unless colonoscopy and biopsy are performed.

KothandaRaman and colleagues[12] evaluated the pain experienced by patients with IBS compared with that experienced by patients who had Crohn's disease. They studied 12 patients with IBS and 22 with Crohn's disease, all of whom completed the McGill Pain Questionnaire, the Pain Disability Index, the Pain Catastrophizing scale, the Multi-Dimensional Pain Inventory, and a quality-of-life measure (the 36-Item Short-Form Health Survey [SF-36]). Pain descriptors were similar in both groups, although the patients with Crohn's disease had a more helpless attitude and a lower overall quality of life. Therefore, it appears that the pain experience is similar in IBS and Crohn's disease and that using pain descriptors to differentiate IBS from IBD is unlikely to be effective.

Zaman and associates[13] evaluated symptoms in patients with Crohn's disease (n = 30) and left-sided ulcerative colitis (n = 25) or IBS (n = 21). In patients with IBS compared with active IBD, the symptoms were remarkably similar, suggesting that it can be difficult to differentiate IBD based on gastrointestinal symptoms alone. The precise utility of the Rome II criteria in IBD remains poorly defined, but these criteria are likely to be insufficient on their own. Alternatively, alarm symptoms, such as rectal bleeding or weight loss, in combination with typical IBS symptoms may be considerably more helpful in differentiating active IBD from IBS, as may be the use of inflammatory markers, such as a sensitive assay for C-reactive protein or calprotectins.[1]

Sugar Intolerance
Another condition that can be confused with IBS is sugar intolerance; however, the role of fructose and sorbitol in the etiology of symptoms typical of IBS remains controversial. A high prevalence of sugar malabsorption has been observed in patients with IBS, although the benefits of restricting intake of the problematic sugars has been highly variable.[14,15]

Gagliardi and colleagues[16] noted that the mean fructose intake in the United States is at least 37 g/d. They studied 15 healthy adult patients who consumed both 25 g and 50 g of fructose on separate days. Breath hydrogen testing was then conducted. The study authors observed that 50% of patients had hydrogen peak levels above 20 ppm with the 25-g dose of fructose, whereas 75% taking the 50-g dose had an abnormal hydrogen peak. This finding suggests that in the normal population a large number of individuals have fructose malabsorption. Furthermore, symptom scores were greater after both doses of fructose, although the higher dose did not increase the scores.

Choi and associates[17] specifically assessed fructose intolerance in the setting of IBS. They studied 209 patients with unexplained bloating, altered bowel habit, and pain who were given either a 25-g or 50-g fructose challenge. It was observed that in patients receiving the higher fructose load, symptom scores were higher for diarrhea but not for other gastrointestinal symptoms. Overall, one third of patients with suspected IBS in this tertiary referral center appeared to have fructose intolerance. However, avoidance of fructose and symptom relief were not evaluated. Clinicians may wisely wish to consider prescribing a low-fructose diet as part of their initial management of IBS with diarrhea, but the benefits even among patients with coexistent fructose intolerance are as yet not established.

Prognosis
Durability of Diagnosis
Traditionally, IBS is considered to be a "safe" diagnosis.[1] Adeniji and colleagues[18] studied a well-characterized cohort of patients to confirm the safety (durability) of a diagnosis of IBS. They reviewed a cohort of patients who were diagnosed with IBS between 1989 and 1992 and who fulfilled the Rome I criteria for the diagnosis. The study population was reinterviewed for IBS symptoms 10-13 years after the initial diagnosis. In 75 patients, the mean time to the second interview was 11.8 years, and none had the diagnosis refuted. There were other gastrointestinal diagnoses noted in small numbers among patients in this cohort, including 5 cases of diverticulitis and 3 of gallbladder disease. Many patients (46%) had undergone a second, but arguably unnecessary, structural evaluation that ultimately produced negative results (no change in diagnosis). Of particular interest was the finding that only 43% of patients continued to meet the Rome I criteria for IBS, implying that some symptoms in IBS will often fluctuate. This finding suggests that the current symptom criteria for IBS may require reconsideration to include subthreshold cases.

Postenteritis IBS
Currently, another area of major interest in IBS is the prognosis of postenteritis IBS.[19] It is now well recognized that up to 1 in 5 cases of IBS will occur after infection, and a low-grade inflammatory process has been documented in some of these cases, although histologically the colonic mucosa is normal.[1,19]

In a study by Spears and colleagues,[20] patients with acute infectious enteritis were administered standardized questionnaires 3 months after infection as part of a repeat evaluation. Although a small study, the investigators observed that 2 patients with IBS 3 months after infection also had depression. In contrast, the remaining 9 patients who did not develop postenteritis IBS were negative for depression on the patient health questionnaire. These results are consistent with the literature, which suggests that psychological factors may identify a vulnerability to the development of postinfectious IBS.[1] The latter may in turn reflect disturbed central down-regulation of visceral afferent signals from the gut that may be genetically determined.

Pathophysiology
Altered Serotonin Signaling?
The pathogenesis of IBS remains obscure, and in particular, an explanation for alternating diarrhea and constipation has been elusive. In arguably one of the most important papers presented during this year's meeting, Moses and colleagues[21] studied potential deregulation of the gut's serotonin transporter in IBS.

It is known that serotonin (5-hydroxytryptamine or 5HT) is released from enteroendocrine (or enterochromaffin) cells in response to either chemical or mechanical stimulation of the gut mucosa. Serotonin in turn initiates peristalsis, and then the serotonin released is taken up in health by a highly selective serotonin transporter (SERT). One potential mechanism that could explain altered bowel function in IBS is an abnormality in the serotonin transporter itself. The study authors evaluated this hypothesis in patients with IBS with constipation and IBS with diarrhea compared with patients with ulcerative colitis and healthy controls. They were able to convincing show on blinded review that SERT immunoreactivity was less intense in patients with IBS with constipation and patients with ulcerative colitis.

If these findings are indeed correct, they represent a landmark observation. The findings suggest that patients with constipation and IBS may have a reduced capacity to reuptake serotonin, leading to excess free serotonin and then desensitization of these receptors, thus reducing motor function. In contrast, in the setting of diarrhea, serotonin uptake was normal. If the underlying abnormality in serotonin transporter function alternated, then this would in turn explain alternating constipation and diarrhea.

These data strongly suggest that IBS is a "real" gut disease and a potential diagnostic disease marker. They also suggest that it is valid to subdivide IBS into constipation and diarrhea symptom subgroups. This study also provides additional rationale for the use of serotonin-modulating agents in IBS and provides a new target for drug modulation. Confirmation of these very exciting initial findings in larger patient samples is awaited with great interest.

Therapy
Tegaserod
Tegaserod is a partial serotonin type 4 agonist (at least in the guinea pig ileum) and is a prokinetic agent that also promotes fluid secretion.[7] Recent randomized, controlled trials have shown that this drug is effective in IBS with constipation, with significant global improvement and improvement in constipation symptoms and abdominal pain.[22] One issue to be resolved is whether the benefits of tegaserod are purely due to its prokinetic action relieving constipation. Animal data suggest that tegaserod has some visceral analgesic actions, although the relevance of this to humans is not yet established.[7]

Dunger-Baldauf and colleagues[23] aimed to evaluate the relevance of the improvement in constipation by performing a meta-analysis of the available tegaserod phase 3 clinical trials. They compared the time course of daily abdominal pain and discomfort and daily bowel movements and failed to show any temporal relationship between these symptoms. The study authors concluded that any benefit to abdominal pain was independent of the drug's prokinetic action. However, a proof-of-concept study comparing standard osmotic laxatives with tegaserod is warranted to validate this finding.

An important issue for clinicians is the safety of tegaserod. Ruegg and colleagues[24] evaluated the combination of antidepressant drugs with tegaserod in the phase 3 tegaserod clinical trials. They showed that tegaserod in combination with antidepressants appeared to be well tolerated and that there were no increased adverse events in this setting. This finding is reassuring because combination therapy is likely to be used by clinicians for IBS in difficult cases.

Tegaserod is a prokinetic, and hence diarrhea would be expected with its use. However, this appears not to be a major issue according to data reported by Earnest and associates.[25] The study authors found that when diarrhea was reported, it occurred early in treatment and that the majority of patients (71%) had only 1 episode. The safety of tegaserod, even in IBS with diarrhea, has been described elsewhere recently.[26] Therefore, although 1 in 10 patients will experience diarrhea, this appears to be a mild and transient issue that typically requires no additional therapy. There are 5-hydroxytryptamine type 4 or 5HT4 receptors on the atria in the heart, but other data support the safety of tegaserod in terms of an absence of electrocardiographic effects.[27]

Probiotics
Probiotics are gaining increasing attention as potential therapies for IBS.[28] Uncontrolled studies have been encouraging, as evidenced by presentations during this year's scientific sessions. Positive results were reported by Bazzocchi and coworkers[29] in an open, uncontrolled trial. Similarly, in a retrospective study, Faber[30] reported significant improvement in symptoms and quality of life from baseline with probiotic therapy. However, Kim and colleagues[31] conducted a randomized, double-blind, placebo-controlled trial and found more sobering and likely more accurate results. They found no overall symptomatic improvement associated with the probiotic they administered (although bloating did improve), and they also found no change in colonic transit.

Only high-quality randomized controlled trials will address the issue of whether probiotics have a place in the treatment of IBS. Furthermore, any benefit will need a mechanistic explanation, which at present is lacking.

Conclusion
This year's annual meeting of the American College of Gastroenterology has provided a forum for the presentation of new and important insights into IBS. Some truly exciting developments have emerged that will hopefully translate into improved patient outcomes as we begin to unravel this increasingly better understood disease entity.

References
Talley NJ, Spiller R. Irritable bowel syndrome: a little understood organic bowel disease? Lancet. 2002;360:555-564.
Hungin APS, Tack J, Mearin F, Whorwell PJ, Dennis E, Barghoui V. Irritable bowel syndrome (IBS): prevalence and impact in the USA - the truth in IBS (T-IBS) survey. Am J Gastroenterol. 2002;97:242. [Poster #460]
Saito YA, Schoenfeld P, Locke GR III. The epidemiology of irritable bowel syndrome in North America: a systematic review. Am J Gastroenterol. 2002;97:1910-1915.
Badia X, Mearin F, Balboa A, et al. Burden of illness in irritable bowel syndrome comparing Rome I and Rome II criteria. Pharmacoeconomics. 2002;20:749-758.
Koloski NA, Talley NJ, Boyce PM. Epidemiology and health care seeking in the functional GI disorders: a population-based study. Am J Gastroenterol. 2002;97:2290-2299.
Tuteja AK, Joos SK, Talley NJ, Hickam DH. Functional bowel disorders: a population based study of prevalence and risk factors. Am J Gastroenterol. 2002;97:241. [Poster #454]
Talley NJ. Serotonergic neuroenteric modulators. Lancet. 2001;358:2061-2068.
Hungin APS, Tack J, Mearin F, Whorwell PJ, Dennis E, Barghoui V. The truth in IBS (T-IBS) survey - healthcare utilization and medication use among IBS patients in the USA. Am J Gastroenterol. 2002;97:243. [Poster #461]
Sach JA, Chang L, Naliboff B, Emeran A. Are there gender specific predictors of health related quality of life (HRQOL) impairment in patients with irritable bowel syndrome? Am J Gastroenterol. 2002;97:122. [Abstract #41]
Crowell MD, Schattler-Duncan A, Dennis EH. Symptomatic differentiation of irritable bowel syndrome with constipation vs. functional constipation. Am J Gastroenterol. 2002;97:308. [Poster #721]
Garcia Rodriguez LA, Ruigomez A, Wallander MA, Johansson S, Olbe L. Detection of colorectal tumor and inflammatory bowel disease during follow-up of patients with initial diagnosis of irritable bowel syndrome. Scand J Gastroenterol. 2000;35:306-311.
KothandaRaman M, Turnbull GK, Valis TM. The pain experience by patients with irritable bowel syndrome. Am J Gastroenterol. 2002;97:308. [Poster #723]
Zaman MS, Robson KM, Lembo AJ. Overlap of irritable bowel syndrome (IBS) symptoms in patients with inflammatory bowel disease (IBD). Am J Gastroenterol. 2002;97:241. [Poster #455]
Fernandez-Banares F, Esteve-Pardo M, de Leon R, et al. Sugar malabsorption in functional bowel disease: clinical implications. Am J Gastroenterol. 1993;88:2044-2050.
Ledochowski M, Widner B, Bair H, Probst T, Fuchs D. Fructose- and sorbitol-reduced diet improves mood and gastrointestinal disturbances in fructose malabsorbers. Scand J Gastroenterol. 2000;35:1048-1052.
Gagliardi M, Beyer P, Pehlivanov N, McCallum R. Should we be testing for fructose tolerance in patients with GI complaints? Am J Gastroenterol. 2002;97:308. [Poster #724]
Choi YK, Jacdson M, Summers R, Rao S. Fructose intolerance and irritable bowel syndrome (IBS). Am J Gastroenterol. 2002;97:309. [Poster #725]
Adeniji OA, Barnett B, DiPalma JA. Durability of the irritable bowel syndrome. Am J Gastroenterol. 2002;97:121. [Abstract # 40]
Neal KR, Barker L, Spiller RC. Prognosis in post-infective irritable bowel syndrome: a six year follow up study. Gut. 2002;51:410-413.
Spears AD, Tuteja A, Frederick S, et al. Evaluation of the natural history and role of psychological factors in post-enteritis irritable bowel syndrome. Am J Gastroenterol. 2002;97:308. [Poster # 722]
Moses PL, Bannon C, Linden DR, Crowell MD, Sharkey KA, Mawe GM. Evidence for altered serotonin signalling in IBD and constipation predominant IBS. Am J Gastroenterol. 2002;97:240. [Poster #452]
Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT4 receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15:1655-1666.
Dunger-Baldauf C, Rueegg PC, Lefkowitz M. Is relief from abdominal discomfort/pain in tegaserod treated IBS-C, patients due to an increased frequency of bowel movements. Am J Gastroenterol. 2002;97:177. [Poster #199]
Ruegg P, Lefkowitz M, Drossman D, Shi V. Tegaserod alone or in combination with antidepressant drugs is well tolerated in patients with IBS-C. Am J Gastroenterol. 2002;97:176. [Poster #195]
Earnest D, Rueegg PC, Dunger Baldauf C, Lefkowitz M. Diarrhea in patients treated with tegaserod for irritable bowel syndrome with constipation (IBS-C) is infrequent and usually self-limited. Am J Gastroenterol. 2002;97:177. [Poster #197]
Fidelholtz J, Smith W, Rawls J, et al. Safety and tolerability of tegaserod in patients with irritable bowel syndrome and diarrhea symptoms. Am J Gastroenterol. 2002;97:1176-1781.
Morganroth J, Ruegg PC, Dunger-Baldauf C, Appel-Dingemanse S, Bliesath H, Lefkowitz M. Tegaserod, a 5-hydroxytryptamine type 4 receptor partial agonist, is devoid of electrocardiographic effects. Am J Gastroenterol. 2002;97:2321-2327.
Hunter JO, Madden JA, Hunter JO. A review of the role of the gut microflora in irritable bowel syndrome and the effects of probiotics. Br J Nutr. 2002;88:67-72.
Bazzocchi G, Almerigi PF, Gionchetti P, Campieri M. Changes in symptoms, distension-stimulated colonic motility and in fecal microbiological features after oral bacteriotherapy in patients with diarrhea-predominant IBS (D-IBS) or with functional diarrhea (FD). Am J Gastroenterol. 2002;97:176. [Poster # 196]
Faber SM. Irritable bowel syndrome and reinoculation with probiotics. Am J Gastroenterol. 2002;97:211. [Poster #336]
Kim HJ, Camilleri M, McKinzie S, Burton D, Thomforde G, Zinsmeister AR. Effect of a probiotic, VSL#3 in diarrhea-predominant irritable bowel syndrome: a randomised, double blind, placebo controlled trial. Am J Gastroenterol. 2002;97:177. [Poster #200]

Copyright © 2002 Medscape.

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Features of eating disorders in patients with IBS new
      #14080 - 07/15/03 11:12 AM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

J Psychosom Res. 1998 Aug;45(2):171-8.

Features of eating disorders in patients with irritable bowel syndrome.

Tang TN, Toner BB, Stuckless N, Dion KL, Kaplan AS, Ali A.

Women's Mental Health Research Programme, Clarke Institute of Psychiatry, Toronto, Ontario, Canada.

The relationship between characteristics of irritable bowel syndrome (IBS) and eating disorders (ED) was investigated in a clinical sample of 43 female and 17 male IBS patients who completed the Eating Disorder Inventory (EDI). A diagnosis of IBS was generally unrelated to the Body Dissatisfaction, Perfectionism, and Ineffectiveness subscales of the EDI, but symptom severity was correlated with Perfectionism and Ineffectiveness. Severe bouts of vomiting were significantly associated with desires for lower body weight and reported binge-purge behaviors and cognitions measured by the Bulimia subscale of the EDI. Results suggest the need for a more comprehensive understanding of both types of illness as well as a possible framework for future empirical work.

PMID: 9753389 [PubMed - indexed for MEDLINE]

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Functional GI disorders and eating disorders - Relevance of the association new
      #14081 - 07/15/03 11:14 AM
HeatherAdministrator

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

Scand J Gastroenterol. 1998 Jun;33(6):577-82.

Functional gastrointestinal disorders and eating disorders. Relevance of the association in clinical management.

Porcelli P, Leandro G, De Carne M.

Dept. of Gastroenterology, Scientific Institute of Gastroenterology Saverio de Bellis, Castellana Grotte (Bari), Italy.

BACKGROUND: As functional gastrointestinal disorders (FGID) are common in eating disorder patients, we aimed to assess past eating disorders in patients referred for current FGID. METHODS: One hundred and twenty-seven consecutive FGID outpatients and 163 patients with gallstone disease (GD) were enrolled. All patients were interviewed to detect GI symptoms (by means of the GI Symptom Rating Scale), lifetime eating disorders (on the basis of DSM-IV criteria), and current psychologic distress (on the Hospital Anxiety and Depression Scale). RESULTS: Past eating disorders were significantly more prevalent in FGID (15.7%) than in GD patients (3.1%) (chi-square = 14.6, P < 0.001). FGID patients with past eating disorders were significantly younger, more educated, more psychologically distressed, more dyspeptic, and more were women than FGID patients without past eating disorders. CONCLUSIONS: This study confirms the previously found association between functional GI symptoms and eating disorders and shows that functional GI symptoms may still persist even after the recovery from eating disorders, particularly in psychologically distressed patients.

PMID: 9669626 [PubMed - indexed for MEDLINE]

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Dieting severity and GI symptoms in college women. new
      #14090 - 07/15/03 01:13 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

J Am Coll Health. 1996 Sep;45(2):67-71.

Dieting severity and gastrointestinal symptoms in college women.

Krahn D, Kurth C, Nairn K, Redmond L, Drewnowski A, Gomberg E.

Department of Psychiatry, University of Wisconsin-Madison Medical School, USA.

Young women report symptoms associated with irritable bowel syndrome (IBS), such as pain, bloating, and changes in bowel movements, more often than young men. Young women with eating disorders also report these gastrointestinal symptoms frequently. We hypothesized that if dieting behaviors were associated with these symptoms, the prevalence and frequency of the symptoms would be positively related to dieting severity in young women. We interviewed 301 1st-year college women representing the continuum of dieting severity. We found that severity of dieting was positively related to frequency of abdominal pain, bloating, diarrhea, and constipation, and that the women who reported 3 or more symptoms regularly scored higher on a scale for dieting severity. Although this study did not examine the relationship between dieting severity and clinical IBS, the findings suggested that dieting is associated with gastrointestinal symptoms in young women.

PMID: 8908880 [PubMed - indexed for MEDLINE]

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Postinfectious irritable bowel syndrome. new
      #14123 - 07/15/03 06:19 PM
HeatherAdministrator

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Gastroenterology. 2003 May;124(6):1662-71.

Postinfectious irritable bowel syndrome.

Spiller RC.

Division of Gastroenterology, University Hospital, Nottingham, United Kingdom. robin.spiller@noittingham.ac.uk

A small but significant subgroup of patients with irritable bowel syndrome (IBS) report a sudden onset of their IBS symptoms after a bout of gastroenteritis. Population-based surveys show that although a history of neurotic and psychologic disorders, pain-related diseases, and gastroenteritis are all risk factors for developing IBS, gastroenteritis is the most potent. More toxigenic organisms increase the risk 11-fold, as does an initial illness lasting more than 3 weeks. Hypochondriasis and adverse life events double the risk for postinfective (PI)-IBS and may account for the increased proportion of women who develop this syndrome. PI-IBS is associated with modest increases in mucosal T lymphocytes and serotonin-containing enteroendocrine cells. Animal models and some preliminary human data suggest this leads to excessive serotonin release from the mucosa. Both the histologic changes and symptoms in humans may last for many years with only 40% recovering over a 6-year follow-up. Celiac disease, microscopic colitis, lactose intolerance, early stage Crohn's disease, and bile salt malabsorption should be excluded, as should colon cancer in those over the age of 45 years or in those with a positive family history. Treatment with Loperamide, low-fiber diets, and bile salt- binding therapy may help some patients. Serotonin antagonists are logical treatments but have yet to be evaluated.

Publication Types:
Review
Review, Tutorial

PMID: 12761724 [PubMed - indexed for MEDLINE]
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Extraintestinal symptoms in IBS and IBD new
      #14125 - 07/15/03 06:21 PM
HeatherAdministrator

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Posts: 7788
Loc: Seattle, WA

Dig Dis Sci. 2003 Apr;48(4):743-9.

Extraintestinal symptoms in irritable bowel syndrome and inflammatory bowel diseases: nature, severity, and relationship to gastrointestinal symptoms.

Zimmerman J.

The Gastroenterology Unit, Hadassah University Hospital, Jerusalem, Israel 91 120.

Patients suffering from the irritable bowel syndrome (IBS) tend to have extraintestinal symptoms. The purposes of this study were to compare the nature and severity of these symptoms in IBS patients in relation to patients with inflammatory bowel disease (IBD) and to nonpatients and to clarify the relationship between intestinal and extraintestinal symptoms. A consecutive group of male patients and a control group of age-matched male subjects were studied. Symptoms were graded for severity using a validated, self-administered inventory. There were 53 IBS patients, 55 IBD patients (32 Crohn's disease), and 56 controls. IBS patients scored significantly higher than IBD patients on constipation, dyspepsia, and reflux scales. Musculoskeletal symptoms, neurasthenia, and sleep scores were similar in IBS and IBD patients, and both groups scored significantly higher than the controls. The scores of urinary, thoracic, and oral symptoms were similar in IBD patients and in controls. However, IBS patients scored significantly higher than both groups on all these scales. Reflux symptoms were the most powerful predictors of extraintestinal symptoms, both in IBS and in IBD. Diarrhea was predictive of extraintestinal symptoms only in IBD. In conclusion, IBS patients experienced extraintestinal symptoms to the same extent, or even more than patients with IBD. However, the relationship between intestinal and extraintestinal symptoms differed in the two conditions.

PMID: 12741465 [PubMed - indexed for MEDLINE]
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Treatment of the irritable bowel syndrome. new
      #14151 - 07/15/03 11:02 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Gastroenterol Clin North Am. 1991 Jun;20(2):325-33.

Treatment of the irritable bowel syndrome.

Friedman G.

Department of Medicine, Mt. Sinai School of Medicine, New York, New York.

Individualization of treatment for patients with IBS is predicated on a thorough analysis of the patient's symptoms, consideration of the reasons for seeking health care, evaluation of symptom-precipitating factors, elimination of confounding features, and the absolute knowledge of the absence of organic illness. Collecting and codifying appropriate historical data allow the physician to educate the patient with respect to the origin of his symptoms, and to enlist the patient as a partner in his future health care. There is no single, universally accepted therapeutic agent available for the treatment of the IBS patient. As a result, treatment is directed at reducing the frequency and intensity of triggering factors as well as ameliorating the symptoms when they arise. Symptoms evoked by psychologic factors may be effectively reduced by psychotherapy or hypnotherapy. Situational anxiety may be treated for brief periods by using antianxiety agents such as diazepam, chlordiazepoxide, buspirone, or similar agents. Depressive reactions may be reduced with suitable doses of antidepressant agents such as amitriptyline. Smooth muscle hyperreactivity may be dulled with small amounts of selected anticholinergics, which are usually most effective in reducing meal-induced discomfort. Peppermint oil may be of additional benefit. Gas-related symptoms require elimination of contributory dietary factors, such as lactose-containing foods, sorbitol, or fructose, as well as certain oligosaccharides. Simethecone, charcoal, or beanase may be helpful. Functional constipation is best treated with graded doses of insoluble or soluble fiber. Diarrheal episodes may be reduced with either loperamide or diphenoxylate. Careful, continued follow-up assessment of therapeutic endeavors, a sincere interest in the patient's concerns, and surveillance for intercurrent organic illness are the cornerstones of complete ongoing care.

Publication Types:
Review Review, Tutorial

PMID: 2066156 [PubMed - indexed for MEDLINE]

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Antibiotics increase functional abdominal symptoms. new
      #14325 - 07/18/03 11:41 AM
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Am J Gastroenterol. 2002 Jan;97(1):104-8.

Antibiotics increase functional abdominal symptoms.

Maxwell PR, Rink E, Kumar D, Mendall MA.

Department of General Practice and Primary Care, St George's Hospital Medical School, London, United Kingdom.

OBJECTIVES: Data suggest that subjects with irritable bowel syndrome are more likely to report a recent course of antibiotics. This study tests the hypothesis that a course of antibiotics is a risk factor for an increase in the number of functional bowel complaints over a 4-month period in a general population sample. METHODS: We initiated a prospective case-control study in three general practices in South London. Consecutive patients aged 16-49 attending their general practitioner with non-GI complaints and given a prescription for antibiotics were invited to participate. Comparison subjects who had not had antibiotics for 1 yr were identified from the practice records by age group, gender, and previous general practitioner visits. Fifty-eight antibiotic and 65 control patients agreed to participate. Questionnaires covering demographic, GI, and psychological data were sent at recruitment and at 4 months. Seventy-four percent of subjects completed the study. The number of symptoms at follow-up compared to that at recruitment. RESULTS: Twenty of 42 antibiotic subjects (48%) versus 11/49 control subjects (22%) demonstrated one or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 3.14 [1.27-7.75]) (chi2 = 6.4, p = 0.01). Ten of 42 antibiotic subjects (24%) versus 3/49 control subjects (6%) demonstrated two or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 4.79 [1.22-18.80]) (chi2 = 5.8, p = 0.02). CONCLUSIONS: Functional bowel symptoms come and go, but subjects who are given a course of antibiotics are more than three times as likely to report more bowel symptoms 4 months later than controls.

PMID: 11808932 [PubMed - indexed for MEDLINE]
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Eradication of small intestinal bacterial overgrowth reduces symptoms of IBS new
      #14329 - 07/18/03 11:44 AM
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Am J Gastroenterol. 2000 Dec;95(12):3503-6.

Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome.

Pimentel M, Chow EJ, Lin HC.

Department of Medicine, Cedars-Sinai Medical Center, CSMC Burns & Allen Research Institute, and School of Medicine, University of California, Los Angeles, 90048, USA.

OBJECTIVES: Irritable bowel syndrome is the most common gastrointestinal diagnosis. The symptoms of irritable bowel syndrome are similar to those of small intestinal bacterial overgrowth. The purpose of this study was to test whether overgrowth is associated with irritable bowel syndrome and whether treatment of overgrowth reduces their intestinal complaints. METHODS: Two hundred two subjects in a prospective database of subjects referred from the community undergoing a lactulose hydrogen breath test for assessment of overgrowth were Rome I criteria positive for irritable bowel syndrome. They were treated with open label antibiotics after positive breath test. Subjects returning for follow-up breath test to confirm eradication of overgrowth were also assessed. Subjects with inflammatory bowel disease, abdominal surgery, or subjects demonstrating rapid transit were excluded. Baseline and after treatment symptoms were rated on visual analog scales for bloating, diarrhea, abdominal pain, defecation relief, mucous, sensation of incomplete evacuation, straining, and urgency. Subjects were blinded to their breath test results until completion of the questionnaire. RESULTS: Of 202 irritable bowel syndrome patients, 157 (78%) had overgrowth. Of these, 47 had follow-up testing. Twenty-five of 47 follow-up subjects had eradication of small intestinal bacterial overgrowth. Comparison of those that eradicated to those that failed to eradicate revealed an improvement in irritable bowel syndrome symptoms with diarrhea and abdominal pain being statistically significant after Bonferroni correction (p < 0.05). Furthermore, 48% of eradicated subjects no longer met Rome criteria (chi2 = 12.0, p < 0.001). No difference was seen if eradication was not successful. CONCLUSIONS: Small intestinal bacterial overgrowth is associated with irritable bowel syndrome. Eradication of the overgrowth eliminates irritable bowel syndrome by study criteria in 48% of subjects.

PMID: 11151884 [PubMed - indexed for MEDLINE]
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Diagnosis of irritable bowel syndrome. new
      #14332 - 07/18/03 11:54 AM
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ogy. 2002 May;122(6):1701-14.

Diagnosis of irritable bowel syndrome.

Olden KW.

Department of Medicine, Division of Gastroenterology, Mayo Clinic Scottsdale, 13400 E. Shea Boulevard, Scottsdale, Arizona 85259, USA. olden.kevin@mayo.edu

Irritable bowel syndrome (IBS) is the most common disorder seen in gastroenterology practice. It is also a large component of primary care practices. Although the classic IBS symptoms of lower abdominal pain, bloating, and alteration of bowel habits is easily recognizable to most physicians, diagnosing IBS remains a challenge. This is in part caused by the absence of anatomic or physiologic markers. For this reason, the diagnosis of IBS currently needs to be made on clinical grounds. A number of symptom-based diagnostic criteria have been proposed over the last 15 years. The most recent of these, the Rome II criteria, seem to show reasonable sensitivity and specificity in diagnosing IBS. However, the role of the Rome II criteria in clinical practice remains ill defined. A review of the literature shows that, in patients with no alarm symptoms, the Rome criteria have a positive predictive value of approximately 98%, and that additional diagnostic tests have a yield of 2% or less. Diagnostic evaluation should also include a psychosocial assessment specifically addressing any history of sexual or physical abuse because these issues significantly influence management strategies and treatment success.

Publication Types:
Review
Review, Tutorial

PMID: 12016433 [PubMed - indexed for MEDLINE]
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Bacterial Overgrowth in IBS new
      #14337 - 07/18/03 12:15 PM
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BACTERIAL OVERGROWTH IN IBS
Douglas A. Drossman, MD
Center Co-Director

In the December issue of the American Journal of Gastroenterology, a relatively small study peaked the interest of news reporters, primarily because it was believed that "the answer" to understanding and treating IBS was at hand. The article entitled "Eradication of Small Intestinal Bacterial Overgrowth Reduces Symptoms of IBS" by M. Pimental, E.J. Chow and H.C. Lin found that 78% of 157 patients referred to their center for breath hydrogen testing for bacterial overgrowth were found to have bacterial overgrowth. Furthermore, over half (25 of 47) of the patients who were treated with antibiotics and came back for later testing had a reduction in their IBS symptoms.

We recognize bacterial overgrowth in the small intestine to be associated with symptoms similar to IBS (bloating, abdominal pain and diarrhea), and those who have the proper equipment (as we do at our Center), can perform this test easily and painlessly. The subject drinks about a quart of a sugar solution (e.g., lactose) that is not absorbed in the small intestine, so it usually passes to the large intestine where it is broken down by bacteria and gas is produced as a waste product which is sent to the lung as hydrogen. Because bacteria are found in very high concentration in the large, but not the small intestine, the production of the gas occurs late (after 90 minutes). So when more than the usual number of bacteria is found in the small intestine (bacterial overgrowth), they will digest the lactose sooner, producing an earlier excretion of hydrogen in the lungs. In addition, the patients may also develop symptoms of gas, bloating and diarrhea. When bacterial overgrowth is diagnosed, it can be treated with antibiotics and this will reduce the symptoms, at least. What was different about this article was that the frequency of bacterial overgrowth in this study was far higher than clinicians and investigators had previously found.

The information reported was met with a great deal of enthusiasm. To quote Reuter's press on 12/13:"Los Angeles, CA - Irritable bowel syndrome, a chronic condition believed to plague 20% of the adult population…..May be caused by too much bacteria in the small intestine, researches said Wednesday. ' It was the first time a potential cause for the disease has been identified and could lead to a radical shift in treatment', according to the lead investigator of the study. 'This is really exciting because it points to the cause of the disease. Treatments for IBS to this point have been directed at symptoms, not any cause' said Dr. Mark Pimental…..". This kind of information was communicated in newspapers, TV and the Internet, and Drs. Whitehead and I were asked to comment as to whether this was indeed a major breakthrough in research.

Before getting too encouraged, it would help to identify some of the limitations of this study before drawing any conclusions:

Patients were referred to the medical center specifically for breath hydrogen testing after being evaluated by physicians who suspected this diagnosis. This would tend to skew the proportion of persons with positive studies, simply because the doctors have already suspected the diagnosis. So the 78% figure may be higher than might occur in a better designed study.


This is not a placebo-controlled double-blinded study. In well-designed studies, a proportion of subjects receive a placebo, so the investigators can compare the benefits of those on the active treatment to those on placebo. In addition, usually, neither the study subjects nor the investigators know who is getting the active drug or placebo. But when there is no placebo, then all patients (and investigators) will know they are receiving the active treatment (i.e., the antibiotics), and they may do better ("placebo effect") because they expect to do better. So the level of improvement here might be higher than if the study subjects did not know which treatment they were getting.


Although 157 patients were tested for bacterial overgrowth, less than 1/3 were actually tested with regard to benefits from treatment. It is unclear why so few patients came back. Were the ones who didn't come back doing better or worse? Preferably, efforts need to be made to study all patients in order to know if the results are valid.


This was a "convenience study". It appears that the authors went back in the clinical records to report their results rather than design a prospective study where patients follow a specific protocol. For example, at least four different antibiotics were used by different physicians. So it is unknown whether one antibiotic might be better than another, and these kinds of differences in how the study is conducted will interfere with the conclusions that can be drawn from the study.
In summary, I believe that while the findings being reported are not a major breakthrough, they should increase awareness of one disorder that can mimic or worsen IBS. In our experience at the UNC Center for Functional GI and Motility Disorders, the frequency is much lower (maybe <10%) of people who come to us with IBS. But when we suspect bacterial overgrowth based on certain clinical features, we then test for it, and of course, there is a greater chance the test will be positive. In those cases we treat, and many (but not all) will respond; however, the symptoms may return.

Patients with IBS should consider a diagnosis of bacterial overgrowth if you have diarrhea, abdominal swelling and increased gas production within 30-45 minutes after eating. But these symptoms are also quite typical just for IBS. Your physician will work with you to determine if breath testing for bacterial overgrowth may be helpful.

UNC Center for Functional GI & Motility Disorders
Bioinformatics Building, CB #7080
Chapel Hill, NC 27599-7080
(919) 843-0821 (phone)

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UCLA/CURE Neuroenteric Disease Program Newsletter new
      #14676 - 07/23/03 10:38 AM
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UCLA/CURE Neuroenteric Disease Program Newsletter

The Inside Trak

Our Newsletter "The Inside Trak" is a semiannual publication aimed at patients suffering from IBS and other chronic disorders of the gastrointestinal tract. The articles appearing in the newsletter are written by the members of the Neuroenteric Disease Program and deal with a wide range of issues which we feel our patients are interested in. In particular, we are aiming to update patients on new developments in research, drug development and ongoing clinical studies. Get newsletter issues here:
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Distinctive features of postinfective irritable bowel syndrome new
      #15251 - 07/28/03 03:18 PM
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Distinctive clinical, psychological, and histological features of postinfective irritable bowel syndrome

Simon P. Dunlop M.Sc. a , David Jenkins M.D. b and Robin C. Spiller M.D.



--------------------------------------------------------------------------------


Abstract

Objective


Irritable bowel syndrome after gastroenteritis is well recognized. Our aim was to determine whether postinfective IBS (PI-IBS) has histological or clinical features that are distinct from those of IBS patients with no history of preceding infection.


Methods


A total of 75 consecutive IBS outpatients and 36 healthy control subjects completed a questionnaire detailing symptoms, mode of onset, and previous psychiatric history. All underwent a full diagnostic workup including rectal biopsy, which included immunostaining and quantification for lamina propria or intraepithelial T lymphocytes, serotonin-containing enterochromaffin (EC), and mast cells. Patients were divided according to onset of symptoms into PI-IBS (n = 23) or non–PI-IBS (n = 52) patients.


Results


Diarrhea predominance occurred more frequently in PI-IBS (70%) than in non–PI-IBS (42%) patients (p = 0.03). A history of previous treatment for anxiety or depression was present in 26% of PI-IBS patients compared to 54% of non–PI-IBS (p = 0.02). Biopsy results for all patients were normal using conventional criteria; however, quantification revealed that PI-IBS showed increased EC cells compared to those of non–PI-IBS patients (p = 0.017) and controls (p = 0.02). Lamina propria T lymphocytes were increased in PI-IBS (p = 0.026) and non–PI-IBS (p = 0.011) patients compared to controls. Mast cells were increased in non–PI-IBS patients (p = 0.054) compared to controls.


Conclusions


Individuals with PI-IBS are a clinically distinct subgroup characterized by diarrheal symptoms, less psychiatric illness, and increased serotonin-containing EC cells compared to those with non–PI-IBS.

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Cognitive-behavioral therapy versus education and desipramine versus placebo for IBS new
      #17068 - 08/12/03 12:54 PM
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Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders

Gastroenterology July 2003 • Volume 125 • Number 1



Background & aims: Studies of antidepressants and psychological treatments in functional bowel disorders (FBD) are methodologically limited. The aim of this study was to assess the clinical efficacy and safety of cognitive-behavioral therapy (CBT) against education (EDU) and desipramine (DES) against placebo (PLA) in female patients with moderate to severe FBD (irritable bowel syndrome, functional abdominal pain, painful constipation, and unspecified FBD). We also evaluated the amenability of clinically meaningful subgroups to these treatments.

Methods: This randomized, comparator-controlled, multicenter trial enrolled 431 adults from the University of North Carolina and the University of Toronto with moderate to severe symptoms of FBD. Participants received psychological (CBT vs. EDU) or antidepressant (DES vs. PLA) treatment for 12 weeks. Clinical, physiologic, and psychosocial assessments were performed before and at the end of treatment.

Results: The intention-to-treat analysis showed CBT as significantly more effective than EDU (P = 0.0001; responder rate, 70% CBT vs. 37% EDU; number needed to treat [NNT ], 3.1). DES did not show significant benefit over PLA in the intention-to-treat analysis (P = 0.16; responder rate, 60% DES vs. 47% PLA; NNT, 8.1) but did show a statistically significant benefit in the per-protocol analysis (P = 0.01; responder rate, 73% DES vs. 49% PLA; NNT, 5.2), especially when participants with nondetectable blood levels of DES were excluded (P = 0.002). Improvement was best gauged by satisfaction with treatment. Subgroup analyses showed that DES was beneficial over PLA for moderate more than severe symptoms, abuse history, no depression, and diarrhea-predominant symptoms; CBT was beneficial over EDU for all subgroups except for depression.

Conclusions: For female patients with moderate to severe FBD, CBT is effective and DES may be effective when taken adequately. Certain clinical subgroups are more or less amenable to these treatments.

*UNC Center for Functional GI and Motility Disorders, Division of Digestive Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
‡Center for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
§Division of Gastroenterology, University of Toronto, Toronto, Ontario, Canada
''GlaxoSmithKline, Research Triangle Park, North Carolina, USA
¶Global Outcomes Research, Pharmacia Corp., Kalamazoo, Michigan, USA
#Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA

Supported by a research grant from the National Institutes of Health (RO1-DK49334).

1This study was registered with ClinicalTrials.gov (trial registry no. NCT00006157).
Submitted December 6, 2002.

Accepted on April 3, 2003.

Copyright © 2003 by American Gastroenterological Association

doi:10.1016/S0016-5085(03)00669-3

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Do published guidelines for evaluation of IBS reflect practice? new
      #19119 - 08/30/03 02:40 PM
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Do published guidelines for evaluation of Irritable Bowel Syndrome reflect practice?

BMC Gastroenterol. 2001; 1 (1): 11

Barbara P. Yawn, ,1 Eva Lydick, ,2 G Richard. Locke,3 Peter C. Wollan,1 Susan L. Bertram,1 and Margary J. Kurland1

1Department of Research, Olmsted Medical Center, Rochester, Minnesota, USA 2SmithKline Beecham Pharmaceuticals, Division of Epidemiology, Collegeville, Pennsylvania, USA 3Gastroenterology Outcomes Research Unit, Mayo Clinic, Rochester, Minnesota, USA

Received July 25, 2001; Accepted October 26, 2001; Published October 26, 2001.

Background
The only US guidelines listed in the National Guideline Warehouse for the diagnosis of Irritable Bowel Syndrome (IBS) are the expert opinion guidelines published by The American Gastroenterology Association. Although the listed target audience of these guidelines includes family physicians and general internists, the care recommended in the guidelines has not been compared to actual primary care practice. This study was designed to compare expert opinion guidelines with the actual primary care provided and to assess outcomes in the 3 years following the IBS diagnosis.

Methods
This is a retrospective medical record review study using a random sample of incident IBS cases from all Olmsted County, Minnesota providers diagnosed between January 1, 1993 and December 31, 1995. Data was collected on all care and testing provided to the subjects as well as 3-year outcomes related to the IBS diagnosis.

Results
Of the 149 IBS patients, 99 were women and the mean age was 47.6 years. No patient had all of the diagnostic tests recommended in the guidelines. 42% had the basic blood tests of CBC and a chemistry panel. Sedimentation rate (2%) and serum thyroxine level (3%) were uncommon. Colon imaging studies were done in 41% including 74% of those over the age of 50. In the 3 years following the diagnosis, only one person had a change in diagnosis and no diagnoses of gastro-intestinal malignancies were made in the cohort.

Conclusions
Primary care practice based diagnostic evaluations for IBS differ significantly from the specialty expert opinion-based guidelines. Implementation of the specialty guidelines in primary care practice would increase utilization with apparent limited improvement in diagnostic outcomes.


Irritable bowel syndrome is a gastro-intestinal (GI) disorder of unknown etiology often described as a functional bowel problem. [1-3] The diagnosis of IBS rests on the occurrence of a set of symptoms and the exclusion of other GI pathology. [4-7] The only published US guidelines for evaluation of patients with possible IBS have been developed by the American Gastroenterological Association (AGA).[3] Due to the lack of higher levels of evidence, the guidelines are based on expert opinion and are likely to reflect the clinical experience of these specialists with the small percent (6 to 8%)[8] of all IBS patients seen by gastroenterologists in the US. [9] Little has been written about the potential implications of implementing the only currently available IBS diagnostic guidelines[10] or how the guidelines compare to existing community practice.

Using a community population-based sample of subjects with an incident diagnosis of IBS, we reviewed the GI-related health care utilization and diagnostic evaluations completed around the time of first (incident) IBS diagnosis and compared those evaluations to the AGA guidelines for the diagnosis of IBS. In addition, we evaluated the utilization implications of implementing the AGA guidelines in this patient population. The purpose of the study is not to validate the guidelines but to see how they compare to current primary care practice and to understand the potential implications of full guideline implementation.


Setting
Olmsted County is a metropolitan statistical area (MSA) of 135,000 people 90 miles south of Minneapolis, Minnesota. The population is estimated to be 92 percent white non-Hispanic. [11] Olmsted County has local resources for primary, and specialty care. Previous studies estimate that over 98 percent of all Olmsted County residents' health care is delivered within Olmsted County [11] by the Mayo Medical Center (MMC), the Olmsted Medical Center (OMC) or the single solo practice family physician's office in Rochester.

Data Collection
The cohort was identified using the database of the Rochester Epidemiology Project (REP)[11,12] that collects all diagnoses made within all Olmsted County medical facilities and links all people in Olmsted County to all sources of health care they use. All people with a diagnosis of functional or irritable bowel syndrome (564.1) or spastic colon – psychogenic (306.4) during 1993–1995 were identified from the database. Broad criteria were used for the search to increase sensitivity at the risk of reducing specificity. This type of search strategy was possible since final subject selection relied on medical record review rather than only administrative data. [13] The initial search identified 1245 potential cases (a combination of incident and prevalent cases) of which 36 (2.9%) had previously refused general record review research authorization and thus could not be included in the study according to Minnesota statute.[14] The goal was to identify 150 subjects for in-depth review using data from all sources of medical care each individual has used within the county. The sample size was selected based on the desire to have a sufficient sample to provide estimates of compliance with individual elements of the guidelines with confidence intervals of +/- 5% for those tests with very high and very low compliance and +/-8% for those near 50% compliance. This is a descriptive study and therefore no other types of sample size calculations were made.

The 1245 people identified by the initial search of the REP database, were put into a random order and the medical records of potential subjects' were screened until the final cohort of 150 patients who met the inclusion criteria were identified. A total of 416 potential IBS subjects were screened to identify the final incident cohort of 150 subjects who had lived in Olmsted County for at least 3 years and had no previous diagnoses of IBS listed in any medical records in the county. The minimum of 3 years of residency within Olmsted County was used to improve the likelihood that review of the complete available medical records would identify prevalent rather than incident cases of IBS. The assurance that patients represented an incident diagnosis of IBS was especially important in this study comparing diagnostic evaluations completed to the recommended guidelines for initial evaluation. Potential subjects from the group of 416 were excluded during screening primarily for 1 of 3 reasons: they were prevalent rather than incident cases of IBS (n = 67), no actual diagnosis of IBS was documented in any of the subject's medical records (n = 41) or they had been an Olmsted County resident for < 3 years (n = 93). Another 65 people had a group of miscellaneous reasons for exclusion including incident diagnosis date outside the window of this study, age < 16 at diagnosis, and missing records.

All medical records of the 150 subjects in the final cohort (those meeting the eligibility criteria) were reviewed in detail to abstract data on demographic characteristics, visits for gastro-intestinal or abdominal problems, and non-GI symptom-related visits from 10 years before the first IBS diagnosis to 3 years after. GI symptom-related visits were those in which any symptom, sign or complaint referable to the GI tract was recorded. This included such complaints as diarrhea, abdominal pain, constipation, change in stool habits, and vomiting. All other visits were considered non-GI related. Information on the presenting complaint, specialty of physician seen, tests ordered and site of the visit (emergency department, office, or hospital) was recorded. Data collection began at the earliest visit that occurred 10 years or less before the incident IBS diagnosis. Long term data were available for most patients (mean = 7.3 years, median 7 years) and were used to assure that there was no previous diagnosis of IBS. The data of most interest for this comparison of diagnostic evaluations completed and the testing recommended in the guidelines were visits in 2 years before the diagnosis of IBS. Diagnostic outcomes were assessed during the 3 years after the incident diagnosis. These data were present in 100% of subjects.

Data analysis
One subject revoked general research authorization (required by Minnesota statute) during data analysis and thus the analysis was completed for the remaining 149 subjects. Descriptive information is presented as summary statistics.

Health care utilization was stratified into 2 major time periods: a) the 60 days surrounding the incident IBS diagnosis (30 days before to 30 days after) called the immediate diagnostic period; and b) the 2 years prior to the diagnosis, excluding the 30 days before termed the extended diagnostic period. For referral to a GI specialist we also included the 1 year after the diagnosis since referral for non-urgent conditions may take a considerable period of time. The designation of the 60-day "diagnostic period" was based on the clinical judgement of the authors and was felt to reflect the usual time required to complete a diagnostic evaluation. The percent of subjects using each of the recommended services was calculated for the diagnostic period and then for the extended immediate diagnostic period (included the 2 year period prior to the incident diagnosis). The extended window of time was important for such tests as colonoscopy that may not be repeated within 2 years of a normal examination.

Comparisons of test utilization between age groups, genders and those who did and did not have a gastroenterologist involved in their care were made using the Wilcoxon rank-sum test. Chi-square tests were used to compare frequencies of events.

The potential impact of fully implementing the AGA guidelines (Table 1) was assessed. The additional tests that would be needed for full implementation was calculated by subtracting the tests provided in this study from tests that would need to be completed if all subjects' evaluations met the guidelines. Diagnostic outcomes (e.g. changes in diagnoses from IBS to another GI disease in the 3 years following first IBS diagnosis) is reported as a single percent of total diagnosis.

This study was approved by the Olmsted Medical Center and the Mayo Medical Center Institutional Review Boards. The funding agency had no role in study design or right of approval of manuscripts submitted for publication. The author who worked for the funding agency was one of the epidemiologist members of the design team and reviewed the final draft of the manuscript.

Two thirds of the 149 subjects (n = 99) were women. The mean age of the subjects at the time of diagnosis was 47.6 years (s.d. 17.8 years and range 16 to 91 years) and was the same for men and women. Most of the IBS diagnoses (94%) were made by family physicians and general internists with 13% of subjects seeing a gastroenterologist at any time in the period 2 years before to 1 year after the diagnosis.

Table 2 summarizes the percent of people having each test or group of tests that are recommended for diagnostic evaluation by the AGA guidelines. In this cohort, testing did not vary significantly by sex. Only the completion of some type of colon imaging (flexible sigmoidoscopy, colonoscopy or barium enema) varied by age with 74% (n = 46) of those 50 and older at diagnosis versus 38% (n = 33) of those younger than 50 at diagnosis having one of the tests documented. Since the guidelines were developed by a panel of gastroenterologists, the compliance with the guidelines in those subjects seeing a GI specialist was also calculated (n = 19). All types of colon imaging were more common in those with GI specialty visits [79% (n = 15) versus 50% (n = 64), p > 0.05] but only the increase in flexible sigmoidoscopies reached statistical significance [53%, (n = 10) versus 19%, (n = 25), p < 0.05]. The only other diagnostic tests that were statistically more likely to be completed in those seen by a gastroenterologist were stool testing for ova and parasites [53%, (n = 10) versus 16%, (n = 21), p < 0.05] and fecal occult blood [26%, (n = 5) versus 9% (n = 12), p < 0.05].

The final column of Table 2 reflects the additional number of people (and percent of the subjects) who would require each category of test to comply with the AGA guidelines [3] for diagnosis of IBS.

In those subjects with primarily diarrhea (n = 82), the guidelines suggest a small bowel radiograph and a lactose/dextrose H2 breath test. Twelve subjects (15%) had a small bowel radiograph and none had H2 breath testing. For those with abdominal pain (n = 110) the guidelines recommend a plain film of the abdomen. Thirteen of these patients (12%) had a flat plate.

In the three years after the diagnosis of IBS, only one subject had any change in diagnosis from IBS to another condition related to the symptoms. This 23-year old subject was diagnosed with inflammatory bowel disease approximately one year after the initial IBS diagnosis. No subject was diagnosed with any type of GI-related malignancy and there were no deaths in the cohort.

The evaluation of IBS in this community population-based cohort of primary care patients differed significantly from that recommended by the AGA guidelines [3] for IBS evaluation. The evaluation of GI-related signs and symptoms appeared to be based primarily on history and physical examination with minimal specific testing or imaging of the GI tract. The inclusion of a GI specialist in the subject's care increased but did not guarantee compliance with the AGA guidelines.

The diagnostic guidelines developed and published by the AGA are available in several formats including as part of the guideline warehouse sponsored by the Agency for Health Care Research and Quality (AHRQ) www.guidelines.gov/ibs where they are listed as applicable to family medicine, internal medicine, gastroenterology and primary care. Physicians who are familiar with the medical literature will know that almost all elements of the IBS guideline required expert opinion since little other evidence was available. Unfortunately, the level of evidence used is not clearly stated. [15] Furthermore, the AGA guidelines were developed by a panel limited to gastroenterologist physicians. However, gastroenterologists see only a minority of IBS patients.[8] Over 94% of the subjects in this sample were initially evaluated by family physicians and general internists with only 13% ever seeing a gastroenterologist in the 7 years before or 3 years after the incident IBS diagnosis. Therefore, subspecialty developed guidelines may not be appropriate for the majority of IBS care especially when the guidelines have to be based primarily on opinion which likely reflects only the experience of physicians included in the guideline development panel.

The complete printed position statement that accompanies the original publication of the AGA guidelines does note the potential lack of applicability to primary care patients (> 85% of all IBS patients) stating "...Primary care patients may be different and may be followed with expectant management". [3] However, expectant management is not specified nor are the specific indications for referral to a specialist presented. The position paper also recognizes that "...there is a risk of overdoing the diagnostic evaluation to rule out organic disease". Within the guideline warehouse www.guidelines.gov these modifiers are missing. No data are presented in any format that provide any rationale for extending the AGA guidelines to primary care practice.

The additional testing that would be required to meet the AGA guidelines [3] is extensive (Table 2) and would likely result in significant increases in health care expenditures. Even if the guidelines were applied only to those visiting a gastroenterologist (assumed to be 13% of subjects in our study), additional health care utilization would be required. The anticipated gain in improved diagnostic accuracy appears to be limited since in this cohort only one diagnosis was changed from IBS in the 3 years of follow up after the incident IBS diagnosis.

The value of completing all of the additional testing recommended by the guidelines cannot be completely assessed with this data set. However, the outcome of no new GI malignancies in the three years of follow up of this cohort is comparable to other studies of prognosis in IBS [16] and suggests additional testing would be of limited value in identifying life threatening conditions. The value of the additional testing or referrals on the patient's quality of life or other health conditions is not known and requires additional research. The format of that additional research might be similar to the studies for other guidelines such as the study of the cost implications of implementing guidelines that recommend radiographs for evaluation of low back pain. [17] Such a study for IBS guidelines would need to assess the added value of the extensive work-up recommended by the specialty guidelines in a larger population over a longer period of time and could be compared to the outcomes (including patient satisfaction) of a group assigned to more limited evaluation as completed in this study. It would be important to determine if the additional tests or referrals would identify other diseases, serve to more fully reassure the patient or simply have become what patients and specialist expect to occur with a GI specialty visit. [18]

Failure to comply with one aspect of the guidelines is worth specific mention. While subjects over age 50 were more likely to have colon-imaging studies, 25% of them had no colon imaging studies or assessment of fecal occult blood. This is not consistent with the published evidence based U.S. Preventive Services Task Force (USPSTF) guidelines for routine screening and preventive care related to colon cancer for asymptomatic people 50 years and older and appear to represent missed screening opportunities. [19,20] The addition of a GI specialist in the patient's care increased but did not guarantee compliance with the USPSTF guidelines for screening studies of the colon.

The AGA[3] had little evidence of any higher level than expert opinion on which to base IBS guidelines. The disparity between the testing family physicians and general internists choose to evaluate potential IBS and that recommended in the guidelines highlights the potential impact of using subspecialty experts to define recommended care in a primary care condition with limited research based evidence. If indeed gastroenterologists do see a sicker or otherwise different group of people with IBS than seen by family physicians and general internists then more extensive evaluation by gastroenterologists would be appropriate to consider. If the GI specialty patients are no more likely to have other diseases but are just more likely to be dissatisfied with care and need additional reassurance, more testing may not be the most cost effective solution. Alternative considerations such as group therapy, support groups or additional education may be a better use of resources and time. [21] In this population, the disparity between the care given and that recommended reinforces the value of understanding the full spectrum of disease when developing opinion based guidelines as well as the importance of developing evidence based guidelines as opposed to expert opinion based guidelines whenever possible.

This is a relatively small cohort of primary care patients from a single county. Practices in other communities and with patients of more diverse racial and ethnic background may be different. Medical records rarely reflect every thing that happens during any medical encounter. It is possible that additional testing did occur. However, tests often involve people other than the physician, are billable items in the non-capitated care environment we studied and therefore significant amounts of undocumented testing is unlikely. The use of medical records did allow the date of the incident diagnosis to be pinpointed and allowed us to assess diagnostic evaluation in temporal relation to the incident diagnosis making comparison with diagnostic guidelines possible. Our limited sample size may not have been sufficient to allow accurate assessment of missed GI malignancies.

Conclusion
Community based evaluation of IBS differs from the consensus based guidelines developed by specialists. The limited testing done in this population appeared to limit health care expenditures without adversely impacting the recognition of life threatening GI disease. To allow physician assessment of the potential applicability of published guidelines, the guidelines should always be accompanied by information regarding the target population (i.e. primary care patients versus specialty care patients) and the evidence basis of the guidelines.


References
Lynn, RB & Friedman, LS: Irritable bowel syndrome. N Engl J Med 1993, 329:194045.[PubMed][Full Text]

Maxwell, PR, Mendall, MA, & Kumar, D: Irritable bowel syndrome. Lancet 1997, 350:169195.[PubMed][Full Text]

American Gastroenterological Association Medical Position Statement.: Irritable Bowel Syndrome. Gastroenterology 1997, 112:21182137.[PubMed]

Manning, AP, Thomson, P, Heaton, KW, et al. : Toward positive diagnosis of the irritable bowel BMJ 1978, ii:653654.

Talley, NJ, Phillips, SF, Melton, LJ, III, et al. : Diagnostic value of the Manning criteria in irritable bowel syndrome Gut 1990, 31:7781.[PubMed]

Vanner, SJ, Depew, WT, Paterson, WG, et al. : Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome Am J Gastroenterol 1999, 94:29127.[PubMed][Full Text]

Beck, E & Hurwitz, B: Irritable bowel syndrome Occas Pap R Coll Gen Pract 1992, 58:3235.[PubMed]

Everhart, JE & Renault, PF: Irritable bowel syndrome in office-based practice in the United States. Gastroenterology 1991, 100:9981005.[PubMed]

Harvey, RF, Salih, SY, & Read, AE: Organic and functional disorders in 2000 gastroenterology outpatients Lancet 1983, i:632634.[PubMed]

Thompson, WG: Irritable bowel syndrome: a management strategy. Bailliere's Clin Gastroenterology 1999, Pages:453460.

Melton, LJ, III: History of the Rochester Epidemiology Project. Mayo Clin Proc 1996, 71:266274.[PubMed]

Kurland, LT & Molgaard, CA: The patient record in epidemiology. Scientific American 1981, 245:5463.[PubMed]

Mark, DH: Race and the Limits of Administrative Data (editorial) JAMA 2001, 285:33738.[PubMed][Full Text]

Yawn, BP, Yawn, RA, Geier, GR, et al. : The impact of requiring patient authorization for use of data in medical records research. J Fam Pract 1998, 47:361365.[PubMed]

Shaneyfelt, TM, Mayo-Smith, MF, & Rothwangle J, J: Are Guidelines Following Guidelines? The Methodological Quality of Clinical Practice Guidelines in the Peer-Reviewed Medical Literature. JAMA 1999, 281:19001905.[PubMed][Full Text]

Harvey, RF, Mauad, EC, & Brown, AM: Prognosis in the irritable bowel syndrome: a 5-year prospective study. Lancet 1987, i:963965.[PubMed]

Suarez-Almazor, ME, Belseck, E, Russell, AS, & Mackel, JV: Use of lumbar radiographs for the early diagnosis of low back pain. Proposed guidelines would increase utilization. JAMA 1997, 277:17826.[PubMed]

Thompson, WG, Heaton, KW, Smyth, GT, et al. : Irritable bowel syndrome in general practice: prevalence, characteristics, and referral. Gut 2000, 46:7882.[PubMed][Full Text]

U.S. Preventive Services Task Force.: Guide to Clinical Preventive Services 2nd ed. Alexandria, VA: International Medical Publishing 1996, xxlii, 519:521529.

Helm, JF & Sandler, RS: Colorectal cancer screening. Medical Clinics of North America 1999, 83:140322.[PubMed]

Bertram S, S, Kurland, M, Lydick, E, Locke, GR, III, & Yawn, BP: The Patient's Perspective of Irritable Bowel Syndrome. JFP 2001, 50:521525.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=59674

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Contributions of suggestion, desire, and expectation to placebo effects in IBS patients new
      #20914 - 09/16/03 03:28 PM
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Contributions of suggestion, desire, and expectation to placebo effects in irritable bowel syndrome patients

Lene Vase a, Michael E. Robinson b * merobin@uf1.edu , G. Nicholas Verne c and Donald D. Price d,e

PAIN®, Vol. 105 (1-2) (2003) pp. 17-25
© 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
PII: S0304-3959(03)00073-3

Abstract
In order to investigate external factors that may influence the magnitude of placebo analgesia as well as psychological factors that mediate placebo analgesia, 13 irritable bowl syndrome (IBS) patients rated evoked rectal distension and cutaneous heat pain under the conditions of natural history (NH), rectal placebo (RP), rectal nocebo (RN), rectal lidocaine (RL) and oral lidocaine (OL). Patients were given verbal suggestions for pain relief and rated expected pain levels and desire for pain relief for both evoked visceral and cutaneous pain, respectively. Large reductions in pain intensity and pain unpleasantness ratings were found in the RP, RL and OL condition as compared to the natural history condition, whereas no significant difference in pain reduction between the three treatment conditions was found. Ratings during RN and NH were not statistically different. Compared to a previous study, which shows that rectal lidocaine reverses visceral and cutaneous hyperalgesia, these results suggest that adding a verbal suggestion for pain relief can increase the magnitude of placebo analgesia to that of an active agent. Since IBS patients rate these stimuli as much higher than do normal control subjects and since placebo effects were very large, they probably reflect anti-hyperalgesic mechanisms to a major extent. Expected pain levels and desire for pain relief accounted for large amounts of the variance in visceral pain intensity in the RP, RL, and OL condition (up to 81%), and for lower amounts of the variance in cutaneous pain intensity. Hence, the combination of expected pain levels and desire for pain relief may offer an alternative means of assessing the contribution of placebo factors during analgesia.

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Constipation and its management new
      #20917 - 09/16/03 03:41 PM
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Constipation and its management

BMJ 2003;327:459-460 (30 August)

Options go beyond laxatives and include behavioural treatment as well as new drugs

Although slow to emerge, major advances have occurred in understanding the causes and management of constipation. It now receives the attention deserved of a symptom that affects a quarter of the population at some time. Most important is the recognition that different pathophysiological processes can result in the final common symptoms of decreased bowel frequency or impaired rectal evacuation. Different clinical syndromes require different therapeutic approaches.

Bowel frequency is influenced by several factors including intake of dietary fibre, emotional make up, and psychological morbidity. Introspective individuals have a lower bowel frequency and produce less stool than extroverts. Infrequent bowel actions in the absence of symptoms can be regarded as part of the normal spectrum of bowel frequency. Low bowel frequency is more common in women.

Controlled cross sectional studies have shown that psychological morbidity is commonly associated with severe constipation.1 In some patients it is the key causative factor. Other factors include childhood problems such as sexual or physical abuse, loss of a parent through death or separation, or disturbed toileting behaviour. Underlying depression is another cause. For some the gut is their "outlet valve" for the normal stresses of living. The pathways between brain and gut that link emotions to bowel function have been largely characterised and shown to involve cerebral corticotrophin releasing factor and efferent autonomic pathways. Although psychological factors should be sought at initial assessment, in some patients they are less important. Not all patients have a psychological "skeleton."

The distinction as to whether a patient has a normal diameter or dilated large bowel is of practical importance. Severe intractable constipation with resistance to laxatives in the presence of an apparently normal (non-dilated) colon is seen most commonly in women of reproductive age. When transit is slow the key physiological abnormality is diminished colonic propulsive activity. There are associated changes in upper gut transit and sensory function. Although neural abnormalities can be shown in the colon, such as changes in the pacemaker cells of Cajal, these may be secondary to chronic ingestion of laxatives. The reversibility of impaired function by behavioural treatment2 implies that neural changes are often secondary.

Constipation is now recognised as an important symptom in a range of patients' groups with other primary pathology. Almost all patients with spinal injury experience constipation; lack of bowel control is one of their most distressing symptoms.3 It is also common in patients with multiple sclerosis. Patients with mild disease can be helped by behavioural treatment, which shows that in patients with neurological disease bowel dysfunction often has a reversible component.

Patients with a dilated bowel constitute a different clinical problem. Those with a dilated rectum and faecal impaction—so called idiopathic megarectum—are usually teenagers or young adults of either sex.4 They have often soiled since childhood. In some the problem has a behavioural basis, whereas in others there may be subtle neuromuscular abnormalities of the gut. Constipation with faecal impaction is also seen in elderly patients, especially those in care. Poor general health, impaired mobility, inadequate toilet facilities, and drugs may all contribute. Patients with dilation throughout the gut are rare and they usually have a discrete abnormality of enteric nerves or muscle, leading to impaired propulsion. In such patients with chronic intestinal pseudo-obstruction, constipation is only part of a complex mix of symptoms including pain, vomiting, and nutritional impairment.

For people with mild longstanding constipation investigations are not required, and dietary management is usually sufficient to relieve symptoms. When chronic constipation is more severe, detailed consideration of likely causes and other treatments is warranted.

Many patients with mild constipation can be managed with simple bulking agents or laxatives. After thousands of years of empirical use of such agents, prescribing can now be based on evidence from controlled trials. In elderly patients with resistant constipation, a stimulant such as senna, possibly combined with a bulking agent, is more effective and cheaper than lactulose.5 Polyethylene glycol based laxatives have recently been shown to provide long term benefit in patients with idiopathic constipation and faecal impaction.

For many patients, however, laxatives do not provide sustained relief of symptoms. In addition increasing dietary fibre has been shown to worsen symptoms in many patients by causing increased bloating without an improvement in bowel function.6

Behaviour therapy, including biofeedback (teaching the patient to normalise pelvic floor function while watching real time feedback about sphincter function) and habit training, has become established as the most effective form of treatment for patients with either slow transit or impaired evacuation, when traditional treatments have failed.2 Behavioural treatments comprise a "package" of care, including exercises focused on the gut, help in coming off laxatives, and psychological support. Such treatment has been shown to improve symptoms, transit time through the gut, psychological wellbeing, and quality of life, as well as leading to reduced use of laxatives.2 7 8 It has been shown to be effective in patients with slow gut transit, impaired rectal emptying, constipation after childbirth or pelvic surgery such as hysterectomy, solitary rectal ulcer from the trauma of straining, rectocele (anterior rectal wall bulge from repeated straining), and in patients with mild degrees of neurological disease such as multiple sclerosis. Long term follow up of cohorts of patients has shown that for most of these conditions about two thirds of patients are helped.7

For those who do not benefit from simple bulking agents, laxatives, or behavioural treatments, new pharmacological approaches may offer help. The neurochemical basis for peristalsis is now better appreciated and known to involve 5-hydroxytryptamine4 (serotonin type 4) receptors.9 In contrast to laxatives, which work via a luminal mechanism, the newly developed 5-hydroxytryptamine4 agonists are absorbed in the small intestine and induce peristalsis through a systemic mechanism. Tegaserod and prucalopride are two such drugs; the former is licensed in the United States but not in the United Kingdom or most of Europe. The latter is still under development.

Patients with idiopathic megarectum should have their bowel emptied completely before titrating an osmotic laxative.4 Such a laxative may be required in the long term, although behavioural treatment seems also to help some of these patients.

Surgery was commonly used in the past to treat patients with intractable constipation, such as young women with severe idiopathic constipation. The variable and unpredictable results of colectomy,10 together with the success of conservative treatments, has made this necessary only rarely. When surgery is being considered, new techniques, such as sacral nerve stimulation, may modify bowel neuromuscular control while avoiding irreversible bowel resection.11 This treatment involves chronic neural stimulation via percutaneously placed fine sacral electrodes.

The paradigm of a drug or operation for every condition needs broadening when treating constipation. When simple treatments have failed and specialist treatment is sought, broadly based multidisciplinary teams need to be able to offer more than laxatives and surgery. It might be argued that such a trivial symptom is not deserving of such use of resources. However, patients with functional gut symptoms have impaired quality of life and consume a large amount of healthcare resources. While relieving symptoms, effective treatments are also likely to be cost effective.

Michael A Kamm, professor of gastroenterology

St Mark's Hospital, Harrow HA1 3UJ (kamm@imperial.ac.uk)




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Competing interests: MK has been an adviser to Abbott, Johnson and Johnson, Medtronic, and Novartis.
References


Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological morbidity in women with idiopathic constipation. Am J Gastroenterol 2000;95: 2852-7.[CrossRef][ISI][Medline]
Chiotakakou-Faliakou E, Kamm MA, Roy AJ, Storrie JB, Turner IC. Biofeedback provides long term benefit for patients with intractable, slow and normal transit constipation. Gut 1998;42: 517-21.[Abstract/Free Full Text]
Glickman S, Kamm MA. Bowel dysfunction in spinal cord injury patients. Lancet 1996;347: 1651-3.[ISI][Medline]
Gattuso JM, Kamm MA. Clinical features of idiopathic megarectum and idiopathic megacolon. Gut 1997;41: 93-9.[Abstract/Free Full Text]
Passmore AP, Wilson-Davies K, Stoker C, Scott ME. Chronic constipation in long stay elderly patients: a comparison of lactulose and a senna-fibre combination. BMJ 1993;307: 769-71.[ISI][Medline]
Francis CY, Whorwell PJ. Bran and irritable bowel syndrome: time for reappraisal. Lancet 1994;344: 39-40.[ISI][Medline]
Emmanuel AV, Kamm MA. Response to a behavioural treatment, biofeedback, in constipated patients is associated with improved gut transit and autonomic innervation. Gut 2001;49: 214-9.[Abstract/Free Full Text]
Mason HJ, Serrano-Ikkos E, Kamm MA. Psychological state and quality of life in patients treated by behavioral treatment (biofeedback) for intractable constipation. Am J Gastroenterol 2002;97: 3154-9.[CrossRef][ISI][Medline]
Grider JR, Foxx-Orenstein AE, Jin JG. 5-Hydroxytryptamine4 receptor agonists initiate the peristaltic reflex in human, rat, and guinea pig intestine. Gastroenterology 1998;115: 370-80.[ISI][Medline]
Kamm MA, Hawley PR, Lennard-Jones JE. Outcome of colectomy for severe idiopathic constipation. Gut 1988;29: 969-73.[Abstract]
Kenefick NJ, Nicholls RJ, Cohen RG, Kamm MA. Permanent sacral nerve stimulation for treatment of idiopathic constipation. Br J Surg 2002;89: 882-8.[CrossRef][ISI][Medline]

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Association Between Pain Episodes & High Amplitude Pressure Waves in IBS new
      #20921 - 09/16/03 03:54 PM
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Gastroenterology, August 2003 Journal Scan

From
The American Journal of Gastroenterology
August 2003 (Volume 98, Number 8)

Association Between Pain Episodes and High Amplitude Propagated Pressure Waves in Patients With Irritable Bowel Syndrome

Clemens CH, Samsom M, Roelofs JM, van Berge Henegouwen GP, Smout AJ

The American Journal of Gastroenterology. 2003;98(8):1838-1843

The underlying pathogenesis of irritable bowel syndrome (IBS) appears to involve both increased visceral sensitivity and altered colonic motility. In healthy individuals, colonic motility patterns known as high amplitude propagated pressure waves (HAPPWs) occur approximately 6 times daily. These waves are believed to be the driving force in the colon that generates transit of colonic content over long distances; they appear essential for maintenance of physiologic bowel activity.

In the normal, healthy individual, HAPPWs occur more often in the postprandial period or after awakening, and infrequently occur at night. However, as might be expected, in patients with IBS with diarrhea, there is generally a trend toward an increased number of HAPPWs, whereas in those patients with IBS with constipation, a decreased number of propagated contractions are observed.

Recently, an association was demonstrated between the occurrence of HAPPWs and abdominal cramps in patients with IBS, but these propagated waves were induced by cholecystokinin and a high-calorie meal in a laboratory setting. So, under physiologic conditions, do patients with IBS perceive HAPPWs as painful?

To address this question and determine the temporal relationship between occurrence of pain and HAPPWs, Clemens and colleagues recorded abdominal pain and HAPPWs during a prolonged, fully ambulatory manometric study of the left colon in patients with IBS with the predominant nonconstipation pattern (n = 11) vs controls (n = 10). The link between episodes of abdominal pain and occurrence of HAPPWs was assessed by using a modification of the symptom association probability (SAP). An SAP > 95% was considered to indicate that the observed association did not occur by chance.

This represents the first study using techniques of objective analysis to demonstrate an association between HAPPWs and pain in a subset of patients with IBS studied under physiologic conditions. The study authors found that for 4 of 7 patients reporting pain on day 2, the SAP was > 95%. HAPPWs that were associated with episodes of abdominal pain originated at a more proximal level (P = .026) and occurred earlier (P = .007) than HAPPWs that were not associated with pain. The duration of a pain period was correlated with the number of pain-related HAPPWs occurring in that period (r = 0.906, P = .013). Two of the 10 control patients experienced pain, but these pain episodes were not related to occurrence of HAPPWs.

As these investigators pointed out, it was interesting to note that HAPPWs related to pain (in patients with SAP>95%) did not appear to show any major differences from those not associated with pain, except for occurring more proximally in the left colon and earlier in the day. Therefore, it was suggested that pain induced by a stimulus that does not normally produce pain, rather than hyperalgesia, may actually be important in pain generation in patients with IBS with SAP > 95%.


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Infectious Gastroenteritis Linked to Irritable Bowel Syndrome new
      #22116 - 09/30/03 02:27 PM
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Infectious Gastroenteritis Linked to Irritable Bowel Syndrome


Laurie Barclay, MD


Sept. 25, 2003 — Infectious gastroenteritis is associated with the development of irritable bowel syndrome (IBS), according to the results of a prospective, community-based study published in the September issue of the American Journal of Gastroenterology.

"IBS might develop after gastroenteritis," write Sally D. Parry, from the University of Newcastle in the U.K., and colleagues. "Most previous studies of this relationship have been uncontrolled, and little is known regarding other functional gastrointestinal disorders (FGIDs) after gastroenteritis."

In this case-control study, cases had proven bacterial gastroenteritis, and control patients were community-based. Self-administered Rome II modular questionnaires diagnosed FGIDs at baseline, three, and six months. Subjects with prior FGIDs were excluded from the study. Of 500 identified cases, 265 patients (53%) consented to take part in the study, as did 705 control patients, of whom 219 were eligible. Six-month questionnaire data were available for 108 cases and 206 controls.

The primary end point, defined as the presence of one of the three specific FGIDs at six months, occurred in significantly more cases than in controls (27 [25%] vs. 6 [2.9%]; OR = 11.11; 95% confidence interval [CI], 4.42 - 27.92). At three months, 29% of cases and 2.9% of controls had an FGID.

Although functional dyspepsia was uncommon in both case and control patients, IBS was diagnosed in 18 cases (16.7%) and four controls (1.9%; OR = 10.1; 95% CI, 3.32 - 30.69), and functional diarrhea was diagnosed in six cases (5.6%) and in no control patients.

Study limitations include very low participation rate, exclusion of a significant proportion of potential subjects because of a pre-existing FGID, fairly high drop-out rate, and lack of endoscopic data.

"Symptoms consistent with IBS and functional diarrhea occur more frequently in people after bacterial gastroenteritis compared with controls, even after careful exclusion of people with pre-existing FGIDs," the authors write. "The proportion of patients with an FGID was maintained between 3 and 6 months, which suggests that the symptoms are likely to be long-lasting. Clearly, more needs to be known about the natural history of FGIDs after bacterial gastroenteritis, and the field of postinfectious IBS is rich in possibilities for discovering more about the pathoetiology of these common gut disorders."

Northumbria NHS Healthcare Trust funded this study.

Am J Gastroenterol. 2003;98 (9):1970-1975

Reviewed by Gary D. Vogin, MD

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Three in Four People With IBS Also Have Functional Dyspepsia new
      #23512 - 10/15/03 03:28 PM
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Three in Four People With IBS Also Have Functional Dyspepsia


Charlene Laino


Oct. 14, 2003 (Baltimore) — More patients than thought may suffer from multiple functional gastrointestinal disorders, according to researchers who found that nearly three quarters of people who suffer from irritable bowel syndrome (IBS) also have functional dyspepsia.

"Physicians need to realize that many patients seeking care for gastrointestinal symptoms are likely to have more than one clinical disorder," said lead researcher Ashok K. Tuteja, MD, from the Department of Gastroenterology at the University of Utah in Salt Lake City.

Dr. Tuteja presented the findings here on Monday at the 68th annual scientific meeting of the American College of Gastroenterology. About 1 in 10 American suffer from IBS and even more from dyspepsia, he said.

It has been suggested that dyspepsia and IBS represent the same disease entity — the so-called irritable gut, Dr. Tuteja said. As a result, he and colleagues undertook a study to determine how common each syndrome is and how much the two overlap.

The researchers followed 723 people who filled out questionnaires asking about their upper and lower gastrointestinal symptoms. Their ages ranged from 24 to 77 years (median, 47 years).

IBS was defined as having continuous or recurrent symptoms for three months or more in the previous 12 months. Symptoms included abdominal pain or discomfort that is relieved with defecation or associated with changes in stool, hard or loose stool, straining or urgency, and bloating.

Functional dyspepsia was defined as having upper abdominal pain or discomfort six months or more in the previous year.

Nearly 15% of the patients reported symptoms of dyspepsia: 6.2% reported ulcer-like dyspepsia, 6.1% reported dysmotility-like dyspepsia, and 9.4% reported reflux dyspepsia. Also, 8.9% of patients had IBS symptoms, and 6.2% reported both dyspepsia and IBS.

Of the patients with IBS, 70% also had functional dyspepsia and of subjects with dyspepsia, 43% also had IBS, the study showed.

The association between the two syndromes was much greater than that expected by chance (kappa = 0.48), Dr. Tuteja reported.

Both IBS and the overlap syndrome were more common in women, but these differences were not statistically significant (P > .27). There was no association between any of the disorders and alcohol or aspirin use (P > .19), the study showed.

The people who reported symptoms of both disorders or symptoms of IBS were much more likely to consult a physician about their problems than those with dyspepsia alone, Dr. Tuteja reported. Thirty-three percent of those with both dyspepsia and IBS symptoms visited a physician in the previous year compared with 17% of patients with dyspepsia alone and 31% with IBS alone.

Richard G. Locke, III, MD, associate professor of medicine at the Mayo Clinic in Rochester, Minnesota, said that physicians are increasingly recognizing that many patients will have symptoms of more than one gastric disorder.

The question, he said, is "should we be rearranging the deck? Are people who have IBS and dyspepsia somehow different than those who have only one or the other?"

As drugs targeting the molecular aberrations that cause gastric disorders are developed, knowing the answer to that question will become increasingly important, he said.

Kevin W. Olden, MD, associate professor of medicine in the Division of Gastroenterology at the Mayo Clinic in Scottsdale, Arizona, agreed. "Each person has different molecular changes. The patient with both IBS and dyspepsia will have a different molecular change than the person with just IBS or dyspepsia."

Understanding these molecular changes is the wave of the future, he said.

ACG 68th Annual Scientific Meeting: Abstract 301. Presented Oct. 13, 2003.

Reviewed by Gary D. Vogin, MD

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Molecular Alterations In Patients With Irritable Bowel Syndrome new
      #24043 - 10/20/03 03:46 PM
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Date: 2003-10-15

Researchers Identify Molecular Alterations In Patients With Irritable Bowel Syndrome

BALTIMORE, Md. – Novel research shows that alterations in serotonin signaling in the gastrointestinal (GI) tract are present in patients with Irritable Bowel Syndrome (IBS). These data shed light on the alterations in gut motility, secretion, sensation, as well as the clinical manifestations of IBS, which include abdominal discomfort, pain, bloating, constipation and/or diarrhea.

The study findings were presented today by two lead investigators from the University of Vermont, Peter Moses, M.D., Associate Professor of Medicine and Director of Clinical Research in the Digestive Diseases, and Gary Mawe, Ph.D., Professor of Anatomy and Neurobiology, in an oral presentation during the plenary session at the 68th Annual Scientific Meeting of the American College of Gastroenterology in Baltimore.

"Serotonin is a critical signaling molecule necessary for normal gut function – when released, it causes gut motility and secretion, and triggers signals to the brain and spinal cord," said Moses. "Our finding that key elements of serotonin signaling are changed in IBS lends credibility to the notion that IBS is not simply a psychological or social disorder as was once thought, but instead due to altered gut biochemistry and interactions between the gut and the brain."

Serotonin (5-HT) is a naturally occurring neurotransmitter and signaling molecule. Ninety-five percent of all serotonin is localized in the GI tract where it plays a key role in the motor, sensory and secretory functions of the gut. For some time, scientists have suspected that alterations in serotonin may contribute to abnormal conditions in the GI tract.

"Now we have a perspective on molecular changes in the intestines of individuals with IBS that we did not have before," said Mawe. "We identified a significant decrease in the serotonin transporter in cells that form the inner lining of the bowel – the same serotonin transporter that is located in cells in the brain. In the gut, this transporter acts as a sponge to remove serotonin once it is released, and therefore stops its actions. Because the transporter is diminished in IBS, serotonin stays around longer, and this can lead to changes in motility, secretion and sensitivity."

The study examined tissue obtained from 43 healthy controls and 32 patients with IBS and 22 patients with inflammatory bowel disease (IBD). IBS patients were defined strictly using ROME II criteria. Each biopsy was evaluated by five parameters: immunohistochemical staining, histological assessment, serotonin content, serotonin release and the measurement of mRNA encoding. The study also examined the molecular components of serotonin signaling, including the serotonin re-uptake system.

Specifically, the investigators measured serotonin content, the endocrine cell number, serotonin release and presence of serotonin transporters (SERT). Serotonin transporters are regulatory molecules that control the activity of serotonin within nerve endings in the GI tract to coordinate motility, visceral sensitivity and intestinal secretion.

In patients with IBS, the study found a significant decrease in serotonin content and significantly higher endocrine cell (EC) populations in patients with IBS compared to controls, while the release of serotonin from EC cells was not significantly different. In terms of the way the body inactivates serotonin signaling, or the serotonin re-uptake system, SERT mRNA and SERT immunoreactivity were markedly reduced. This reduction led to a decrease in the capacity to remove serotonin from intracellular space once it was released, thus increasing serotonin availability.


The study was sponsored through a research grant from Novartis Pharmaceuticals, maker of Zelnorm® (tegaserod maleate) for IBS-C. In addition to Moses and Mawe, members of the study team included Matthew Coates, Christine Mahoney, David Linden, Joanna Sampson and Eric Newton of the University of Vermont; Michael Gershon and Jason Chen of the Department of Anatomy and Cell Biology at Columbia University; Keith Sharkey of the Department of Physiology and Biophysics at the University of Calgary, and Michael Crowell of the Clinical Research department at Novartis Pharmaceuticals.

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Mind-Body Technique Eases Kids' Gut Pain new
      #24955 - 10/30/03 11:17 AM
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Mind-Body Technique Eases Kids' Gut Pain

Kids Have Fewer Days of Abdominal Pain When Using Relaxation Technique

By Jeanie Lerche Davis

WebMD Medical News
Reviewed By Brunilda Nazario, MD

Aug. 5, 2003 -- For kids with chronic abdominal pain, relaxation techniques can help them cope.


Some 20% of school-age children suffer from recurrent abdominal pain -- and for 10% of them, there is a real problem in the gut. But for the rest, the pain is often unexplained -- yet persists, sometimes into adulthood.


It's a big problem that upsets their quality of life. "Not only are these children in pain, they are missing school, making frequent doctor visits and may suffer from anxiety and depression," says lead researcher Thomas M. Ball, MD, MPH, professor of clinical pediatrics at the University of Arizona, in a news release.


His report is published in the July/August issue of Clinical Pediatrics.


In it, he describes using guided imagery therapy -- which combines relaxation, imagery, and hypnosis -- to help children gain control over their pain. Other studies have shown that the technique helps kids with other types of pain, says Ball.


The technique affects the autonomic nervous system -- the nerves that are involved in involuntary functions in the body, such as digestion. In essence, it taps the body's own healing power, he says.


Each child was trained in relaxation and guided imagery during four weekly sessions. Each filled out a daily "pain diary" three times a day to track the effectiveness of the technique.


During the month of training, the children had 36% fewer days with pain.
In the second month, "pain days" decreased an additional 50%.
Total decrease in pain days was 67% less within two months of starting therapy.
Of the 10 children, seven showed improvement by the end of therapy and nine showed results one month later. Only one child showed no improvement.

The intensity of abdominal pain did not change during the period, but there were far fewer pain days, Ball reports.

SOURCES: Clinical Pediatrics, July/August 2003.

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Travelers' Diarrhoea Can Trigger Irritable Bowel new
      #25510 - 11/04/03 03:21 PM
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Travelers' Diarrhoea Can Trigger Irritable Bowel
By M.M. Pennell

SAN DIEGO, CA -- October 22, 2003 -- About 10% of people who report cases of travelers' diarrhoea are at risk for developing chronic gastrointestinal disorders, including irritable bowel syndrome (IBS).

This news comes as a result of a study presented October 11th at the 41st Annual Meeting of the Infectious Diseases Society of America.

Lead investigator, Pablo Okhuysen, MD, associate professor of medicine, Division of Infectious Diseases, University of Texas Health Sciences Center, Houston, United States, prospectively followed 146 students who traveled to Mexico. Said Dr. Okhuysen, "Having diarrhoea while they were in Mexico -- and having more than one episode while traveling -- correlated with the likelihood of developing IBS. This confirms that there is probably a relationship between infectious gastroenteritis and IBS."

Dr. Okhuysen said that many IBS patients report onset of chronic symptoms after an initial attack of gastroenteritis. Published studies suggest that 7% to 33% of patients with bacterial gastroenteritis develop post-infection IBS.

Dr. Okhuysen and colleagues recruited 146 students who were followed prospectively for 4 weeks after arrival in Mexico. Students who developed diarrhoea were assessed for the presence of enteric pathogens. Assessment of chronic gastrointestinal symptoms was performed by questionnaire, which was mailed to the students 6 months after their return to the United States. Symptoms were evaluated according to the Rome II criteria to determine the presence of post-infection IBS.

Sixty-two students developed diarrhoea while traveling in Mexico, and a total of 98 students completed the 6-month follow-up, Dr. Okhuysen said.

Before travel, only 1 student met the criteria for IBS, but, after travel, seven students met IBS criteria, said Dr. Okhuysen. Additionally, at the 6-month follow-up 17 students reported chronic abdominal pain compared to five students before the trip, and 17 reported chronic diarrhoea, defined as diarrhea lasting 2 weeks or longer, while one student reported chronic diarrhoea before traveling to Mexico, he said.

All students who reported post-travel IBS experienced diarrhoea while in Mexico, while none of the students who were asymptomatic while in Mexico met the definition of IBS 6 months after travel. Dr. Okhuysen said the risk of post-travel IBS or post-travel gastrointestinal symptoms correlated with the severity of traveler's diarrhoea while in Mexico. Typically students who reported chronic gastrointestinal complaints experienced at least two episodes of diarrhoea while traveling, Dr. Okhuysen noted.


[Study Title: Frequency and Characteristics of Post Infectious Irritable Bowel Syndrome in Travelers to Mexico: Abstract 876]

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Doctors unmoved by bowel misery new
      #27736 - 11/18/03 03:28 PM
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BBC News World Edition


The distress and discomfort of irritable bowel syndrome (IBS) earns little sympathy from many doctors, according to a survey.

The majority of US doctors interviewed believed that IBS, while unpleasant, was not a serious medical condition, while four out of five admitted that they did not follow established treatment guidelines.

Nearly a third of the doctors said that IBS was mainly a psychological problems, instead of a genuine physical complaint.

Even in the UK, support groups say that some doctors still have little time for patients complaining of IBS symptoms.

The condition, which affects thousands of women and men in the UK, is characterized by chronic abdominal pain and irregular bowel movements.

It can leave sufferers afraid to leave the house in case they urgently need to go to the toilet.

The root causes of IBS are still unknown, although attacks are thought to be made worse or triggered by stress.

It is suggested that the nerves lining the lower bowel are more sensitive than normal to bowel contractions and the passage of gas and fluid, leading to painful spasms.

Some patients have found that eating certain foods, such as dairy products or fatty foods, makes their condition worse.

The survey of three thousand sufferers and ordinary people found that IBS sufferers took many more days off work through sickness - 13.4 compared to 4.9 days.

Almost half the IBS patients said the condition limited their social life, holidays and travel.

Two out of five reported pain that was intolerable without painkillers, with nearly 70% saying they had experienced pain for more than three months in the past year.

Penny Nunn, a development worker at the UK support group IBS Network, said: "Some UK doctors are sympathetic and some are not. It's certainly a difficult condition to treat.

"Many of the women who come to us have already been through the mill as regards GPs, gastroenterologists and the like, and they are looking for a cure.

"But there are no quick fixes."

Doctors are currently working on guidelines for both patients and GPs on how to treat IBS.

http://news.bbc.co.uk/1/hi/health/459884.stm

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Outlook affects bowel disorder patients new
      #27737 - 11/18/03 03:30 PM
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BBC News World Edition

Outlook affects bowel disorder patients

People's perception of their bowel disorder affects how they cope with the condition, researchers have found.
If they believe their Irritable Bowel Syndrome (IBS) is due to an external factor, such as a virus and that it can be controlled, they cope well.

But if they believe it is caused by psychological factors, they are less likely to cope with IBS.

Researchers from the University of Kent interviewed over 200 patients with IBS.

They were asked about their symptoms and what they believed about the causes and the severity of the disorder.

Patients were also asked to what extent people believed their IBS can be controlled or cured, how they coped with it and how anxious or depressed they were.

It was found that those who believed it could be controlled or cured were likely to accept their IBS and have a better quality of life.

But those who thought IBS was a very serious illness with potentially serious consequences suffered more anxiety and depression.

They also had a lower quality of life.

But Drs Claire and Derek Rutter, who carried out the research, said these people were more likely to try to avoid thinking or dealing with their IBS, which meant they were likely to fare less well.

They said therapy may help IBS patients to feel better.

Writing in the British Journal of Health Psychology, they said: "The effectiveness of psychological therapy for IBS patients may improve if therapists challenge patients' perceptions of serious consequences and may offer alternatives to behavioural disengagement and venting emotions.

"Therapists might also try to increase control beliefs and acceptance of the illness."

IBS varies between patients, but it usually includes cramping discomfort, a feeling of fullness or bloating, constipation and diarrhoea.

Women are affected more than men.

Sufferers often desperately need to go to the toilet with little warning, which severely limits their lifestyle.

No-one knows what causes the condition, although it is suggested that stress can make it worse.

Most people are advised to try to manage the condition by changing their diet and trying to reduce stress levels, as well as taking other medication.

http://news.bbc.co.uk/1/hi/health/2385631.stm


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Familial aggregation of irritable bowel syndrome new
      #29619 - 12/01/03 05:49 PM
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Gut 2003;52:1703-1707
© 2003 by BMJ Publishing Group Ltd & British Society of Gastroenterology

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FUNCTIONAL BOWEL DISEASE

Familial aggregation of irritable bowel syndrome: a prospective study
J S Kalantar1, G R Locke, III2, A R Zinsmeister3, C M Beighley3 and N J Talley4
1 Department of Medicine, University of Sydney, Australia
2 Division of Gastroenterology and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
3 Division of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
4 Division of Gastroenterology and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN, USA, and Department of Medicine, University of Sydney, Australia


Correspondence to:
Professor N J Talley
Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA; talley.nicholas@mayo.edu


ABSTRACT
Background: Patients with irritable bowel syndrome (IBS) often report family members with similar symptoms, but family studies are lacking. We hypothesised that if there is familial aggregation, there would be an increased frequency of IBS in first degree relatives of IBS patients compared with relatives of controls (the patient's spouse).

Methods: A valid self report bowel disease questionnaire (BDQ) that recorded symptoms, the somatic symptom checklist (a measure of somatisation), and a family information form (FIF) to collect the names and addresses of all first degree relatives were mailed to two groups of patients and their spouses (patients attending an IBS educational programme and residents of Olmsted County, Minnesota, who had been coded as IBS on a database). A BDQ was then mailed to all first degree relatives of subjects identified from the FIF. IBS diagnosis in the relatives was based on the Manning criteria.

Results: The BDQ was sent to a total of 355 eligible relatives; 71% responded (73% relatives of patients, 67% relatives of spouses). Relatives were comparable in mean age, sex distribution, and somatisation score. IBS prevalence was 17% in patients' relatives versus 7% in spouses' relatives (odds ratio adjusted for age and sex 2.7 (95% confidence interval (CI) 1.2, 6.3)). When also adjusted for somatisation score, the odds ratio was reduced to 2.5 (95% CI 0.9, 6.7).

Conclusions: Familial aggregation of IBS occurs, supporting a genetic or intrafamilial environment component, but this may be explained in part by familial aggregation of somatisation.

http://gut.bmjjournals.com/cgi/content/abstract/52/12/1703

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Overlapping upper and lower GI symptoms in IBS patients with constipation or diarrhea new
      #29620 - 12/01/03 05:51 PM
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Volume 98 , Issue 11 , Pages 2454-2459


Overlapping upper and lower gastrointestinal symptoms in irritable bowel syndrome patients with constipation or diarrhea

Nicholas J. Talley b * , Eslie Helen Dennis a , V. Ann Schettler-Duncan a , Brian E. Lacy c , Kevin W. Olden d and Michael D. Crowell c

Received: 1/16/2003. Accepted: 5/20/2003.



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Abstract

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.





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Affiliations:
a Mayo Foundation, Mayo Medical School, Rochester, Minnesota, USA. b Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. c Mayo Foundation and Medical School, Scottsdale, Arizona, USA. d Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA.


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Copyright
© 2003 Am. Coll. of Gastroenterology

http://www.medicinedirect.com/journal/journal/article?acronym=AMGAST&format=abstract&uid=PIIS0002927003007056

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Colonic Propulsive Impairment in Intractable Slow-Transit Constipation new
      #32155 - 12/16/03 12:03 PM
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Colonic Propulsive Impairment in Intractable Slow-Transit Constipation

Gabrio Bassotti, MD, PhD; Fabio Chistolini, MD; Francis Sietchiping Nzepa, MD; Antonio Morelli, MD


Arch Surg. 2003;138:1302-1304.
Vol. 138 No. 12, December 2003

Hypothesis:

Intractable constipation, especially of the slow-transit subtype, may represent several pathophysiologic entities with a common final symptomatic appearance. An overall impairment of colonic propulsive activity may represent a major disease mechanism.

Design: Case series.

Setting: Tertiary university hospital.

Subjects: Twenty-nine severely constipated patients with clinical and homogeneous features of slow-transit constipation that were unresponsive to conventional medical measures and 16 age-matched healthy volunteers.

Interventions: Twenty-four–hour manometric recordings obtained in patients and controls to assess high- and low-amplitude colonic propulsive activity.

Results: Compared with controls, patients showed heavily reduced high-amplitude propagated activity (average, <1 event per subject per day). No differences were found in low-amplitude propagated activity.

Conclusions: Patients with severe constipation that is refractory to medical treatment may display an important reduction of colonic forceful propulsive activity. This may justify a surgical approach, which may offer the best results in such patients. It is, however, important to obtain thorough physiologic documentation before such a drastic approach is considered. The residual low-amplitude propulsive activity might represent a partially compensatory mechanism in these patients. Studies in more homogeneous groups of such patients are needed.


From the Gastroenterolgy and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia Medical School, Perugia, Italy.

http://archsurg.ama-assn.org/cgi/content/abstract/138/12/1302



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Abnormal Colonic Propagated Activity in Patients with Constipation new
      #32160 - 12/16/03 12:07 PM
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Abnormal Colonic Propagated Activity in Patients with Slow Transit Constipation and Constipation-Predominant Irritable Bowel Syndrome

Gabrio Bassotti, Fabio Chistolini, Gabriele Marinozzi, Antonio Morelli

Gastroenterology and Hepatology Section, Department of Clinical and Experimental Medicine, University of Perugia, Perugia, Italy


Digestion 2003;68:178-183 (DOI: 10.1159/000075554)


Background: The pathophysiological basis of constipation is still unclear, and the role of colonic dysfunction is debated, especially in irritable bowel syndrome. Objective data are quite scarce, especially concerning colonic propulsive activity. Aims: To evaluate high- and low-amplitude colonic propulsive activity in constipated patients (slow-transit type and irritable bowel syndrome) in comparison with normal controls. Patients and Methods: Forty-five constipated patients (35 with slow-transit constipation and 10 with constipation-predominant irritable bowel syndrome) were recruited, and their data compared to those of 18 healthy subjects. Twenty-four-hour colonic manometric recordings were obtained in the three groups of subjects, and data concerning high- and low-amplitude colonic propulsive activity were then compared. Results: High-amplitude propagated contractions were significantly (p < 0.05) decreased in patients with slow-transit constipation and constipation-predominant irritable bowel syndrome with respect to controls (1.5 ± 0.4, 3.7 ± 2, and 6 ± 1 events/subject/day, respectively). In slow-transit constipation, a significant decrease of contractions' amplitude was also observed. Concerning low-amplitude propagated contractions, patients with slow-transit constipation had significantly less events with respect to patients with constipation-predominant irritable bowel syndrome (46 ± 7 vs. 87.4 ± 19, p = 0.015); no differences were found between patients with slow-transit constipation and controls and between patients with constipation-predominant irritable bowel syndrome and controls. All three groups displayed a significant increase of low-amplitude propagated contractions after meals (6.3 ± 2 vs. 18.2 ± 5 for controls, p < 0.005; 6.4 ± 1.4 vs. 16.3 ± 2.4 for slow-transit constipation, p < 0.005; 10.5 ± 3.2 vs. 32.6 ± 7 for constipation-predominant irritable bowel syndrome, p = 0.001). Conclusions: Low-amplitude propagated contractions may represent an important physiologic motor event in constipated patients, reducing the severity of constipation in patients with irritable bowel syndrome and preserving a residual colonic propulsive activity in patients with slow-transit constipation.

Copyright © 2003 S. Karger AG, Basel

http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ProduktNr=223838&Ausgabe=229844&ArtikelNr=75554

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Faecal incontinence - Many treatment options now exist new
      #32168 - 12/16/03 12:17 PM
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BMJ 2003;327:1299-1300 (6 December), doi:10.1136/bmj.327.7427.1299


Faecal incontinence - Many treatment options now exist for this embarrassing condition

Faecal incontinence, not a glamorous area of medicine, has changed markedly in its recognition and management over the past 10 years. Patients and doctors can talk about it now as the taboo is disappearing. Pathophysiology is better understood, helped by advances in imaging. Treatments are improving as they move away from invasive sphincter surgery as an early step to the use of simple pharmacological treatments, behavioural techniques, injectable biomaterials, and, when necessary, minimally invasive surgery.

Faecal incontinence affects both sexes and all age groups. Approximately 2% of the adult population have it on a frequent basis.1 The commonest cause of faecal leakage is probably degeneration of the delicate smooth muscle of the internal anal sphincter—the muscle that maintains sphincter closure.2 The commonest cause in young women is obstetric anal sphincter damage. Most sphincter damage is occult; approximately a third of first vaginal deliveries result in endosonographically identifiable structural sphincter damage; about a third of these are associated with new bowel symptoms of faecal incontinence or urgency.3 Forceps delivery is the greatest risk factor; others are a large baby, occipito-posterior position, and a prolonged second stage of labour. The same risk factors apply to the 1% of vaginal deliveries complicated by a recognised third degree tear.4

Structural damage to the sphincter can also result from surgery. This may be an unavoidable consequence of necessary treatment such as in the care of an anal fistula. Or it may result from anal dilatation, an outmoded form of treatment for chronic fissure or constipation.

In elderly people, especially those in care, faecal impaction is a common cause of leakage. Many factors contribute to this process, including constipating medications and poor mobility.5 Children with faecal impaction leak stool. Others have impaired continence after correction of congenital anorectal abnormalities.

A complete history, examination for sphincter damage or faecal impaction, and correction of predisposing factors, can lead to successful treatment in many patients. If further investigation is required anal endosonography has become the standard means of imaging the anal sphincter, and is now available in most specialist centres.6 It enables identification of structural damage and degenerative disorders of the sphincter muscles. When sepsis involves the sphincter complex, such as in complex perianal fistulas or Crohn's disease, magnetic resonance imaging provides accurate information.

Factors contributing to continence include the integrity of the sphincter muscles, the force of bowel contraction, consistency of stools, and cognitive factors. Each of these can act as a suitable target for treatment. Most commonly a combination of treatments is useful. For example, for patients with urge faecal incontinence, learning to overcome a sense of panic, sustain contraction of the sphincter, and titrate loperamide can lead to marked improvement in the symptom sometimes even when there is structural damage to the sphincter.7

Drugs that diminish the force of bowel contractions and enhance absorption of luminal colonic water can transform bowel control and the ability to function socially. Loperamide is effective in patients with symptoms of either urgency or leakage. The wide therapeutic to toxic ratio makes this a very safe drug in adults and one that should be titrated to achieve control of symptoms. If one capsule is too constipating patients can use smaller doses of the syrup formulation.

Topical application to the perianal skin is an alternative pharmacological approach. Topical phenylephrine, which increases the tone of the sphincter smooth muscle, is under development.8

Behavioural techniques have transformed the management of this condition.9 Even in patients with structural damage it is often possible to improve continence substantially, which implies that there is often an element of reversibility and that a complex combination of factors contributes to continence.7 9

A recent randomised study examined which component of behavioural treatment was most important.7 Treatment with bowel focused counselling, including advice on resisting urgency and titrating loperamide, was as effective as providing the patient with real time feedback—biofeedback—about sphincter function. The pharmacological treatment, advice, and nature of the interaction between therapist and patient seemed to be more important than the technical aspects of treatment.

In institutionalised elderly patients a combination of treatments is most likely to be fruitful, including attention to medications, regular toileting, and sometimes use of gentle laxatives.5 When non-invasive treatments have failed minimally invasive treatments can be considered. Injection of silicone biomaterial can improve leakage caused by a weak internal anal sphincter.10 Surgery should be reserved for patients with major incontinence that has failed to respond to conservative treatment and is necessary in only very few patients. However, no operation is capable of restoring the sphincter to its original finely tuned state.

An overlap repair of the sphincter is still the first line surgical treatment for major disruption of the sphincter due to obstetric causes, especially if there is loss of the perineal body. However, although the short term results are good, the long term results are less satisfactory.11

More invasive procedures include the artificial bowel sphincter or repositioning the gracilis muscle as a neo-sphincter around the anal canal.12 Both operations have a substantial learning curve, a success rate of about 50% in good hands, and are associated with considerable morbidity. Another treatment undergoing evaluation is radiofrequency ablation at the anorectal junction, a process that may induce fibrosis and prevent neurally mediated sphincter relaxations.

An alternative to sphincter surgery entails modulating the neural control of the lower bowel and sphincter. Chronic low amplitude stimulation of sacral nerves, via percutaneously inserted fine wire electrodes, is substantially less invasive than sphincter surgery and has proved successful.13

The socially disabling symptom of faecal incontinence is usually amenable to simple and inexpensive treatments. General practitioners need to be familiar with the condition, initiate treatment, or obtain help from continence advisers. Surgeons need to exhaust conservative treatments before proceeding to surgery and be realistic about the outcome of surgery. Healthcare providers need to establish multiskilled regional centres offering a range of diagnostic and treatment expertise.

Michael A Kamm, professor of gastroenterology

St Mark's Hospital, Watford Road, Harrow HA1 3UJ
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Competing interests: MK has acted as an adviser to Curon, Johnson and Johnson, Medtronic, and Uroplasty, and has received financial support from SLA Pharma.

References:

Perry S, Shaw C, McGrother C, Matthews RJ, Assassa RP, Dallosso H, et al. Prevalence of faecal incontinence in adults aged 40 years or more living in the community. Gut 2002;50: 480-4.[Abstract/Free Full Text]
Vaizey CJ, Kamm MA, Bartram CI. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence. Lancet 1997;349: 612-5.[CrossRef][ISI][Medline]
Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993;329: 1905-11.[Abstract/Free Full Text]
Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308: 887-91.[Abstract/Free Full Text]
Potter J, Norton C, Cottenden A, eds. Bowel care in older people. Research and practice. London: Royal College of Physicians of London, 2002.
Law PJ, Kamm MA, Bartram CI. Anal endosonography in the investigation of faecal incontinence. Br J Surg 1991;78: 312-4.[ISI][Medline]
Norton C, Chelvanayagam S, Wilson-Barnett J, Redfern S, Kamm MA. Randomized controlled trial of biofeedback for fecal incontinence. Gastroenterology (in press).
Cheetham, Kamm MA, Phillips RKS. Topical phenylephrine increases anal canal resting pressure in patients with faecal incontinence. Gut 2001;48: 356-9.[Abstract/Free Full Text]
Norton C, Kamm MA. Anal sphincter biofeedback and pelvic floor exercises for faecal incontinence in adults - a systematic review. Aliment Pharmacol Ther 2001;15: 1147-54.[CrossRef][ISI][Medline]
Kenefick NJ, Vaizey CJ, Malouf AJ, Norton CS, Marshall M, Kamm MA. Injectable silicone biomaterial for faecal incontinence due to internal anal sphincter dysfunction. Gut 2002;51: 225-8.[Abstract/Free Full Text]
Malouf AJ, Norton CS, Engel AF, Nicholls RJ, Kamm MA. Long term results of overlapping anterior anal sphincter repair for obstetric trauma. Lancet 2000;355: 260-5.[CrossRef][ISI][Medline]
Madoff RD, Rosen HR, Baeten CG, LaFontaine LJ, Cavina E, Devesa M, et al. Safety and efficacy of dynamic muscle plasty for anal incontinence: lessons from a prospective multicenter trial. Gastroenterology 1999;116: 549-56.[ISI][Medline]
Kenefick NJ, Vaizey CJ, Cohen RCG, Nicholls RJ, Kamm MA. Medium-term results of permanent sacral nerve stimulation for faecal incontinence. Br J Surg 2002;89: 896-901.[CrossRef][ISI][Medline]


Prevalence of faecal incontinence
Peter J Elton
bmj.com, 8 Dec 2003

http://bmj.bmjjournals.com/cgi/content/full/327/7427/1299

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Intestinal gas distribution determines abdominal symptoms new
      #32181 - 12/16/03 12:27 PM
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Reged: 12/09/02
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Gut 2003;52:1708-1713

Intestinal gas distribution determines abdominal symptoms

H Harder1,*, J Serra1, F Azpiroz1, M C Passos1,**, S Aguadé2 and J-R Malagelada1

1 Digestive System Research Unit, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain

2 Department of Nuclear Medicine, University Hospital Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain


Correspondence to:
Dr F Azpiroz
Digestive System Research Unit, Hospital General Vall d'Hebron, 08035-Barcelona, Spain;



ABSTRACT
Background: Patients with functional gut disorders manifest poor tolerance to intestinal gas loads but the mechanism of this dysfunction is unknown.

Aim: Our aims were firstly, to explore the relative importance of the amount of intestinal gas versus its distribution on symptom production, and secondly, to correlate gut motility and perception of gas loads.

Subjects: Fourteen healthy subjects with no gastrointestinal symptoms.

Methods: In each subject a gas mixture was infused (12 ml/min) either into the jejunum or rectum for one hour during blocked rectal gas outflow, and subsequently gas clearance was measured over one hour of free rectal evacuation. We measured abdominal perception, distension, and gut tone by duodenal and rectal barostats.

Results: Similar magnitude of gas retention (720 ml) produced significantly more abdominal symptoms with jejunal compared with rectal infusion (perception score 4.4 (0.4) v 1.5 (0.5), respectively; p<0.01) whereas abdominal distension was similar (15 (2) mm and 14 (1) mm girth increment, respectively). Jejunal gas loads were associated with proximal contraction (by 57 (5)%) and colonic loads with distal relaxation (by 99 (20)%).

Conclusion: The volume of gas within the gut determines abdominal distension whereas symptom perception depends on intraluminal gas distribution and possibly also on the gut motor response to gas loads.

© 2003 by BMJ Publishing Group Ltd & British Society of Gastroenterology

http://gut.bmjjournals.com/cgi/content/abstract/52/12/1708

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Irritable Bowel Syndrome's Possible Genetic Link new
      #35694 - 01/07/04 11:40 AM
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Wed Dec 10 14:48:40 2003 Pacific Time

Irritable Bowel Syndrome's Possible Genetic Link Studied by Mayo Clinic Researchers

ROCHESTER, Minn., Dec. 10 (AScribe Newswire) -- Researchers at Mayo Clinic studying irritable bowel syndrome say their study of people with this disorder suggests genetic factors may play a role.

Irritable bowel syndrome is a common problem affecting about one in 10 adults. However, many people don't talk about irritable bowel syndrome, which causes abdominal cramping, constipation and diarrhea. The study, which is published in the December issue of Gut, an international journal in gastroenterology, shows that the risk of having irritable bowel syndrome is nearly double in the families of people with the disorder.

"The next challenge is determining nature versus nurture," said G. Richard Locke, M.D., a Mayo Clinic gastroenterologist and one of the authors of the study. "Is this due to a gene or genes or is it due to a shared environmental factor? Our group is active in investigating these issues."

In developing the study, researchers noted that people with irritable bowel syndrome often report family members with similar symptoms. The researchers hypothesized that if there is a familial connection, there would be an increased frequency of irritable bowel syndrome in direct relatives of irritable bowel syndrome patients compared to relatives of people without irritable bowel syndrome.

Others who conducted the study include Jamshid Kalantar, M.D., Alan Zinsmeister, Ph.D., Christopher Beighley, and Nicholas Talley, M.D., Ph.D. Dr. Kalantar was a research fellow at Mayo Clinic during the study, but is now with the Department of Medicine, University of Sydney, Australia. Mr. Beighley now works in West Virginia. The others are with Mayo Clinic in Rochester.

In the study, patients with irritable bowel syndrome seen at Mayo Clinic and their spouses filled out a bowel disease questionnaire and provided the names and addresses of their direct relatives. Researchers then sent a bowel disease questionnaire to 355 relatives of the patients and their spouses, and 71 percent responded. Irritable bowel syndrome occurred in 17 percent of the patients' relatives compared with 7 percent in spouses' relatives.

http://www.ascribe.org/cgi-bin/spew4th.pl?ascribeid=20031210.142614&time=14%2048%20PST&year=2003&public=1

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Electric activity of the colon in irritable bowel syndrome new
      #35700 - 01/07/04 11:52 AM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Journal of Gastroenterology and Hepatology

The Official Publication of the Asian Pacific Association for the Study of the Liver and the Asian Pacific Association of Gastroenterology

Edited by:
R.K. Tandon


Print ISSN: 0815-9319
Online ISSN: 1440-1746
Issues per Volume: Monthly
Current Volume: 19
ISI Journal Citation Reports® Ranking: 2002: 25/47 (Gastroenterology & Hepatology)
Impact Factor: 1.521



--------------------------------------------------------------------------------

Table of Contents > Issue > Abstract

Volume 19: Issue 2

Electric activity of the colon in irritable bowel syndrome: The 'tachyarrhythmic' electric pattern

AHMED SHAFIK
OLFAT EL-SIBAI
ALI A SHAFIK
ISMAIL AHMED




Abstract

Background and Aim:
The etiology of irritable bowel syndrome is unknown. It presents with crampy abdominal pain associated with alternating constipation and diarrhea but with no anatomic abnormality on diagnostic testing. Because the condition is related to motility disturbance, the hypothesis that a disorder of the colonic electromyographic activity is responsible for the colonic motile disorders in irritable bowel syndrome, was investigated.

Methods:
The electromyographic activity of the sigmoid colon was recorded transcutaneously in 18 patients with irritable bowel syndrome (49.6 ± 10.2 years, 12 women) and 14 healthy volunteers (47.2 ± 9.9 years; eight women) by applying three electrodes to the abdominal skin below the umbilicus. The sigmoid colon pressure was measured by means of a saline-perfused tube connected to a pneumohydraulic capillary infusion system.

Results:
Slow waves with a regular rhythm were recorded in the healthy volunteers exhibiting the same frequency, amplitude and conduction velocity from all three electrodes. Action potentials (AP) were not registered. The basal sigmoid colon pressure was interrupted by bouts of elevation. In irritable bowel syndrome, the electromyographic rhythm was irregular and the slow wave variables were higher than those of the normal volunteers and were not the same from the three electrodes; occasional AP were also recorded. The sigmoid colon basal pressure was significantly higher, and was interrupted by pressure bouts significantly higher, than those of the volunteers.

Conclusions:
Irritable bowel syndrome exhibited a 'tachyarrhythmic' pattern of electromyographic activity with higher slow wave variables than normal and occasional AP. The resulting elevated basal colonic pressure and tone may explain some of the irritable bowel syndrome symptoms. Because diagnostic testing of the irritable bowel syndrome shows no anatomic abnormalities, it is suggested that the cause of irritable bowel syndrome is related to an abnormal focus in one or more of the colonic pacemakers emitting these abnormal waves. However, further studies are required to verify these findings.



Article Type: Original Article
Page range: 205 - 210

http://www.blackwellpublishing.com/abstract.asp?ref=0815-9319&vid=19&iid=2&aid=14&s=&site=1



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Visceral perception thresholds in irritable bowel syndrome new
      #35704 - 01/07/04 11:56 AM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Journal of Gastroenterology and Hepatology

The Official Publication of the Asian Pacific Association for the Study of the Liver and the Asian Pacific Association of Gastroenterology

Edited by:
R.K. Tandon


Print ISSN: 0815-9319
Online ISSN: 1440-1746
Issues per Volume: Monthly
Current Volume: 19
ISI Journal Citation Reports® Ranking: 2002: 25/47 (Gastroenterology & Hepatology)
Impact Factor: 1.521



--------------------------------------------------------------------------------

Table of Contents > Issue > Abstract

Volume 19: Issue 2
Visceral perception thresholds after rectal thermal and pressure stimuli in irritable bowel syndrome patients

YANQING LI
YANMEI WANG
XIULI ZUO
YUTING GUO
HAIYAN ZHANG
XUEFENG LU
JUNMAN LI
PAUL V DESMOND




Abstract

Background and Aim:
Visceral hypersensitivity has been shown to be present in irritable bowel syndrome (IBS). The current study sought to compare the characteristics of visceral perception thresholds after rectal thermal and pressure stimuli between IBS patients and healthy subjects.

Methods:
A total of 46 patients with IBS were diagnosed using Rome II criteria. Thirteen healthy individuals participated in the study. Rectal visceral perception thresholds were examined in patients with IBS and in normal controls after thermal and pressure stimuli. Subjects were asked to report the sensation type, location, and spread.

Results:
Compared with healthy subjects, IBS patients demonstrated significantly initially lower perception thresholds and defecation thresholds to rectal thermal and pressure stimuli, particularly in patients with diarrhea-predominant IBS. Ice stimuli on the abdominal wall had varied effects on symptoms in patients with IBS and did not affect perception thresholds.

Conclusions:
Visceral perception thresholds were decreased significantly after rectal thermal and pressure stimuli in patients with IBS. Visceral hypersensitivity may be one of the important pathogenic mechanisms in IBS.



Article Type: Original Article
Page range: 187 - 191

http://www.blackwellpublishing.com/abstract.asp?ref=0815-9319&vid=19&iid=2&aid=11&s=&site=1



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IBS Subgroups by Bowel Habit Predominance new
      #41032 - 01/26/04 03:13 PM
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Posts: 7788
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IBS Subgroups by Bowel Habit Predominance

Lin Chang, MD

Although there are symptom-based Rome II diagnostic criteria for IBS and for the subgroups of IBS with diarrhea and IBS with constipation, the subgroup criteria are not evidence-based and were developed using expert opinion.

A study was performed to develop a symptom-based algorithm to classify patients with IBS into 3 subgroups: IBS with constipation, IBS with diarrhea, and IBS with alternating symptoms.[15] Similar to the methodology used in the previously mentioned IBS study assessing burden of illness,[8] clinical characteristics and gastrointestinal symptoms were gathered in an IBS patient population comprising members of the Intestinal Disease Foundation (n = 1340). Expert opinion was used to define symptom criteria for each subgroup. A hierarchical classification algorithm was developed based on the frequency of patients experiencing a combination of relevant gastrointestinal symptoms (diarrhea, constipation, and other Rome symptom criteria for IBS and functional constipation). The classification of patients with IBS by this algorithm was then compared with that determined by the Rome II criteria for subgroup classification. Of the 657 (49%) members who responded to the survey, 430 (65%) had IBS. The symptom-based algorithm classified 40% with IBS with diarrhea, 33% with IBS with constipation, and 12% with IBS alternating symptoms. Using the Rome II criteria, 31% had IBS with diarrhea, 10% had IBS with constipation, 41% had IBS with alternating symptoms, and 18% were unclassified.

The study authors concluded that the symptom-based algorithm was "more reflective" of the estimated prevalence of IBS subgroups in the general population. A few relevant points should be considered when interpreting these results: (1) the symptoms used in the algorithm consist of more constipation symptoms than diarrhea symptoms, and therefore may bias the classification towards IBS with constipation; (2) there are only symptom-based Rome II criteria for IBS with diarrhea and IBS with constipation, but not IBS with alternating symptoms; therefore, patients who do not meet criteria for IBS with diarrhea or IBS with constipation are in an intermediate group with no absolute criteria -- this may explain the significant number of unclassified IBS patients; and (3) the symptoms used to determine subgroups in the algorithm were based on expert opinion and were not evidence-based.

A study by Locke and colleagues[16] specifically addressed the symptom profile in a community population that self-reported having alternating constipation and diarrhea. Four thousand twenty-nine randomly selected households were sent gastrointestinal symptom questionnaires and 2718 respondents were eligible for the analysis; 9.2%, 2.5%, and 7.6% of respondents reported their usual bowel pattern as constipation, diarrhea, or alternating diarrhea and constipation, respectively. The respondents were not required to meet diagnostic criteria for IBS (ie, presence of chronic or recurrent abdominal pain or discomfort associated with altered bowel habits). In general, self-report of bowel pattern approximated symptom criteria. Eighty-three percent of individuals with self-reported constipation met constipation symptom criteria; 67% of individuals self-reporting diarrhea met criteria for diarrhea. Among those individuals with alternating bowel habits (mean age 54 years, 63% women), 59% met symptom criteria for constipation, 35% met criteria for diarrhea, 20% met criteria for both, and 25% did not meet criteria for either. Predictive symptoms of alternators were incomplete evacuation and the presence of mucus.

Clearly, additional studies need to be performed to more accurately classify patients with IBS into bowel habit subgroups and characterize symptoms in patients with IBS with alternating symptoms (which is lacking in the literature). But first, it should be determined whether subclassifying IBS into these subgroups is even clinically relevant for patient care and research studies, given the fluctuation of IBS symptoms over time.

References
Wells NE, Hahn BA, Whorwell PJ. Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther. 1997;11:1019-1030.
Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119:654-60.
Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.
Hungin P, Chang L, Barghout V, Kahler K. The impact of IBS on absenteeism and work productivity: United States and eight European countries. Am J Gastroenterol. 2003;98:S227. [Abstract # 687]
Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1151.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Impairments in worker productivity and health-related quality of life among employees with irritable bowel syndrome: Does bowel habit predominance make a difference? Am J Gastroenterol. 98:S233, 2003. [Abstract # 703]
Palsson OS, Whitehead WE, Barghout V, et al. IBS severity and health-related quality of life improve with age in women but not in men. Am J Gastroenterol. 98:S272, 2003. [Abstract #818]
Gore M, Frech F, Tai K-S, Nguyen AB, Shetzline MA. Burden of illness in patients with irritable bowel syndrome with constipation. Am J Gastroenterol. 2003;98:S219. [Abstract # 662]
Whitehead WE, Cheskin LJ, Heller BR, et al. Evidence for exacerbation of irritable bowel syndrome during menses. Gastroenterology. 1990;98:1485-1489.
Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg. 2000;87:1568-1563.
Longstreth GF, Yao JF. Irritable bowel syndrome and surgery in HMO health examinees. Am J Gastroenterol. 2003;98:S265. [Abstract #797]
Ganguly R, Barghout V, Pannicker S, Martin BC. Prevalence of GI related surgical procedures among Medicaid eligible patients with and without irritable bowel syndrome. Am J Gastroenterol. 2003 98:S274-S275. [Abstract # 825]
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999; 45(suppl II):1143-1147.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Identifying IBS patients using Rome II symptom criteria: 3- or 12-month reporting? Am J Gastroenterol. 2003;98:S235-S236. [Abstract # 711]
Gore M, Frech F, Nguyen AB, Tai K-S, Shetzline MA. Development of a new symptom-based algorithm for classifying IBS patients into IBS subgroups. Am J Gastroenterol. 2003;98:S219. [Abstract # 663]
Locke GR, Zinsmeister AR, Melton LJ, Talley NJ. Who is an "alternator?" -- a population based study. Am J Gastroenterol. 2003;98:S275. [Abstract # 828]
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.
Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology. 2002;122:1140-1156.
Crowell MD, Schettler VA, Lacy BE, Jones MP, Olden KW, Whitehead WE. Impact of somatization on gastrointestinal (GI) and extra-intestinal comorbidities in IBS. Am J Gastroenterol. 2003;98:S271-S272. [Abstract #816]
Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15:1655-1666.
Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D, Mangel AW. Efficacy and safety of alosetron in women with irritable bowel syndrome: A randomised placebo-controlled trial. Lancet. 2000;355:1035-1040.
Dunger-Baldauf C, Nyhlin H, Rueegg P, Wagner A. Subject's global assessment of satisfactory relief as a measure to assess treatment effect in clinical trials in irritable bowel syndrome (IBS). Am J Gastroenterol. 2003;98:S269. [Abstract #809]
Prather CM, Camilleri M, Zinsmeister AR, McKinzie S, Thomforde G. Tegaserod accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome. Gastroenterology. 2000;118:463-468.
Talley N, Kamm M, Mueller-Lissner S, et al. Tegaserod is effective in relieving the multiple symptoms of constipation: Results from a 12-week multinational study in patients with chronic constipation. Am J Gastroenterol. 2003;98:S269-S270. [Abstract #810]
Kariv R, Tiomny E, Grenshpon R, Waisman G, Halpern Z. Low-dose naltrexone for the treatment of irritable bowel syndrome. Am J Gastroenterol. 2003 98:S268. [Abstract #805]



http://www.medscape.com/viewarticle/463421

--------------------
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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Surgery and IBS new
      #41035 - 01/26/04 03:21 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Surgery and IBS

Lin Chang, MD

An increased number of abdominal surgeries have been reported in a random population of patients with IBS compared with individuals without IBS.[9,10] Two studies presented during these meeting proceedings evaluated the prevalence of surgery in patients with IBS compared with control subjects in 2 different patient populations.

In one study,[11] the prevalence of potentially unnecessary surgeries was investigated using computerized patient questionnaire data in HMO health examinees. An analysis of health data on 89,008 examinees was performed. IBS was reported in 5.2% of subjects (3.0% of men and 7.2% of women). Of the different types of surgeries, cholecystectomy, appendectomy, hysterectomy, and back surgery were significantly more common in patients with IBS than in patients without IBS. Patients with IBS reported these surgeries 2-3 times more than individuals without IBS, except for back surgery (reported 1.5 times more often). Various medical history parameters were evaluated as predictive factors for the types of surgeries. An IBS diagnosis yielded the highest odds ratio (OR) for cholecystectomy and appendectomy. The diagnoses of IBS and fibromyalgia tied for the highest OR for hysterectomy, and fibromyalgia had the highest OR for back surgery.

The second study[12] retrospectively determined the prevalence of gastrointestinal-related surgeries in a 2-state Medicaid IBS patient population compared with a non-IBS control group matched for age, sex, race, and months of eligibility (both, n = 2546). Patients with IBS had a corresponding ICD (International Classification of Diseases) code as a primary or secondary diagnosis. The gastrointestinal-related procedures included cholecystectomy, appendectomy, colectomy, obesity procedures, and abdominal and vaginal hysterectomy. The 1-year prevalence of gastrointestinal-related procedures in the IBS group was significantly higher than that of the control group (n = 42 [1.65%] vs n = 23 [0.9%]; P = .01). The prevalence of vaginal hysterectomy was higher in the IBS group than in the control group (0.5% vs 0.2%; P = .02).

Summary. These studies confirm that factors that contribute to the increased healthcare and economic burden associated with IBS include physician visits, surgical procedures, medication (prescription and OTC), and alternative treatments (that are frequently used by patients with IBS). The lack of satisfaction and effectiveness of current IBS treatments and decreased QOL and work productivity also contribute to the burden of illness.

References
Wells NE, Hahn BA, Whorwell PJ. Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther. 1997;11:1019-1030.
Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119:654-60.
Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.
Hungin P, Chang L, Barghout V, Kahler K. The impact of IBS on absenteeism and work productivity: United States and eight European countries. Am J Gastroenterol. 2003;98:S227. [Abstract # 687]
Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1151.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Impairments in worker productivity and health-related quality of life among employees with irritable bowel syndrome: Does bowel habit predominance make a difference? Am J Gastroenterol. 98:S233, 2003. [Abstract # 703]
Palsson OS, Whitehead WE, Barghout V, et al. IBS severity and health-related quality of life improve with age in women but not in men. Am J Gastroenterol. 98:S272, 2003. [Abstract #818]
Gore M, Frech F, Tai K-S, Nguyen AB, Shetzline MA. Burden of illness in patients with irritable bowel syndrome with constipation. Am J Gastroenterol. 2003;98:S219. [Abstract # 662]
Whitehead WE, Cheskin LJ, Heller BR, et al. Evidence for exacerbation of irritable bowel syndrome during menses. Gastroenterology. 1990;98:1485-1489.
Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg. 2000;87:1568-1563.
Longstreth GF, Yao JF. Irritable bowel syndrome and surgery in HMO health examinees. Am J Gastroenterol. 2003;98:S265. [Abstract #797]
Ganguly R, Barghout V, Pannicker S, Martin BC. Prevalence of GI related surgical procedures among Medicaid eligible patients with and without irritable bowel syndrome. Am J Gastroenterol. 2003 98:S274-S275. [Abstract # 825]
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999; 45(suppl II):1143-1147.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Identifying IBS patients using Rome II symptom criteria: 3- or 12-month reporting? Am J Gastroenterol. 2003;98:S235-S236. [Abstract # 711]
Gore M, Frech F, Nguyen AB, Tai K-S, Shetzline MA. Development of a new symptom-based algorithm for classifying IBS patients into IBS subgroups. Am J Gastroenterol. 2003;98:S219. [Abstract # 663]
Locke GR, Zinsmeister AR, Melton LJ, Talley NJ. Who is an "alternator?" -- a population based study. Am J Gastroenterol. 2003;98:S275. [Abstract # 828]
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.
Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology. 2002;122:1140-1156.
Crowell MD, Schettler VA, Lacy BE, Jones MP, Olden KW, Whitehead WE. Impact of somatization on gastrointestinal (GI) and extra-intestinal comorbidities in IBS. Am J Gastroenterol. 2003;98:S271-S272. [Abstract #816]
Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15:1655-1666.
Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D, Mangel AW. Efficacy and safety of alosetron in women with irritable bowel syndrome: A randomised placebo-controlled trial. Lancet. 2000;355:1035-1040.
Dunger-Baldauf C, Nyhlin H, Rueegg P, Wagner A. Subject's global assessment of satisfactory relief as a measure to assess treatment effect in clinical trials in irritable bowel syndrome (IBS). Am J Gastroenterol. 2003;98:S269. [Abstract #809]
Prather CM, Camilleri M, Zinsmeister AR, McKinzie S, Thomforde G. Tegaserod accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome. Gastroenterology. 2000;118:463-468.
Talley N, Kamm M, Mueller-Lissner S, et al. Tegaserod is effective in relieving the multiple symptoms of constipation: Results from a 12-week multinational study in patients with chronic constipation. Am J Gastroenterol. 2003;98:S269-S270. [Abstract #810]
Kariv R, Tiomny E, Grenshpon R, Waisman G, Halpern Z. Low-dose naltrexone for the treatment of irritable bowel syndrome. Am J Gastroenterol. 2003 98:S268. [Abstract #805]


http://www.medscape.com/viewarticle/463421

--------------------
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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The Effect of Somatization on Gastrointestinal and Extraintestinal Symptoms of IBS new
      #41037 - 01/26/04 03:26 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

The Effect of Somatization on Gastrointestinal and Extraintestinal Symptoms of IBS

Lin Chang, MD

Psychosocial disturbances (eg, depression, anxiety, stressful life events, and somatization) are commonly found in patients with IBS, particularly those with more severe symptoms or those seen in tertiary referral populations.[17] In addition, extraintestinal symptoms, such as fatigue, myalgias, sleep, and sexual disturbances are also frequently reported by patients with IBS.[18] The association between psychosocial factors and extraintestinal symptoms in IBS is not well understood.

Crowell and colleagues[19] studied the influence of somatization (measured by the psychological questionnaire SCL-90R) on gastrointestinal and extraintestinal symptoms in IBS consulters in 133 consecutive Rome-positive IBS patients. Abdominal pain, pain sites, and upper and lower gastrointestinal symptoms were reported to a significantly greater degree by patients with IBS with elevated scores for somatization. In addition, somatization scores significantly correlated with the presence of extraintestinal symptoms such as chronic fatigue, temporomandibular joint, low back pain, and both anxiety and panic attacks. Patients with IBS with elevated scores for somatization also had reduced functional abilities and QOL.

The study authors concluded that IBS is a heterogeneous disorder in which the presence of multiple gastrointestinal and nongastrointestinal symptoms could be a marker for psychologic factors that could play a role in the etiology, healthcare utilization, and treatment outcome of IBS. It is still not known whether the increased prevalence of extraintestinal symptoms is due to coexistent psychologic disorders that may share similar symptoms with IBS, or if the gastrointestinal, extraintestinal, and psychologic symptoms all result from a shared central pathophysiologic mechanism underlying IBS. However, this study supports the concept that somatization is an important confounding factor that should be considered when evaluating or interpreting data on gastrointestinal, extraintestinal, and other psychologic symptoms in IBS.

Summary
These IBS symptom-related studies reiterate the challenges of diagnosing IBS and of understanding the underlying clinical relevance and pathophysiologic mechanisms of specific symptoms, including altered bowel habits, other gastrointestinal symptoms, and extraintestinal symptoms. Future studies that can help establish a biologic marker(s) for IBS would be important in overcoming these challenges.

References
Wells NE, Hahn BA, Whorwell PJ. Clinical economics review: irritable bowel syndrome. Aliment Pharmacol Ther. 1997;11:1019-1030.
Gralnek IM, Hays RD, Kilbourne A, Naliboff B, Mayer EA. The impact of irritable bowel syndrome on health-related quality of life. Gastroenterology. 2000;119:654-60.
Frank L, Kleinman L, Rentz A, Ciesla G, Kim JJ, Zacker C. Health-related quality of life associated with irritable bowel syndrome: comparison with other chronic diseases. Clin Ther. 2002;24:675-689.
Hungin P, Chang L, Barghout V, Kahler K. The impact of IBS on absenteeism and work productivity: United States and eight European countries. Am J Gastroenterol. 2003;98:S227. [Abstract # 687]
Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology. 2002;122:1500-1151.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Impairments in worker productivity and health-related quality of life among employees with irritable bowel syndrome: Does bowel habit predominance make a difference? Am J Gastroenterol. 98:S233, 2003. [Abstract # 703]
Palsson OS, Whitehead WE, Barghout V, et al. IBS severity and health-related quality of life improve with age in women but not in men. Am J Gastroenterol. 98:S272, 2003. [Abstract #818]
Gore M, Frech F, Tai K-S, Nguyen AB, Shetzline MA. Burden of illness in patients with irritable bowel syndrome with constipation. Am J Gastroenterol. 2003;98:S219. [Abstract # 662]
Whitehead WE, Cheskin LJ, Heller BR, et al. Evidence for exacerbation of irritable bowel syndrome during menses. Gastroenterology. 1990;98:1485-1489.
Kennedy TM, Jones RH. Epidemiology of cholecystectomy and irritable bowel syndrome in a UK population. Br J Surg. 2000;87:1568-1563.
Longstreth GF, Yao JF. Irritable bowel syndrome and surgery in HMO health examinees. Am J Gastroenterol. 2003;98:S265. [Abstract #797]
Ganguly R, Barghout V, Pannicker S, Martin BC. Prevalence of GI related surgical procedures among Medicaid eligible patients with and without irritable bowel syndrome. Am J Gastroenterol. 2003 98:S274-S275. [Abstract # 825]
Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut. 1999; 45(suppl II):1143-1147.
Dean BB, Aguilar D, Barghout V, Kahler K, Groves D, Ofman JJ. Identifying IBS patients using Rome II symptom criteria: 3- or 12-month reporting? Am J Gastroenterol. 2003;98:S235-S236. [Abstract # 711]
Gore M, Frech F, Nguyen AB, Tai K-S, Shetzline MA. Development of a new symptom-based algorithm for classifying IBS patients into IBS subgroups. Am J Gastroenterol. 2003;98:S219. [Abstract # 663]
Locke GR, Zinsmeister AR, Melton LJ, Talley NJ. Who is an "alternator?" -- a population based study. Am J Gastroenterol. 2003;98:S275. [Abstract # 828]
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131.
Whitehead WE, Palsson O, Jones KR. Systematic review of the comorbidity of irritable bowel syndrome with other disorders: what are the causes and implications? Gastroenterology. 2002;122:1140-1156.
Crowell MD, Schettler VA, Lacy BE, Jones MP, Olden KW, Whitehead WE. Impact of somatization on gastrointestinal (GI) and extra-intestinal comorbidities in IBS. Am J Gastroenterol. 2003;98:S271-S272. [Abstract #816]
Muller-Lissner SA, Fumagalli I, Bardhan KD, et al. Tegaserod, a 5-HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther. 2001;15:1655-1666.
Camilleri M, Northcutt AR, Kong S, Dukes GE, McSorley D, Mangel AW. Efficacy and safety of alosetron in women with irritable bowel syndrome: A randomised placebo-controlled trial. Lancet. 2000;355:1035-1040.
Dunger-Baldauf C, Nyhlin H, Rueegg P, Wagner A. Subject's global assessment of satisfactory relief as a measure to assess treatment effect in clinical trials in irritable bowel syndrome (IBS). Am J Gastroenterol. 2003;98:S269. [Abstract #809]
Prather CM, Camilleri M, Zinsmeister AR, McKinzie S, Thomforde G. Tegaserod accelerates orocecal transit in patients with constipation-predominant irritable bowel syndrome. Gastroenterology. 2000;118:463-468.
Talley N, Kamm M, Mueller-Lissner S, et al. Tegaserod is effective in relieving the multiple symptoms of constipation: Results from a 12-week multinational study in patients with chronic constipation. Am J Gastroenterol. 2003;98:S269-S270. [Abstract #810]
Kariv R, Tiomny E, Grenshpon R, Waisman G, Halpern Z. Low-dose naltrexone for the treatment of irritable bowel syndrome. Am J Gastroenterol. 2003 98:S268. [Abstract #805]

http://www.medscape.com/viewarticle/463421

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Family practitioners' attitudes and knowledge about IBS new
      #44177 - 02/10/04 02:32 PM
HeatherAdministrator

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Fam Pract. 2003 Dec;20(6):670-4.

Family practitioners' attitudes and knowledge about IBS: effect of a trial of physician education.

Longstreth GF, Burchette RJ.

Department of Gastroenterology, Kaiser Permanente Medical Care Program, 4647 Zion Avenue, San Diego, CA 92120, USA. George.F.Longstreth@kp.org

BACKGROUND: Primary physicians care for most patients with irritable bowel syndrome (IBS), but data on their attitudes and knowledge about the disorder are limited to research in the UK. OBJECTIVE: The purpose of the present study was to assess US family practitioners' attitudes and knowledge about IBS and determine the effect of a single education class on these measures. METHODS: In a large health maintenance organization (HMO), a baseline group of family practitioners twice completed a questionnaire on attitudes and knowledge about IBS, 3 months apart. A class group completed it pre-class, immediately post-class and 3 months post-class. RESULT: Thirty-five physicians ranked IBS among five chronic, painful syndromes as highest in difficulty satisfying patients, tied with headache for highest in difficulty in practice strategy decision, second in time required, and fourth in diagnostic confidence and satisfaction in caring for patients. IBS and heartburn had widely separated rankings in all five attitudes. The correct answer rate on seven of 13 knowledge questions was <50%, and a majority did not identify the Rome II symptom criteria as typical and lacked other important knowledge. Of the 30 class physicians, the knowledge scores (mean +/- SD; maximum possible, 13) of 29 increased from 5.59 +/- 1.84 pre-class to 10.21 +/- 1.76 immediately post-class (P < 0.0001); 3 months later, the scores were lower (8.93 +/- 0.36) than post-class (P < 0.0001), but still higher than pre-class (P < 0.0001). Their attitude rankings were nearly identical pre-class and 3 months later (P > 0.05). In the 19 baseline physicians, IBS attitude rankings and knowledge scores did not change significantly over 3 months (P > 0.05). CONCLUSION: These US family practitioners had attitudes about IBS patients and lacked knowledge that could interfere with patient care. A single class improved short-term knowledge but had little effect on attitudes about IBS.

PMID: 14701890 [PubMed - in process]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14701890&dopt=Abstract

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Utilization patterns and net direct medical cost to Medicaid of IBS new
      #44178 - 02/10/04 02:34 PM
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Curr Med Res Opin. 2003;19(8):771-80.

Utilization patterns and net direct medical cost to Medicaid of IBS.

Martin BC, Ganguly R, Pannicker S, Frech F, Barghout V.

University of Georgia College of Pharmacy, Pharmacy Care Administration Graduate Program, Athens, Georgia 30602, USA. bmartin@rx.uga.edu

BACKGROUND: Patients with irritable bowel syndrome are frequent users of the health care system. DESIGN AND METHODS: This retrospective matched case-control study assessed the economic impact of irritable bowel syndrome on the Medicaid program by comparing the health care utilization and expenditures of Medicaid patients with irritable bowel syndrome in California and North Carolina with age-, sex-, and race-matched control groups without the syndrome. RESULTS: Average annual Medicaid expenditures per case of diagnosed irritable bowel syndrome were 2952 dollars and 5908 dollars in California and North Carolina, respectively; corresponding unadjusted net incremental expenditures were 962 dollars and 2191 dollars, respectively. In both states, patients with irritable bowel syndrome incurred greater costs than controls for physician visits, outpatient visits, and prescription drugs. CONCLUSIONS: Irritable bowel syndrome was shown to impose an economic burden on the Medicaid program. The cost of treating patients with irritable bowel syndrome is higher than the cost of treating matched ambulatory Medicaid recipients without the condition.

PMID: 14687449 [PubMed - in process]

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14687449&dopt=Abstract

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Splitting IBS: from original Rome to Rome II criteria new
      #44179 - 02/10/04 02:35 PM
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Am J Gastroenterol. 2004 Jan;99(1):122-30.

Splitting IBS: from original Rome to Rome II criteria.

Mearin F, Roset M, Badia X, Balboa A, Baro E, Ponce J, Diaz-Rubio M, Caldwell E, Cucala M, Fueyo A, Talley NJ.

Institute of Functional and Motor Digestive Disorders, Centro Medico Teknon, Barcelona, Spain.

OBJECTIVES: Diagnosis of irritable bowel syndrome (IBS) and other functional bowel disorders (FBD) is based on symptom evaluation. Clinical criteria have changed over time, yielding different proportions of subjects fulfilling diagnostic requirements. According to new diagnostic criteria (Rome II), subjects considered some years ago to have IBS no longer do so. The aim of this article is to evaluate how patients diagnosed as having IBS according to original Rome criteria have been split, and to which clinical diagnosis they belong today. METHODS: Two hundred and eleven subjects meeting original Rome IBS diagnostic criteria were studied: 65 also met Rome II criteria while 146 did not. Subjects were extracted from an epidemiological survey, using home-based personal interviews, on 2000 subjects randomly selected as representative of the Spanish population. Clinical complaints, personal well-being, resource utilization, and health-related quality of life (HRQOL) were compared. RESULTS: Of the subjects meeting original Rome but not Rome II criteria, the present diagnosis should be: 40%"minor" IBS (IBS symptoms of less than 12 wk duration), 37% functional constipation, 12% alternating bowel habit, 7% functional diarrhea, 3% functional abdominal bloating, and 1% unspecified functional bowel disorder (FBD). Thus, 52 subjects (36%) should not be diagnosed with IBS because they really had other FBD, 59 (40%) because of symptoms consistent with IBD diagnosis but not the required duration or frequency, and 35 (24%) because of symptoms consistent with some other FBD diagnosis but not meeting the required duration. Clinical complaints, personal well-being, resource utilization, and HRQOL were more severely affected in IBS than in other FBD as a group, and in "major" rather than in "minor" forms. CONCLUSIONS: Many subjects meeting original Rome criteria for IBS do not meet Rome II criteria: approximately one quarter of subjects do not have sufficient symptom duration or frequency to be diagnosed with IBS and almost half are now considered as having other ("major" or "minor") FBD.


http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=14687153&dopt=Abstract

PMID: 14687153 [PubMed - indexed for MEDLINE]

Check here to learn about the Rome II Guidelines for IBS




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Researchers Pioneer Accessible, Cost-Effective Treatments for IBS new
      #48823 - 03/08/04 06:48 PM
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Researchers Pioneer Accessible, Cost-Effective Treatments for Post-Traumatic Stress Disorder and Irritable Bowel Syndrome

Contact: Karl Luntta (518) 437-4980

ALBANY, N.Y. (February 17, 2004) -- University at Albany researchers are pioneering more accessible, cost-effective treatment programs for two of the nation's common ailments, Post-Traumatic Stress Disorder (PTSD) and Irritable Bowel Syndrome (IBS).

Rather than relying on the common face-to-face, therapist-patient relationships, the unique treatments are self-managed, with the patient undertaking much of the therapy through reading material, structured homework, and diagnostic tools.

"It's the wave of the future," says doctoral research supervisor Edward B. Blanchard, director of the UAlbany Center for Stress and Anxiety Disorders. "The treatment is very accessible to people who have limited mobility or limited access to areas where therapists tend to locate, such as cities. It's self-managed and self-paced, and less expensive than traditional treatment. And it's done under the trained eye of a clinician, who can help assess progress."

Therapy for Crash Victims
Doctoral student Jill Sabsevitz is developing a treatment program for sufferers of PTSD specifically related to the aftermath of motor vehicle accidents (MVA). Some studies suggest that 45 percent of accident survivors who seek medical attention will develop PTSD within one year of the event, and an additional 15 to 30 percent will develop less overt, subclinical levels of PTSD. Sabsevitz' treatment utilizes the book Coping With Your Crash, by Blanchard and Edward Hickling, as the focal point of the self-managed program. After an initial consultation and assessment with a therapist, patients undergo a series of exercises described in the book designed to overcome feelings of anxiety, anger, vulnerability, and depression, as well as steps such as the incorporation of pleasant events into the daily routine. The patient mails in "homework" to his therapist, who then gives the okay for advancing to the next step. The last step is self-assessment, in conjunction with a trained therapist.

"With physical injuries often preventing people from traveling," said Sabsevitz, "and with PTSD symptoms also inhibiting accident victims from getting out, this type of therapy aims to meet their needs and get them on the road, literally, to better health, physically and mentally."

Web-based Treatment Reaches Worldwide Audience
Jonathan Lerner has taken the program one step further by researching entirely Web-based self-managed treatments for MVA-related PTSD. He offers a comprehensive assessment, treatment, and evaluation on his Web site www.afterthecrash.com, and to date has had responses from more than 100 MVA survivors on five continents. While his treatment does not offer an initial face-to-face consultation, he has high hopes for its efficacy. He notes, "To date, there's strong evidence indicating that a cognitive-behavioral intervention like the one developed by Dr. Blanchard can successfully decrease symptoms of PTSD and improve functioning in individuals who have survived a motor vehicle accident. There is also preliminary data showing positive clinical outcomes in individuals who have used Internet-based assessment and treatment for problem areas such as headache, panic disorder, substance abuse, weight loss, and smoking cessation."

Stress Management Key to Treating Irritable Bowel Syndrome
Irritable Bowel Syndrome (IBS) is the condition doctoral student Kathryn Sanders seeks to alleviate with her self-managed therapy program. Studies estimate that 11 to 22 percent of Americans suffer from IBS, a gastrointestinal disorder with symptoms that include abdominal pain and tenderness accompanied by either diarrhea, constipation or both. IBS affects roughly twice as many women as men, and as much as $25 billion is spent annually on treating symptoms. No drug therapy currently is available. For her treatment, Sanders utilizes the book Breaking the Bonds of Irritable Bowel Syndrome, by therapist Barbara Bradley-Bolen.

"Our goal," said Sanders, "is to help improve patients' health and quality of life through stress management. Patients will ultimately learn to deal with their stress, and with this self-managed therapy they can also learn to manage their IBS symptoms now and for the future."

Also included in her proposed therapy is an initial assessment by a trained clinician, homework based on the book, and the study of individual diet and various relaxation and stress management techniques, plus various follow-up contacts.

"These students are on the cutting edge of what could be a revolution in the treatment of certain conditions," said Blanchard. "But they're not developing radical alternative therapies. They're researching interventions that are based on traditional theories of therapy, but divert from tradition in ways that make alleviating patients' symptoms accessible, comfortable, widely available, and inexpensive, while still benefiting from the support of a qualified counselor."



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http://www.albany.edu/news/releases/2004/feb2004/pts_disorder_ibs.htm

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New Syndrome Connects Gallbladder Dysfunction And Chronic Diarrhea new
      #48996 - 03/09/04 11:45 AM
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Title: New Syndrome Connects Gallbladder Dysfunction And Chronic Diarrhea

Doctor's Guide

SUMMIT, NJ -- August 7, 2000 -- A study published in this month's issue of the American Journal of Gastroenterology suggests that millions of Americans believed to be afflicted with chronic diarrhea (CD) as a result of an intestinal disorder may in fact be suffering from gallbladder dysfunction. Furthermore, this research is considered by many prominent gastroenterologists to be the first recognition of a new syndrome that links CD to gallbladder dysfunction.

Referred to as the Habba Syndrome, the groundbreaking research described by Saad F. Habba, M.D., attending gastroenterologist at Atlantic Health System's Overlook Hospital in Summit, N.J., establishes a relationship between gallbladder dysfunction and chronic diarrhea. This independent study included 19 patients with varying degrees of CD (four to 10 bowel movements daily for at least three months) who consistently failed to improve on several traditional therapies, such as antispasmodic drugs and lactose-free diets. These patients routinely experienced quality-of-life issues ranging from social embarrassment to debilitation.

Dr. Habba observed that his patients presented CD symptoms that mimicked those found in some individuals who have had their gallbladders removed. In particular, they experienced CD only after meals and rarely at night unless they ate a heavy, late-night meal. After conducting a series of diagnostic tests and therapeutic trials, Dr. Habba was able to rule out the possibility of irritable bowel syndrome (IBS) and other intestinal disorders. Specifically, he was able to confirm his theory of CD caused by a dysfunctional gallbladder as demonstrated by specific tests indicating abnormal contractions of the gallbladder. He then prescribed low doses of cholestyramine, a cholesterol-lowering drug often used by gastroenterologists to treat CD resulting from gallbladder removal. Each patient in the study experienced almost immediate relief from their chronic diarrhea following this treatment.

"Rising accounts of CD treatment failure have led me to believe that the gallbladder dysfunction demonstrated in my study may be a widespread condition," said Dr. Habba. "Chronic diarrhea results from a variety of causes and all possibilities should be explored before making a treatment decision."

Dr. Habba's independent study helps to create a clearer distinction between CD that results from gallbladder dysfunction and a variety of intestinal abnormalities. In particular, irritable bowel syndrome (IBS) is an intestinal condition experienced by an estimated 35 million people in the U.S. and is a common cause of CD. Patients with this syndrome rarely experience the localized pain associated with IBS. In addition, these patients respond to bile acid binding agents (such as cholestyramine) rather than the antispasmodic drugs that typically control the intestinal contractions associated with IBS.

"This is an important clinical syndrome for all physicians who encounter CD patients to be aware of, because it is easily treatable and its early recognition may prevent many unnecessary diagnostic investigations," said Warren Finkelstein, M.D., New Jersey Governor of the American College of Gastroenterology. "Dr. Habba's findings of abnormal gallbladder function in his series of patients with chronic diarrhea is of significant interest."

The Habba Syndrome has the potential to provide a large number of patients with a more focused approach to their condition. "This marks an important milestone in the area of digestive diseases," said Carrol Leevy, M.D., distinguished professor and scientific director of the University of Medicine and Dentistry of New Jersey (UMDNJ) Liver Center. "This work brings into focus a therapeutic category that has gone virtually undocumented in the scientific literature and opens the doors to future research initiatives on the origin of the problem."

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http://www.docguide.com/dg.nsf/PrintPrint/0D16E06A03BFA5E285256934005430C7

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Diverticular Disease: Electrophysiologic Study and a New Concept of Pathogenesis new
      #48997 - 03/09/04 11:48 AM
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World J Surg. 2004 Mar 4

Diverticular Disease: Electrophysiologic Study and a New Concept of Pathogenesis.

Shafik A, Ahmed I, Shafik AA, El Sibai O.

Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt.

Abstract.The cause of diverticular disease (DD) is not exactly known, although colonic motor disorder has been proposed as a factor in the pathogenesis of the condition. We investigated the hypothesis that disordered colonic electrical activity is responsible for the colonic motor dysfunction and the development of DD. The electromyographic (EMG) activity and pressure of the sigmoid colon (SC) were recorded in 36 patients [16 early cases, 20 advanced cases; age (mean +/- SD) 53.3 +/- 5.6 years; 19 women, 17 men] and 22 healthy volunteers. The percutaneous route was used for recording the SC EMG. The healthy volunteers exhibited SC slow waves with a regular rhythm and the same frequency, amplitude, and conduction velocity from the three electrodes in the same subject. The SC basal pressure (7.9 cm H(2)O) was interrupted by bouts of high pressure (26.8 cm H(2)O). The early-DD cases showed slow waves with an irregular rhythm and significantly higher variables ( p < 0.05) than the volunteers. Action potentials followed randomly or were superimposed on the slow waves. The SC basal pressure was significantly higher than that of the volunteers (21.4 cm H(2)O, p < 0.01). Bouts of pressure (58.6 cm H(2)O) coupled with action potentials were recorded. No waves were recorded from 15 of 20 of the advanced-DD patients. In 5 patients, slow waves with an irregular rhythm and lower variables ( p < 0.05) than those of the volunteers were recorded. The basal SC pressure was significantly above normal. Three electrical activity patterns could be identified in DD patients: "tachyrhythmic" in the early-DD patients and "bradyrhythmic" or "silent" in the late-DD patients. These dysrhythmias may result from a disordered colonic pacemaker.

The similarity between early DD and the irritable bowel syndrome suggests that DD is an advanced stage of the irritable bowel syndrome; studies are required to investigate this hypothesis further.

PMID: 14994146 [PubMed - as supplied by publisher]

http://www.docguide.com/news/content.nsf/PaperFrameSet?OpenForm&refid=2&id=48DDE4A73E09A969852568880078C249&c=&newsid=8525697700573E1885256E4D0037934F&u=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=14994146&ref=/news/content.nsf/SearchResults?openform&Query=irritable%20bowel&so=date&id=48DDE4A73E09A969852568880078C249

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A link between irritable bowel syndrome and fibromyalgia new
      #56175 - 03/30/04 01:46 PM
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A link between irritable bowel syndrome and fibromyalgia

An abnormal lactulose breath test (LBT), indicative of small intestinal bacterial overgrowth, in fibromyalgia patients and in irritable bowel syndrome (IBS) patients may help to explain common features of the conditions, researchers report in the April issue of the Annals of the Rheumatic Diseases.

Dr. Mark Pimentel from Cedars-Sinai Medical Center, Los Angeles, California and colleagues note that nearly a third of fibromyalgia patients in some studies are also diagnosed with IBS, suggesting a causal link between the two disorders.

The researchers tested their hypothesis that the lactulose breath test would be abnormal in both IBS and fibromyalgia by performing the test in 42 fibromyalgia patients, 111 IBS patients, and 15 healthy controls.

All 42 patients with fibromyalgia had an abnormal LBT, compared with 93 (84%) of IBS patients and 3 (20%) of the controls.

Hydrogen production was significantly greater in fibromyalgia patients than in IBS patients or healthy controls. Moreover, the researchers note that in 41 fibromyalgia patients, there was a significant correlation between their visual analogue pain score and the peak hydrogen level and hydrogen area under the curve seen on the LBT.

"The additional finding in our study that the degree of pain in fibromyalgia seems to correlate with the degree of hydrogen suggests a possible link between the LBT findings and hyperalgesia," the investigators write.

"This study suggests that an abnormal LBT may be a common link between subjects with fibromyalgia and IBS," the authors conclude. "Further study is needed to determine if treatment and normalization of the breath test with antibiotic treatment can produce an improvement in fibromyalgia in addition to bowel complaints."

Ann Rheum Dis 2004;63:450-452.

http://www.medscape.com/viewarticle/472635



A link between irritable bowel syndrome and fibromyalgia may be related to findings on lactulose breath testing

M Pimentel, D Wallace, D Hallegua, E Chow, Y Kong, S Park and H C Lin

GI Motility Program, Divisions of Gastroenterology and Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, CSMC Burns & Allen Research Institute, Los Angeles, California 90048, School of Medicine, University of California, Los Angeles, Los Angeles, California 90024, USA


Correspondence to:
Dr M Pimentel
Cedars-Sinai Medical Center, 8635 W 3rd St, Suite 770 W, Los Angeles, CA 90048, USA; mark.pimentel@cshs.org


ABSTRACT
Background: An association between irritable bowel syndrome (IBS) and small intestinal bacterial overgrowth (SIBO) has been found.

Objective: To compare the prevalence and test results for bacterial overgrowth between IBS and fibromyalgia.

Methods: Subjects with independent fibromyalgia and IBS were compared with controls in a double blind study. Participants completed a questionnaire, and a lactulose hydrogen breath test was used to determine the presence of SIBO. The prevalence of an abnormal breath test was compared between study participants. Hydrogen production on the breath test was compared between subjects with IBS and fibromyalgia. The somatic pain visual analogue score of subjects with fibromyalgia was compared with their degree of hydrogen production.

Results: 3/15 (20%) controls had an abnormal breath test compared with 93/111 (84%) subjects with IBS (p<0.01) and 42/42 (100%) with fibromyalgia (p<0.0001 v controls, p<0.05 v IBS). Subjects with fibromyalgia had higher hydrogen profiles (p<0.01), peak hydrogen (p<0.0001), and area under the curve (p<0.01) than subjects with IBS. This was not dependent on the higher prevalence of an abnormal breath test. The degree of somatic pain in fibromyalgia correlated significantly with the hydrogen level seen on the breath test (r = 0.42, p<0.01).

Conclusions: An abnormal lactulose breath test is more common in fibromyalgia than IBS. In contrast with IBS, the degree of abnormality on breath test is greater in subjects with fibromyalgia and correlates with somatic pain.

http://ard.bmjjournals.com/cgi/content/abstract/63/4/450

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Heartburn May Not Reflect Gastroesophageal Reflux Disease Severity new
      #56189 - 03/30/04 02:43 PM
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Heartburn May Not Reflect Gastroesophageal Reflux Disease Severity

Mar 12 - Particularly in the elderly, the severity of heartburn may not reflect the severity of erosive gastroesophageal reflux disease, according to a report in the March issue of Gastroenterology.

"Gastroesophageal reflux disease is common in adults of all ages, but its complications are more frequent in elderly patients," Dr. David A. Johnson, of Eastern Virginia Medical School, in Norfolk and Dr. Brian Fennerty of Oregon Health Sciences University, Portland, point out.

To investigate further, the researchers examined the relationship of age, severe heartburn symptoms, and severe erosive esophagitis. The team pooled data from five prospective, randomized, controlled trials that examined the effect of proton pump inhibitors on healing of erosive esophagitis and symptom resolution. Involved in the study were 11,945 patients with gastroesophageal reflux disease and erosive esophagitis.

The investigators observed a progressive increase in the prevalence of severe erosive esophagitis with each decade of age. In patients younger than 21 years, only 12% had severe esophagitis at baseline, compared with 37% of those older than 70 years.

Severe heartburn was present in more than 50% of patients younger than 50 years with severe esophagitis. However, severe heartburn was less common in older patients with severe esophagitis and was least likely to be found in those older than 70 years.

Given these findings, the investigators call for more aggressive diagnosis and treatment of elderly patients, "regardless of the reported severity of their presenting symptoms."

Gastroenterology 2004;126:660-664.

http://www.medscape.com/viewarticle/471671?mpid=26286

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Are Your Bowels Irritable? IBS Awareness Month is Here new
      #59811 - 04/09/04 07:11 PM
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Are Your Bowels Irritable? IBS Awareness Month is Here

Seattle, WA (PRWEB) April 6, 2004 -– Imagine being struck out of the blue with abdominal cramps so severe they leave you unconscious on the floor. Imagine suffering from diarrhea or constipation so unpredictable and debilitating you plan your daily life around access to bathrooms. Now imagine being told by the doctor who diagnoses you that there is no cure.

If you're one of the 50 million Americans with Irritable Bowel Syndrome, you know exactly how this feels, but odds are you're unaware of much help is now available for you. This April marks the 8th annual IBS Awareness Month, designated to publicize avenues of help for a condition so prevalent that, though rarely talked about, is the leading cause of worker absenteeism after the common cold. IBS affects 15-20 percent of the population, causing abdominal pain and bowel dysfunction. Symptoms arise from a disruption of the gut's nervous system, and that system's interaction with the brain.

For too long, IBS sufferers were dismissed by physicians, ignored by researchers, and given no alternative to suffering in silence. In recent years this situation has changed dramatically, with a rising awareness of the profound differences lifestyle modifications can make. In particular, significant patient self-help avenues such as HelpForIBS.com have been created to offer information, support, and immediate tangible help for Irritable Bowel Syndrome sufferers.

"If you have IBS, you are NOT alone," says HelpForIBS.com founder and CEO Heather Van Vorous. "Living with this disorder does not mean leading a miserable life. There are numerous strategies a person can adopt to help prevent all IBS symptoms, and a happy healthy lifestyle is absolutely possible. Though IBS is still often portrayed as simply the punch line to a joke, it's not a laughing matter to those who suffer, and these people need to hear that their suffering is completely unnecessary."

Though IBS patients report using nearly 300 different types of prescription and over-the-counter medications in unsuccessful attempts to find relief, many are now discovering that non-medical approaches to the disorder are far more effective and safer. Specifically, patients find success with:

* the groundbreaking IBS dietary guidelines and recipes from the book Eating for IBS
* a reduction of stress triggers through gut-directed hypnosis for IBS or yoga practice
* herbal and soluble fiber supplements for specific IBS symptoms and overall GI health
* emotional support via internet IBS message boards and local IBS support groups

Self-help management of IBS has proven so successful that physicians are embracing these approaches, and are referring patients to IBS internet communities such as HelpForIBS.com, hypnotherapists with IBS training, and hometown support groups.

IBS Awareness Month spreads the news that lBS patients are finally being given the lifestyle assistance they need, and not simply a diagnosis. While there is no cure for IBS on the horizon, there are now many healthy ways to successfully manage - and even prevent - all Irritable Bowel Syndrome symptoms.

About HelpForIBS.com
HelpForIBS.com is the largest IBS community on the internet, with over 2 million visits per year and a subscriber list of over 21,000 IBS patients and physicians. HelpForIBS.com is dedicated to serving people with IBS, and their mission is to offer education, support, and help that allows people with Irritable Bowel Syndrome to successfully manage their symptoms through healthy lifestyle modifications. HelpForIBS.com is owned by Heather Van Vorous, an IBS author and a sufferer since age 9. Heather's groundbreaking work in the IBS dietary field has led to her inclusion in Marquis Who's Who in Medicine and Healthcare, has been licensed by Novartis pharmaceuticals, and has been publicized worldwide by physicians, IBS organizations, and patients.

Contact:
Heather Van Vorous
heather@helpforibs.com
http://www.HelpForIBS.com

http://www.prweb.com/releases/2004/4/prweb116856.htm




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Intestinal Gas May Contribute to IBS Symptoms new
      #69120 - 05/10/04 02:29 PM
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Intestinal Gas May Contribute to IBS Symptoms

Intestinal gas and its associated symptoms (eg, bloating, distension, and flatulence) have long been trivialized and dismissed by many medical practitioners. Recent studies examining the relationship between these symptoms and the quality of life of patients with irritable bowel syndrome (IBS) report, however, that patients experience substantial distress because of these symptoms. In fact, patients with IBS often report that, even though they may be able to cope with the abdominal pain, they cannot tolerate the bloating and distension.

In an article in the December 2003 issue of Gut, Eamonn Quigley, MD, discusses the role of intestinal gas in IBS and its relationship to IBS symptoms. Patients with IBS do not appear to produce more gas than do individuals not suffering from IBS. They do appear, however, to suffer from abnormal gas transit, which result in gas retention in the small intestine. This gas retention, combined with visceral hypersensitivity, is likely to cause symptoms (ie, gas retention causes bloating and distension, whereas hypersensitivity causes patients with IBS to experience greater discomfort than is experienced by persons without IBS at the same level of retention). Gas content and transit appear to conspire with the motor and sensory responses of the gut to produce gas-related symptoms in patients with IBS as well as in individuals not suffering from IBS, according to Dr. Quigley.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=939367&specid=13&ok=yes

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Natural History of Irritable Bowel Syndrome new
      #69123 - 05/10/04 02:36 PM
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Natural History of Irritable Bowel Syndrome

H. B. El-Serag; P. Pilgrim; P. Schoenfeld

Background: The natural history of irritable bowel syndrome is unclear, including the likelihood that these patients will be diagnosed with an alternative organic or functional gastrointestinal disorder. Understanding the stability of an irritable bowel syndrome diagnosis may limit repeated diagnostic evaluation among these patients.

Methods: The inclusion criteria included observational longitudinal studies of clinic-based samples of adult patients with irritable bowel syndrome. Only studies published in the English language in full manuscript form were included. Literature searches, selection and review of eligible articles, and data abstraction were performed in a duplicate, independent manner.

Results: Fourteen studies met study selection criteria. In six studies with relevant information, 2-5% of irritable bowel syndrome patients were diagnosed with an alternative organic GI disorder after 6 months to 6 years of follow-up. Long-term follow-up indicated that 2-18% of patients developed worse irritable bowel syndrome symptoms, approximately 30-50% of patients had unchanged symptoms, and the rest either improved or had symptoms disappear. Prior surgery (one study), higher somatic scores (one study), higher baseline anxiety (two studies), depression scores (one study) were predictive of worsening of symptoms during long-term follow-up.

Conclusions: Irritable bowel syndrome, a chronic disorder, is a stable diagnosis. Once initial investigations are negative, fewer than 5% are diagnosed with an alternative organic GI disorder. Repeated diagnostic evaluations of patients with recurrent or persistent symptoms similar to their baseline symptoms are not warranted.

http://www.medscape.com/viewarticle/473351?src=mp

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Moms with Bowel Symptoms Take Baby to Doctor More new
      #73255 - 05/25/04 11:53 AM
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Moms with Bowel Symptoms Take Baby to Doctor More

Tue 25 May, 2004 16:19

By Amy Norton

NEW YORK (Reuters Health) - Mothers with irritable bowel syndrome (IBS) may be more likely than other women to seek a doctor's help when their babies have colds or other common ills, a UK study suggests.

The findings, according to researchers, suggest that learned responses to bodily symptoms early in life could help explain why the children of people with IBS tend to be more affected by bowel symptoms later in life.

IBS is a common disorder in which normal colon function is disrupted, causing symptoms such as abdominal pain, bloating, constipation and diarrhea. Its underlying cause is unclear, and studies show that only some people with symptoms of the condition are affected severely enough to seek treatment.

Why people differ in their reactions to IBS symptoms, and why symptoms interfere with daily life in some individuals but not in others, is unknown, according to Dr. Catherine Crane of the University of Oxford, the new study's lead author.

Previous research has suggested that children whose parents have IBS are both more likely to be taken the doctor as kids and more likely to complain of bowel symptoms as adults, Crane told Reuters Health.

One theory is that these individuals may be particularly sensitive to such symptoms because of the influence of their parents.

The new findings, according to Crane, suggest that differences in how parents respond to their children's illnesses could be part of this learning process.

The study involved 73 mothers who were on medication for bowel symptoms -- mainly IBS -- and 154 mothers with current or past stomach ulcers. The women were asked about their children's illnesses and health problems during their first 18 months of life, and whether they responded by taking the child to the doctor.

The findings are published in the American Journal of Gastroenterology. The researchers found that moms with IBS were more likely than those with stomach ulcers to seek care when their babies had a stuffy nose, cough or accident. Their children did not, however, have higher rates of health problems.

Some past studies have suggested that, as a group, people being treated for problems with bowel function tend to be particularly concerned about the underlying cause of their symptoms, Crane said.

So it's possible that moms with IBS are especially cautious when it comes to their babies' symptoms, she speculated.

But this attention to illness, according to Crane and her colleagues, may be translated to children in such a way that they later become more vulnerable than average to so-called functional disorders, such as chronic back pain and IBS.

"Social learning seems to play a part in the transmission of IBS from one generation to the next," Crane said, "and this study suggests that differences in parental responses to symptoms may be part of this social learning."

That doesn't mean, however, that parents should refrain from taking children to the doctor out of fear of teaching them "illness behavior."

"It is always wise for a parent to seek medical advice if they are concerned about their child's health," Crane noted.

However, she said, this study does suggest there should be more research into how parents' responses to their young children's physical symptoms influence them as they get older.

SOURCE: American Journal of Gastroenterology, April 2004.

http://www.reuters.co.uk/newsArticle.jhtml?type=healthNews&storyID=5251222&section=news

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Biases Affect Treatment of IBS new
      #76356 - 06/04/04 06:45 PM
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Reported June 1, 2004

Biases Affect Treatment

(Ivanhoe Newswire) -- Doctors' stereotypes about certain diseases may keep patients from receiving effective treatment, according to a new study in the British Medical Journal.

Researchers in London gathered 46 general practitioners to discuss treating chronic fatigue syndrome and irritable bowel syndrome. The study's authors say they chose these conditions because both have complex, poorly understood causes and these patients often have symptoms that are difficult to characterize.

The doctors admit they tend to view patients with CFS as having undesirable traits, such as a weaker work ethic or a refusal to play the "sick role," meaning they are seen as not making every effort to get better as quickly as possible. On the other hand, doctors view patients with IBS in a more positive light, giving them credit for "battling through it" or rarely missing work because of the condition.

The researchers say many of the doctors were frustrated by a clear treatment option for chronic fatigue syndrome. One doctor went so far as to say, "I would rather treat a whole surgery full of people with irritable bowel syndrome than people with chronic fatigue."

Previous research has indicated that mental health interventions may be effective for patients with both chronic fatigue syndrome and irritable bowel syndrome who do not respond to symptom management by their primary care doctor. The authors of this study conclude many physicians say they do not consider a referral to a mental health provider because they are unfamiliar with these interventions or they think they're either unnecessary or unavailable.

The researchers suggest these set of beliefs are keeping patients from receiving effective treatment. They write, "To overcome these barriers, doctors must recognize their deeply held beliefs that mediate their understanding of complex disease mechanisms." Such a change in perception, they say, must be supplemented by the establishment of locally available effective interventions.

This article was reported by Ivanhoe.com, who offers Medical Alerts by e-mail every day of the week. To subscribe, go to: http://www.ivanhoe.com/newsalert/.

SOURCE: British Medical Journal, doi:10.1136/bmj.38078.503819.EE, published online May 29, 2004

http://www.ivanhoe.com/channels/p_channelstory.cfm?storyid=8784

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Irritable Bowel Syndrome - An Evidence-Based Approach to Diagnosis new
      #83741 - 06/27/04 01:14 PM
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From Alimentary Pharmacology & Therapeutics

Irritable Bowel Syndrome - An Evidence-Based Approach to Diagnosis

Posted 06/21/2004

B.D. Cash; W.D. Chey

Summary and Introduction
Summary
Irritable bowel syndrome (IBS) represents one of the most common reasons for primary care visits and consultation with a gastroenterologist. It is characterized by abdominal discomfort, bloating and disturbed defecation in the absence of any identifiable physical, radiologic or laboratory abnormalities indicative of organic gastrointestinal disease. IBS is a costly disorder, responsible for significant direct and indirect costs to patients and society. Much of the cost attributed to IBS arises from the time and resources used to establish the diagnosis. Historically IBS has been viewed by many as a diagnosis of exclusion rather than as a primary diagnosis, and many patients with typical symptoms will undergo an extensive array of diagnostic tests and procedures prior to the eventual diagnosis of IBS.

Recent reviews addressing the management of such patients have cast doubt on the necessity for this degree of testing. Current best evidence does not support the routine use of blood tests, stool studies, breath tests, abdominal imaging or lower endoscopy in order to exclude organic gastrointestinal disease in patients with typical IBS symptoms without alarm features. Serological testing for celiac sprue in this population may eventually prove useful but validation of studies indicating an increased prevalence of this disease in patients with suspected IBS is needed.

The development and refinement of symptom-based criteria defining the clinical syndrome of IBS has greatly facilitated the diagnosis of this condition, which can be confidently diagnosed through the identification of typical symptoms, normal physical examination and the exclusion of alarm features. The presence of alarm features or persistent non-response to symptom-directed therapies should prompt a more detailed diagnostic evaluation dictated by the patient's predominant symptoms.

Introduction
Irritable bowel syndrome (IBS) is a chronic gastrointestinal condition characterized by abdominal discomfort, bloating and disturbed defecation. It is considered one of a group of functional gastrointestinal disorders in which a variety of factors including altered motility, abnormal visceral sensation and psychosocial factors interplay to cause symptoms. By definition, IBS is characterized by the absence of any identifiable physical, radiologic or laboratory abnormalities indicative of organic disease. IBS is a common condition, with prevalence estimates ranging between 7 and 24% in women and between 5 and 19% in men in the United States and Britain.[1-3] The symptoms of IBS represent one of the most common reasons for primary care visits, and consultation with a gastroenterologist accounting for 2.4-3.5 million physician visits per year.[1,4] Patients with IBS visit their physicians more frequently than those without IBS for both GI-related and non-GI-related problems, reflecting the increased likelihood of a variety of other conditions such as migraine headache, fibromyalgia and chronic pelvic pain.[5,6]

Based upon these observations, it should come as no surprise that the annual economic consequences of IBS in the United States are substantial. It has been estimated that IBS accounts for $1.7-10 billion in annual direct medical costs in the USA.[7,8] Perhaps more importantly, an additional $10-20 billion in indirect costs, largely resulting from work absenteeism and decreased productivity, has been attributed to IBS.[8,9] These estimates do not include prescription or over the counter-medications for IBS, so it is likely that a substantial portion of these costs may be attributed to the diagnostic testing that is frequently conducted as part of the evaluation of patients with suspected IBS. This paper will examine the current recommendations for the diagnostic evaluation of patients with suspected IBS and will critically review the evidence regarding the yield of various diagnostic tests and procedures that are routinely performed in this group of patients in order to exclude organic disease.




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Section 1 of 5 Next Page: Evidence-Based Medicine Approach to Diagnosis

Click here to read this entire article http://www.medscape.com/viewarticle/481182


B.D. Cash* & W.D. Chey†

*Division of Gastroenterology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA; †Division of Gastroenterology, University of Michigan School of Medicine, Ann Arbor, MI, USA



Aliment Pharmacol Ther 19(12):1235-1245, 2004. © 2004 Blackwell Publishing


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Drug-Free Ways to Treat IBS new
      #88757 - 07/11/04 01:47 PM
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Drug-Free Ways to Treat IBS

DIGESTIVE HEALTH Article Archive

By Greg Arnold, May 4, 2004, Abstracted from "Relieve IBS
Holistically" in the May 2004 edition of Taste for Life Magazine

Irritable bowel syndrome (IBS) is a condition that affects 10 - 25% of the general population. Along with pain and suffering coupled with medical expenses, IBS exacts a toll on social and job-related activities. IBS can be the result of dysfunction in any part of the brain-gut axis in the central nervous system caused by psychological or other factors, abnormal gastrointestinal motility, or heightened
visceral sensations (1).

The most popular method of dealing with IBS is through prescription drugs. Popular prescription drugs include anti-diarrhea drugs, anticholinergic (antispasmodic) drugs, and Tricyclic antidepressants (to provide antidepressive and analgesic properties) (2). But these drugs can take a heavy toll on the liver, with risks outweighing the benefits.

Alternative therapies for IBS have increased in recent years, and the following treatment have demonstrated considerable success:

ACUPUNCTURE. Research on acupuncture's role in alleviating IBS symptoms has shown promise, with one studying showing acustimulation to "significantly increased the threshold of rectal sensation of gas, desire to defecate and pain" as well as reducing rectal sensitivity in IBS patients (3).

HYPNOTHERAPY. Another increasingly popular treatment, hypnotherapy reduces the sensory and motor component of the gastrocolonic response in patients with irritable bowel syndrome. These effects may be involved in the clinical efficacy of hypnotherapy in IBS (4).

PROBIOTICS. One of the most effective ways to help treat IBS is by strengthening the environment where IBS flourishes: the intestines. Probiotics are live, microbial food supplements that benefit the host animal by improving intestinal microbial balance. Their major role in
preventing and treating gastrointestinal disease appears to be from their effect on the immune process, protection against abnormal invasive bacteria, and in the production of short-chain fatty acids from starch and non-starch polysaccharides (5). By introducing healthy
bacteria into the digestive tract, such as acidophilus and bifidus, IBS has less of a chance of being a threat. Although sold as powders and capsules, Probiotics can be found in a variety of foods, including yogurt and kefir.

References:

1. Farhadi A. rritable bowel syndrome: an update on therapeutic modalities. Expert Opinion on Investigational Drugs 2001; 10(7): 1211-22

2. Emedicine website: "Irritable Bowel Syndrome" posted
November 19 , 2003.

3. Xing J. Transcutaneous electrical acustimulation can reduce visceral perception in patients with the irritable bowel syndrome: a pilot study. Alternative Therapy and Health in Medicine 2004; 10(1): 38-42.

4. Simren M. Treatment with hypnotherapy reduces the sensory and motor component of the gastrocolonic response in irritable bowel syndrome. Psychosomatic Medicine 2004; 66(2): 233-8

5. Floch MH. Probiotics, Irritable Bowel Syndrome, and
Inflammatory Bowel Disease. Current Treatment Options in
Gastroenterology 2003; 6(4): 283-288

Contact Mary Tevis [mailto;weeklynews@nowfoods.com]
Visit Citizens for Health, the Consumer Voice for Natural Health.

Copyright 2004 NOW Foods
Physical Address:
395 South Glen Ellyn Rd
Bloomingdale, IL 60108



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Irritable Bowel Syndrome Linked to High Rates of Various Surgeries new
      #88760 - 07/11/04 02:15 PM
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NEW YORK (Reuters Health) - People with irritable bowel syndrome (IBS) -- a disease of unknown origin involving abdominal pain and diarrhea -- are more likely than other people to undergo several types of surgery, including gallbladder removal and appendectomy, a new study shows.
Many of these operations are probably unnecessary, according to a related editorial.

The findings, which appear in the medical journal Gastroenterology, are based on a study of nearly 90,000 subjects who completed medical and lifestyle questionnaires.

Of the six surgeries studied, gallbladder removal, appendectomy, hysterectomy, and back surgery were all significantly more common among IBS patients than among other subjects, note Dr. George F. Longstreth, from Kaiser Medical Center in San Diego, California, and Dr. Janis F. Yao, from the Permanente Medical Group in Pasadena, California.

The strongest link was with gallbladder removal, which was twice as common among patients with IBS as those without the condition.

By contrast, rates for coronary artery surgery and peptic ulcer surgery were similar for subjects with and without IBS, the report indicates.

"Although it is impossible to know how much of the surgical predisposition we identified resulted from misdiagnosis, consideration of our findings with those of other studies suggests that diagnostic error is an important factor," the researchers note.

In a related editorial, Dr. Nicholas J. Talley, from the Mayo Clinic in Rochester, Minnesota, comments that follow-up "data on the indications and outcomes of surgery in IBS is now needed."

He adds that "whether the excess surgery in IBS is cause or effect, unnecessary surgery must be avoided and gastroenterology (doctors) should take responsibility for actions to protect the public."

SOURCE: Gastroenterology, June 2004.

© Reuters 2004. All Rights Reserved.


http://www.reuters.com/newsArticle.jhtml?type=healthNews&storyID=5546266

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Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis new
      #92809 - 07/24/04 01:42 PM
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Gut 2004;53:1096-1101
© 2004 by BMJ Publishing Group Ltd & British Society of Gastroenterology

--------------------------------------------------------------------------------

IRRITABLE BOWEL SYNDROME

Bacillary dysentery as a causative factor of irritable bowel syndrome and its pathogenesis

L-H Wang, X-C Fang and G-Z Pan
Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China


Correspondence to:
Professor G-Z Pan
Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Beijing 100730, The People's Republic of China; pangz2@btamail.net.cn


ABSTRACT
Background and aims: The incidence of irritable bowel syndrome (IBS) or functional bowel disorders (FBD) after bacillary dysentery (BD) has not been extensively evaluated, and little is known of the pathogenesis of post-infective (PI) IBS. Therefore, we investigated the incidence of IBS and FBD in a Chinese patient population who had recovered from BD. To further elucidate its pathogenesis, neuroimmunological changes, including interleukins (IL), mast cells, neuropeptides, and the relationship between mast cells and intestinal nerves, were investigated.

Methods: A cohort study of 295 patients who had recovered from BD (shigella identified from stool in 71.4%) and 243 control subjects consisting of patient siblings or spouses who had not been infected with BD were included in the study. All subjects were followed up using questionnaires for 1–2 years to explore the incidence of FBD and IBS, as defined by the Rome II criteria. In 56 cases of IBS (PI and non-PI) from another source, the number of mast cells in biopsy specimens from the intestinal mucosa were stained with antitryptase antibody and counted under light microscopy. Also, the relationship of mast cells to neurone specific enolase (NSE), substance P (SP), 5-hydroxytryptamine (5-HT), or calcitonin gene related peptide positive nerve fibres was observed using double staining with alcian blue and neuropeptide antibodies. In 30 cases of IBS (PI-IBS, n = 15) taken at random from the 56 cases, expression of interleukin (IL)-1, IL-1ß, and IL-1 receptor antagonist (IL-1ra) mRNAs in intestinal mucosa were identified using reverse transcription-polymerase chain reaction. The above results were compared with 12 non-IBS controls.

Results: In the BD infected cohort, the incidences of FBD and IBS were 22.4% and 8.1% (in total)–10.2% (among those in who shigella were identified) respectively, which were significantly higher (p<0.01) than the incidences of FBD (7.4%) and IBS (0.8%) in the control cohort. A longer duration of diarrhoea (7 days) was associated with a higher risk of developing FBD (odds ratio 3.49 (95% confidence interval 1.71–7.13)). Expression of IL-1ß mRNA in terminal ileum and rectosigmoid mucosa was significantly higher in PI-IBS patients (p<0.01). The number of mast cells in the terminal ileum mucosa in PI-IBS (11.19 (2.83)) and non-PI-IBS patients (10.78 (1.23)) was significantly increased compared with that (6.05 (0.51)) in control subjects (p<0.01). Also, in the terminal ileum and rectosigmoid mucosa of IBS patients, the density of NSE, SP, and 5-HT positively stained nerve fibres increased (p<0.05) and appeared in clusters, surrounding an increased number of mast cells (p<0.01 compared with controls).

Conclusions: BD is a causative factor in PI-IBS. The immune and nervous system may both play important roles in the pathogenesis of PI-IBS.



--------------------------------------------------------------------------------

Abbreviations: BD, bacillary dysentery; FBD, functional bowel disorder; IBS, irritable bowel syndrome; IL, interleukin; IL-1ra, interleukin 1 receptor antagonist; PI, post-infective; RT-PCR, reverse transcription-polymerase chain reaction; NSE, neurone specific enolase; SP, substance P; CGRP, calcitonin gene related peptide; 5-HT, 5-hydroxytryptamine; SA-HRP, streptavidin-horseradish peroxidase; PBS, phosphate buffered saline

http://gut.bmjjournals.com/cgi/content/abstract/53/8/1096

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Irritable Bowel Syndrome Remains a Difficult Condition to Manage new
      #92816 - 07/24/04 02:09 PM
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Irritable Bowel Syndrome Remains a Difficult Condition to Manage

Posted 07/08/2004

Nicholas J. Talley, MD, PhD

Abstract and Introduction
Abstract
Irritable bowel syndrome (IBS) remains challenging to manage, with no universally agreed treatment protocol. Complicating the treatment picture is the placebo response, which can vary from 20% to 70% and can be sustained long term. Results of the most recent meta-analysis on fiber intake suggest that soluble fiber (psyllium, ispaghula, and calcium polycarbophil) is of benefit in alleviating IBS symptoms, while insoluble fiber (corn and wheat bran) is not. A meta-analysis of antispasmodic agents suggests that the use of this class of drugs improves global symptoms in IBS and reduces abdominal pain, but the anticholinergic drugs available in the United States have limited efficacy. Opioid agonists are effective antidiarrheal agents; loperamide is superior to placebo for IBS-associated diarrhea but not other symptoms. Meta-analyses support the efficacy of tricyclic antidepressants, but the efficacy of the selective serotonin reuptake inhibitors is unclear. Tegaserod is efficacious in constipation-predominant IBS in women. Alosetron is efficacious in women with diarrhea-predominant IBS, but side effects limit its use. A number of newer agents are being tested, but which of these will reach the clinical setting remains uncertain.

Introduction
Irritable bowel syndrome (IBS) represents a symptom complex comprising abdominal discomfort or pain associated with disturbed defecation, often coexisting with bloating.[1,2] A number of pathophysiologic abnormalities have been identified in IBS, but the exact cause remains unknown and treatment is largely empirical.[1] IBS is a highly prevalent condition, affecting approximately 10% of US adults, and it can be disabling.[1,2] In part, the disability results from the inability of patients to predict when their symptoms will occur; they may often experience unplanned interruptions to work and home activities because of physical discomfort and shame.

Specific symptom-based criteria, such as the Rome criteria, have been developed for IBS that allow clinicians to make a positive diagnosis, particularly in the absence of red flags, or alarm features, such as weight loss, GI bleeding, or vomiting.[1,2] The American College of Gastroenterology (ACG) Functional Gastrointestinal Disorders Task Force concluded that patients with IBS who present for care typically have impaired quality of life and deserve to be offered treatment; the goal, then, is to improve global symptoms of the condition.[3]

IBS symptoms tend to come and go, which may account for some of the relatively high–and varied–placebo responses observed in clinical trials, ranging from 20% to 70%.[2] Furthermore, in a 12-month trial of alosetron versus placebo, it is striking that the placebo response was maintained for at least 12 months, which is as yet unexplained.[4] However, a clinical trial represents an artificial setting. The efficacy of the placebo response in IBS in clinical practice is unknown and is likely to be substantially lower than that which has been reported in the trials.

Some drugs have a significant place in the management of IBS, although evidence that many of the therapies used are superior to placebo remains lacking.

Dr Talley is professor of medicine and co-director of the Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn.



Drug Benefit Trends 16(6):313-322, 2004. © 2004 Cliggott Publishing, Division of CMP Healthcare Media

http://www.medscape.com/viewarticle/482425?src=mp

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

Reged: 12/09/02
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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
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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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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: 7788
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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.



--------------------------------------------------------------------------------


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
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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
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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? new
      #108487 - 09/26/04 03:25 PM
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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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Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life new
      #112099 - 10/11/04 03:25 PM
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Racial Differences in the Impact of Irritable Bowel Syndrome on Health-Related Quality of Life.
Journal of Clinical Gastroenterology. 38(9):782-789, October 2004.
Gralnek, Ian M MD, MSHS *+++[S]++; Hays, Ron D PhD [//][P]; Kilbourne, Amy M PhD, MPH #**; Chang, Lin MD +++++; Mayer, Emeran A MD +++++
Abstract:
Goals: To compare the impact of irritable bowel syndrome (IBS) on health related quality of life (HRQOI) for non-white and white IBS patients.

Background: There are no reported data evaluating the HRQOL of non-white persons with IBS.

Study: SF-36 scores are compared between non-white IBS patients (n = 166), white IBS patients (n = 707), the general US population, and patients with selected chronic diseases.

Results: Of the n = 166 non-white IBS patients included for analysis, 66 (40%) described themselves as African-American, 56 (34%) as Hispanic, 25 (15%) as Asian-American, 2 (1%) as Native American and the remaining 17 (10%) as "other." Compared with white IBS patients, non-white IBS patients reported similar decrements in their HRQOL after controlling for age, gender, income and education level. On all 8 SF-36 scales, non-white IBS patients had significantly worse HRQOL compared with the general US population, (P < 0.001). Compared with GERD patients, non-white IBS patients scored significantly lower on all SF-36 scales (P < 0.001) except physical functioning. Similarly, non-white IBS patients had significantly worse HRQOL on selected SF-36 scales compared with diabetes mellitus and ESRD patients. Non-white IBS patients had significantly better emotional well-being than depressed patients, (P < 0.001).

Conclusions: Non-white IBS patients experience impairment in vitality, role limitations-physical, and bodily pain. Yet overall, non-white IBS patients report similar HRQOL to white IBS patients. These data provide the first detailed evaluation of the impact of IBS on HRQOL in non-white IBS patients.

(C) 2004 Lippincott Williams & Wilkins, Inc.


http://www.mdlinx.com/GILinx/thearts.cfm?artid=1066771&specid=13&ok=yes

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Clinical Update on the Treatment of Constipation in Adults new
      #112101 - 10/11/04 03:34 PM
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Clinical Update on the Treatment of Constipation in Adults

Rosemary R. Berardi , PharmD, FCCP, FASHP

Behavioral Objectives
After participating in this activity, participants should be better able to:

Define constipation (from clinical research, physician, and patient perspectives), and discuss the impact of poorly controlled constipation on patients and society.
List examples of primary and secondary causes of constipation, and distinguish between the acute, temporary forms and the ongoing, chronic forms of constipation.
Differentiate the efficacy and tolerability profiles and discuss the role of traditional pharmacologic agents used to treat constipation.
Explain the current hypothesis regarding the pathophysiology of chronic constipation, discuss the role of serotonin in normalizing gastrointestinal function, and summarize the role of new and emerging agents in the treatment of patients with chronic constipation.
Identify ways in which pharmacists can assist self-treating patients who report constipation, and describe clinical situations that require referral to a health care practitioner.
Constipation often is regarded simply as a minor annoyance, but, in actuality, the disorder places a substantial burden on patients and society. In some cases, constipation is a temporary problem that can be self-treated. In other instances, however, it is a complex problem that requires the attention of a health care practitioner. Patients and health care practitioners often define constipation differently. Pharmacists are in an ideal position to help bridge this communication gap. This article will (1) provide an overview of the burden that constipation places on society; (2) differentiate key aspects of treatment options; and (3) assist pharmacists in determining when referral or further evaluation is necessary.

To read this entire article, check here....

https://secure.pharmacytimes.com/lessons/200410-01.asp

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Relationship Between Colon Ischemia, Irritable Bowel Syndrome new
      #112114 - 10/11/04 04:15 PM
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From Medscape Gastroenterology

Irritable Bowel Syndrome Expert Column

On the Relationship Between Colon Ischemia, Irritable Bowel Syndrome, and Serotonergic Therapy of Irritable Bowel Syndrome

Posted 09/24/2004

Lawrence J. Brandt, MD

Introduction and Context

The Problem

Colon ischemia and irritable bowel syndrome (IBS) are 2 common gastroenterologic disorders that, until recently, were thought to occur independently in very different populations. We know now, however, that there is a complex association between the 2: (1) colon ischemia appears to be more common in the IBS patient than was recognized previously; and (2) there is concern that the newly developed serotonin receptor agonists or antagonists may increase the risk of colon ischemia, and serotonergic signaling may be abnormal in patients with colitis. This review highlights some of the relationships between colon ischemia, IBS, and therapy for IBS.

IBS -- Pathophysiology and Clinical Presentation
IBS is a disorder that is diagnosed by various symptom-based criteria, such as the Manning, Rome, and Rome II criteria. IBS lacks any biologic, physiologic, structural, or serologic marker, and so diagnosis is symptom-based. Symptoms typically include abdominal discomfort or pain, bloating, diarrhea, fecal urgency, and constipation. Symptoms may change with time, and patients who have diarrhea or constipation as a major part of their illness may evolve to the opposite bowel habit or develop a pattern in which they alternate between the 2. IBS must never be considered as the explanation for rectal bleeding, bloody diarrhea, weight loss, fever, constitutional symptoms, or anemia, and in the presence of these "alarm" symptoms or signs, organic disease must be excluded using conventional stool tests, endoscopic, and radiologic examinations. For the IBS patient without alarm symptoms, the routine use of these tests is not recommended, although for patients with IBS and diarrhea, serologic testing for celiac sprue may be appropriate and cost-effective.[1,2] Of course, screening tests for colon cancer are recommended for all patients 50 years of age or older, including those with IBS.

Colon Ischemia -- Pathophysiology and Clinical Presentation
Colon ischemia generally presents in individuals older than 55 years, a population considerably older than that typically affected by IBS. The known causes of colon ischemia are many, but in the usual case, no definitive cause is found; most episodes of colon ischemia are thought to be caused by brief periods of localized nonocclusive ischemia. The acute onset of mild, lower abdominal pain accompanied or followed by diarrhea, rectal bleeding, or bloody diarrhea is typical. Most patients with colon ischemia have spontaneous resolution of symptoms within several days. Computed tomography of the abdomen usually shows segmental thickening of the colon, although this is not a specific finding. Colonoscopy, if performed within the first 24-48 hours, usually will show submucosal hemorrhage or edema in a segmental pattern (ischemic colopathy). If the examination is repeated within a few days after the onset of symptoms, it will show the disease process to have evolved into a segmental (ischemic) colitis pattern with ulceration and even pseudopolyp formation, an appearance that may mimic inflammatory bowel disease or infectious colitis; biopsy usually is nonspecific, with only infarction and ghost cells pathognomonic of ischemic injury. In general, mesenteric angiography is not used to evaluate patients suspected of having colon ischemia, because by the time of presentation, colonic blood flow usually has normalized.

It is important for primary care practitioners to be aware of colon ischemia because it is a common cause of bloody diarrhea in the elderly and can be seen in patients of all ages, especially those who have a coagulation disorder, systemic illness associated with vasculitis, or those with IBS. Moreover, colon ischemia can mimic or be mimicked by infectious colitis or inflammatory bowel disease. Most patients who develop colon ischemia do well with conservative management. For the patient who continues to have symptoms for more than 2 weeks, referral to a gastroenterologist is recommended because it is likely that these individuals will have a complicated course.




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Section 1 of 6 Next Page: Issues in Epidemiology

Read this entire article here http://www.medscape.com/viewarticle/488174?src=mp


Lawrence J. Brandt, MD, Chief of Gastroenterology, Montefiore Medical Center, Bronx, New York; Professor of Medicine and Surgery, Albert Einstein College of Medicine, Bronx, New York


Disclosure: Lawrence J. Brandt, MD, has served as an advisor or consultant for Novartis, GlaxoSmithKline, Solvay, and TAP. He has also disclosed he is on the speakers bureau for AstraZeneca.

Medscape Gastroenterology 6(2), 2004. © 2004 Medscape






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Stress Therapy Can Help Irritable Bowel new
      #115470 - 10/24/04 07:38 PM
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Stress Therapy Can Help Irritable Bowel

Don't Just Put Up With Symptoms; Treatments Can Improve Life Quality

By Jeanie Lerche Davis

Reviewed By Brunilda Nazario, MD
on Monday, September 13, 2004

Sept. 13, 2004 -- Tense, tired, depressed: For people with irritable bowel syndrome (IBS), dealing with their disease takes a mental and physical toll. Emotional state and energy level -- not just bowel problems -- need a doctor's attention, a new study shows.

Many doctors do a poor job of addressing their patients' fears and concerns and understanding how quality of life is affected, writes lead researcher Brennan M.R. Spiegel, MD, MSHS, a gastroenterologist with The David Geffen School of Medicine at UCLA and the VA Greater Los Angeles Healthcare System.

His paper appears in the latest Archives of Internal Medicine.

"There's a disconnect between how patients and doctors view the disease," Spiegel tells WebMD. "Doctors are trained to think about bowel movements -- their frequency, their color, texture. But this study shows that our patients feel we are underestimating the severity of the effect on their quality of life."

It's very clear that IBS can reduce quality of life, he adds. "It causes what we refer to as 'vital exhaustion' -- loss of vitality, sleep disorders, sexual dysfunction, feeling tired all the time, dispirited, low energy -- all the things that interfere with quality of life."

Picture of Health

Spiegel has developed a quality-of-life survey that busy doctors can use. He used the survey on 770 patients with irritable bowel syndrome. Each completed the questions: Do you feel low in energy? Nervous? Hopeless? Tense? Tire easily? Have sleep difficulties? Not interested in sex? Feel there is something seriously wrong with your body? They also answered questions related to their bowel problems.

Physical health-related quality of life is related to the severity of bowel problems, frequency, and pain, he explains. But mental health-related quality of life is related to sexuality, mood, and anxiety.

His study showed that how patients felt physically and mentally affected their quality of life. Patients who got tired easily had a 9% lower physical health-related quality-of-life score, compared with those who didn't tire easily. Patients whose symptoms flared up for a day had a 4% lower physical health-related quality-of-life score. If they had both problems, they lost 13% in quality-of-life scores.

Mental health had a similar impact; patients who felt tense had a 14% lower mental health-related quality of life. When their IBS symptoms interfered with their sexual function, they had a 4% lower mental health-related quality of life. For those who had both problems, their mental health-related quality of life was 17% lower.

"We have to spend some time talking about these emotional issues," Spiegel tells WebMD. "Sometimes, all that's necessary is letting a patient know it's not cancer, that it will not cause cancer. That in itself can help relieve the depression and anxiety."

Stress Therapy, Medications Help

Many people put up with symptoms of IBS without getting treatment. "Yet the quality-of-life impact of IBS has been shown to be comparable to congestive heart disease and may be as great as diabetes," says William E. Whitehead, PhD, director of the Center for Functional GI and Motility Disorders Center at the University of North Carolina School of Medicine.

"The anxiety and stress can impact how well a patient interacts with friends and family," he tells WebMD. "Also, work absenteeism is three times higher for irritable bowel patients, compared to rest of the population."

There are a range of effective treatments for irritable bowel, says Whitehead. "Treatments range from low doses of antidepressants, hypnosis, [stress] therapy to dietary changes, medicines for constipation and diarrhea, a whole spectrum of treatments."

It's true that "with IBS one symptom can make other symptoms seem worse," says Ryan Madanick, MD, a gastrointestinal specialist at the University of Miami School of Medicine. "It's like when you're under stress, you tend to respond more negatively to stimuli that don't normally cause you problems, they irritate you. With IBS, it seems to be the same thing going on in the intestine.

"Antidepressants and anti-anxiety medications probably help the most, because unfortunately stress-related disorders and IBS go hand in hand," Madanick tells WebMD. "If you can decrease the stress, you're breaking the cycle and improving overall quality of life."

Also, make regularly scheduled visits for irritable bowel problems, not visits on an emergency basis, he advises.


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SOURCES: Spiegel, B. Archives of Internal Medicine, Sept. 15, 2004; vol 164: pp 1773-1780. Brennan M.R. Spiegel, MD, MSHS, gastroenterologist, The David Geffen School of Medicine, UCLA, and the VA Greater Los Angeles Healthcare System. William E. Whitehead, PhD, director, Center for Functional GI and Motility Disorders, University of North Carolina School of Medicine. Ryan Madanick, MD, gastrointestinal specialist, University of Miami School of Medicine.


http://content.health.msn.com/content/article/94/102633.htm?pagenumber=2

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Obesity is Associated With Increased Risk of Gastrointestinal Symptoms new
      #115473 - 10/24/04 07:42 PM
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From The American Journal of Gastroenterology

Obesity is Associated With Increased Risk of Gastrointestinal Symptoms: A Population-Based Study

Posted 09/23/2004

Silvia Delgado-Aros, M.D., Ph.D.; G. Richard Locke, III, M.D.; Michael Camilleri, M.D.; Nicholas J. Talley, M.D., Ph.D.; Sara Fett, B.S.; Alan R. Zinsmeister, Ph.D.; L. Joseph Melton, III, M.D

Abstract and Introduction
Abstract
Objectives: Perception of sensations arising from the gastrointestinal tract may be diminished in obese subjects and thus facilitate overeating. Alternatively, excess food intake may cause gastrointestinal (GI) symptoms in obese patients. We evaluated the relationship between body mass index (BMI) and specific GI symptoms in the community.
Methods: Residents of Olmsted County, MN were selected at random to receive by mail one of two validated questionnaires. The association of reported GI symptoms with BMI (kg/m2) was assessed using a logistic regression analysis adjusting for age, gender, psychosomatic symptom score, and alcohol and tobacco use.
Results: Response rate was 74% (1,963 of 2,660). The prevalence of obesity (BMI >/= 30 kg/m2) was 23%. There was a positive relationship between BMI and frequent vomiting (p = 0.02), upper abdominal pain (p = 0.03), bloating (p = 0.002), and diarrhea (p = 0.01). The prevalence of frequent lower abdominal pain, nausea, and constipation was increased among obese (BMI >/= 30 kg/m2) compared to normal weight participants, however, no significant association was found between BMI and these symptoms.
Conclusions: In the community, increasing BMI is associated with increased upper GI symptoms, bloating, and diarrhea. Clarification of the cause-and-effect relationships and the mechanisms of these associations require further investigation.

Introduction
Obesity has reached epidemic proportions. Data from the National Center for Health Statistics show that 64.5% of the U.S. population of age 20 or above is overweight (body mass index, BMI >/= 25 kg/m2), and 31% is clinically obese (BMI >/= 30 kg/m2).[1] Obesity has a substantial impact on morbidity[2-8] and on the quality of life of these individuals, who have a poorer general health perception and daily functioning.[9,10] Obesity induces an enormous psychological burden.[11,12]

There are many factors involved in the development of obesity including environmental, psychological, and social factors as well as physiological mechanisms. Most of these mechanisms and their interactions are not fully understood.[13-16]

Dysregulation of the mechanisms that control food intake and energy expenditure is a key to the development of obesity. The gastrointestinal (GI) tract is a source of satiation factors, which contribute to meal termination, and hence determine meal size.[17-20] A decreased satiation response to food intake may play a role in the development of obesity.[21,22]

In contrast to the observation of decreased satiation in obese individuals, an increased prevalence of different GI symptoms has been reported in obese patients seeking treatment in a tertiary care center compared to community controls.[23] However, obese patients seeking treatment may not be representative of obese individuals in the community.

We have previously reported that BMI is an independent risk factor for the presence of self-reported heartburn and regurgitation in a community-based population in the United States.[24] Although BMI was not found to be associated with irritable bowel syndrome (IBS) in another study,[25] the relationship between BMI and other GI symptoms has not previously been explored in the community.

If perception of satiation signals arising in the gut is reduced in obesity, one could entertain the hypothesis that perception of other sensations originated from the GI tract would be similarly reduced in obese individuals. An exception to this hypothesis would be the association between obesity and GERD symptoms, for which a mechanistic role (i.e., hiatal hernia) is assumed to be the cause of the symptoms. An alternative hypotheses is that excess food intake could lead to responses that increase GI symptoms.

In this study, we aimed to evaluate the relationship between BMI and specific GI symptoms, other than heartburn and regurgitation, in a community-based population.




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Section 1 of 4 Next Page: Methods


Silvia Delgado-Aros, M.D., Ph.D., G. Richard Locke, III, M.D., Michael Camilleri, M.D., Nicholas J. Talley, M.D., Ph.D., Sara Fett, B.S., Alan R. Zinsmeister, Ph.D., and L. Joseph Melton, III, M.D, Clinical Enteric Neuroscience Translational & Epidemiological Research (C.E.N.T.E.R.) Program; and Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota



Am J Gastroenterol 99(9):1801-1806, 2004. © 2004 Blackwell Publishing

To continue reading this article click here http://www.medscape.com/viewarticle/489428_2


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Obese Women Face Higher Risk of Colorectal Cancer new
      #120111 - 11/08/04 04:48 PM
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Source: American College of Gastroenterology (ACG) Released: Tue 26-Oct-2004, 10:00 ET


Obese Women Face Higher Risk of Colorectal Cancer

New study findings show a high body mass index (BMI) among women is a more significant risk factor for colorectal neoplasia than for men.



Newswise — New study findings show a high body mass index (BMI) among women is a more significant risk factor for colorectal neoplasia than for men. According to data released today at the 69th Annual Scientific Meeting of the American College of Gastroenterology, researchers from Stony Brook University found a positive correlation between increased body mass index (BMI) and the risk of colorectal neoplasia among asymptomatic women who underwent colonoscopies.

The researchers examined a population of 2300 patients, including 1250 men and 1050 women. Overall, their findings reveal that increasing BMI is associated with higher risk of significant colorectal neoplasia. This effect was shown to be statistically significant in women but not men.

The researchers divided the women into several groups based on BMI and evaluated whether their screening tests detected large polyps or multiple polyps, high grade dysplasia (a precancerous change in the colon) or cancer. Women who had a BMI of 40 (considered obese) or more were 5.2 times as likely to have significant colonic neoplasia detected during colonoscopy as women with a BMI of 25 or less (considered healthy weight) while controlling for smoking, age, alcohol use and family history of colorectal cancer.

Explaining the disparity in the findings between men and women, Joseph C. Anderson, M.D., one of the Stony Brook investigators, said, "We use body mass index as a surrogate measure for body fat. It may be that for men and women with similar BMI, women have less muscle than men. This needs to be explored further." According to Dr. Anderson, the implications of this study are important for physicians counseling overweight and obese women about colorectal cancer screening in light of their increased risk.

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© 2004 Newswise. All Rights Reserved.

http://www.newswise.com/articles/view/507863/?sc=wire

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Symptom patterns in functional dyspepsia and irritable bowel syndrome new
      #125858 - 11/28/04 02:34 PM
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Gut 2004;53:1445-1451
© 2004 by BMJ Publishing Group Ltd & British Society of Gastroenterology

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IRRITABLE BOWEL SYNDROME

Symptom patterns in functional dyspepsia and irritable bowel syndrome: relationship to disturbances in gastric emptying and response to a nutrient challenge in consulters and non-consulters

S Haag1, N J Talley2 and G Holtmann1

1 Department of Internal Medicine, Division of Gastroenterology and Hepatology, University Hospital Essen, Hufelandstr 55, D-45122 Essen, Germany
2 Mayo Clinic, College of Medicine, Rochester, MN, USA

ABSTRACT
Background: Our aim was to assess the relationship between gastric motor and sensory function and symptom patterns in community subjects and patients with functional dyspepsia (FD) or irritable bowel syndrome (IBS).

Methods: We recruited 291 asymptomatic blood donors, 151 symptomatic blood donors (recurrent abdominal pain or discomfort), and 40 patients with FD or IBS. Abdominal symptoms were assessed using the bowel disease questionnaire (BDQ) and, in addition, the most bothersome symptom complex identified (dysmotility-type, ulcer-type dyspepsia, or IBS). Gastric emptying time (GET (t1/2, min)) was measured by 13C-octanoic breath test and a nutrient challenge performed. Twenty randomly selected asymptomatic blood donors, 48 symptomatic blood donors (30 FD, 18 IBS), and 40 patients (23 FD, 17 IBS) had additional function testing.

Results: GET (t1/2) was significantly (p<0.05) longer in blood donors with FD symptoms (99 (6) min) and FD patients (110 (12) min) compared with asymptomatic controls (76.7 (7) min), but was not significant in IBS blood donors or patients. Overall, 25 of 48 blood donors with symptoms and 18 of 40 patients had slow gastric emptying. GET was most delayed in subjects with predominantly dysmotility-type symptoms (167 (36) min v controls; p<0.01). Symptom intensities after a nutrient challenge were significantly higher in FD patients and symptomatic blood donors compared with asymptomatic controls; 14 of 48 blood donors with symptoms and 16 of 40 patients had a symptom response to the nutrient challenge exceeding the response (mean (2SD)) of healthy asymptomatic controls.

Conclusion: Gastric emptying and the global symptom response to a standardised nutrient challenge are abnormal in population based (non-health care seeking) subjects with dyspepsia.

http://gut.bmjjournals.com/cgi/content/abstract/53/10/1445

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Advances in the Treatment of Chronic Constipation new
      #125864 - 11/28/04 02:55 PM
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From Medscape Gastroenterology

Expert Interview

Advances in the Treatment of Chronic Constipation: An Expert Interview With Lawrence R. Schiller, MD

11/10/2004

Editor's Note:
Chronic constipation is a common clinical problem. It generally refers to unsatisfactory defecation, as defined in terms of alterations in the frequency, size, consistency, and ease of passage of stool. Although reports of prevalence vary depending on whether estimates are derived from self-reports or are based on the Rome criteria, chronic constipation accounts for approximately 2.5 million physician visits each year in the United States. Medscape spoke with Lawrence R. Schiller, MD, Program Director, Gastroenterology Fellowship, Baylor University Medical Center, Dallas, Texas, to discuss the clinical impact of this problem upon the patient and the healthcare industry alike, and the current challenges facing the physician treating the patient with chronic constipation.

Medscape: Although physicians generally relate constipation with decreased stool frequency, patients often apply this term to a number of defecatory complaints. How would you clinically define chronic constipation and how does the multiple-symptom nature of this disorder affect the healthcare industry?

Dr. Schiller: The definitions that really matter are the ones that individual patients have for this group of defecation problems. Physicians must take the time to understand what the patient means by the complaint of "constipation." The main features that patients describe in their definitions include altered consistency ("hard" or "lumpy" stools), small stool size (diameter or volume), and infrequency of defecation. It is important to realize that these changes are relative to the patients' usual habits, and are not necessarily those cited in published criteria. In addition, a variety of coexisting symptoms, such as bloating, abdominal distension, and discomfort or pain, influence patients when they report the symptom of "constipation" to their physicians.

The diverse nature of patients' definitions makes the study of constipation and its treatment difficult. To introduce some uniformity to the definition of constipation for research purposes, the Rome II committee has set forth criteria for a diagnosis of chronic functional constipation. These criteria include a chronicity definition (at least 3 months' duration) and 2 or more specific alterations in defecation occurring at least 25% of the time (fewer than 3 bowel movements per week, hard or lumpy stools, straining with evacuation, a sensation of incomplete evacuation, a sense of anorectal obstruction, and the use of manual maneuvers to assist defecation). In addition, criteria for irritable bowel syndrome are not present. Operationally, this means that abdominal pain is not a prominent symptom. It is important to realize that patients who complain of chronic constipation may or may not meet these criteria. To the extent that they do, they will behave like other patients who meet criteria and have been studied in research projects. Patients who do not meet these specific criteria may still respond to treatments for constipation, but with less certainty.

The impact of constipation on the healthcare system is substantial. Patients presenting with chronic constipation require at least some evaluation. The variety of presenting symptoms may cause excessive evaluation if the physician does not recognize the connected nature of these complaints.

Medscape: What can you tell us about patients' overall satisfaction with the traditionally available treatment options (bulking agents, laxatives) for chronic constipation?

Dr. Schiller: Last spring a consumer panel of more than 37,000 Americans selected to be representative of the US population was queried about chronic constipation.[1] Over 24,000 individuals consented to be questioned and 4680 (19%) had 2 or more Rome II symptoms of chronic constipation. A total of 1147 respondents had sought medical attention for constipation in the previous year and of these, 557 were not diagnosed as having irritable bowel syndrome with constipation or some other gastrointestinal disease-causing constipation. Only 4% of these patients had never been treated with over-the-counter or prescription drugs; 80% had tried over-the-counter remedies and 35% had tried prescription drugs.

Only half of the respondents were satisfied with their current treatments. Lack of efficacy was the reason for dissatisfaction cited by 82% of those unhappy with their therapy. Major problems with efficacy included both the agents not working well enough as well as inconsistency of results. Sixteen percent of respondents cited side effects as the reason that they were dissatisfied with the results of treatment.

When asked about the effect of specific products on quality of life, 64% of individuals were dissatisfied with fiber, 68% were dissatisfied with over-the-counter laxatives, and 44% were dissatisfied with prescription laxatives. Thus, from the patients' viewpoints, there was plenty of room for improvement in the treatment of constipation.

Medscape: A study presented during the 69th Annual Meeting of the American College of Gastroenterology assessed the primary care physician's perception of the clinical impact of chronic constipation as a medical condition and looked at its effect on patients' lives as well as physicians' impressions of the current therapeutic armamentarium. What can you tell us about this study, and what were the key findings with respect to the physicians' vs patients' perceptions regarding the clinical impact and unmet medical needs in this setting?

Dr. Schiller: In April 2004, approximately 8000 primary care physicians listed in an American Medical Association database were contacted about participating in a survey about constipation; 461 were screened for eligibility. The main eligibility criteria were being board-certified or board-eligible in family practice or internal medicine, having been in practice for 2-40 years, spending 75% or more of the time in clinical practice, and treating 5 or more patients with constipation each week. Three hundred and eleven eligible physicians then completed a 37-question survey administered by trained interviewers.[2]

Physicians reported that their typical patients had symptoms for 2-3 years, but 17% had typical patients with symptoms for 10 or more years. Two thirds of the physicians reported that their typical patients had 1-2 bowel movements per week.

The vast majority of physicians felt that constipation was at least somewhat severe as a medical condition (83%), was at least somewhat bothersome (98%), and had at least some impact on their patients' quality of life (95%). Physicians reported that abdominal discomfort or pain, straining, bloating, and hard stools were at least as important as infrequency of defecation as causes of severity, "bothersomeness," and decreased quality of life. Gas, the sensation of incomplete evacuation, rectal pain, and urgency were also cited as problematic for patients with constipation.

Surveyed physicians believed that worsening symptoms, frustration with symptom control, and frustration with current treatment were the main reasons that patients consulted with them for constipation. Most of these physicians were dissatisfied with the ability of fiber products (58%) and over-the-counter laxatives (63%) to improve quality of life in these patients. Even existing prescription laxatives were unsatisfactory in the opinion of 42% of the physicians surveyed; 90% wished that there were better treatment options for these patients.

Thus, while most physicians view constipation as an important medical problem for their patients, they are dissatisfied with the available treatments and wish that they had better therapeutic options for these patients.

Medscape: Results of a survey conducted to examine the prevalence of constipation, the symptoms that patients include in their description of constipation, and patients' satisfaction with the current treatment options were also presented during this year's meeting. What can you tell us about this study and what were the key findings?

Dr. Schiller: The prevalence of chronic constipation has been estimated to be as high as 28% of the adult population in the United States, based on a number of surveys over the years, as recently reviewed by Higgins and Johanson.[3] To reexamine the prevalence of this condition using modern definitions of constipation and its symptoms, we took advantage of an existing large panel of consumers selected to be representative of the US population who regularly participate in Internet-based surveys.[1] Of the 37,000 individuals in this panel, 24,090 consented to be questioned about their bowel habits. A total of 4680 of these individuals (19%) met Rome II criteria for functional constipation: experiencing 2 or more symptoms (fewer than 3 bowel movements per week, hard or lumpy stools, straining with evacuation, a sensation of incomplete evacuation, a sense of anorectal obstruction, and the use of manual maneuvers to assist defecation) more than 25% of the time for at least 3 months. This estimate of prevalence is very much in keeping with older estimates in the literature.

We next looked at the 1147 of these individuals who sought attention from a physician for constipation during the last year. About half of these subjects were diagnosed as having some gastrointestinal disease or irritable bowel syndrome that was causing their constipation, leaving a pool of 557 participants with "functional constipation" who were queried in more detail about their symptoms.

The percentages of men and women in this select group were nearly identical to those in the pool of 24,090 who consented to enter the study (56% women and 44% men), indicating that the prevalence of constipation was roughly equal between the sexes. There was an enhancement in the proportion of older individuals in the select constipation group (27% vs 17% >/= 65 years of age), suggesting that constipation is more common in the elderly.

A majority of the respondents (72%) reported that they had constipation for 5 years or less, but 21% described symptoms that lasted 10 years or longer. Half of respondents reported having 2 or fewer bowel movements per week, but the other half had 3 or more bowel movements per week, a "normal" stool frequency. Straining during evacuation was the most common defining symptom (reported by 77%), followed by lumpy or hard stools (73%), sensation of incomplete evacuation (58%), fewer than 3 bowel movements per week (47%), and the sensation of blocked defecation (40%).

Constipation degraded quality of life, with 52% of respondents claiming that it had at least some impact on their lives; 12% of those employed or going to school missed time from work or class because of constipation symptoms.

Almost all of the respondents (96%) had tried some treatments for constipation, with 80% having tried over-the-counter remedies and 35% having used prescription drugs for constipation. Yet only 53% of individuals were completely satisfied with their treatment. Those respondents who were dissatisfied cited ineffectiveness and inconsistency of effect as the main reasons for their unhappiness; 16% cited side effects as the reason for their dissatisfaction. These results suggest that a substantial proportion of patients with constipation want and need better treatments.

Medscape: Were there any other data presented during the meeting that would help put this information into clinical context? Also, how do you view the path forward in terms of the treatment of chronic constipation?

Dr. Schiller: There were several other studies presented during this year's meeting of the American College of Gastroenterology that addressed chronic constipation.

An analogous population survey conducted in Canada[4] showed very similar findings as the US patient survey mentioned above, although the prevalence rates for lower gastrointestinal tract symptoms were somewhat lower than in the US study. Important to note is that a large proportion of Canadians with constipation were dissatisfied with their therapies.

A survey of constipated patients in Alabama addressed a problem not covered in our study (discussed above) -- the problem of medication-associated constipation.[5] Of 329 subjects with self-reported constipation, 195 (59%) were taking drugs associated with constipation, such as antidepressants, pain medications, and calcium-channel blockers. Clearly, clinicians must take a careful drug history when evaluating patients with constipation.

Another study looked at bloating and gaseousness in patients with functional constipation or irritable bowel syndrome with constipation.[6] Lower abdominal bloating was present in 90% of the patients in this study. Constipated patients with lower abdominal bloating were likely to have upper abdominal bloating as well. There were only modest associations with belching and flatulence in the constipated patients.

Several reports highlighted the impact of constipation on healthcare utilization. Using the California Medicaid database, healthcare expenses during the period around a first physician encounter for constipation were compiled.[7] Gastrointestinal-related procedures and laboratory tests accounted for most of the $18 million spent over 15 months on 76,854 individuals. Nearly 0.6% of these patients were hospitalized for constipation. This somewhat surprising statistic was confirmed in another study that documented over 38,000 admissions primarily for constipation, nationally.[8] Of course, most physician encounters with patients for constipation occur in the outpatient or emergency room setting; more than 5.7 million constipation-related visits occurred in outpatient venues in 2001 according to another study abstract.[9]

The impact of constipation on quality of life was addressed in a study involving patients with refractory constipation.[10] SF-36 questionnaires were administered to 31 patients with constipation who were referred to a pelvic floor laboratory and showed significantly lower quality-of-life scores than healthy controls. Work productivity and activity impairment was demonstrated in a subanalysis of our patient survey data.[11]

A systematic review of traditional therapy for chronic constipation pointed out the lack of evidence to support most currently used treatments.[12] The ineffectiveness of current treatments was examined in a study of 1660 HMO (health maintenance organization) patients, 334 of whom met Rome II criteria for functional constipation.[13] These patients had less improvement than patients with other functional bowel disorders when treated with therapies that included diet changes, exercise, reducing life-stress, laxatives, and antispasmodics.

It is fairly clear from these reports that clinicians need to do a better job in treating chronic constipation so that we can improve our patients' quality of life and reduce losses in productivity and healthcare-related expenses. Fortunately, new agents are being developed and introduced that make these goals feasible. For example, tegaserod has recently been approved by the US Food and Drug Administration for the treatment of chronic constipation in men and women. Studies have shown that this agent improves constipation symptoms in significantly more patients than placebo and is well tolerated by most patients with chronic constipation. Tegaserod works by stimulating peristalsis via its effects on 5-HT4 receptors in the enteric nervous system. Because slow transit is the mechanism underlying most cases of constipation, tegaserod provides targeted therapy. I expect that additional drugs that target other physiologic activities of the gut will eventually allow us to provide satisfactory results for more patients with chronic constipation.


References
Schiller LR, Dennis E, Toth G. An Internet-based survey of the prevalence and symptom spectrum of chronic constipation. Am J Gastroenterol. 2004;99:S234. [Abstract #723]
Schiller LR, Dennis E, Toth G. Primary care physicians consider constipation as a severe and bothersome medical condition that negatively impacts patients' lives. Am J Gastroenterol. 2004;99:S234. [Abstract #724]
Higgins PD, Johanson JF. Epidemiology of constipation in North America: a systematic review. Am J Gastroenterol. 2004;99:750-759.
Hunt R, Dhaliwal S, Tougas G, et al. Lower GI symptoms: A Canadian prescriptive drug study assessing prevalence, impact, and satisfaction with treatments. Am J Gastroenterol. 2004;99:S227. [Abstract #703]
Rutland TJ, Adeniji OA, Di Palma JA. Prevalence of medication-associated constipation. Am J Gastroenterol. 2004;99:S103. [Abstract #320]
Williams M, Wessinger S, Soanier J, et al. Bloating and gaseousness in healthy subjects and patients with constipation. Am J Gastroenterol. 2004;99:S287. [Abstract #879]
Singh G, Kahler K, Bharathi V, et al. Adults with chronic constipation have significant health care resource utilization and costs of care. Am J Gastroenterol. 2004;99:S227. [Abstract #701]
Martin BC, Barghout V. National estimates of constipation-related hospitalizations in the United States. Am J Gastroenterol. 2004;99:S244. [Abstract #753]
Martin BC, Barghout V. National estimates of office and emergency room constipation-related visits in the United States. Am J Gastroenterol. 2004;99:S244. [Abstract #754]
Robson K, Barrett R, Liberman RF. Psychological profiles and quality of life in patients with refractory constipation. Am J Gastroenterol. 2004;99:S278. [Abstract #852]
Bracco A, Kahler K. Burden of chronic constipation must include estimates of work productivity and activity impairment in addition to traditional healthcare utilization. Am J Gastroenterol. 2004;99:S233. [Abstract #719]
Ramkumar DP, Rao SS. Systematic review: the efficacy and safety of traditional medical therapies for chronic constipation. Am J Gastroenterol. 2004;99:S278. [Abstract #853]
Palsson OF, Whitehead WE, Levy RL, et al. Constipation less effectively treated than other functional bowel problems in a health maintenance organization (HMO). Am J Gastroenterol. 2004;99:S287. [Abstract #878]



Disclosure: Lawrence R. Schiller, MD, has disclosed that he has received grants for clinical research from GlaxoSmithKline, Procter & Gamble, and Novartis, and has received grants for educational activities from AstraZeneca, Procter & Gamble, and TAP Pharmaceuticals. He has served as an advisor or consultant for Salix Pharmaceuticals, Novartis, McNeil, and Boehringer Ingelheim. He has also served on the Speaker's Bureau for AstraZeneca, Procter & Gamble, Novartis, and TAP Pharmaceuticals.

Medscape Gastroenterology 6(2), 2004. © 2004 Medscape

http://www.medscape.com/viewarticle/492110?src=mp

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Complementary and alternative medicine in gastroenterology new
      #131895 - 12/20/04 01:16 PM
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Clin Gastroenterol Hepatol. 2004 Nov;2(11):957-67.

Complementary and alternative medicine in gastroenterology: the good, the bad, and the ugly.

Koretz RL, Rotblatt M.

Department of Medicine, Olive View--UCLA Medical Center, Sylmar, California 91342, USA. rkoretz@ladhs.org

A large proportion of the American population avails itself of a variety of complementary and alternative medicine (CAM) interventions. Allopathic practitioners often dismiss CAM because of distrust or a belief that there is no sound scientific evidence that has established its utility. However, although not widely appreciated, there are thousands of randomized controlled trials (RCTs) that have addressed the efficacy of CAM. We reviewed the RCTs of herbal and other natural products, acupuncture, and homeopathy as examples of typical CAM modalities, focusing on conditions of interest to gastroenterologists. Peppermint (alone or in combination) has supportive evidence for use in patients with dyspepsia, irritable bowel syndrome, and as an intraluminal spasmolytic agent during barium enemas or endoscopy. Ginger appeared to be effective in relieving nausea and vomiting due to motion sickness or pregnancy. Probiotics were useful in childhood diarrhea or in diarrhea due to antibiotics; one particular formulation (VSL#3) prevented pouchitis. Acupuncture appeared to ameliorate postoperative nausea and vomiting and might be useful elsewhere. There is even a suggestion that homeopathy has efficacy in treatment of gastrointestinal problems or symptoms. The major problem in interpreting these CAM data is the generally low quality of the RCTs, although that quality might not be different compared to RCTs in the general medical literature. Gastroenterologists should become familiar with these techniques; it is likely that their patients already are.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15551247

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Link Between Irritable Bowel Syndrome (IBS), Alcoholism and Mental Illness new
      #131896 - 12/20/04 01:24 PM
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Friday, November 05, 2004

Mayo Clinic Researchers Find Link Between Irritable Bowel Syndrome (IBS), Alcoholism and Mental Illness

ROCHESTER, Minn. -- Mayo Clinic researchers have found evidence to suggest a common genetic link between irritable bowel syndrome, alcoholism and mental illness. The results of this study are being presented on Monday at the 69th Annual Scientific Meeting of the American College of Gastroenterology (ACG) in Orlando, Fla.

In previous work, this research team found that IBS runs in families. Alcoholism and mental illness run in families as well. The team was interested in knowing if alcoholism and mental illness were more common in family members of people who have IBS. G. Richard Locke, M.D., senior author of the research and a Mayo Clinic gastroenterologist, says the findings point researchers closer to finding a specific therapy to help families who have these conditions. IBS is estimated to be present in 10 to 20 percent of the general population, according to the International Foundation for Functional Gastrointestinal Disorders. MayoClinic.com reports that IBS typically begins around age 20. Overall, two to three times as many women as men have the condition.

"This work confirms what doctors see every day in our patients," says Dr. Locke. "People who have IBS often have mental illness and alcoholism in their families."

Specifically, the Mayo Clinic researchers found that people who have IBS but who do not drink are more likely to have a family history of alcoholism or mental illness. "Our thinking is that there is a common gene that can manifest itself as IBS, alcoholism or mental illness in a family member, so a person who chooses not to drink is more likely to have IBS," says Dr. Locke.

Others who conducted research from Mayo Clinic in Rochester are: James Knight, Alan Zinsmeister, Ph.D., Cathy Schleck, and Nicholas Talley, M.D.

A gastrointestinal symptom survey was mailed to a group of Olmsted County (Minn.) residents who had been randomly selected and responded to a similar symptom survey in the past. Survey responses were used to identify people who have IBS (cases) and healthy controls for this study. The electronic medical record was reviewed to record the subjects' self-reported personal and family health histories. In the study, 2,457 people responded to the questionnaire. The researchers found IBS reported in 13 percent of the respondents. In the analysis, the cases had a mean age of 62 years and 70 percent were female in the IBS group, while the group it was compared with had a mean age of 61 years and 64 percent were female.

MayoClinic.com notes that IBS is characterized by abdominal pain or cramping and changes in bowel function, including bloating, gas, diarrhea and constipation -- problems most people don't like to discuss. Up to one in five American adults has irritable bowel syndrome. The disorder accounts for more than one of every 10 doctor visits. For most people, signs and symptoms of irritable bowel disease are mild. Only a small percentage of people who have IBS have severe signs and symptoms.

http://www.mayoclinic.org/news2004-rst/2502.html

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Constipation and Laxative Use Found to Increase Colon Cancer Risk new
      #131899 - 12/20/04 01:30 PM
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12.10.04 -- Constipation and Laxative Use Found to Increase Colon Cancer Risk


By Greg Arnold, DC, CSCS, September 30, 2004, abstracted from "Constipation, laxative use and risk of colorectal cancer: The Miyagi Cohort Study" in the September 2004 issue of the European Journal of Cancer

Constipation is one of the most common gastrointestinal complaints in the United States, resulting in about 2 million doctor visits annually. According to the 1996 National Health Interview Survey, about 3 million people in the United States suffer from constipation, particularly women and adults aged 65 and over.1

Constipation's role as a risk factor for colon cancer has received inconsistent reviews in the literature. While a review found a significantly increased risk between constipation and colon cancer,2 the only prospective cohort study ever conducted did not support an association between constipation and colon cancer.3

Regardless of the risk, patients turn to laxatives to help treat their constipation, with laxative sales exceeding $500 million each year.4 Now a new study5 suggests that constipation coupled with laxative use is a risk for colon cancer.

Researchers studied questionnaires completed by nearly 42,000 Japanese men and women 40-64 years old. The questionnaire asked about education, personal and family history of cancer and other diseases, health habits, including frequency of bowel movements, laxative use, smoking, alcohol consumption, diet and physical activity.

The researcher found a "modest, marginally significant, association" between constipation and colon cancer. They also found an increased risk between laxative use and colon cancer, agreeing with previous studies.6 While constipation is thought to contribute to colon cancer due to the increased the time ammonium acetate in waste has to be absorbed by the body,7 laxatives are thought to contribute to cancer risk because of their ingredients.8

When looking at ways to remedy this situation, we can look to fiber intake among Americans. The National Center for Health Statistics9 states that Americans eat an average of 5 to 14 grams of fiber each, far short of the 20 to 35 grams recommended by the American Dietetic Association.

Supplementation can be very effective in helping Americans increase their daily fiber intake. One such supplement is psyllium husk fiber, with one tablespoon providing 7 grams of fiber. Recent research has found psyllium to exhibit anti-cancer properties, with 3.5 grams of psyllium per day helping to prevent colon cancer.10

Reference:
1 National Library of Medicine's National Digestive Diseases Information Clearinghouse (NDDIC) website http://digestive.niddk.nih.gov/ddiseases/pubs/constipation/index.htm

2 Sonnenberg, A. and A.D. Muller, Constipation and cathartics as risk factors of colorectal cancer: a meta-analysis. Pharmacology, 1993. 47 Suppl 1: p. 224-33

3 Dukas, L., et al., Prospective study of bowel movement, laxative use, and risk of colorectal cancer among women. Am J Epidemiol, 2000. 151(10): p. 958-64

4 Murray, M. Natural Alternatives to OTC and Prescription Drugs, Morrow, NY, 1994, p. 196

5 Watanabe, T., et al., Constipation, laxative use and risk of colorectal cancer: The Miyagi Cohort Study. Eur J Cancer, 2004. 40(14): p. 2109-15

6 Wu, A.H., et al., Alcohol, physical activity and other risk factors for colorectal cancer: a prospective study. Br J Cancer, 1987. 55(6): p. 687-94

7 Zarkovic, M., et al., Tumor promotion by fecapentaene-12 in a rat colon carcinogenesis model. Carcinogenesis, 1993. 14(7): p. 1261-4

8 Borrelli, F., et al., Effect of bisacodyl and cascara on growth of aberrant crypt foci and malignant tumors in the rat colon. Life Sci, 2001. 69(16): p. 1871-7

9 National Center for Health Statistics. Dietary Intake of Macronutrients, Micronutrients, and Other Dietary Constituents: United States, 1988-94. Vital and Health Statistics, Series 11, number 245. July 2002

10 Bonithon-Kopp, C., et al., Calcium and fibre supplementation in prevention of colorectal adenoma recurrence: a randomised intervention trial. European Cancer Prevention Organisation Study Group. Lancet, 2000. 356(9238): p. 1300-6

http://www.nowfoods.com/?action=itemdetail&item_id=42677

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Salt intake and smoking play major roles in GERD new
      #131909 - 12/20/04 02:11 PM
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Salt intake and smoking play major roles in GERD

Heartburn experts praised a Norwegian study but add that there is not yet enough evidence to eliminate dietary restrictions on alcohol, coffee and tea consumption.
By Victoria Stagg Elliott, AMNews staff. Dec. 13, 2004.


--------------------------------------------------------------------------------

The usual bits of advice -- that gastroesophageal reflux disease patients give up on alcohol, coffee and tea -- may not actually be words of wisdom, according to a study published in this month's Gut.

Scandinavian researchers analyzed data from two extensive public health surveys of thousands of people in Norway. They found that smoking, long considered a culprit in causing GERD, increased the risk of the disease by 70%. The use of table salt, which has never been implicated in this condition, also increased the risk by 70%.

Alcohol, coffee and tea intake did not appear to make a difference. Dietary fiber and regular exercise seemed to be protective.

"The present study indicates an important role for exogenous exposures in the form of lifestyle-related factors in the etiology of GERD," wrote the authors.

Heartburn experts widely praised the study for taking a closer look at the eating, drinking and other activities that may play a role in the disease's development and for suggesting a research path that might lead to prevention strategies.

"This study brings up the under-appreciated point that lifestyle-related factors may bring on the very common symptoms of heartburn," said A. Mark Fendrick, MD, a member of the medical advisory board of the National Heartburn Alliance and professor of internal medicine and health management and policy at the University of Michigan Medical School. "And maybe we can try to prevent the disease process from starting."

Primary care physicians appreciated the paper because it adds weight to the argument that their patients, particularly if they have reflux, should quit smoking, reduce their salt intake, eat fiber and exercise.

"The conclusions for this article really kind of go along with what we need to be promoting in primary care anyway," said Joel Heidelbaugh, MD, clinical assistant professor in the Dept. of Family Medicine at the University of Michigan and a co-author of his institution's GERD management guidelines.

Continuing questions

Experts said, however, that while these were intriguing data, it would be premature to advise GERD patients, many of whom may have cut out or reduced coffee, tea and alcohol intake, to now return to their old ways.

"This is going to raise new questions" said Dr. Heidelbaugh. "But one study is not going to change everybody's mind."

Smoking and use of table salt increase GERD risks 70%.
Meanwhile, critics suggested that some of the conclusions may not be that generalizable to the United States, and that, although the belief that alcohol, tea and coffee play a role in GERD is not backed by much science, it is supported by experience.

"I would love to see this survey duplicated here or across several nations," said Edward Zurad, MD, a family physician from Tunkhannock, Pa. "In our American population, both from a pragmatic and anecdotal standpoint, we believe that there is a causal connection."

Some experts also questioned the conclusions.

They said this population-based case control study supported the idea that there was an association between these lifestyle factors and GERD, but not whether one caused the other. This study also relied on patient self-reporting of symptoms rather than a physician-confirmed diagnosis.

"These are important associations, but they don't necessarily tell us about risk because there may be other confounders that they didn't consider," said Charlene Prather, MD, a gastroenterologist and associate professor of medicine at Saint Louis University School of Medicine.

Experts also suggested that salt or fiber intake could be indicators of other players in the condition such as the amount of fat in a diet.

"Dietary fiber may just be a surrogate marker for a lower-fat diet, and we do know that higher fat increases your risk for reflux disease," said Dr. Prather. "Also, perhaps people who salt their food are people who eat higher-fat food?"

This study adds to the growing body of literature about lifestyle factors that may lead to the development of the disease, but physicians working with GERD patients concede there is still little evidence that changing these factors can make a difference once symptoms occur.

Also, by the time patients approach physicians with questions about reflux, they have usually tried lifestyle changes and over-the-counter remedies and are looking for something more advanced.

"Most of our patients when they come to us really want to go to sophisticated pharmacologic approach in addition to a review of lifestyle changes," said Dr. Zurad.


--------------------------------------------------------------------------------


ADDITIONAL INFORMATION:
When life leads to reflux
Objective: Determine which lifestyle habits are associated with the development of gastroesophageal reflux disease.

Participants: More than 3,000 people with GERD symptoms and more than 40,000 without who participated in two large public health surveys in Nord-Trondelag, Norway.

Methods: Using a case control design, the data were analyzed to develop odds ratios linking GERD with smoking and exercise as well as with the consumption of alcohol, coffee, tea, table salt and fiber.

Results: People who smoked for more than 20 years or always used extra table salt were 70% more likely to have reflux symptoms. No association was found between reflux and coffee, tea or alcohol. Eating bread high in dietary fiber and regular exercise appeared to be protective.

Conclusions: Smoking and excess salt intake are risk factors for GERD. A diet high in fiber and regular exercise may be protective. Alcohol, coffee and tea, which have long been viewed as aggravators of this condition, may not play a role.

Source: Gut, December


http://www.ama-assn.org/amednews/2004/12/13/hlsb1213.htm

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New Risk for Asthma, Allergy Found in the Gut new
      #136194 - 01/07/05 04:53 PM
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New Risk for Asthma, Allergy Found in the Gut

Changes in gut bacteria and fungi may increase chances of problems


THURSDAY, Dec. 23 (HealthDayNews) -- Do you have the guts to resist allergies and asthma?

A University of Michigan study says changes in the bacteria and fungi (microflora) in the gastrointestinal tract may intensify immune system response to common allergens inhaled into the lungs. This can result in an increased risk of developing chronic asthma or allergies.

"Our research indicates that microflora lining the walls of the gastrointestinal tract are a major underlying factor responsible for the immune system's ability to ignore inhaled allergens. Change the microflora in the gut and you upset the immune system's balance between tolerance and sensitization," study author Gary Huffnagle, an associate professor of internal medicine and of microbiology and immunology, said in a prepared statement.

He and a colleague tested this theory in a mouse they developed that mimics how some humans develop allergies after taking antibiotics, which can upset the balance of gut microflora.

The study appears in the January issue of Infection and Immunity .

"If lungs are repeatedly exposed to an allergen, regulatory T-cells (immune cells that can moderate immune system response) learn to recognize the allergen as not dangerous and something that can be safely ignored," Huffnagle said.

"Most researchers think that tolerance develops in the lungs, but we believe it actually occurs in the gut. When immune cells in the GI tract come in contact with swallowed allergens, that interaction triggers the development of regulatory T-cells, which then migrate to the lungs," he said.

More information

The Cleveland Clinic Foundation has more about allergies .

SOURCE: -- Robert Preidt, University of Michigan Health System, news release, Dec. 23, 2004

http://www.healthscout.com/template.asp?ap=1&page=newsdetail&id=523011

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Suicide in IBS patients emphasizes need for improvements in treatment new
      #136210 - 01/07/05 05:47 PM
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Background & Aims: Irritable bowel syndrome (IBS) traditionally is considered as more of a nuisance than having especially serious consequences. However, this is not the picture witnessed in tertiary care where we have encountered some tragic cases, prompting an assessment of suicidal ideation in such patients.

Methods: One hundred follow-up, tertiary care IBS (tIBS) patients were compared with 100 secondary IBS (sIBS), 100 primary IBS (pIBS) care patients, and 100 patients with active inflammatory bowel disease (IBD). Patients were asked if they had either seriously contemplated or attempted suicide specifically because of their bowel problem as opposed to other issues. The hospital anxiety depression score was recorded, as were other clinical details on all patients.

Results: A total of 38% of tIBS patients had contemplated suicide because of their symptoms compared with 16% and 4% in the sIBS and pIBS groups (tIBS vs. sIBS vs. pIBS, P = .002, P < .001). The figure for IBD was 15% (tIBS v. IBD, P < .001). Five tIBS and 1 IBD patient had attempted suicide for gastrointestinal reasons. Mean depression scores did not exceed threshold (10) in the sIBS group contemplating suicide (9.7), but were increased in the equivalent tIBS group (11.7). Hopelessness because of symptom severity, interference with life, and inadequacy of treatment were highlighted as crucial issues for all IBS patients.

Conclusions: IBS has the potential for a fatal outcome from suicide with depression not accounting for all the variance in suicidal ideation. Our observations emphasize the level of hopelessness felt by these patients and the need for improvement in the services provided to them.

Copyright © 2004 by American Gastroenterological Association

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Irritable bowel syndrome: colonoscopy painful and difficult? new
      #136212 - 01/07/05 05:50 PM
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Med Klin (Munich). 2004 Dec 15;99(12):713-8.

Irritable bowel syndrome: colonoscopy painful and difficult?

Nattermann C, Fimmers R, Bayer B.

Hochtaunus-Kliniken gGmbH, Medizinische Klinik, Usingen. chnattermann@hotmail.com

BACKGROUND AND PURPOSE: Hyperalgesia induced by pelvic colon distension has been demonstrated in patients with irritable bowel syndrome (IBS). In this study the authors analyzed whether colonoscopy of patients with IBS is more painful and technically more demanding as compared to non-IBS patients.

PATIENTS AND METHODS: In a prospective study 639 patients (132 with IBS, 507 without IBS) who underwent colonoscopy were evaluated for sex, age, body mass index, administration of sedatives and analgesics, time for cecal intubation, intensity of pain during examination (intensity graduated 1-5), diagnosis and degree of diverticulosis, spasticity, loop formation, elongation and distortion, respectively. A statistical comparison of both patient groups was performed.

RESULTS: Patients of the IBS group were significantly younger compared with patients in the control group (p < 0.001). In an age-matched comparison of both groups low pain (intensity 1) was noted in 29 (22%) of IBS patients and 82 patients (31%) in the control group. Severe pain (intensity 4 and 5) occurred in 17 (12.9%) and six (4.5%), respectively, of IBS patients and in 21 (8%) and five patients (2%), respectively, of the control group. The differences were statistically not significant (p = 0.1). Administration of analgesics occurred significantly more frequently in the IBS group (p = 0.01), however, only nine IBS patients (6.8%) and four patients without IBS (1.5%) received analgesics. All other parameters analyzed did not show significant differences between the groups.

CONCLUSION: Regarding perception of procedure-related pain and technical problems in colonoscopy, patients with IBS do not show significant differences compared to patients without IBS.

PMID: 15599681 [PubMed - in process]

http://www.docguide.com/news/content.nsf/PaperFrameSet?OpenForm&refid=2&id=48DDE4A73E09A969852568880078C249&c=&newsid=8525697700573E1885256F6E0074EA17&u=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15599681&ref=/news/content.nsf/SearchResults?openform&Query=ibs&so=date&id=48DDE4A73E09A969852568880078C249

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Treatment of irritable bowel syndrome with colonic pacing new
      #136214 - 01/07/05 05:53 PM
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Hepatogastroenterology. 2004 Nov-Dec;51(60):1708-12.

Treatment of irritable bowel syndrome with colonic pacing: evaluation of pacing parameters required for correction of the "tachyarrhythmia" of the IBS.


Shafik A, Shafik AA, Ahmed I, el-Sibai O.

Department of Surgery and Experimental Research, Faculty of Medicine, Cairo University, Cairo, Egypt. shafik@ahmed-shafik.org

BACKGROUND/AIMS: A recent study of the electromyographic (EMG) activity of irritable bowel syndrome (IBS) has shown that the frequency, amplitude and conduction velocity of the slow waves (SWs) of the sigmoid colon (SC) were significantly higher in IBS patients than in the healthy volunteers. The SW rhythm was irregular. A "tachyarrhythmic pattern" was characteristic of the IBS. The SC pressure in the IBS was also significantly higher than that of the healthy controls. We suggested that the cause of IBS is related to an aberrant focus in one or more of the colonic pacemakers which possibly triggers abnormal impulses to the colon. We hypothesized that stimulation of the pacemaker which delivers electric waves to the SC, may correct the abnormal electric waves and eliminate the IBS symptoms. In this communication we tried to define the adequate pacing parameters necessary for normalization of the tachyarrhythmic pattern of the electric waves in IBS.

METHODOLOGY: Nineteen subjects with IBS were divided into a study group (age 48.6+/-9.8 years; 7 women, 4 men) and a control group (age 47.6+/-9.2 years; 5 women, 3 men). The study also included 8 healthy volunteers (47.9+/-9.7 years; 5 women). Three 28-gauge cardiac pacing electrodes were used: one for pacing applied to the pacemaker at the colosigmoid junction (CSJ) and 2 for recording applied to the SC mucosa. In the study group, the CSJ electrode was stimulated using an electrical stimulator which delivered a constant current. The optimal pacing parameters had been determined after repeated trials with different variables. In the control group, recording was done without pacemaker activation. The SC pressure was measured by a 10-F saline-perfused tube.

RESULTS: In the healthy volunteers, the basal SWs were regular and followed or superimposed by action potentials (APs). Pacing produced a significant increase in the SW variables and SC pressure; the latency was 20.3+/-3.6 s. The study and the control group exhibited a basal tachyarrhythmic pattern and a significantly higher SC pressure than the healthy volunteers. Pacing of the study group effected lowering of the SW variables and SC pressure which did not show a significant difference against those of the healthy volunteers at rest. The optimal pacing parameters comprised an amplitude of 6 mA, a pulse width of 150 ms and a 25% higher frequency than that of the already recorded basal colonic waves. The control group showed no change in the tachyarrhythmic pattern.

CONCLUSIONS: CS pacing parameters were identified and succeeded in normalizing the tachyarrhythmic pattern of the IBS. We suggest that this method be used for the treatment of patients with IBS when other measures have failed to cure the condition.

PMID: 15532810 [PubMed - in process]

http://www.docguide.com/news/content.nsf/PaperFrameSet?OpenForm&refid=2&id=48DDE4A73E09A969852568880078C249&c=&newsid=8525697700573E1885256F4900362EDF&u=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15532810&ref=/news/content.nsf/SearchResults?openform&Query=ibs&so=date&id=48DDE4A73E09A969852568880078C249

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Stress Increases Visceral Sensitivity in IBS Patients new
      #136221 - 01/07/05 06:13 PM
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Stress Increases Visceral Sensitivity in IBS Patients

NEW YORK (Reuters Health) Dec 30 - Acute stress appears to alter gut-specific efferent autonomic innervation in patients with irritable bowel syndrome (IBS) and in healthy controls. However, UK researchers report that only IBS patients show heightened visceral sensation.

"Stress is an important causative factor in IBS," Dr. Anton V. Emmanuel, of St. Mark's Hospital, Harrow and colleagues note in the December issue of Gastroenterology. However, "it remains unknown whether stress-related changes in gut function are mediated by altered autonomic efferent gut-specific innervation."

The researchers examined the effect of acute physical and psychological stress on autonomic innervation and visceral sensitivity in 24 patients with constipation-predominant IBS and 12 healthy controls.

Baseline perception of stress was higher among patients with IBS. During physical stress, rectal mucosal blood flow, a measure of gut-specific innervation, decreased by 29.6% in IBS patients and 28.7% in controls. During psychological stress, the corresponding decreases were 24.4% and 23.5%.

During physical stress, patients with IBS experienced decreased rectal perception thresholds compared to controls (23.2% versus 0.6%) as well as decreased and rectal pain thresholds (27.0% versus 1.3%).

During psychological stress, patients with IBS had reduced thresholds for rectal perception (19.4% versus 8%) and rectal pain (28.4% versus 3.4%). They also had increased anal perception thresholds during physical and psychological stress.

"Visceral sensitivity but not somatic sensitivity is heightened in patients with IBS in response to stress," Dr. Emmanuel and colleagues conclude." This, they add suggests "involvement of a different regulator mechanism, either central or peripheral."

Gastroenterology 2004;127:1695-1703.


http://www.medscape.com/viewarticle/496750?src=mp

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Diagnostic Criteria for Irritable Bowel Syndrome - Family Practice Doctors Unaware of Guidelines new
      #136222 - 01/07/05 06:20 PM
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Diagnostic Criteria for Irritable Bowel Syndrome: Utility and Applicability in Clinical Practice

R. Lea, V. Hopkins, J. Hastleton, L.A. Houghton, P.J. Whorwell

Medical Academic Department, South Manchester University Hospitals, Manchester, UK


Digestion 2004;70:210-213 (DOI: 10.1159/000082891)

------------------------------------------------------------------------------

--------------------------------------------------------------------------------

Abstract

Background/Aims: Symptom-based criteria have been introduced to aid the diagnosis of irritable bowel syndrome (IBS). Although they have been widely adopted and have proved useful for research purposes by ensuring homogeneity of study populations, there is little information about their utility in routine clinical practice. It was the aim of this study to assess the applicability of the Manning, Rome I and Rome II criteria in the clinical setting and to ascertain how often hospital specialists and general practitioners (GPs) use them.

Methods: Hundred secondary-care IBS patients were assessed for their conformity to these criteria. Forty-eight hospital specialists and 68 GPs were asked about their knowledge and utilization of these criteria.

Results: Seventy-three percent of IBS patients met Rome II diagnostic criteria with 82 and 94% meeting Rome I and Manning, respectively.

Approximately 80% of GPs had no knowledge of any of the specific criteria, and only 4% had ever used them. The majority of specialists had knowledge of the criteria, with 70% having used them.

Conclusion: The Rome II criteria are remarkably insensitive and if rigidly applied in the clinical situation would lead to much diagnostic uncertainty. The current lack of interest in them, especially amongst GPs, is unlikely to change unless they can be considerably improved.

Copyright © 2004 S. Karger AG, Basel


http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ProduktNr=223838&Ausgabe=230654&ArtikelNr=82891

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10% to 20% of older adults have IBS new
      #141619 - 01/23/05 05:05 PM
HeatherAdministrator

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Irritable bowel syndrome

10% to 20% of older adults have symptoms
consistent with diagnosis

Although irritable bowel syndrome (IBS) is a common disorder, IBS is
traditionally considered to be a condition that primarily affects young
and middle-aged adults. However, increasing evidence suggests that
prevalence of IBS in older adults may be similar to that in younger
adults; therefore, the diagnosis should be considered when a geriatric
patient presents with unexplained abdominal symptoms. Because
incidences of other conditions with similar symptoms are higher in the
geriatric population, use of certain diagnostic tests (eg, colonoscopy) is
warranted in this patient population. In addition, because older adults
are more likely than younger adults to suffer from comorbid conditions,
polypharmacy is common in this patient population, and this should be
considered when diagnosing and treating these patients.

Ehrenpreis ED. Irritable bowel syndrome in older adults. Geriatrics 2005; 60(Jan):25-28.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1141420&specid=13&ok=yes

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High interdigestive and postprandial motilin levels in patients with the irritable bowel syndrome new
      #147267 - 02/06/05 02:12 PM
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Neurogastroenterology and Motility
Volume 17 Issue 1 Page 51 - February 2005
doi:10.1111/j.1365-2982.2004.00582.x


High interdigestive and postprandial motilin levels in patients with the irritable bowel syndrome

M. Simrén, E. S. Björnsson & H. Abrahamsson

Abstract

Motilin shows cyclic variation with the different phases of the migrating motor complex (MMC). (Motilin is a 22 amino acid peptide secreted by endocrinocytes in the mucosa of the proximal small intestine. Based on amino acid sequence, motilin is unrelated to other hormones. Motilin participates in controlling the pattern of smooth muscle contractions in the upper gastrointestinal tract.)

Altered motilin levels have been found in irritable bowel syndrome (IBS) patients, but in these studies motilin levels were analysed without the knowledge of the phases of MMC. We included 13 healthy controls (HC) and 24 patients with IBS [12 diarrhoea-predominant (IBS-D) and 12 constipation-predominant (IBS-C)].

We performed interdigestive and postprandial antroduodenojejunal manometry and blood samples for analysis of motilin were drawn. Group differences in plasma levels of motilin were analysed during mid-phase II, just before the start of phase III (pre-III), during phase I, immediately before the meal and 30 and 60 min after the 500 kcal mixed meal. Higher motilin levels were observed in IBS vs HC in both the interdigestive and postprandial periods (P < 0.05). No significant differences between IBS-C and IBS-D were observed. The cyclic variation of motilin during MMC and the meal response was similar in IBS and controls. IBS patients, irrespective of the predominant bowel habit, demonstrate higher motilin levels than HCs in all phases of the MMC and also after a meal. These findings may bear some pathophysiological importance in IBS and relate to the gastrointestinal dysmotility often seen in these patients.


http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2004.00582.x/abs/

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Is Constipation Associated with Decreased Physical Activity in Normally Active Subjects? new
      #147269 - 02/06/05 02:18 PM
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Posts: 7788
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The American Journal of Gastroenterology
Volume 100 Issue 1 Page 124 - January 2005
doi:10.1111/j.1572-0241.2005.40516.x


Is Constipation Associated with Decreased Physical Activity in Normally Active Subjects?

Ashok K. Tuteja, M.D., M.P.H.1, Nicholas J. Talley, M.D., Ph.D.1, Sandra K. Joos, Ph.D., M.P.H.1, James V. Woehl, K.V.C.N.P.1, and David H. Hickam, M.D., M.P.H.1

BACKGROUND: The effectiveness of physical activity in the management of constipation remains controversial. We examined the associations among physical activity, constipation, and quality of life (QoL) in a population of employed adults to determine whether the risk of constipation is related to physical activity.

METHODS: A total of 1,069 employees (age range 2477) of the Veterans Affairs (VA) Black Hills Health Care System were mailed validated questionnaires (response rate 72%), inquiring about bowel habits, QoL (SF 36), and physical activity (modified Baecke questionnaire). Constipation was defined using the Rome I criteria.

RESULTS: One hundred and forty (19.4%, 95% CI 16.222.4) employees reported constipation. The average total physical activity and all subscales of physical activity were not significantly different in subjects with and without constipation (all p 0.2). Subjects with constipation had lower QoL scores than subjects without constipation, and physical activity was positively correlated with physical functioning and health perception.

CONCLUSION: Physical activity appears to be unrelated to the risk of constipation in employed adults, but higher physical activity was associated with improved QoL. Recommendations to increase physical activity may not alter symptoms of constipation but may improve overall well-being.


http://www.blackwell-synergy.com/links/doi/10.1111/j.1572-0241.2005.40516.x/abs/

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The value of a general therapeutic approach in subjects with irritable bowel syndrome new
      #147272 - 02/06/05 02:22 PM
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Alimentary Pharmacology & Therapeutics
Volume 21 Issue 1 Page 21 - January 2005
doi:10.1111/j.1365-2036.2004.02302.x


The value of a general therapeutic approach in subjects with irritable bowel syndrome

K. W. Monsbakken*, P. O. Vandvik*, & P. G. Farup*,

Summary

Background: The general therapeutic approach is the cornerstone in the management of irritable bowel syndrome, but the effect is poorly documented.

Aim: To evaluate the effect of the general therapeutic approach for irritable bowel syndrome.

Methods: Subjects with irritable bowel syndrome identified in a public screening were included. Scores for abdominal symptom (range 012), musculoskeletal pain and mood disorders were calculated. After exclusion of other disorders, a doctor presented irritable bowel syndrome as a positive diagnosis, gave information, reassurance and lifestyle advice, but no pharmacotherapy. A dietician gave dietary advice. There was a follow-up after 6 months.

Results: Sixty-five persons (females/males: 44/21) with mean age 49 years (range 3176) were included, 31 (48%) were recommended dietary changes. Twenty subjects (31%) had satisfactory relief of symptoms after 6 months. The scores for abdominal symptom was reduced from 3.1 to 2.2 (P = 0.007), the reduction was 2.2 in the diarrhoea-predominant group given advice compared with 0.4 in the other subjects (P = 0.035). Previous consultations for the complaints, visits for psychiatric disorders, and presence of mood disorders were predictors of persistent complaints.

Conclusions: There was a significant relief of symptoms after 6 months, those with psychological co-morbidity responded less well.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1151236&specid=13&ok=yes

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Magnetic pill tracking: a novel non-invasive tool for investigation of human digestive motility new
      #147273 - 02/06/05 02:27 PM
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Neurogastroenterology and Motility
Volume 17 Issue 1 Page 148 - February 2005
doi:10.1111/j.1365-2982.2004.00587.x


Magnetic pill tracking: a novel non-invasive tool for investigation of human digestive motility

e. stathopoulos*, v. schlageter*, b. meyrat, y. de ribaupierre* & p. kucera*

Abstract

A new minimally invasive technique allowing for anatomical mapping and motility studies along the entire human digestive system is presented. The technique is based on continuous tracking of a small magnet progressing through the digestive tract. The coordinates of the magnet are calculated from signals recorded by 16 magnetic field sensors located over the abdomen. The magnet position, orientation and trajectory are displayed in real time. Ten young healthy volunteers were followed during 34 h. The technique was well tolerated and no complication was encountered. The information obtained was 3-D configuration of the digestive tract and dynamics of the magnet displacement (velocity, transit time, length estimation, rhythms). In the same individual, repeated examination gave very reproducible results. The anatomical and physiological information obtained corresponded well to data from current methods and imaging. This simple, minimally invasive technique permits examination of the entire digestive tract and is suitable for both research and clinical studies. In combination with other methods, it may represent a useful tool for studies of GI motility with respect to normal and pathological conditions.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2004.00587.x/abs/

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Overlap of GI symptom complexes in a US community new
      #147274 - 02/06/05 02:35 PM
HeatherAdministrator

Reged: 12/09/02
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Neurogastroenterology and Motility
Volume 17 Issue 1 Page 29 - February 2005
doi:10.1111/j.1365-2982.2004.00581.x

G. R. Locke III, A. R. Zinsmeister, S. L. Fett, L. J. Melton III & N. J. Talley

Overlap of GI symptom complexes in a US community

Background: Although the Rome criteria define a number of individual functional gastrointestinal disorders, people may have symptoms of multiple disorders at the same time. In addition, therapies may be effective in subsets of people with specific disorders, yet at the same time help people with multiple disorders.

Aim: To estimate the prevalence of combinations of gastrointestional (GI) symptom complexes.

Methods: A valid self report questionnaire which records GI symptoms was mailed to an age- and gender-stratified random sample of Olmsted County, MN residents aged 3064 years. Standard definitions were used to identify people with gastro-oesophageal reflux, dyspepsia, irritable bowel syndrome (IBS), constipation and diarrhoea. The prevalence of people meeting multiple symptom complexes was estimated. Specifically, combinations of dyspepsia, IBS and constipation were compared to dyspepsia, IBS and diarrhoea.

Results: A total of 657 (69%) of 943 eligible subjects responded; 643 provided data for each of the necessary symptom questions. Each two-way combination of symptom group was present in between 4 and 9% of the population; each three-way combination was present in 14% of the population. The overlap between dyspepsia, IBS and constipation was similar to dyspepsia, IBS and diarrhoea, except body mass index was higher in the diarrhoea overlap group (P = 0.03).

Conclusion: Symptom complex overlap is common in the community; for each condition, the majority of sufferers reported an additional symptom complex. This overlap of symptoms challenges the current paradigm that functional GI disorders represent multiple discreet entities.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2004.00581.x/abs/

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Intestinal infection and irritable bowel syndrome. new
      #152018 - 02/19/05 05:36 PM
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Eur J Gastroenterol Hepatol. 2005 Jan;17(1):5-9. Related Articles, Links


Intestinal infection and irritable bowel syndrome.

Parry S, Forgacs I.

Department of Gastroenterology, King's College Hospital, London, UK.

The observation that the symptoms of irritable bowel syndrome (IBS) in some patients might follow an episode of acute gastroenteritis came from epidemiological studies. Both retrospective and prospective studies suggest that between 4% and 26% of patients develop IBS for the first time after gastroenteritis. The diagnosis of post-infectious IBS is typically made from the history. In addition, as with the diagnosis of IBS more generally, it is important to exclude other clinical causes for persistent bowel dysfunction. There is little, if any, evidence to support the widely-held view that patients with post-infectious IBS carry a better prognosis than IBS patients more generally. The management of patients with post-infectious IBS is the standard approach that might be applied to all patients with IBS. Post-infectious IBS patients may differ from IBS patients in general in having a low-level of intestinal inflammation. Work in animal models, and detection of low-grade inflammation in intestinal biopsies combined with markers of intestinal inflammation such as faecal calprotectin all indicate a strong possibility that persisting inflammation after the acute infection may be important in the pathogenesis of post-infectious IBS.

PMID: 15647632 [PubMed - in process]

http://www.docguide.com/news/content.nsf/PaperFrameSet?OpenForm&refid=2&id=48DDE4A73E09A969852568880078C249&c=&newsid=8525697700573E1885256F8A0044E7D7&u=http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15647632&ref=/news/content.nsf/SearchResults?openform&Query=ibs&so=date&id=48DDE4A73E09A969852568880078C249

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Chronic constipation in children new
      #152020 - 02/19/05 05:53 PM
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Journal of Paediatrics and Child Health
Volume 41 Issue 1-2 Page 1 - January 2005
doi:10.1111/j.1440-1754.2005.00527.x


Review article

Chronic constipation in children: Organic disorders are a major cause

BR Southwell 1,3, SK King 2,4,5 and JM Hutson 2,4,5

Abstract: Diagnostic tools for paediatric chronic constipation have been limited, leading to over 90% of patients with treatment-resistant constipation being diagnosed with chronic idiopathic constipation, with no discernible organic cause. Work in our institution suggests that a number of children with intractable symptoms actually have slow colonic transit leading to slow transit constipation.

This paper reviews recent data suggesting that a significant number of the children with chronic treatment-resistant constipation may have organic causes (slow colonic transit and outlet obstruction) and suggests new approaches to the management of children with chronic treatment-resistant constipation.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1440-1754.2005.00527.x/abs/

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Surgical Treatment of Chronic Functional Constipation? new
      #157025 - 03/04/05 11:24 AM
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From Ask the Experts about General Gastroenterology
From Medscape Gastroenterology

Surgical Treatment of Chronic Functional Constipation?

Question
What is the appropriate work-up for chronic functional constipation, and how successful is partial colectomy in patients whose very-slow-transit constipation is "resistant" to routine treatment?

Response from Yehuda Ringel, MD

Assistant Professor of Medicine, University of North Carolina at Chapel Hill; Staff Physician, Department of Medicine, University of North Carolina Hospital, Chapel Hill

Surgical treatment of chronic functional constipation should be considered only in the most severe cases of slow-colonic-transit constipation for those patients who do not respond to aggressive medical therapy. Prior to surgery, patients should be carefully evaluated for existence of other gastrointestinal conditions and symptoms, particularly abdominal pain and irritable bowel syndrome. It is crucial to inform the patient that the surgical procedure is aimed to ease the constipation but is not likely to alleviate other gastrointestinal symptoms. A detailed work-up should include: (1) exclusion of known causes of constipation, such as medications (eg, opiates and anticholinergics); low-fiber diet; mechanical obstruction (eg, colon cancer or stricture); metabolic disorders (eg, hypothyroidism, hypercalcemia); psychological disorders (severe depression); and others; (2) confirming the diagnosis of severe functional colonic inertia (slow transit)-type constipation by studying colonic transit time (eg, radiopaque marker studies); and (3) exclusion of other possible treatable conditions, such as disturbed defecation, as assessed by anorectal manometry (eg, for Hirschsprung's disease and other pelvic floor dysfunctions) and defecation studies (eg, for rectocele and rectal prolapse); and chronic intestinal pseudo-obstruction, as assessed by radiologic or manometric studies.

The recommended surgical procedure is subtotal colectomy with ileorectal anastomosis. Partial colectomy has not been found to be helpful and should therefore not be considered. A comprehensive review of 13 reported studies of 362 patients who underwent colectomy and who were followed for 1.2-8.9 years reported a success rate of 88%.[1] A recent prospective long-term (mean follow-up of 56 months) study of 52 patients who were carefully evaluated and underwent surgery for slow-transit constipation showed that over 90% of patients were satisfied with the results of surgery, and reported a good or improved quality of life.[2] Postoperative complications may include small-bowel obstruction, prolonged ileus, abdominal pain, and diarrhea.

More recently, antegrade continent enema has been suggested as an alternative approach in patients who are unable or unwilling to undergo colectomy. Conduits can be created from the appendix, cecum, or ileum. A recent retrospective study of 32 patients who underwent this procedure, with a median of 36 months' (range, 13-140 months) follow-up, reported satisfactory long-term results in approximately half of the patients -- although revision procedures were often required.[3] However, the procedure is reversible and does not preclude subsequent surgical intervention.



--------------------------------------------------------------------------------

References
Pikarsky AJ, Singh JJ, Weiss EG, Nogueras JJ, Wexner SD. Long-term follow-up of patients undergoing colectomy for colonic inertia. Dis Colon Rectum. 2001;44:179-183. Abstract
Nyam DC, Pemberton JH, Ilstrup DM, Rath DM. Long-term results of surgery for chronic constipation. Dis Colon Rectum. 1997;40:273-279. Abstract
Lee NP, Hodson P, Hill J, Pearson RC, MacLennan I. Long-term results of the antegrade continent enema procedure for constipation in adults. Colorectal Dis. 2004;6:362-368. Abstract




Disclosure: Yehuda Ringel, MD, has disclosed that he has received grants for clinical research from GlaxoSmithKline, AstraZeneca, and Novartis. He has received grants for educational activities from Solvay. Dr. Ringel has also reported that he is on the speaker's bureau for Novartis and has served as an advisor or consultant for GlaxoSmithKline.




Medscape Gastroenterology. 2005; 7 (1): ©2005 Medscape

http://www.medscape.com/viewarticle/497702?src=mp

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Post-infectious IBS in patients with Shigella infection new
      #157043 - 03/04/05 12:03 PM
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Journal of Gastroenterology and Hepatology
Volume 20 Issue 3 Page 381 - March 2005
doi:10.1111/j.1440-1746.2005.03574.x


GASTROENTEROLOGY

Post-infectious irritable bowel syndrome in patients with Shigella infection

SANGWON JI*, HYOJIN PARK*, DOKYONG LEE*, YOUNG KOO SONG*, JAE PHIL CHOI* AND SANG-IN LEE*

Abstract

Background and Aims: Bacterial gastroenteritis has been known as a risk factor of irritable bowel syndrome (IBS). Several risk factors of post-infectious IBS (PI-IBS) have been documented. The aims of this study were to verify the role of bacterial gastroenteritis in the development of IBS and the risk factors for the development of PI-IBS. The clinical course of PI-IBS was also investigated.

Methods: We recruited 143 patients with shigellosis during its outbreak and 113 controls. Both groups were followed up for 12 months. Bowel symptoms were evaluated by use of questionnaires at 3, 6 and 12 months after the initial recruitment.

Results: Complete data were obtained from 101 patients (70.6%) and 102 healthy controls (90.3%). At 12 months, 15 patients and six controls had IBS (adjusted OR; 2.9, 95% CI; 1.17.9). Of the 15 patients, five had IBS symptoms consistently for 12 months, three did not have IBS symptoms initially and seven had fluctuating bowel symptoms. The duration of diarrhea was an independent risk factor of PI-IBS.

Conclusions: Bacterial gastroenteritis is a risk factor of IBS and the duration of diarrhea as the index of severity of initial illness is an independent risk factor of PI-IBS. The clinical course of PI-IBS is variable over the 1 year of follow-up.


Accepted for publication 30 April 2004.


Affiliations

*Yonsei Institute of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea


Correspondence

Dr Hyojin Park, Department of Internal Medicine, Yongdong Severance Hospital, Yonsei University College of Medicine, Yongdong PO Box 1217, Seoul 135-270, Korea. Email: HJPARK21@yumc.yonsei.ac.kr

To cite this article
JI, SANGWON, PARK, HYOJIN, LEE, DOKYONG, SONG, YOUNG KOO, CHOI, JAE PHIL & LEE, SANG-IN (2005)
Post-infectious irritable bowel syndrome in patients with Shigella infection.
Journal of Gastroenterology and Hepatology 20 (3), 381-386.
doi: 10.1111/
j.1440-1746.2005.03574.x

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http://www.blackwell-synergy.com/links/doi/10.1111/j.1440-1746.2005.03574.x/abs/

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Fecal Microbiota of Irritable Bowel Syndrome Patients new
      #157047 - 03/04/05 12:11 PM
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The American Journal of Gastroenterology
Volume 100 Issue 2 Page 373 - February 2005
doi:10.1111/j.1572-0241.2005.40312.x


Analysis of the Fecal Microbiota of Irritable Bowel Syndrome Patients and Healthy Controls with Real-Time PCR

Erja Malinen, Ph.D.1, Teemu Rinttilä, M.Sc.1, Kajsa Kajander, M.Sc.1, Jaana Mättö, Ph.D.1, Anna Kassinen, M.Sc.1, Lotta Krogius, M.Sc.1, Maria Saarela, Ph.D.1, Riitta Korpela, Ph.D.1, and Airi Palva, Ph.D.1

OBJECTIVE: The gut microbiota may contribute to the onset and maintenance of irritable bowel syndrome (IBS). In this study, the microbiotas of patients suffering from IBS were compared with a control group devoid of gastrointestinal (GI) symptoms.

METHODS : Fecal microbiota of patients (n = 27) fulfilling the Rome II criteria for IBS was compared with age- and gender-matched control subjects (n = 22). Fecal samples were obtained at 3 months intervals. Total bacterial DNA was analyzed by 20 quantitative real-time PCR assays covering approximately 300 bacterial species.

RESULTS: Extensive individual variation was observed in the GI microbiota among both the IBS- and control groups. Sorting of the IBS patients according to the symptom subtypes (diarrhea, constipation, and alternating predominant type) revealed that lower amounts of Lactobacillus spp. were present in the samples of diarrhea predominant IBS patients wheras constipation predominant IBS patients carried increased amounts of Veillonella spp. Average results from three fecal samples suggested differences in the Clostridium coccoides subgroup and Bifidobacterium catenulatum group between IBS patients (n = 21) and controls (n = 15). Of the intestinal pathogens earlier associated with IBS, no indications of Helicobacter spp. or Clostridium difficile were found whereas one case of Campylobacter jejuni was identified by sequencing.

CONCLUSIONS: With these real-time PCR assays, quantitative alterations in the GI microbiota of IBS patients were found. Increasing microbial DNA sequence information will further allow designing of new real-time PCR assays for a more extensive analysis of intestinal microbes in IBS.


Received February 20, 2004; accepted October 31, 2004.


Affiliations

1Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Section of Microbiology, P.O. Box 66, FIN-00014 University of Helsinki, Finland; Valio Ltd, R&D, P.O. Box 30, FIN-00039 Helsinki, Finland; VTT Biotechnology, P.O. Box 1500, FIN-02044 VTT, Finland; and Institute of Biomedicine, Pharmacology, P.O. Box 63, FIN-00014 University of Helsinki, Finland


Correspondence

To cite this article
Malinen, Erja, Rinttilä, Teemu, Kajander, Kajsa, Mättö, Jaana, Kassinen, Anna, Krogius, Lotta, Saarela, Maria, Korpela, Riitta & Palva, Airi (2005)
Analysis of the Fecal Microbiota of Irritable Bowel Syndrome Patients and Healthy Controls with Real-Time PCR.
The American Journal of Gastroenterology 100 (2), 373-382.
doi: 10.1111/
j.1572-0241.2005.40312.x

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http://www.blackwell-synergy.com/links/doi/10.1111/j.1440-1746.2005.03574.x/abs/

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Alternating Bowel Habit Subtype in Patients with Irritable Bowel Syndrome new
      #164735 - 03/28/05 12:28 PM
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The American Journal of Gastroenterology
Volume 100 Issue 4 Page 896 - April 2005
doi:10.1111/j.1572-0241.2005.41211.x


Characterization of the Alternating Bowel Habit Subtype in Patients with Irritable Bowel Syndrome

Kirsten Tillisch, M.D.1, Jennifer S. Labus, Ph.D.1, Bruce D. Naliboff, Ph.D.1, Roger Bolus, Ph.D.1, Michael Shetzline, M.D.1, Emeran A. Mayer, M.D.1, and Lin Chang, M.D.1

BACKGROUND: Due to a wide range of symptom patterns, patients with irritable bowel syndrome (IBS) are often subgrouped by bowel habit. However, the IBS subgroup with alternating bowel habits (IBS-A) has been poorly characterized.

OBJECTIVES: (i) To determine a set of bowel habit symptom criteria, which most specifically identifies IBS patients with an alternating bowel habit, (ii) to describe IBS-A bowel symptom patterns, and (iii) to compare clinical characteristics among IBS-A, constipation-predominant (IBS-C), and diarrhea-predominant IBS (IBS-D).

METHODS: One thousand one hundred and two Rome I positive IBS patients were analyzed. Three sets of potential criteria for IBS-A were developed and compared by multirater Kappa test. Gastrointestinal, psychological, extraintestinal symptoms, and health-related quality of life were compared in IBS-A, IBS-C, and IBS-D using 2 test and analysis of variance (ANOVA).

RESULTS: Stool consistency was determined to be the most specific criteria for alternating bowel habits. IBS-A patients reported rapid fluctuations in bowel habits with short symptom flares and remissions. There was a greater prevalence of psychological and extraintestinal symptoms in the IBS-A subgroup compared to IBS-C and IBS-D. No differences were seen between bowel habit subtypes in health-related quality of life.

CONCLUSIONS: IBS-A patients have rapidly fluctuating symptoms and increased psychological comorbidity, which should be taken into account for clinical practice and clinical trials.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1572-0241.2005.41211.x/abs/

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Stress and the gastrointestinal tract new
      #164743 - 03/28/05 01:27 PM
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Journal of Gastroenterology and Hepatology
Volume 20 Issue 3 Page 332 - March 2005
doi:10.1111/j.1440-1746.2004.03508.x


REVIEW
Stress and the gastrointestinal tract

VIKRAM BHATIA* AND RAKESH K TANDON*

Stress, defined as an acute threat to homeostasis, evokes an adaptive or allostatic response and can have both a short- and long-term influence on the function of the gastrointestinal tract. The enteric nervous system is connected bidirectionally to the brain by parasympathetic and sympathetic pathways forming the braingut axis. The neural network of the brain, which generates the stress response, is called the central stress circuitry and includes the paraventricular nucleus of the hypothalamus, amygdala and periaqueductal gray.

It receives input from the somatic and visceral afferent pathways and also from the visceral motor cortex including the medial prefrontal, anterior cingulate and insular cortex. The output of this central stress circuit is called the emotional motor system and includes automatic efferents, the hypothalamuspituitaryadrenal axis and pain modulatory systems. Severe or long-term stress can induce long-term alteration in the stress response (plasticity). Corticotropin releasing factor (CRF) is a key mediator of the central stress response.

Two CRF receptor subtypes, R1 and R2, have been described. They mediate increased colonic motor activity and slowed gastric emptying, respectively, in response to stress. Specific CRF receptor antagonists injected into the 0 block these visceral manifestations of stress. Circulating glucocorticoids exert an inhibitory effect on the stress response by receptors located in the medial prefrontal cortex and hippocampus.

Many other neurotransmitters and neuroimmunomodulators are being evaluated. Stress increases the intestinal permeability to large antigenic molecules. It can lead to mast cell activation, degranulation and colonic mucin depletion. A reversal of small bowel water and electrolyte absorption occurs in response to stress and is mediated cholinergically. Stress also leads to increased susceptibility to colonic inflammation, which can be adaptively transferred among rats by sensitized CD4+ lymphocytes.

The association between stress and various gastrointestinal diseases, including functional bowel disorders, inflammatory bowel disease, peptic ulcer disease and gastroesophageal reflux disease, is being actively investigated. Attention to the close relation between the brain and gut has opened many therapeutic avenues for the future.

Stress and the gastrointestinal tract.
Journal of Gastroenterology and Hepatology 20 (3), 332-339.
doi: 10.1111/
j.1440-1746.2004.03508.x


http://www.blackwell-synergy.com/links/doi/10.1111/j.1440-1746.2004.03508.x/abs/




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Irritable bowel syndrome in developing countries new
      #164746 - 03/28/05 01:29 PM
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Neurogastroenterology and Motility
doi:10.1111/j.1365-2982.2005.00627.x


Irritable bowel syndrome in developing countries: a disorder of civilization or colonization?

k.-a. gwee


While irritable bowel syndrome (IBS) is common in the West, early studies suggest that the prevalence is low in developing countries. However, recent studies point to increasing prevalence in newly developed Asian economies. The presentation appears to differ from the West, with a lack of female predominance, a greater frequency of upper abdominal pain and defecatory symptoms perceived as being less bothersome. This difference, together with the preoccupation with organic disease, could explain why we may be missing IBS in Asia and also why excess surgery has been observed in some Asian countries.

While a recent study from China, consistent with western studies, support an important role for infection and inflammation, early studies from India reporting no association between amoebic infection and IBS appear to dispute this observation. To reconcile these seemingly contradictory observations, an hygiene hypothesis model is proposed.

Exposure to a variety of microorganisms early in life could result in the colonization of the intestine with microflora that can respond more efficiently to an episode of gastroenteritis. Together with the changes with evolution of Asian economies such as westernization of the diet and increased psychosocial stress, it is proposed that loss of this internal protective effect, could give rise to a more uniform worldwide prevalence of IBS.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2005.00627.x/abs/

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New Recommendations for Treating Children With Chronic Abdominal Pain new
      #164767 - 03/28/05 01:59 PM
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New Recommendations for Treating Children With Chronic Abdominal Pain

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

March 4, 2005 — A subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics (AAP) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have generated a clinical report to provide guidance to clinicians treating children with this condition. The clinical report and an accompanying technical report are published in the March issue of Pediatrics.

"Children and adolescents with chronic abdominal pain pose unique challenges to their caregivers," write Richard B. Colletti, MD, and colleagues from the Subcommittee on Chronic Abdominal Pain. "Affected children and their families experience distress and anxiety that can interfere with their ability to perform regular daily activities. Although chronic abdominal pain in children is usually attributable to a functional disorder rather than organic disease, numerous misconceptions, insufficient knowledge among health care professionals, and inadequate application of knowledge may contribute to a lack of effective management."

Recommendations in the clinical report are based on the evidence reviewed in the technical report and on consensus opinion of the subcommittee members. However, the subcommittee acknowledges that the recommendations do not indicate an exclusive course of treatment or serve as a standard of medical care and that variations based on individual circumstances may be appropriate.

Although the classic definition of chronic abdominal pain used during the last four decades has used the criterion of at least three pain episodes for at least three months interfering with function, the authors suggest that in clinical practice, pain that exceeds one or two months in duration can be considered chronic.

Specific recommendations are as follows:

The term "recurrent abdominal pain" should no longer be used. Functional abdominal pain, the most common cause of chronic abdominal pain, is a specific diagnosis distinct from anatomic, infectious, inflammatory, or metabolic causes of abdominal pain. Specific categories may include functional dyspepsia, irritable bowel syndrome, abdominal migraine, or functional abdominal pain syndrome.


Without needing additional diagnostic testing, the primary care clinician can generally diagnose functional abdominal pain correctly in children four to 18 years of age with chronic abdominal pain, provided there are no alarm symptoms or signs, the physical examination is normal, and stools are negative for occult blood.


Alarm symptoms prompting additional diagnostic testing may include involuntary weight loss, linear growth deceleration, gastrointestinal tract blood loss, significant vomiting, chronic severe diarrhea, persistent right-upper or right-lower quadrant pain, unexplained fever, family history of inflammatory bowel disease, or abnormal or unexplained physical findings. Alarm signs may include localized right-upper or right-lower quadrant tenderness, localized fullness or mass effect, hepatomegaly, splenomegaly, costovertebral angle tenderness, spine tenderness, and perianal abnormalities.


If pain significantly decreases quality of life, testing may also be indicated to reassure the patient, parent, and physician of the absence of organic disease.


Psychological factors should be addressed in diagnostic evaluation and management, even though they may not help distinguish between organic and functional pain.


Family education is an important part of management of functional abdominal pain, using simple language to explain that the pain is real, but that there is most likely no underlying serious or chronic disease.


Reasonable treatment goals should be established, aimed at return to normal function and to school rather than the complete disappearance of pain.


Medications for functional abdominal pain "are best prescribed judiciously as part of a multifaceted, individualized approach to relieve symptoms and disability." Time-limited use of medications, such as acid-reduction therapy, antispasmodic agents, smooth muscle relaxants, low doses of psychotropic agents, or nonstimulating laxatives or antidiarrheals may be appropriate to decrease symptom frequency or severity.


Additional research is needed to advance still limited knowledge on chronic abdominal pain in children. The authors recommend detailed description of symptoms, eligibility criteria, work-up, and findings; use of validated outcome measures; evaluation of potential differences in course and treatment in subgroups of patients with different symptom phenotypes; research in diverse populations; and validation of the Rome II criteria in a range of clinical settings and populations.
"In view of the paucity of published literature on therapeutic approaches to this condition, there is an urgent need for trials of all currently used interventions in children with functional abdominal pain," the authors conclude.

The current authors also support the statements of the Functional Bowel Disorders Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition meeting that "there is a need to develop drugs to modulate abnormalities in sensorimotor function of the enteric nervous system in functional disorders to relieve specific symptoms and to assess the proper role of these drugs in the treatment of children and adolescents," and that "the role of antidepressants (tricyclics, selective serotonin reuptake inhibitors) in the treatment of functional gastrointestinal disorders associated with abdominal pain needs to be assessed."

Pediatrics. 2005;115:812-815, e370-e381

http://www.medscape.com/viewarticle/500799

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IBS is a risk factor for GERD new
      #168750 - 04/10/05 06:25 PM
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Alimentary Pharmacology & Therapeutics
Volume 21 Issue 7 Page 821 - April 2005
doi:10.1111/j.1365-2036.2005.02426.x


Risk factors for gastro-oesophageal reflux disease symptoms: a community study
I. Mohammed*, P. Nightingale & N. J. Trudgill*
Summary

Aim: To examine the prevalence of gastro-oesophageal reflux disease symptoms and potential risk factors among community subjects.

Methods: A questionnaire was sent to 4000 subjects, stratified by age, gender and ethnicity to be representative of the local population. Gastro-oesophageal reflux disease symptoms were defined as at least weekly heartburn or acid regurgitation.

Results: 2231 responded (59%), 691 refused to participate and seven were incomplete. 1533 (41%) were evaluable (637 male, mean age 51 years, range: 2080). The prevalence of gastro-oesophageal reflux disease symptoms was 21%. Smoking, excess alcohol, irritable bowel syndrome, increasing body mass index, a family history of upper gastrointestinal disease, increasing Townsend deprivation index, anticholinergic drugs (all P < 0.0001), weight gain, antidepressant drugs, inhaled bronchodilators, no educational attainment (all P < 0.01), south Asian origin (P = 0.02) and manual work (P < 0.05) were associated with gastro-oesophageal reflux disease symptoms. Multivariate logistic regression revealed increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin (all P < 0.0001), smoking, excess alcohol, no educational attainment and anticholinergic drugs (all P < 0.01) were independently associated with gastro-oesophageal reflux disease symptoms.

Conclusions: Frequent gastro-oesophageal reflux disease symptoms affect 21% of the population. Increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin, smoking, excess alcohol, social deprivation and anticholinergic drugs are independently associated with gastro-oesophageal reflux disease symptoms.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1192685&specid=13&ok=yes

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Towards a better understanding of abdominal bloating and distension in functional GI disorders new
      #173166 - 04/24/05 03:40 PM
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Neurogastroenterology and Motility
OnlineEarly
doi:10.1111/j.1365-2982.2005.00666.x


REVIEW
Towards a better understanding of abdominal bloating and distension in functional gastrointestinal disorders

l. a. houghton & p. j. whorwell
Abstract Abdominal bloating is an extremely common symptom affecting up to 96% of patients with functional gastrointestinal disorders and even 30% of the general population. To date bloating has often been viewed as being synonymous with an actual increase in abdominal girth, but recent evidence suggests that this is not necessarily the case. This review examines the relationship between the symptom of bloating and the physical sign of abdominal distension, as well as examining the epidemiology, pathophysiology and treatment options available for this debilitating aspect of the functional gastrointestinal disorders. Pathophysiological mechanisms explored include psychological factors, intestinal gas accumulation, fluid retention, food intolerance and malabsorption of sugars, weakness of abdominal musculature, and altered sensorimotor function. Treatment options are currently rather limited but include dietary changes, pharmacological approaches, probiotics and hypnotherapy.

http://www.blackwell-synergy.com/links/doi/10.1111/j.1365-2982.2005.00666.x/abs/

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What Does the Future Hold for Irritable Bowel Syndrome new
      #177493 - 05/08/05 06:02 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

What Does the Future Hold for Irritable Bowel Syndrome and the Functional Gastrointestinal Disorders?

Journal of Clinical Gastroenterology. The Spectrum of Functional Gastrointestinal Disorders (FGID). 39(4) Supplement 3:S251-S256, May/June 2005.

Drossman, Douglas A MD

Abstract:
Our understanding of irritable bowel syndrome and the functional GI disorders has grown considerably over the last 15 years. In part this relates changes in their classification and definition from being due solely to motility disturbances, to being symptom based (eg, Rome criteria). This opened the door to the study of many other factors that contribute to the clinical expression of these disorders, including visceral hypersensitivity, sensitization, altered mucosal immunity, and dysfunction in brain-gut regulatory processes. New knowledge has been gained in areas of genetics, central nervous system and enteric nervous system neurotransmitters of motility, sensitivity and secretion, the effect of altered mucosal inflammation on cytokine and paracrine activation, and neural sensitization, postinfectious disorders, the influence of psychologic stress on gut functioning via alterations in regulatory pathways (eg, hypothalamic-pituitary adrenal axis, or pain regulatory system like the cingulate cortex), improved accuracy of diagnosis using Rome II criteria plus "red flags" the institution of behavioral treatments, and the use of new pharmacologic treatments both at the gut and brain level.

Future research will improve upon this new knowledge via basic and translational studies of neuropeptide signaling with new neurotransmitters, new knowledge on the mechanisms for central nervous system-enteric nervous system communication and dysfunction, and more advanced clinical research on education, communication skills and their effects on outcome, genetics, pharmacogenetics and genetic epidemiology, better understanding as to how certain psychosocial domains (eg, catastrophizing, abuse) affect symptom behavior and outcome, newer pharmacologic treatments, and the use of combined pharmacologic and behavioral treatment packages. I am pleased to have the opportunity to provide a personal perspective on what the future will be for irritable bowel syndrome and the other functional GI disorders. Having been involved in this field for almost 30 years, I have been fortunate to witness tremendous changes. The focus of this presentation is to address the advances that have recently occurred that set the stage for proposing future research to help move the field along and ultimately to help our patients.

(C) 2005 Lippincott Williams & Wilkins, Inc.



--------------------------------------------------------------------------------
Copyright © 2005, Lippincott Williams & Wilkins. All rights reserved.
Published by Lippincott Williams & Wilkins.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1212785&specid=13&ok=yes

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Nerves, Reflexes, and the Enteric Nervous System: Pathogenesis of the Irritable Bowel Syndrome new
      #177494 - 05/08/05 06:06 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Nerves, Reflexes, and the Enteric Nervous System: Pathogenesis of the Irritable Bowel Syndrome.

Journal of Clinical Gastroenterology. The Spectrum of Functional Gastrointestinal Disorders (FGID). 39(4) Supplement 3:S184-S193, May/June 2005.

Gershon, Michael D MD

Abstract:
The bowel exhibits reflexes in the absence of CNS input. To do so, epithelial sensory transducers, such as enterochromaffin (EC) cells, activate the mucosal processes of intrinsic (IPANs) and extrinsic primary afferent (sensory) neurons. EC cells secrete serotonin (5-HT) in response to mucosal stimuli. Submucosal IPANs, which secrete acetylcholine and calcitonin gene-related peptide, initiate peristaltic and secretory reflexes and are activated via "5-HT1P" receptors.

Release of neurotransmitters is enhanced by 5-HT4 receptors, which are presynaptic and strengthen neurotransmission in prokinetic pathways. 5-HT3 receptors mediate signaling to the CNS and thus ameliorate cancer chemotherapy-associated nausea and the visceral hypersensitivity of diarrhea-predominant irritable bowel syndrome (IBS-D); however, because 5-HT3 receptors also mediate fast ENS neurotransmission and activate myenteric IPANs, they may be constipating.

5-HT4 agonists are prokinetic and relieve discomfort and constipation in IBS-C and chronic constipation. 5-HT4 agonists do not initiate peristaltic and secretory reflexes but strengthen pathways that are naturally activated. Serotonergic signaling in the mucosa and the ENS is terminated by a transmembrane 5-HT transporter, SERT. Mucosal SERT and tryptophan hydroxylase-1 expression are decreased in experimental inflammation, IBS-C, IBS-D, and ulcerative colitis. Potentiation of 5-HT due to the SERT decrease could account for the discomfort and diarrhea of IBS-D, while receptor desensitization may cause constipation. Similar symptoms are seen in transgenic mice that lack SERT. The loss of mucosal SERT may thus contribute to IBS pathogenesis.

(C) 2005 Lippincott Williams & Wilkins, Inc.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1212776&specid=13&ok=yes

--------------------
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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Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS new
      #177495 - 05/08/05 06:11 PM
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Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Impairment in Work Productivity and Health-related Quality of Life in Patients With IBS


Bonnie B. Dean, PhD; Daniel Aguilar, MPH; Victoria Barghout, MSPH; Kristijan H. Kahler, SM; Feride Frech, MPH; David Groves, PhD; and Joshua J. Ofman, MD


Irritable bowel syndrome (IBS) is a long-term and episodic medical disorder shown to have an impact on work productivity and health-related quality of life (QOL). The objective of this study was to assess the impact of IBS on work productivity and on health-related QOL in an employed population in the United States and to quantify the cost of these factors to the employer. A 2-phase survey was sent to the workforce of a large US bank to assess the presence of IBS among employees and to measure their work productivity (absenteeism [time lost from work] and presenteeism [reduced productivity at work]) and health-related QOL. Forty-one percent of the 1776 employees responding to both phases of the survey met the Rome II criteria for IBS. Employees with IBS reported a 15% greater loss in work productivity because of gastrointestinal symptoms than employees without IBS and had significantly lower Medical Outcomes Study Short Form 36 (SF-36) scores than those without IBS. IBS was associated with a 21% reduction in work productivity, equivalent to working less than 4 days in a 5-day workweek. Employees with IBS also had significantly lower scores on all domains of the SF-36, indicating poorer functional outcomes. Reduced work productivity and diminished QOL of these magnitudes may have substantial financial impact on employers.

(Am J Manag Care. 2005;11:S17-S26)





Patients with irritable bowel syndrome (IBS) report symptoms that may wax and wane in type and severity over time1,2 and that can have a negative impact on health-related quality of life (QOL).3-6 IBS affects adults of all ages, primarily those of working age (30-50 years old).2 In the United States, an estimated 10% to 20% of adults are believed to have symptoms consistent with this disorder.3

Although estimates of the direct costs associated with IBS are staggering and can vary greatly,7 the impact of IBS on absenteeism (hours absent from work), presenteeism (reduced productivity while at work), and health-related QOL is of increasing concern to employers in the United States, who rely heavily on a healthy workforce and who contract with health plans and other payers to cover the healthcare costs of their employees. For these reasons, employers often implement wellness and disease management programs to optimize workforce health.

Leong and colleagues8 studied healthcare insurance data of the employees of a self-insured Fortune 100 company and determined that direct and indirect costs for patients with IBS were substantially greater than those for a matched non-IBS control group. In 1998, the direct and indirect medical costs to the employer for 1 employee with IBS were $3997 and $2367, respectively, which were $1651 and $468 greater than the direct and indirect medical costs for 1 employee without IBS. The indirect cost for patients with IBS is likely to have been underestimated, however, because this estimate included absenteeism but not presenteeism.

Hahn and colleagues9 measured the impact of IBS on absenteeism. Although the actual number of hours employees were absent from work because of IBS was not substantial, the number of missed workdays increased significantly as the severity of illness increased. In a separate study of IBS patients, Hahn and colleagues10 found that Medical Outcomes Study Short Form 36 (SF-36) scores of respondents from the United States and the United Kingdom were significantly lower, meaning that they were worse than the respective population norms. Moreover, 30% of US respondents missed at least 1 full day of work in the 4 weeks preceding the survey, and 46% reported "cutting back" on some workdays because of IBS.

Although several studies have reported reduced health-related QOL in IBS populations, 3-6 limited research has been conducted to assess health-related QOL or absenteeism in an employed population with IBS, and even less research has been conducted to quantify the economic impact of these factors on the employer. Additionally, these studies have largely ignored the specific impact of IBS-associated gastrointestinal (GI) symptoms on presenteeism.

Our objective was to assess the impact of IBS on work productivity (presenteeism and absenteeism) and on health-related QOL in a US employed population and to quantify the cost of these factors to the employer.

Methods

Participants were employees of Comerica Incorporated, a nationwide bank with major branches in multiple states (Michigan, California, Texas, and Florida). From April 2002 to August 2002, all employees of Comerica (N = 11 806) were invited to participate in a 2-phase survey regarding GI health and related symptoms.

All Comerica employees were mailed a survey designed to (1) identify those with IBS (including subgroup classification for constipation [IBS-C] or diarrhea [IBS-D]) using the Rome II criteria11-13; (2) measure the frequency, severity, and bothersomeness of IBS symptoms; and (3) capture information on sociodemographics, long-term health conditions (including physician-diagnosed IBS), and job characteristics. A postcard was included in the initial mailing to request signed consent for participation in the followup survey. Employees who completed initial surveys and consent forms received a second survey measuring work productivity loss because of IBS and assessing QOL (Figure 1). The Cedars-Sinai Health System Institutional Review Board approved this study.



Names of initial survey participants were entered in a raffle for 1 of 9 gift checks valued between $100 and $500. Second-phase survey participants received a gift check for $25. All participants received educational material regarding IBS at the conclusion of the study.

Rome II Criteria. Employees were administered the Rome II diagnostic criteria questionnaire11-13 to assess the presence of IBS. According to the Rome II criteria, IBS is defined by the presence of abdominal discomfort or pain for at least 12 weeks, which need not be consecutive, during the preceding 12 months, and the discomfort or pain should have 2 of the following 3 features: it should be relieved with defecation; its onset should be associated with a change in the frequency of the stool; its onset should be associated with a change in the form (appearance) of the stool.13 Supportive symptoms can be used to classify IBS patients into symptom subgroups: IBS-C, characterized by less than 3 stools per week, hard/lumpy stools, straining, and feeling of incomplete bowel evacuation; IBS-D, characterized by more than 3 stools per week, loose or watery stools, and urgency; and mixed-pattern subtypes (alternating IBS).13,14

Assessment of Work Productivity. Work productivity was measured using the Work Productivity and Activity Impairment (WPAI) questionnaire,15 which was developed and validated as a general health measure that can be easily modified for specific health conditions. Adapted versions of the WPAI16 have been developed for use in patients with conditions such as allergy,16,17 long-term hand dermatitis,18 and gastroesophageal reflux disease (GERD).19,20 We adapted the WPAI to estimate the impact of GI symptoms consistent with IBS, including abdominal pain or discomfort, bloating, and constipation or diarrhea, on work productivity.16 Areas assessed included level of impairment during work and other daily activities and hours absent from work because of IBS symptoms during the previous 7 days. A scale from 0 to 10 was used to assess the degree to which GI symptoms consistent with IBS negatively affected a patient's productivity while working and to assess how they affected daily activity. Measures of productivity and absenteeism were combined in the work productivity score (WPS), which quantifies reduced work productivity (absenteeism and presenteeism) attributed to GI symptoms consistent with IBS as a percentage of potential total work productivity during a full-time workweek. The WPS was calculated as follows:



WPAI measures are interpreted as a percentage reduction in productivity (or a percentage of productivity lost) and are adjusted for part-time status. For example, a WPS of 5% indicates that a full-time employee is working at only 95% of full work potential (eg, 40 hours) because of reductions associated with absenteeism and presenteeism. A WPS of 5% for an employee working 40 hours per week would imply a reduction of 2 hours of potential work productivity lost.

Medical Outcomes Study Short Form. QOL was assessed using the SF-36 questionnaire, a generic instrument designed to measure overall health status.21,22 The WPS = [(hours absent from work + percentage of reduced productivity at work × hours actually worked)/(hours missed because of ill health + hours worked)] × 100. SF-36, which has previously been validated for use in the measurement of health-related QOL among IBS patients,23 assesses health status across 8 subscales, including physical functioning, physical role limitations, emotional role limitations, social functioning, bodily pain, general mental health, vitality, and general health perceptions. Additionally, subscale scores can be collapsed into 2 summary scores, the mental component summary (MCS) and the physical component summary (PCS).24 Scores for each subscale and summary score range from 0 (poor health) to 100 (optimal health).

Statistical Analysis. Employees meeting the Rome II criteria for IBS were compared with those not meeting the criteria with respect to a variety of variables, including demographic and work-related measures, presence of comorbid conditions, and history of hysterectomy or surgeries of the GI tract. Chi-square tests were used for categorical variables and t tests for continuous variables. Two-sided P values were calculated, and statistical significance was set at the &#954;= 0.05 level.

The kappa coefficient was calculated to assess the agreement between respondents meeting the Rome II criteria (based on the questionnaire) and respondents indicating a diagnosis of IBS by a physician or another medical professional (formal diagnosis). The kappa statistic describes the degree of agreement between 2 variables. Kappa values range between -1.0 (perfect disagreement) and +1.0 (perfect agreement), with zero indicating agreement that is completely accounted for by chance. Values of 0.0 to 0.2 indicate slight agreement, 0.2 to 0.4 fair agreement, 0.4 to 0.6 moderate agreement, 0.6 to 0.8 substantial agreement, and 0.8 to 1.0 near-perfect agreement.

Employees with and without IBS (as determined by their having met the Rome II criteria) were compared with respect to mean percentage reductions across WPAI measures of productivity, and a similar comparison was made between IBS-C and IBS-D subgroups. A nonparametric method, bootstrapping, was used to estimate the 95% confidence interval (CI) for differences in productivity impairments. Bootstrapping is a statistical approach for estimating CIs from data simulations when distributions deviate considerably from the assumptions of parametric statistics. Mean percentage reductions in WPAI measures of productivity were converted to lost work productivity based on total number of hours absent from work (absenteeism) and total number of hours at reduced productivity while at work (presenteeism) based on a 40-hour workweek (using the WPS formula presented in this article). These hours were also quantified based on the mean salary and mean wages of employees in the sample. The mean cost in dollars of reduced work productivity (absenteeism and presenteeism) per year (assuming full-time employment of 2080 hours of potential work time annually per employee) because of GI symptoms consistent with IBS was calculated as the difference in cost of reduced work productivity between employees with and without IBS. The cost per employee was extrapolated to a company with 10 000 employees assuming IBS prevalence estimates ranging from 10% to 20%.

Health-related QOL scores were calculated for the MCS and PCS and for each of the 8 SF-36 subscales. Mean differences in scores between IBS and non-IBS groups and between IBS-C and IBS-D subgroups were calculated with 95% CI.

Results

Survey participation is outlined in Figure 1. The initial survey was sent to all 11 806 Comerica employees and was returned by 2615 (22.2%) employees. Compared with the general Comerica employee population, respondents were similar in age, sex, and work status (full-time vs part-time). Completed surveys along with consent forms were submitted by 2276 (87.0%) employees, who then received the phase 2 survey; that survey was completed by 1776 (78.0%) of the initial respondents. The 1776 phase 2 respondents were similar to the 500 phase 2 nonrespondents in age, sex, education, compensation type (salary vs hourly wage), and work status (full-time vs part-time) (P >.05 for each). However, those who completed the survey were more likely to be white (P = .0002).

Patient Characteristics. Among the 1776 phase 2 respondents, 720 (40.5%) employees met Rome II criteria for IBS. Of these, 191 (27%) and 255 (35%) met Rome II IBS subtype criteria for IBS-C and IBS-D, respectively; the remaining 38% reported mixed-pattern bowel habit. Employees with IBS were similar to those without IBS (n = 1056) in age, compensation type (salary vs hourly wage), and work status (full-time vs part-time) (P >.05 for each) (Table 1). Employees with IBS were more likely to be women (P <.0001) (man/woman ratio, 1:5.1), were less likely to have a graduate degree (P = .03), and differed slightly with regard to race and ethnicity (P = .04). Employees with IBS were also more likely to have allergies, anxiety, depression, GERD, stomach ulcers, gallstones, and incontinence than employees without IBS (P <.001 for each).



Symptoms of abdominal pain or discomfort, diarrhea, constipation, gas, and bloating were each significantly more frequent and severe among employees with IBS than among those without IBS (P <.05). In addition, the IBS group reported greater levels of distress (moderate to extreme) because of each of the above symptoms than the group without IBS (P <.05). The greatest differences in reported frequency of symptoms between employees with and without IBS were for abdominal pain or discomfort and bloating, whereas the greatest reported differences in distress were attributed to the symptoms of constipation, diarrhea, and bloating. Exploratory and excisional surgeries associated with abdominal pain or symptoms were significantly more common among employees with IBS (Table 2), as were other types of surgery, such as appendectomy, cholecystectomy, and hysterectomy (P <.05). Small bowel resection and obstruction were more common among employees with IBS (P = .06).



Agreement Between Rome II Criteria and Professional Diagnosis of IBS. Data from the initial survey responders (n = 2615) were used to assess agreement between employees meeting Rome II symptom criteria (n = 1042) and those reporting a previous diagnosis of IBS determined by a physician or another medical professional (n = 269) (Figure 2). Agreement between a diagnosis of IBS by a physician or a medical professional and a diagnosis of IBS using the Rome II criteria was low (&#954;= 0.22), indicating that most patients whose IBS was diagnosed using the Rome II criteria had not been previously diagnosed by a physician or a medical professional. Among employees reporting a previous diagnosis of IBS by a physician or another medical professional, 86% (n = 230) met Rome II criteria; in comparison, of the 2346 employees who did not report a diagnosis of IBS by a physician or a medical professional, 35% (n = 812) met Rome II criteria. Thus, the Rome II captured most of the IBS diagnoses previously made by a physician or another medical professional, and it was also able to capture a significant number of IBS cases that had not yet been formally diagnosed. Of the total number of respondents who met Rome II criteria during the initial survey (n = 1042), 22% (n = 230) also reported IBS previously diagnosed by a physician or another medical professional, whereas only 2% (n = 39) of employees not meeting the Rome II criteria for IBS (n = 1573) reported a physician or a medical professional diagnosis of IBS. Thus, the proportion of diagnoses by a physician or a medical professional that were not identified using the Rome II criteria was small.



Impact of IBS on Work Productivity. Figure 3 provides measures of work productivity (absenteeism and presenteeism) and activity impairment for employees with and without IBS. Among employees with IBS, productivity at work (presenteeism) was reduced by more than 21% because of GI symptoms consistent with IBS; this figure was 15% (95% CI, 13.4-16.6) higher than that reported among employees without IBS. The percentages of work time missed (absenteeism) were 1.7% and 0.4% (mean percentage difference, 1.3; 95% CI, 0.7-1.9) among those with and without IBS, respectively.



The largest contributor to total productivity loss, WPS, was reduced productivity at work (presenteeism) (15%; 95% CI, 13-17). In comparison, absenteeism contributed only slightly to the total WPS (1.3%; 95% CI, 0.7-1.9). GI symptoms consistent with IBS were associated with a 21.1% reduction in total WPS among employees with IBS compared with a 6.1% reduction among those without IBS. Reductions in total WPS among employees with IBS-C and IBS-D were comparable at 18.2% and 20.8%, respectively. Based on the average hourly wage of each employee, reduction in total WPS resulted in average losses of $10 884 and $3147 for employees with and without IBS, respectively. Thus, the value of work productivity loss per individual because of IBS-attributable GI symptoms was $7737 (95% CI, $7332-$8143) per year.

Employees with IBS reported a mean reduction of nearly 27% in regular daily activities (ie, work around the house, shopping, childcare, exercising, studying) because of GI symptoms consistent with IBS. This accounted for the largest difference between IBS and non-IBS employees, as shown by a 19% (95% CI, 16.9-20.7) mean difference in daily activity impairment.

Impact of Work Productivity Reduction on the Employer. The incremental work productivity loss associated with IBS represents an additional 39 days of reduced productivity at work and an additional 3.4 days of absence per year for each employee with IBS. Assuming participants are representative of the Comerica employee population (10 000 employees) and assuming a 10% prevalence of IBS, the employer loses a total of $7 737 600 per year. If the prevalence of IBS is 20%, the resultant work productivity loss increases to $15 475 200 per year. Among salaried employees with IBS (n = 481), mean work productivity losses attributable to GI symptoms consistent with IBS ranged from 19% to 21%, regardless of salary range ($15 000-$35 000, $35 000-$55 000, $55 000-$80 000, and >$80 000). In contrast, hourly employees with IBS earning &#8804;$15 per hour (n = 155) experienced a 44% greater work productivity loss than those with IBS earning >$15 per hour (n = 100) (26% vs 18% work productivity loss for &#8804;$15 per hour vs >$15 per hour, respectively).

Impact of IBS on Health-related QOL. Scores for all SF-36 subscales were significantly lower for employees with IBS than for those without IBS (P <.05) (Figure 4). The most significant difference was in physical role limitations, with a mean difference of 24.6 (95% CI, 21.4-27.7) points between employees with and employees without IBS. Compared with subjects with IBS-D, those with IBS-C scored lower on the MCS and reported greater impairment on 6 of 8 SF-36 domains (although only emotional role functioning was statistically significant).



MCS and PCS scores were lower among employees with IBS than among those with- out IBS, with mean differences of 5.9 (95% CI, 5.0-6.9) and 5.4 (95% CI, 4.7-6.0), respectively.

Discussion

IBS is a long-term and episodic disorder, with GI symptoms (abdominal pain or discomfort and bloating associated with altered bowel function) that can wax and wane and that affect many persons during their most productive years of adulthood. This study is one of the first evaluations performed in a US employed population that measure the impact of IBS on work productivity and on health-related QOL. We found that IBS is significantly associated with reduced work productivity and that it significantly impacts health-related QOL, suggesting that management strategies targeting improvements in symptoms consistent with IBS and health-related QOL should be expected to have a positive impact on work productivity.

Reduced productivity while at work (presenteeism) because of GI symptoms consistent with IBS was a major contributor to total reduced work productivity. Employees with IBS experienced an additional 15% reduction in work productivity beyond that reported among controls. For an employee who works 40 hours per week, this 15% difference amounts to another 6 hours of work productivity lost per week. Although reduced work productivity resulting from GI symptoms amounts to approximately 15.8 days per year for employees without IBS, it accounts for more than 54.8 days per year for employees with IBS.

The largest component of total productivity reduction in employees with IBS was impairment while working. Absenteeism because of GI symptoms consistent with IBS contributed less to reductions in work productivity in this population. Absenteeism was low among all participants—1.7% and 0.4% among those with and without IBS, respectively (Figure 3), corresponding to approximately 3 hours per month of absence among employees with IBS and less than 1 hour per month of absence for non-IBS employees. Although studies have reported higher average absenteeism rates of 1 to 2 days per month, they have assessed absenteeism from all causes, not just GI symptoms.9,25

The impact of IBS on absenteeism and presenteeism observed in this study may impose a substantial financial burden on employers. It is possible that this study has underestimated the work productivity loss—a previous study using objective measures of productivity among employees from a large US credit card company found that mean total time lost per month from presenteeism, absenteeism, and disability for employees with digestive disorders was equivalent to more than twice the hours per month of work productivity loss measured in the present study.26 Few data are available to compare subjective (self-report) and objective measures of productivity, but the validation studies of the Work Limitations Questionnaire and the WPAI suggest that estimates based on self-reported data are valid.15,27

Our findings on overall work impairment in employees with IBS (21%) are comparable with those previously reported for other GI disorders, such as GERD (16%-35%).19,20 Overall work impairment was also comparable with that for other health conditions, including chronic hand dermatitis (17%)18 and allergic rhinitis (23%-42%),28 in studies that used the WPAI.

Employees with IBS had SF-36 scores within the range of scores reported for other long-term health conditions, such as back pain, ulcer, osteoarthritis, and congestive heart failure,29 and were comparable with previous measurements of health-related QOL in IBS populations.3-5

There are limitations to this observational study. As with all surveys, there is a risk for selection bias, particularly given the 22% response rate. Although low, this response rate is consistent with rates seen in other employer-based studies (20%-50%).30-34 The study cover letter sent to employees indicated that the study dealt with GI symptoms, a disclosure required by the employer and the institutional review board. It is possible that employees with symptoms were more likely to participate, leading to an overrepresentation of IBS patients in the study population. The similarity between employees with and without IBS along demographic and workrelated variables suggests that study results were unlikely to have been biased by differences in these variables. The banking industry employs a disproportionate number of women, but the ratio of women to men with IBS in our study was approximately 1.5:1—similar to proportions observed in other epidemiologic studies of IBS.25,35,36 Additionally, treatment for IBS symptoms may influence the degree of reduced work productivity. However, we were unable to explore the percentages of reduced work productivity among IBS patients being treated compared with those who had not sought care, because we did not question employees regarding their current treatments.

Our results indicate that IBS significantly affects work productivity. Further studies are required to better assess this impact in more defined populations of IBS, such as those seeking or receiving medical care, and in other employed populations. In addition, there is a need to better understand the determinants of work productivity losses in IBS and the relationship between direct medical costs and indirect costs (absenteeism and presenteeism). Finally, from an employer's perspective, additional efforts are needed to ensure that patients are identified and offered appropriate treatment because unique therapeutic agents can decrease symptom severity and frequency while improving employee health-related QOL and work productivity. Such efforts could pay dividends in the form of improved productivity and reduced absenteeism.




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13. Thompson WG, Longstreth GF, Drossman DA, Heaton K, Irvine EJ, Muller-Lissner S. Rome II: The Functional Gastrointestinal Disorders. 2nd ed. McLean, Va: Degnon Associates; 2000.

14. Brandt LJ, Bjorkman D, Fennerty MB, et al. Systematic review on the management of irritable bowel syndrome in North America. Am J Gastroenterol. 2002;97(suppl):S7-S26.

15. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993;4:353-365.

16. Reilly MC, Bracco A, Ricci JF, Santoro J, Stevens T. The validity and accuracy of the Work Productivity and Activity Impairment questionnaire—irritable bowel syndrome version (WPAI:IBS). Aliment Pharmacol Ther. 2004;20:459-467.

17. Murray JJ, Nathan RA, Bronsky EA, Olufade AO, Chapman D, Kramer B. Comprehensive evaluation of cetirizine in the management of seasonal allergic rhinitis: impact on symptoms, quality of life, productivity, and activity impairment. Allergy Asthma Proc. 2002;23:391-398.

18. Reilly MC, Lavin PT, Kahler KH, Pariser DM. Validation of the Dermatology Life Quality Index and the Work Productivity and Activity Impairment-Chronic Hand Dermatitis questionnaire in chronic hand dermatitis. J Am Acad Dermatol. 2003;48:128-130.

19. Wahlqvist P. Symptoms of gastroesophageal reflux disease, perceived productivity, and health-related quality of life. Am J Gastroenterol. 2001;96(suppl):S57-S61.

20. Wahlqvist P, Carlsson J, Stalhammar NO, Wiklund I. Validity of a Work Productivity and Activity Impairment questionnaire for patients with symptoms of gastroesophageal reflux disease (WPAI-GERD): results from a cross-sectional study. Value Health. 2002;5:106-113.

21. McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36), II: psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-263.

22. Ware JE Jr, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36), I: conceptual framework and item selection. Med Care. 1992;30:473-483.

23. Bensoussan A, Chang SW, Menzies RG, Talley NJ. Application of the general health status questionnaire SF36 to patients with gastrointestinal dysfunction: initial validation and validation as a measure of change. Aust N Z J Public Health. 2001;25:71-77.

24. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A. Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care. 1995;33(suppl):AS264-AS279.

25. Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders: prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569-1580.

26. Burton WN, Conti DJ, Chen CY, Schultz AB, Edington DW. The role of health risk factors and disease on worker productivity. J Occup Environ Med. 1999;41:863-877.

27. Lerner D, Amick BC 3rd, Rogers WH, Malspeis S, Bungay K, Cynn D. The Work Limitations Questionnaire. Med Care. 2001;39:72-85.

28. Meltzer EO, Casale TB, Nathan RA, Thompson AK. Once-daily fexofenadine HCl improves quality of life and reduces work and activity impairment in patients with seasonal allergic rhinitis. Ann Allergy Asthma Immunol. 1999;83:311-317.

29. Ware JE Jr, Kosinski M. SF-36 Physical & Mental Health Summary Scales: A Manual for Users of Version 1. 2nd ed. Lincoln, RI: QualityMetric Incorporated;2001.

30. Chang LA. Job satisfaction, dissatisfaction of Texas newspaper reporters. Dissertation Abstracts International Section A: Humanities & Social Sciences. 1999;59:3260.

31. Miller-Burke JA. The impact of traumatic events and organizational response. Dissertation Abstracts International Section B: The Sciences & Engineering. 1998;58:5177.

32. Productivity and quality in the USA today. Management Services. 1990;34:27-31.

33. Seiler RE, Sapp RW. Just how satisfied are accountants with their jobs? Management Accounting. 1979;60:18-21.

34. Industrial engineers describe productivity improvement efforts, identify obstacles to their success. Industrial Engineering. 1983;15:84-88.

35. Talley NJ, Zinsmeister AR, Van Dyke C, Melton LJ 3rd. Epidemiology of colonic symptoms and the irritable bowel syndrome. Gastroenterology. 1991;101:927-934.

36. Saito YA, Locke GR, Talley NJ, Zinsmeister AR, Fett SL, Melton LJ 3rd. A comparison of the Rome and Manning criteria for case identification in epidemiological investigations of irritable bowel syndrome. Am J Gastroenterol. 2000;95:2816-2824.

Copyright© 2003-2005 Medical World Communications, Inc.


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Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation new
      #177496 - 05/08/05 06:16 PM
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From Medscape General Medicine™

MedGenMed Gastroenterology

Partnering With Gastroenterologists to Evaluate Patients With Chronic Constipation

Posted 4/28/2005
Brian E. Lacy, MD, PhD; Stephen A. Brunton, MD


Abstract and Introduction
Abstract
Constipation is a highly prevalent and bothersome disorder that negatively affects patients' social and professional lives and imposes a heavy economic burden on patients and society. Most patients with chronic constipation are evaluated and treated in the primary care setting. Primary care clinicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral. There are numerous steps that primary care clinicians can take to address these issues and maximize the benefits of the referral process, including understanding key elements of an effective diagnostic work-up, familiarizing themselves with the utility of various diagnostic tests of colonic and anorectal function, implementing strategies/instruments to optimally communicate what they are striving to achieve through the referral process (eg, via a referral form), and developing a network of long-term working relationships with local gastroenterologists.

Introduction
Constipation is a highly prevalent disorder that affects approximately 12% to 19% of North Americans -- estimates vary widely depending on study design and methodology.[1-6] For many persons, constipation is a chronic problem, lasting from several months to several years.[2] The multiple symptoms of chronic constipation encompass much more than reduced stool frequency; many patients report straining, feelings of incomplete evacuation, abdominal pain/discomfort, bloating, hard and/or small stools, or a need for digital manipulation to enable defecation.[5,7-12] For research purposes (eg, enrolling patients into clinical trials), the Rome II diagnostic criteria for constipation are generally used ( Table 1 ).[2,13]

Chronic constipation leads to decreased quality of life. The general well-being of patients with this disorder is lower than that of comparable normal populations,[14,15] and symptom severity has a negative correlation with perceived quality of life (ie, the more severe the symptoms, the lower the quality of life).[14]

The economic impact of constipation is substantial both for patients and society as a whole. Between 1979 and 1981, constipation resulted in 13.7 million days per year of restricted activity; in 1975, 3.43 million days per year of bed disability[16] occurred; and annually in the United States, over-the-counter (OTC) laxative sales total more than $800 million.[1] Although they account for only approximately one third of those with chronic constipation, adults with chronic constipation who seek medical care consume significant and costly healthcare resources. For instance, total healthcare costs for patients with constipation enrolled in the California Medicaid program (n = 105,130) for a 15-month period amounted to $18,891,007.[17]

Most patients with chronic constipation are evaluated and treated in the primary care setting. In 2000, constipation was 13th on the list of leading physician diagnoses for gastrointestinal (GI) disorders in outpatient clinic visits in the United States. Furthermore, constipation was ranked as the sixth leading GI symptom that prompts outpatient visits.[16] One study estimated ambulatory healthcare use related to constipation in the United States by assessing data from the 2001 National Ambulatory Medical Care Survey and the 2001 National Hospital Ambulatory Medical Care Survey. Study findings showed that more than 5.7 million visits related to constipation were made in the outpatient setting in 2001. Of these, constipation was the primary reason for a visit or was the primary diagnosis in 44%, 51%, and 56% of visits to physician offices, hospital outpatient clinics, and emergency rooms, respectively.[18]

Primary care clinicians are often frustrated when faced with patients who do not respond to empiric treatment measures. When, how, and to whom to refer such patients is often unclear, and expectations of the referral process -- to gain a better understanding of the underlying cause of the constipation and guidance on management strategies -- are often not met (see Sidebar). Furthermore, primary care physicians often underestimate how much they can accomplish in the evaluation of a patient with constipation before they make a referral.

This article discusses common communication barriers between primary care clinicians and gastroenterologists in the care of patients with chronic constipation, and suggests strategies and tools that can be used to facilitate effective communication and optimize patient care. Suggestions for conducting a thorough prereferral work-up for patients with constipation are also presented, and the usefulness of various diagnostic tests that are commonly employed is discussed.[19]

Section 1 of 6 Next Page and Footnotes: Considerations Regarding the Referral Process

Please click here to continue reading this full article:

http://www.medscape.com/viewarticle/501075?src=mp


Brian E. Lacy, MD, PhD , Associate Professor of Medicine; Director, GI Motility Laboratory, Division of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Stephen A. Brunton, MD , Director of Faculty Development, Cabarrus Family Medicine Residency, Charlotte, North Carolina


Disclosure: Brian E. Lacy, MD, PhD, has received investigator-initiated grant support in the past from Novartis Pharmaceuticals for both basic and clinical research. He currently has funding for investigator-initiated research from AstraZeneca. He was a member of an advisory board for Novartis Pharmaceuticals during calendar year 2004, and is on the speaker's bureau for both AstraZeneca and Novartis.

Disclosure: Stephen A. Brunton, MD, has served as a consultant for GlaxoSmithKline, Novartis, Santarus, and Wyeth.


Medscape General Medicine. 2005; 7 (2): ©2005 Medscape



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Nongastrointestinal symptoms of irritable bowel syndrome new
      #180703 - 05/22/05 07:14 PM
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Nongastrointestinal symptoms of irritable bowel syndrome: An office-based clinical survey

Noel B. Hershfield

Irritable bowel syndrome (IBS) is the most prevalent gastrointestinal problem faced by practicing gastroenterologists. For many years, nongastrointestinal symptoms have been documented in IBS patients, but the medical literature does not emphasize them.

The present study explored how IBS and inflammatory bowel disease patients differ in their reporting of nongastrointestinal symptoms. Information from 200 consecutive patients with IBS and a similar number of patients with Crohn's disease (in a single gastroenterology practice) was obtained at the initial visit using a simple questionnaire.

Comparison of the data revealed that IBS patients describe certain nongastrointestinal symptoms far more frequently than do those with inflammatory bowel disease. It is recommended that these symptoms be considered along with the generally accepted criteria for making a positive diagnosis of IBS.

http://www.mdlinx.com/GILinx/thearts.cfm?artid=1206844&specid=13&ok=yes

Dr. Hershfield is currently conducting a groundbreaking clinical trial of the dietary guidelines original to the book Eating for IBS. You can participate in his study, and help change the way all physicians treat their IBS patients!


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Colon Cancer Test Misses Growths in Women new
      #183766 - 06/05/05 05:56 PM
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Colon Cancer Test Misses Growths in Women

May 19, 2005

BOSTON (AP) -- A widely used screening tool for colon cancer, sigmoidoscopy, misses precancerous growths in almost two-thirds of women -- a disturbing failure rate twice as high as the one seen in men, a government-backed study found.

"All our data until now has been based on men. What this data shows is it's a lot worse in women," said Dr. Philip Schoenfeld of the University of Michigan and U.S. Department of Veterans Affairs.

The researchers said colonoscopy -- a more reliable but more expensive test than sigmoidoscopy -- should now be considered the preferred method for most women.

Even before the study, patients were increasingly choosing colonoscopies, in part because of serious questions about the reliability of sigmoidoscopies. The latest research is likely to accelerate the trend.

Both colonoscopy and sigmoidoscopy involve the use of a long, flexible tube to inspect the twisting colon for precancerous growths, or polyps. But a colonoscope is longer and is used to examine the entire 6-foot length of the colon, while a sigmoidoscope inspects only the lower 2 feet or so.

The new study, led by Schoenfeld, involved 1,463 women, ages 50 to 79, at four military hospitals. It was published Thursday in The New England Journal of Medicine and funded by the National Cancer Institute.

The researchers first used colonoscopes to find all polyps. They then calculated how many worrisome ones would have been missed by sigmoidoscopy alone.

Sigmoidoscopes were already in question because they find precancerous tumors in only 66 percent of average-risk men who have them. In this new study, sigmoidoscopes did even worse in average-risk women, detecting precancerous tumors in just 35 percent of the patients who had them.

Medical guidelines recommend either regular sigmoidoscopies or colonoscopies after age 50. The number of colonoscopies has already been rising in recent years, especially among high-risk patients. A federal survey put the number of colonoscopies at 14 million in 2002, compared to 3 million sigmoidoscopies.

Sigmoidoscopies are still performed for several reasons. A sigmoidoscopy is quicker, it is more convenient because it does not require the use of a sedative, and it costs far less than of a colonoscopy -- perhaps $150 instead of $400 or more.

Also, many doctors had believed that the failure rate for sigmoidoscopies would be similar for both sexes.

A recent study by the Veterans Affairs Department found that demand for colonoscopies already outstrips availability. The researchers estimated that more than 30,000 additional doctors would be needed to screen people once every 10 years.

About 56,000 Americans are expected to die of colorectal cancer this year.

Copyright 2005 The Associated Press

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Diagnostic Yield of Alarm Features in Irritable Bowel Syndrome new
      #187555 - 06/20/05 03:44 PM
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Diagnostic Yield of Alarm Features in Irritable Bowel Syndrome and Functional Dyspepsia

Hammer J, Eslick GD, Howell SC, Altiparmak E, Talley NJ
Gut. 2004;53(5):666-672

Objective: The diagnostic value of the addition of alarm symptoms in distinguishing functional from organic gastrointestinal disease remains uncertain. We aimed to establish the value of alarm features in differentiating between organic disease and irritable bowel syndrome (IBS) and functional dyspepsia (FD).
Methods: A total of 568 consecutive patients (63% female; mean age 44.7 years) completed a detailed symptom questionnaire and then received a complete diagnostic workup, as required. Questionnaire data were collected prospectively and audited retrospectively; the treating physician was blinded to the results of the questionnaires. Patients were coded and allocated to the following diagnostic groups: IBS, FD, organic diseases of the upper gastrointestinal tract, or organic diseases of the lower gastrointestinal tract. Logistic regression was used to identify the best subset of symptoms that discriminated organic disease from functional illness. Separate models compared IBS (n = 214) with diseases of the lower gastrointestinal tract (n = 66), and FD (n = 70) with diseases of the upper gastrointestinal tract (n = 250).
Results: Age (50 years at symptom onset: odds ratio (OR) 2.65 (95% confidence interval 1.4–5.0); p = 0.002) and blood on the toilet paper (OR 2.7 (1.4–5.1);p = 0.002) emerged as alarm features that discriminated IBS from lower gastrointestinal illness. A diagnosis of IBS was typically associated with female sex (OR 2.5 (1.3–4.6); p = 0.004), pain on six or more occasions in the previous year (OR 5.0 (2.2–11.1); p<0.001), pain that radiated outside of the abdomen (OR 2.9 (1.4–6.3); p = 0.006), and pain associated with looser bowel motions (OR 2.1 (1.1–4.2); p = 0.03). A model incorporating three Manning criteria and alarm features yielded a correct diagnosis of IBS in 96% and a correct diagnosis of organic disease in 52% of cases. Alarm features did not discriminate FD from upper gastrointestinal disease. Patients with FD were significantly more likely to report upper abdominal pain (OR 3.7 (1.7–8.3); p = 0.002) and significantly less likely to report aspirin use (OR 0.26 (0.1–0.6); p = 0.001). The predictive value of symptoms in diagnosing FD was only 17%.
Conclusions: Symptoms plus alarm features have a high predictive value for diagnosing IBS but the predictive value for a diagnosis of FD remains poor. Current criteria for the diagnosis of IBS should incorporate relevant alarm features to improve the diagnostic yield.

Summary: With the burgeoning costs of healthcare, there is ever-increasing pressure placed on the healthcare provider to use the most cost-effective strategy to diagnose and treat a particular health problem. Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are among the most common diagnostic problems presenting the gastroenterologist with the conundrum of whether to perform extensive diagnostic testing or to treat empirically. However, the accuracy of the latter option (a diagnosis based purely on the presenting gastrointestinal symptoms) potentially places a considerable liability on the practitioner, who is subject to the level of confidence that can be placed in the diagnosis that is suspected. Many clinicians have suggested that the presence of "alarm features," such as bleeding, dysphagia, weight loss, vomiting, or later age at onset, may be more suggestive of the need for early diagnostic testing for organic disease. Therefore, the working hypothesis for this present study conducted by Hammer and colleagues was that taking an accurate history to evaluate the presence of alarm features and symptoms would increase the diagnostic potential and avoid unnecessary diagnostic procedures in patients with functional disease. The aim thereby was to further evaluate the yield of these "alarm features" that might suggest that functional disease (eg, IBS and FD) is less likely.

A total of 806 patients consulting a gastroenterology practice in Australia were studied. These patients were prospectively asked to fill out a questionnaire and data were retrospectively analyzed. Although there were no sample-size calculations performed for this study initially, the study authors provided a creditable effort to justify the power of the study by post hoc calculations, which suggest that the sample size was more than appropriate. All functional disorders were diagnosed based on the history and physical examination, as well as on the appropriate exclusionary diagnostic tests, including upper and lower endoscopy. The treating physicians were blinded to the results of the questionnaire. All results were then reviewed by at least one other gastroenterologist. If there were disparate opinions, the diagnosis was established by consensus.

Alarm features that discriminated IBS from organic disease were as follows: onset of symptoms at age > 50 years (odds ratio [OR], 2.7; 95% confidence interval [CI] 1.4-5.0; P = .002) and blood on the toilet paper (OR, 2.7; 95% CI, 1.4-5.1; P = .004). Factors predictive of IBS were: female sex (OR, 2.5; 95% CI, 1.3-4.6; P = .004), pain occurring 6 or more times in a year (OR, 5.0, 95% CI, 2.2-11.1; P < .001), pain radiation out of the abdomen (OR, 2.9; 95% CI, 1.4-6.3; P = .006), and pain associated with loose bowel movements (OR, 2.1; 95% CI, 1.1-4.2; P = .03). A model formulated incorporating the Manning criteria (abdominal pain relieved with bowel movements, pain associated with more frequent stools, sensation of incomplete evacuation, passage of mucus, abdominal distension) and alarm features yielded a correct diagnosis of IBS in 96% and organic disease in 52% of cases.

Only 1 of 16 alarm features discriminated upper gastrointestinal disease from FD. Patients with organic upper gastrointestinal disease were less likely to report decreased appetite (OR, 0.49; 95% CI, 0.26-0.91; P = .02). Patients with FD were more likely to report upper abdominal pain (OR, 3.7; 95% CI, 1.7-8.3; P = .002), and reported less aspirin use (OR, 0.26, 95% CI, 0.1-0.6; P = .001). The predictive value of symptoms in diagnosing FD was only 17%. The study authors concluded that alarm features have a high predictive value for the diagnosis of IBS, but not for FD.

Commentary: So what does this all mean? For IBS, it means that alarm features are the most important factors for establishing the diagnosis. In this study, the absence of alarm features correctly identified IBS in 93% of patients, while the addition of the Manning criteria improved this statistic by only an additional 3%. It is puzzling to me why the investigators used the Manning criteria (developed back in 1978). Clearly, attempts have been made to improve the diagnostic accuracy of IBS through the development of, and revisions in, the Rome criteria (Rome I and II). The clinician reader should be aware that this study may have some limitations. First, there were very few cancers identified, a finding that may reflect a referral bias to the evaluation site. Additionally, the study authors did not fully evaluate all alarm features, rather only those listed on the validated questionnaire employed in this study.

For the dyspepsia portion of this report, data presented suggest that a symptom-based diagnosis had a very poor predictive value. Hence, evaluation of alarm features fails to satisfactorily improve the diagnostic yield of symptoms of FD.

The work group for Rome III revisions will begin late in 2004. It is likely, as based on this study, that the Rome criteria will need to be expanded to include key alarm features for both IBS and FD. Although this should help the diagnostic accuracy for IBS, in contrast, the diagnosis of FD will likely remain as a diagnosis of exclusion. This study provides very weighted support for the recommendation that testing is generally not required in patients with positive symptom criteria for IBS and an absence of alarm features. For the diagnosis of FD, however, it remains caveat emptor.



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Section 1 of 2


David A. Johnson, MD, FACG, FACP, Professor of Medicine, Chief of Gastroenterology, Eastern Virginia School of Medicine, Norfolk, Virginia


Disclosure: David A. Johnson, MD, FACG, FACP, has disclosed that he has received grants for clinical research from AstraZeneca, Wyeth, TAP, BSC, and Novartis.


Medscape Gastroenterology 6(1), 2004. © 2004 Medscape


http://www.medscape.com/viewarticle/479783#a2

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Overlapping Upper and Lower Gastrointestinal Symptoms in Irritable Bowel Syndrome new
      #187558 - 06/20/05 03:52 PM
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Gastroenterology, November 2003 Journal Scan

From
The American Journal of Gastroenterology
November (Volume 98, Number 11)

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
The American Journal of Gastroenterology. 2003;98(11):2454-2459

Findings from a number of studies have suggested that patients with irritable bowel syndrome (IBS) may have motor dysfunction that extends beyond the colon to include other parts of the gastrointestinal tract, such as the stomach, esophagus, and small intestine.

Indeed, the functional gastrointestinal disorders, including IBS and functional dyspepsia, are currently defined by symptom groupings that seem to cluster together in both clinical practice and population-based studies. However, these symptoms commonly overlap, leading some investigators to question the validity of subdividing the disorders based exclusively on symptom presentation.

In this setting, it is recognized that distinguishing between IBS and functional dyspepsia can be diagnostically challenging because of the variations in symptom patterns, which frequently overlap. But this symptom overlap is poorly quantified and defined, and it remains unclear whether symptom patterns differ in subgroups of IBS that have been arbitrarily defined by primary bowel patterns of constipation and diarrhea (Note: The Rome committee has not endorsed subdividing IBS patients according to primary alteration in bowel function because of significant overlap in primary bowel symptoms). Therefore, Talley and colleagues set out to investigate the distribution of upper and lower gastrointestinal symptoms among patients with IBS with constipation and IBS with diarrhea. They hypothesized that IBS with constipation would be associated with more upper gastrointestinal complaints, and would therefore more often overlap with functional dyspepsia.

The study involved 121 consecutive patients who presented with a diagnosis of IBS. Patients were grouped according to primary bowel symptoms as either IBS with constipation (58 women and 18 men, mean age 47 ± 17 years) or IBS with diarrhea (26 women and 19 men, mean age 47 ± 15 years). All patients completed the Hopkins Bowel Symptom Questionnaire (which includes a brief quality-of-life assessment) and the Hopkins Symptom Checklist. Patients with alternating bowel habits (between constipation and diarrhea) were excluded so as to more accurately assess the overlap between upper and lower gastrointestinal complaints.

Overall, results showed that IBS with constipation was associated with more bloating and early satiety; this likely reflects underlying pathophysiologic mechanisms that are distinct from those in IBS with diarrhea. In fact, patients with IBS with constipation reported significantly more overall gastrointestinal symptoms when compared with patients with IBS with diarrhea (6.67 vs 4.62, respectively, P < .001). Abdominal pain patterns differed in patients with IBS with constipation vs in patients with IBS with diarrhea (lower abdominal pain: 40.8% vs 24.4%, and upper abdominal pain: 36.8% vs 24.4%, respectively). However, there were no significant differences in personality subscales by IBS subgroup -- but somatization was positively associated with multiple symptom reports and was negatively correlated with quality of life.

These findings demonstrated that upper gastrointestinal symptoms consistent with functional dyspepsia were more common among patients with IBS with constipation. Despite considerable overlap of upper and lower gastrointestinal symptoms among patients with IBS with constipation and patients with IBS with diarrhea, the former had more frequent lower abdominal pain and bloating. A better elucidation of the overlap between symptoms in patients with IBS may help guide clinical management of this disorder, which should be targeted at the multiple symptoms in these patients.


Abstract


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Medscape Gastroenterology 5(2), 2003. © 2003 Medscape


http://www.medscape.com/viewarticle/465193_4

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Health Economics of IBS new
      #191935 - 07/05/05 03:01 PM
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Health Economics of IBS -- Clinical Implications

Posted 06/24/2005

Brooks D. Cash, MD, FACP

Introduction
Irritable bowel syndrome (IBS) is a chronic gastrointestinal (GI) disorder characterized by impaired regulation of GI function (motility and secretion) and altered visceral sensitivity, resulting in the typical physical manifestations of abdominal pain, bloating, and abnormal bowel habits. IBS is a highly prevalent disorder, and although it does not have a significant impact on mortality, there remains no definitive curative therapy. Thus, patients with this condition may suffer from debilitating symptoms for prolonged periods. The burden of illness on patients, the healthcare industry, and employers that is directly attributable to IBS has only recently begun to be realized. This article summarizes the scope of the economic burden associated with IBS and examines potential targets for cost containment through directed education, recognition, and effective treatment of patients with IBS.

Economic Burden of IBS
IBS is extremely common, with population-based prevalence estimates ranging from 10% to 15% in North America.[1-2] Approximately 12% of patients in the primary care setting and 28% of patients seeking subspecialty gastroenterology care will be diagnosed with IBS.[3-4] Several patterns of healthcare seeking have been identified in patients with IBS. Although IBS affects both sexes, it is largely considered a women's health issue. Epidemiologic data suggest that the female:male ratio of IBS sufferers in the community is 2-3:1, although estimates differ depending on the practice setting from which such assessments are generated. Generally, however, two thirds of IBS sufferers in North America who seek medical care are women.[5,6] Although the minority (25%) of individuals with typical symptoms of the disorder actually do seek medical care, the high prevalence of IBS translates into a sizable absolute number of patients.[2,7] Recent reports estimate physician visits attributable to IBS to be as high as 3.5 million visits annually.[8-10] Additionally, it has been repeatedly demonstrated that patients with IBS are more likely to seek medical care for other, non-GI conditions or physical complaints, such as fibromyalgia or chronic pelvic pain.[5] Because there are no discrete physical abnormalities or biochemical/serological markers that define IBS, this condition has historically been viewed by many clinicians as a diagnosis of exclusion. This view, coupled with the increasing number and cost of available diagnostic studies, can lead to extensive and unnecessary testing. An exhaustive exclusionary diagnostic evaluation, especially in patients with typical IBS symptoms without alarm features (age &#8805; 50 years, fever, abnormal physical examination findings, hematochezia, unintentional weight loss, nocturnal symptoms, or a family history of organic GI disease), contributes to an increased burden on both patients and the medical system, and recently has been challenged regarding its usefulness in the management of such patients.[11]

Direct vs Indirect Costs
When considering the economic burden of a condition, it is important to consider both direct and indirect costs. The direct costs (use of healthcare-related services such as physician visits, diagnostic tests, and prescription or over-the-counter medication) associated with IBS are substantial.[12] Excluding prescription and over-the-counter medicines, direct costs have been estimated to range from $1.5 to $10 billion. The indirect costs of IBS, however, have been estimated to be much greater -- approaching $20 billion.[13] Examples of indirect costs include expenses that are not directly associated with the procurement of healthcare resources, such as the loss of hourly wages resulting from missed work or diminished work productivity resulting from absences for physician visits or incapacitating symptoms. Although direct costs are relatively straightforward and measurable, indirect costs are much more difficult to quantify.

Indirect costs comprise 3 primary components -- absenteeism (time absent from work), presenteeism (decreased productivity at work), and diminished health-related quality of life (HRQoL) -- which, in turn, are intangible costs that may result in diminished productivity.[12,14-16] The economic impact of absenteeism is fairly straightforward to gauge because most employers maintain adequate records of employee absences for illness. It has been estimated that a minimum of one third of IBS patients are absent on average from 1 day of work or school per week because of their symptoms.[17] Results of a recent survey indicate that patients with IBS were absent from work twice as many days per year due to illness as compared with healthy respondents.[18] In 1998 the direct cost of treating an employee with IBS was nearly $4000 compared with $2350 for an employee without IBS.[19] By comparison, indirect costs to the employer were approximately $470 higher for employees with IBS -- a likely underestimate because these indirect costs only included measures of absenteeism.[20]

Presenteeism may represent a significantly larger and less appreciated component of indirect costs than absenteeism.[17-21] Results of a recent study that examined impaired work productivity and HRQoL in employees with IBS demonstrated that the disorder was associated with a 21% reduction in work productivity, the equivalent of working less than 4 days in a 5-day work week.[14] Both absenteeism and presenteeism are growing concerns for both employers as well as interested consumers who are forced to bear the brunt of lost work productivity and subsidize employee healthcare costs. It is, therefore, critical for healthcare providers and managed care organizations to present solutions for employers on how best to manage the large, often unrecognized costs of IBS.

Finally, IBS has a significant negative impact on the HRQoL of affected patients[14,22-25] that is comparable to that of other chronic GI and non-GI disorders.[26-27] Reduction in HRQoL may result from several features of IBS that are also observed with other functional GI disorders. The multiple symptoms of IBS may wax and wane over time, leading patients to put off healthcare consultation, thus resulting in delayed diagnosis of, and extended time suffering from, the disorder.[12,28] Supporting this hypothesis is the observation that although multiple epidemiologic and clinical studies demonstrate that the symptoms of IBS typically appear between the ages of 15-30 years, most IBS patients do not seek their first healthcare consultation for the disorder until they are between the ages of 30 and 50 years, coinciding with peak employment ages.[29] Last, as in other functional GI disorders, the historical absence of effective therapies addressing the multiple symptoms of IBS is also likely have a negative impact on the HRQoL of affected patients.[30]

Clinical and Therapeutic Impact
What, then, can be done to mitigate some of the costs associated with IBS? Although it is not the focus of this column, accurate and timely diagnosis is an important consideration. For IBS, applying clinically proven symptom-based diagnostic criteria (Manning, Rome, Rome I, or Rome II) to make a positive, rather than exclusionary, diagnosis is an important step in the right direction to reduce overall costs. Previous analyses have demonstrated that in patients with suspected IBS who do not manifest alarm features, the pretest probability of organic disease is similar to that of the general population, suggesting that there is little to be gained by implementing exhaustive diagnostic evaluations in such patients.[11,31] Current recommendations for such patients are to initiate empiric therapy, reserving additional testing for nonresponsive patients.[1] There is evidence that this "minimalistic" approach is gaining favor and that such an approach can reduce resource utilization involving diagnostic procedures and frequent office visits.[30] The magnitude of the impact of this approach on the total costs associated with IBS, however, remains to be seen.

Regarding therapeutic interventions and minimization of the costs associated with IBS, it is becoming increasingly clear that the multiplicity of the symptoms may be as important a feature of the disorder as the severity of individual symptoms in terms of how patients report the "bothersomeness" or seriousness of their condition. A significant limitation of the so-called traditional therapies for IBS, such as bulking agents or antispasmodic medications, is that they only target single symptoms, a feature that may explain their absence of proven efficacy in randomized controlled trials. Alternatively, broader acting therapeutic agents or modalities that provide relief for the multiple symptoms of IBS would conceivably have promise in reducing multiple direct and indirect costs of this condition. In a study regarding the effects of psychotherapy in patients with severe IBS, Creed and colleagues[32] demonstrated annual healthcare-related utilization savings of nearly $700 compared with usual care. In this trial, "usual care" was defined as whatever management was considered appropriate by the gastroenterologists or primary care physicians caring for the patients. Although not explicitly delineated in the text of the article, "usual care" in this case, consisted primarily of traditional IBS therapies (such as antispasmodic agents, antidiarrheals, and bulking agents). However, the generalizability of these results to the community setting is not known. Fortunately, physicians now have access to new and increasingly effective medical therapies for the management of the multiple symptoms of IBS in the form of the serotonergic agents, tegaserod and alosetron. It is widely accepted that these agents are effective therapies for IBS; both tegaserod and alosetron were the only agents to receive grade A recommendations as IBS therapies from the American College of Gastroenterology Functional GI Disorder Task Force, based on the high quality of published evidence supporting their global efficacy in IBS with constipation and IBS with diarrhea, respectively.[1] However, although both tegaserod and alosetron are clinically effective, they have been associated with adverse effects. Tegaserod is reported to cause severe but transient diarrhea, whereas patients taking alosetron have reported episodes of ischemic colitis and severe constipation. Ischemic colitis has also been observed in the postmarketing experience with tegaserod, but the incidence rate of ischemic colitis in patients taking tegaserod appears to be similar to that observed in the general population and is actually lower than reported rates in IBS patients. Thus, a causal relationship between tegaserod and ischemic colitis has not been established.[33]

Although the expense associated with these newer agents may result in an initial increase in the direct costs of IBS care, it is possible that they could, when clinically effective for appropriate individual patients, significantly reduce the long-term direct and indirect costs. Limited data exist regarding the use of these serotonergic agents and their actual impact on the costs of IBS. A study utilizing a decision-analysis model examined the benefits of symptom improvement vs the complications associated with alosetron therapy in the treatment of patients with IBS with diarrhea.[33-34] It showed that although the benefit-to-risk profile of alosetron was favorable, this treatment was associated with a potentially large cost per quality-adjusted life-year. Currently, alosetron therapy is limited to women with severe IBS with diarrhea that is refractory to traditional therapies. As a consequence, new or ongoing studies regarding the economic impact of this therapy on IBS are limited. (In order to prescribe alosetron, clinicians must be familiar with the current prescribing guidelines and be enrolled in the prescribing program administered by the manufacturer. Patients who are prescribed alosetron are given a patient information booklet to read and are asked to sign a patient-physician agreement indicating that they have both read and understand the effects of the medication and that they do desire to take it.)

Largely due to the limited availability of data concerning the economic impact of the serotonergic agents in the treatment of IBS, a series of articles addressing many of the issues discussed in this column was recently published in The American Journal of Managed Care .[14,35-39] [14,34-38] The authors of these articles explore the costs associated with IBS as well as treatment options, and provide readers with a comprehensive review of the epidemiology, prevalence, management, and economic impact of the disorder. (It should be noted that 3 of the 5 articles in this series deal with analyses focused on the effects of tegaserod. Given that alosetron administration is restricted, the applicability of additional cost analyses of alosetron-based intervention strategies may be limited. Tegaserod, however, is not restricted and actually has several indications for its use, so analyses of the economic effects of this medicine may be important in steering formulary decisions or benefit coverage.) In one of these studies, a budget-impact model was developed to assess the economic effect of adding tegaserod to the formulary of a managed care organization.[36] This model estimated the economic impact for patients with IBS both 6 months before and 6 months after the initiation of tegaserod therapy. It was found that the total per-patient budget impact for all resources (including the cost of tegaserod) for a 6-month period was approximately $274 for women with IBS. Overall, 29% of the cost of tegaserod was offset by decreases in resource utilization (including pharmacy, inpatient, outpatient, endoscopic, and nonendoscopic resources). These results suggest that effective therapy can indeed decrease GI-related resource utilization, perhaps ultimately leading to a significant cost-offset percentage.

Also included in this issue of the journal was a retrospective, longitudinal study that evaluated the GI-related resource utilization (office visits, hospitalizations, emergency department visits, endoscopic and nonendoscopic procedures) in a managed care population consisting of tegaserod users and nonusers.[37] It was found that GI resource utilization by tegaserod users for all comparisons before and after the initiation of therapy showed significant decrements in all utilization categories except for GI drug prescriptions. Matched nonusers did not show consistent decrements in GI resource utilization. Last, in an effort to illustrate the indirect costs associated with IBS and the potential cost savings that might accrue after effective therapeutic intervention, an economic model was designed to assess the indirect costs associated with tegaserod therapy in female patients with IBS.[38] This model demonstrated that treatment resulted in gains of $1882 through avoided productivity losses per employee. The benefits of decreased amounts of work loss and the cost of therapy in this model predicted a very favorable benefit/cost ratio of 3.75, demonstrating the potential extrapolated value of effective therapy.

Conclusion
The symptoms of IBS and the impact of this chronic disorder on both patients and the healthcare system alike are substantial. Because IBS has such a high prevalence and predominantly affects adults of working age, it imposes a significant burden on the patient as well as the employer, third-party payers, and society through a variety of direct and indirect costs. Although estimates of the degree of this burden vary and may be difficult to ascertain or even recognize, it appears that the indirect costs associated with IBS (upwards of $20 billion annually) comprise the major component of total costs associated with the condition.

Strategies to reduce direct costs will necessarily be directed at recognition of the disorder and should include physician and patient education, paramedical-based education and therapy, lay support groups, optimization of the diagnostic approach to patients with suspected IBS, and implementation of IBS educational awareness and incentive programs similar to initiatives targeting other chronic disorders such as GERD, diabetes mellitus, and hypertension.[35,40] Additionally, there is emerging evidence that continued development and increasing use of clinically effective therapies that target the multiple symptoms of IBS appear to have the potential to facilitate significant reductions in both direct and indirect costs associated with this chronic disorder.

Funding Information

Supported by an independent educational grant from Novartis.




Brooks Cash, MD, FACP , Assistant Professor of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Chief, Gastroenterology Division and Colon Cancer Center Initiative, National Naval Medical Center, Bethesda, Maryland


Disclosure: Brooks Cash, MD, FACP, has disclosed that he has served as an advisor or consultant to Novartis and Wyeth.


Medscape Gastroenterology. 2005;7(1) ©2005 Medscape

http://www.medscape.com/viewarticle/506873_1

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Neural Cross-Talk May Explain Overlap of Irritable Bowel, Interstitial Cystitis new
      #191940 - 07/05/05 03:11 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
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Neural Cross-Talk May Explain Overlap of Irritable Bowel, Interstitial Cystitis

By Megan Rauscher

NEW YORK (Reuters Health) Jul 01 - Researchers have observed in rats that acute irritation of the urinary bladder leads to increased sensitivity in the colorectum, and conversely, irritation of the colorectum leads to sensitization of the urinary bladder.

In a report in the June issue of Gastroenterology, the researchers say these findings provide "compelling" evidence of neural cross-talk and bidirectional cross-sensitization of the colon and lower urinary tract. "This cross-sensitization may account for the substantial overlap of chronic pelvic pain disorders," they surmise.

Lead investigator Dr. Michael A. Pezzone from the University of Pittsburgh School of Medicine in Pennsylvania told Reuters Health "this work has profound clinical implications."

"Irritable bowel syndrome and interstitial cystitis are two very common clinical conditions that affect primarily women of reproductive age," he noted. "In general, these two conditions are treated as separate entities, but in actuality, as many as 40% to 50% of women suffer from both conditions."

Dr. Pezzone and colleagues investigated the hypothesis that afferent irritation in one pelvic organ (the bladder) may adversely influence and sensitize another (the colon) via shared pelvic afferent innervation and/or convergent afferent pathways.

They report that, before bladder irritation in anesthetized female rats, graded colorectal distention to 4 cm H2O produced no notable changes in abdominal wall activity as assessed by electromyography. But after acute bladder irritation, colorectal distention produced "dramatic increases" in abdominal wall activity at much lower distention pressures.

"Analogously, following acute colonic irritation, bladder contraction frequency increased 66%, suggesting sensitization of lower urinary tract afferents," the investigators report.

"This is one of the first studies to show that irritation of one organ can affect another," Dr. Pezzone told Reuters Health. "Because these two organs have convergent sensory input, a neural pathway is likely involved in the acute setting of irritation," he added.

Gastroenterol 2005;128:1953-1964.


http://www.medscape.com/viewarticle/507654

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IBS: Improving Diagnosis, Serotonin Signaling, and Implications for Treatment new
      #191952 - 07/05/05 03:30 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
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Authors: Lucinda Harris, MD; Lin Chang, MD

Over the past 50 years, evolving conceptual mechanisms have been proposed to explain the pathophysiology of IBS. These mechanisms have ranged from a purely psychological disorder to such physiologic conditions as a primary abnormality in gastrointestinal (GI) motility or visceral hypersensitivity. However, recent scientific data have increasingly supported that a dysregulation in brain-gut interactions resulting in alterations in GI motility, secretion, and sensation is the principal pathophysiologic mechanism underlying IBS.[1] Brain-gut interactions are mediated largely by the autonomic nervous system, which is comprised of the parasympathetic (vagal and sacral parasympathetic), sympathetic, and enteric nervous systems (ENS). Many factors (both central and peripheral) may contribute to an altered brain-gut axis, including genetic predisposition, chronic stress, inflammation/infection, and environmental parameters.[1] These alterations may subsequently lead to disturbances in intestinal motility, visceral sensitivity, and mucosal immune response and permeability. In IBS, these disturbances result in symptoms of abdominal pain or discomfort and altered bowel function, the defining characteristics of this disorder.[2]

There are many neurotransmitters and hormones that mediate bidirectional brain-gut communication. Serotonin (5-hydroxytryptamine [5-HT]) is one of the key mediators of gut motility, secretion, and sensation. Most of the serotonin is localized in the GI tract and is found in enterochromaffin (EC) cells and enteric neurons.[3] EC cells sense luminal factors such as food or mechanical distension in the gut, and release serotonin; 5-HT receptors on intrinsic primary afferent neurons (IPANs) as well as extrinsic spinal or vagal afferent neurons are activated. The ENS regulates secretion and peristalsis, whereas vagal and spinal afferents modulate nonpainful and painful sensations, respectively.[4] There are at least 7 main classes of 5-HT receptors. Particularly important for lower gut function and regulation are the 5-HT1P, 5-HT3, and 5-HT4 receptors. These receptors have been the focus of research evaluating the pathophysiologic mechanisms of IBS as well as targets for the development of novel agents in the treatment of functional gastrointestinal disorders. There is also evidence to suggest that other older serotonergic agents -- that is, tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) -- may modulate intestinal function as well.[3] The roles of other neuropeptides and their receptors are also currently being explored as potential molecular targets for drug development.

The development of more effective treatment for IBS is crucial because it is one of the most common disorders seen by gastroenterologists and primary-care physicians, but patients are often not satisfied with traditional therapies. In addition, proper diagnosis and treatment are particularly critical for a number of reasons. Studies have demonstrated the dramatic impact of this disorder on the quality of life of patients with IBS compared with the general population and with individuals with other chronic health conditions.[5,6] In addition, patients with IBS utilize the healthcare system for both GI and non-GI complaints more than patients without IBS.[7] The latter in turn impacts the productivity of patients with IBS such that their absenteeism from work or school has been found to be 3 times higher than that of patients without IBS.[8] Not surprisingly, economic studies have demonstrated that this disorder is costly to the healthcare system and to the economic system as a whole, resulting in an annual associated cost of up to $30 billion.[9,10]

The challenge for clinicians is to identify individuals with IBS despite the fact that no diagnostic biologic marker currently exists for this disorder, and to manage their symptoms despite the lack of effective treatment. Studies evaluating the utility of symptom-based criteria and medical tests in the diagnosis of IBS vs organic GI disorders have resulted in recent recommendations for a more cost-effective diagnostic approach.[11] Although many patients may respond to reassurance, life-style changes, and traditional therapies, it is important for healthcare providers to familiarize themselves with advances in the pathophysiologic mechanisms of IBS that have subsequently led to the development of novel therapeutic agents, such as the serotonergic medications. In addition, these advances have inspired a new look at older medications that affect the serotonin receptors.

Copyright © 2003 Medscape.

http://www.medscape.com/viewarticle/463521

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Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact new
      #191958 - 07/05/05 03:40 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
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From Alimentary Pharmacology & Therapeutics

Irritable Bowel Syndrome in the United States: Prevalence, Symptom Patterns and Impact

A. P. S. Hungin; L. Chang; G. R. Locke; E. H. Dennis; V. Barghout

Summary and Introduction
Summary
Background: The impact of irritable bowel syndrome, a gastrointestinal motility disorder, is underestimated and poorly quantified, as clinicians may see only a minority of sufferers.
Aim: To determine the prevalence, symptom patterns and impact of irritable bowel syndrome in the US.
Methods: This two-phase community survey used quota sampling and random-digit telephone dialling (screening interview) to identify individuals with medically diagnosed irritable bowel syndrome or individuals not formally diagnosed, but fulfilling irritable bowel syndrome diagnostic criteria (Manning, Rome I or II). Information on irritable bowel syndrome symptoms, general health status, lifestyle and impact of symptoms on individuals' lives was collected using in-depth follow-up interviews. Data were also collected for healthy controls identified in the screening interviews.
Results: The total prevalence of irritable bowel syndrome in 5009 screening interviews was 14.1% (medically diagnosed: 3.3%; undiagnosed, but meeting irritable bowel syndrome criteria: 10.8%). Abdominal pain/discomfort was the most common symptom prompting consultation. Most sufferers (74% medically diagnosed; 63% undiagnosed) reported alternating constipation and diarrhoea. Previously diagnosed gastrointestinal disorders occurred more often in sufferers than non-sufferers. Irritable bowel syndrome sufferers had more days off work (6.4 vs. 3.0) and days in bed, and reduced activities to a greater extent than non-sufferers.
Conclusions: Most (76.6%) irritable bowel syndrome sufferers in the US are undiagnosed. Irritable bowel syndrome has a substantial impact on sufferers' well-being and health, with considerable socioeconomic consequences.

Introduction
Irritable bowel syndrome (IBS) is a chronic, episodic functional gastrointestinal (GI) disorder characterized by abdominal pain/discomfort and altered bowel habit (constipation, diarrhoea or alternating periods of both).[1] Patients often experience additional symptoms such as bloating, sensation of incomplete evacuation, straining (constipation) and urgency (diarrhoea). IBS patients can experience symptoms for many years, with an average duration of 10 or more years.[1,2] IBS is often unrecognized or untreated, with as few as 25% of IBS sufferers seeking professional health care.[3] Those seeking care are often frustrated by the lack of effectiveness of traditional treatment and management strategies.[4]

IBS prevalence is estimated to be 10-15% in Western countries.[5-9] Prevalence data and information on the health care-seeking behaviour of IBS sufferers have mostly been derived from independent studies using different methodologies and different diagnostic criteria. As there are no IBS-specific biological markers to aid diagnosis, doctors generally rely on symptom-based criteria. At least three sets of diagnostic criteria have been developed, including the Manning,[10] Rome I[11] and Rome II criteria.[12] The Rome I and II criteria are more refined than the Manning criteria, and include symptom duration within their definitions. Variations in study design, particularly the criteria used to diagnose IBS, affect the ability to compare or summarize data from multiple studies.[13]

One challenge of population-based IBS studies is ensuring that IBS is accurately diagnosed using specific, validated criteria, rather than the clinical judgement of health care professionals.[7]

IBS places a significant financial burden on society. Symptoms can significantly impact on the quality of life of sufferers, with considerable socioeconomic consequences.[14-18] For example, absenteeism from work is more prevalent in individuals with IBS than in those without,[1,19] and employers in the United States (US) are estimated to pay, on average, $1251 more for individuals with IBS than matched control beneficiaries over a 1-year period ( P < 0.001).[20]

A recent European study investigated the prevalence, symptom pattern and impact of IBS across eight countries in an attempt to define the magnitude of the problem facing health care providers.[21] The present study, which used the same methodology, evaluated IBS prevalence, symptom pattern and impact on work, social activities and well-being of sufferers in the US. Attitudes towards the health and consultation behaviour of IBS sufferers were also assessed.

Materials and Methods
Survey Methodology
A random-digit dialling technique as described previously[21] was used to identify study participants. This technique has proven feasibility and accuracy in health research[22-24] and enhances the representativeness of the study. Random-digit dialling allowed large numbers of people in the US to be easily identified while avoiding the possibility of cluster sampling often seen with multiple fixed-site surveys. Sampling limitations often noted with postal surveys were also avoided. Research supports this technique as a highly efficient way of yielding accurate data.[22-24]

This methodology assumed that more than 90% of the US households had a telephone and that approximately 25% of numbers were unlisted. Random-digit dialling sampling enabled numbers in the US to be assigned with a probability of selection. As previously described,[21] a random initial sample was drawn from all known listings using a 1 in n sampling interval and an algorithm was then utilized to randomize the last two digits, thus ensuring the inclusion of unlisted numbers. All telephone numbers were prescreened for a valid dialling tone to maximize data efficiency. All fieldwork was conducted on weekday evenings and weekends so that the working population was represented in the study. In order to enhance representativeness, quota sampling was applied in terms of age and gender. This survey was carried out by The Sample Surveys Research Group (now Synovate), West Malling, UK, and commissioned by Novartis Pharmaceuticals, New Jersey, US.

Development and Application of the Questionnaires
The survey included two questionnaires and was executed in two phases; the development of the original questionnaires has been previously described.[21] The first questionnaire was subjected to five stages of piloting and testing, including respondent validation. Further validation was conducted using clinicians and lay individuals in the US - terminology modification ensured respondent comprehension. The revised US version was piloted amongst 'live' respondents prior to commencement of fieldwork. The locally derived and adapted questionnaire was then tested in the US using the telephone interview technique.

In the first phase, a screening questionnaire was employed to identify subjects already diagnosed with IBS (medically diagnosed by their clinician) and to elicit information that identified non-diagnosed IBS sufferers according to the Manning, Rome I or Rome II diagnostic criteria. Subjects were classified as having undiagnosed IBS if they confirmed that they suffered from at least two of the Manning criteria and experienced abdominal pain/discomfort at least once in every 2 months in the previous 12 months. The screening questionnaire was presented to potential participants as being part of a general health project in order to avoid introducing bias and directing responses towards IBS or other GI conditions.

Patients were defined as having IBS with constipation (IBS-C) if they experienced one or more of the following: harder/more lumpy stools than usual, the need to pass stools less often than usual (<3 times/week), or periods of straining, which was not accompanied by the need to pass stools more often than usual (>3 times/day), looser/more watery stools than usual and periods of urgency. Patients were defined as having IBS with diarrhoea (IBS-D) if they experienced one or more of the following: looser/more watery stools than usual, the need to pass stools more often than usual (>3 times/day), or periods of urgency, which were not accompanied by the need to pass stools less often than usual (<3 times/week), harder/more lumpy stools than usual and periods of straining. Patients with other bowel habit patterns were defined as having alternating IBS (IBS-A). Differentiation into these specific IBS subtypes was based only on the symptoms suffered by each respondent, without reference to a specific time frame.

In the second phase of the survey, respondents who were identified as having IBS in phase I of the survey, either medically diagnosed or diagnosed using IBS criteria (Manning, Rome I or Rome II), were invited to participate in a more formal interview regarding their symptoms, general health factors, lifestyle and impact of IBS symptoms on their lives. Data on comorbid conditions, therapy/medication use and consultation patterns were also collected. Thus, three groups of respondents were identified: those with medically diagnosed IBS; those who had IBS that had not been medically diagnosed, but who fulfilled IBS diagnostic criteria; and a healthy comparator group identified from the screening questionnaire as not having IBS. Any individuals who had experienced IBS symptoms within the previous 12-month period were identified as current IBS sufferers.

For symptoms of constipation or diarrhoea, individuals were questioned (based onthe IBS diagnostic criteria) about: any periods needing to pass stools more often than usual (>3 times/day) or less often than usual (<3 times/week); any periods when stools were looser/more watery than usual or harder/more lumpy than usual; periods of straining when going to pass a stool; periods of urgency when going to pass a stool; feeling of incomplete evacuation after passing a stool; periods of bloating.

As in the European study,[21] the development of the questionnaire used in the US population incorporated the clinical experience of the clinicians involved with this study. Alternative diagnoses (not IBS) were excluded at an early stage of the questionnaire and pilot research was performed to ensure the Manning and Rome I/II criteria were effective in this setting. The questionnaire was designed and carefully validated to avoid order effects, such as suggestion based on earlier questions.

Based on the assumption of a conservative IBS prevalence rate of 5-10%, it was estimated that 5000 respondents would need to be contacted to reach 250-500 IBS sufferers in the US. Specific target age groups for the population were 18-34, 35-54 and over 55 years, with equal numbers contacted within these age groups.

Subjects
The study was carried out in the US in a sample of subjects aged 18 years or over. Those previously diagnosed with Crohn's disease, ulcerative colitis, coeliac disease, diverticulitis, peptic ulcer or cancer (including colon and gynaecological cancers) were excluded from the results because of possible overlap with IBS symptoms.

Results
From approximately 14 000 initial telephone contacts, a total of 5009 screening interviews were conducted; all questions in this section were related to general health. Among these, 708 individuals were identified as having current IBS (any diagnostic criteria) and, from this group, 318 individuals participated in the second phase of the questionnaire (366 individuals either did not want to take part in the second phase of the questionnaire or did agree but were not available when contacted).

Prevalence, Characteristics and Symptom Patterns of IBS (Medically Diagnosed and Not Medically Diagnosed)
Overall 708 individuals (14.1% of total screened) were identified as having current IBS [medically diagnosed ( n = 166; 3.3%) or met any diagnostic criteria (not medically diagnosed; n = 542; 10.8%)]. Results from this questionnaire are shown in Table 1 .

In general, medically diagnosed IBS patients reported a greater prevalence of individual IBS symptoms. The Manning criteria identified all current IBS sufferers (100%); the Rome I criteria identified 73% and the Rome II criteria identified 62%. Thus, only partial overlap of the IBS diagnosis was seen across these diagnostic criteria. The Rome II criteria appeared to be the most restrictive set. Of those individuals who had been medically diagnosed with IBS, 4% were deemed to have IBS-C compared with 21% with IBS-D. In those not medically diagnosed, these percentages were 15% and 21%, respectively. Most individuals with IBS (74% of those medically diagnosed and 63% not medically diagnosed) reported alternating symptoms of constipation and diarrhoea (IBS-A). When IBS sufferers were asked to categorize themselves according to these three subgroups, only approximately one-third of individuals medically diagnosed and not medically diagnosed with IBS defined themselves as having IBS-A (33% and 27%, respectively) compared with IBS-C (17% and 30%, respectively) and IBS-D (45% and 29%, respectively).

Age/Sex Distribution of Current IBS Sufferers (Medically Diagnosed and Not Medically Diagnosed)
Overall, the peak ages for current IBS symptoms were between 25 and 54 years (67.3% of IBS total; Table 1 ). IBS was more common in women than men (64% vs. 36%, respectively), particularly among those who had been medically diagnosed with IBS (81.3% vs. 18.7%, respectively). The highest prevalence of IBS was seen in working women, with a prevalence of 21% (5% medically diagnosed, 16% not medically diagnosed).

Comorbid Conditions
Current IBS sufferers (both medically diagnosed and not medically diagnosed) were more likely to have suffered from other GI disorders of function (previously diagnosed by a doctor) compared with non-IBS sufferers. IBS sufferers were twice as likely to suffer from gastro-oesophageal reflux disease (GERD; 22% vs. 10%, P < 0.001) compared with non-IBS sufferers.

Duration and Patterns of Symptoms
Results of the second phase of this study confirmed that IBS is a chronic disorder, with 16% of current IBS sufferers being medically diagnosed with the condition in the previous 12-month period, 8% in the previous 13-24 months, 26% in the previous 2-5 years and 14% 6-10 years ago. Overall, one-third of current IBS sufferers had had IBS for more than 10 years.

Although respondents had IBS for considerable periods of time, IBS symptoms remained fairly constant over time with 73% of medically diagnosed IBS sufferers reporting that their symptoms had never changed. Only 22% of current IBS sufferers reported some degree of symptom improvement since the screening interview. Current IBS sufferers typically experienced symptoms for an average of 8.1 days/month and reported a wide range of symptoms, with abdominal pain/discomfort being the most commonly reported (90%; Figure 1). The majority (71%) described their overall IBS symptoms as fairly or very painful. On each day with current symptoms (designated as a 'suffering day'), respondents with IBS had an average of 2.4 episodes of IBS. These episodes varied in duration but more than half (52%) of current sufferers experienced episodes more than 60 min in duration. More than half (64%) of individuals with current IBS symptoms believed that an episode of IBS was triggered by a certain food or drink while 30% cited stress as the trigger.

There appeared to be a gender difference in the reporting of IBS-related symptoms in current IBS sufferers. Women were more likely to report constipation, bloating, trapped wind, swollen tummy, tightness of clothing and tiredness. There were no differences in prevalence of abdominal pain, diarrhoea and heartburn between men and women with IBS.

Impact of IBS on Work, Lifestyle and Health
Responses from current IBS sufferers (medically diagnosed and not medically diagnosed) indicate that IBS negatively impacted upon a wide range of daily activities. Work productivity, particularly the ability to concentrate, and time management, was significantly affected in respondents with IBS compared with individuals without IBS (Figure 2; P = 0.01). The proportion of men and women reporting an impact was not significantly different.

In the 12 months prior to the survey, IBS sufferers had more time off work, spent more days in bed and cut down on usual activities on more days compared with non-IBS sufferers. Nearly one-quarter of IBS respondents worked fewer hours, 11% missed work and 67% felt less productive when at work because of their symptoms. Two-thirds of current IBS sufferers had cut back on the number of overall activities during the previous 12-month period for an average of 15 days. The average number of days affected by ill health leading to absenteeism was 6.4 vs. 3.0 days (current IBS sufferers vs. non-IBS sufferers). Overall, current IBS sufferers were twice as likely to spend at least 1 day in bed or cut back on usual activities compared with non-IBS sufferers. Nearly one-quarter of current IBS sufferers had missed social engagements.

IBS symptoms also had a significant impact on social well-being and daily social activities among sufferers compared with non-sufferers ( P = 0.01). Undertaking long journeys, going out for a meal and going on holiday were all noted as more of a problem for IBS sufferers than controls (Figure 3a; P = 0.01). In addition, diet and food choice were also adversely affected by current IBS symptoms (Figure 3b; P = 0.01 vs. individuals without IBS). IBS sufferers reported a wide range of effects of symptoms on daily life (>/=5 points on a scale of 0 = no impact to 10 = significant impact), in particular many felt they had to be either near a toilet or make frequent trips to the toilet (Figure 4). Again, the proportion of men and women reporting an impact was not significantly different.

Current IBS sufferers were more likely to perceive themselves as having poor health; compared with 54% of non-IBS sufferers, only 35% of IBS sufferers described themselves as having good health. More than half (57%) of all current IBS sufferers questioned felt that they would have more control over their life without IBS symptoms. An impact of health on relationships was also more evident amongst current IBS sufferers compared with non-IBS sufferers: more IBS sufferers found it difficult to make new friends (46% vs. 40%, P < 0.001) and have physical relationships (52% vs. 41%, P < 0.001), and they felt that their IBS symptoms affected family relationships (48% vs. 40%, P < 0.001).

Attitudes to Condition

In general, the attitude towards health and overall quality of life appeared to be affected to a greater extent in medically diagnosed patients than in IBS sufferers who were not medically diagnosed ( Table 2 ).

Current IBS sufferers commonly informed their partner about their condition (68%). Although they also often told other family members (56%) and friends (54%), they were less likely to inform colleagues (22%) or their employer (16%). Most confidants were deemed to be very (44%) or fairly (39%) understanding. Overall, one-quarter of IBS sufferers highlighted that their self-confidence was reduced as a result of IBS; this was particularly evident among the medically diagnosed group (46% vs. 17% of those not medically diagnosed). The majority (87%) of respondents medically diagnosed with IBS believed their IBS to be a real medical condition, compared with only 43% of individuals not medically diagnosed ( Table 2 ). As an indication of desire for effective therapy, nearly half of current IBS sufferers (46%) agreed that they would try 'anything' to alleviate their IBS symptoms.

Consultation Pattern and Health Care Use
A primary care doctor was the most common health professional seen by current IBS sufferers (83%); gastroenterologists were the next most commonly consulted group (40%; Table 2 ). Abdominal pain/discomfort was the most common reason for consulting a health professional (28% of consultations), followed by symptom frequency (10%). Current IBS sufferers had seen a doctor or nurse an average of 4.2 times in the past 12 months if medically diagnosed or 1.3 times if not medically diagnosed. More than half (53%) of respondents not medically diagnosed had seen a health professional at some time for their condition. In patients medically diagnosed with IBS, 25% had visited a health professional five or more times before their IBS diagnosis.

Medication Used
More than half (58%) of the current IBS sufferers who had visited their health professional had been prescribed medication and a similar number (57%) received dietary and lifestyle advice ( Table 2 ). The main medications taken were antacid and acid suppression therapy (25%), antidiarrhoeals (22%) and laxatives (11%); the serotonergic agents, tegaserod and alosetron, were not available at the time of the study. Antidepressant/anti-anxiety medication was taken by 1% of participants (5% in the medically diagnosed group and 0% in those not medically diagnosed). Most IBS sufferers regularly used over-the-counter medication (60%) and 47% had altered their diet in an attempt to alleviate their IBS symptoms. Treatments were deemed ineffective for a number of symptoms including constipation (41%), bloating (34%) and trapped wind (31%). Treatments for abdominal pain/discomfort were considered to be fairly effective in 53% of sufferers, although 18% considered them to be not at all effective.

Discussion
This study confirms the high prevalence of IBS in the US population and its impact on the working life, social activities and well-being of sufferers. The overall prevalence of IBS in this population was 14.1%, with only 3.3% being medically diagnosed. This compares with a prevalence rate of 11.5% in a previous European study,[21] and is consistent with other large US-based epidemiological studies, where prevalence estimates cluster around 10-15%.[25,26] Expected variations in diagnostic rates according to Manning, Rome I and Rome II criteria were seen, as previously noted.[21,27,28] Clearly, IBS prevalence can vary substantially depending on the diagnostic criteria employed.[29] This comprehensive, representative survey used specific, validated IBS diagnostic criteria to estimate prevalence and symptom patterns, and also assessed impact of IBS on work, lifestyle and health. In this study, prevalence rates were highest among those aged 25-54 years, and the prevalence of IBS among women was approximately two times higher than that recorded for men in individuals medically or not medically diagnosed with IBS. These findings corroborate previously published reports, which demonstrated a higher IBS prevalence in women than in men.[30,31] In patients medically diagnosed with IBS, 25% had visited a health professional at least five times before being formally diagnosed, suggesting that diagnostic criteria are not being properly utilized, IBS symptoms are not always recognized or are misdiagnosed, and/or that the diagnosis of IBS is not being communicated to the patient.

This US population study adopted a survey methodology similar to that used in a recent European study of IBS prevalence and impact.[21] That study comprised approximately 5000 respondents from each of eight countries with a total sample population of 41 984, whereas in the US, the total sample population was 5000. Thus, comparisons between the two studies remain limited. The only other US study using random-digit dialling to assess IBS included 1014 adult women with IBS.[28,32]

The clinical presentation of IBS is quite varied,[33] with sufferers in the present study reporting a wide range of symptoms. IBS sufferers also reported that their symptoms rarely improve and were fairly or very painful, as highlighted in previous studies.[2,34] In this study, the prevalence of individual IBS symptoms was higher in medically diagnosed IBS patients than in current IBS sufferers who were not medically diagnosed. This finding may be related to IBS severity, which is likely to be greater in patients presenting for treatment. Medically diagnosed patients may also have a greater awareness of IBS and its associated symptoms. Data confirmed that IBS is a long-term condition, with one-third of IBS sufferers having experienced IBS symptoms for over 10 years, a figure comparable with that in Europe (40%).[21]

It is well documented that IBS can have a considerable impact on sufferers' lives,[16,21,26,35-37] and this is compounded by the condition's chronic and episodic nature. This study reinforces that IBS has a substantial impact on quality of life. There was a large impact on absenteeism and work productivity, confirming previous findings in both US[1,2,20,34] and European[21] populations. Additionally, ill health was recorded for an average of 6.4 days in current IBS sufferers, compared with 3.0 days in non-IBS sufferers. One in six current IBS sufferers in the US had changed their work schedule and one in four had worked fewer hours. These data support findings from Drossman et al., [26] who reported that IBS patients missed three times more days from work than non-sufferers. Time management, the ability to concentrate and commuting time were also negatively affected in IBS sufferers in the present study. Regular social activities such as going out for a meal, long journeys or holidays were also hindered. Thus, the symptoms of IBS appear to affect the ability to live a normal life. This is further compounded by the fact that other functional GI disorders often coexist with IBS.[38] Although this was not fully assessed in this study, 24% of IBS sufferers had also suffered from GERD or dyspepsia.

Substantial health care use because of IBS was recorded in this US population. Sufferers used a wide range of medications for relief of IBS symptoms. Medically diagnosed IBS patients with current symptoms appeared to take fewer antisecretory medications and laxatives than those not medically diagnosed, presumably due to the availability of these medications over the counter. This finding contradicts data from Shih et al., [39] who reported that 89% of doctor visits generated prescriptions. At the time of the present study, treatment options for abdominal pain/discomfort, bloating and constipation were only viewed as being completely effective in a small proportion of users. As IBS symptoms are intermittent, treatment was often restricted to times when patients experienced symptoms.

A varying perception of IBS-A was highlighted in this study. Most IBS sufferers (74% medically diagnosed, 63% not medically diagnosed) had alternating symptoms of constipation and diarrhoea as defined by doctors and diagnostic criteria. However, when sufferers were asked to categorize themselves, only approximately one-third of medically and not medically diagnosed respondents with IBS defined themselves as having IBS-A (33% and 27%, respectively) compared with IBS-C (17% and 30%, respectively) and IBS-D (45% and 29%, respectively). This finding is in contrast to other published data, which reported equal prevalence rates of IBS-C, IBS-D and IBS-A.[25,34] A possible explanation for this discrepancy is the use of more strict criteria for IBS-A in the current study than in the Rome II subclassification.

In conclusion, IBS is a prevalent disorder that significantly impacts work, lifestyle and social well-being. Diagnosing and managing IBS can be challenging due to the lack of a diagnostic marker and effective treatment options. Individuals with IBS who are not formally diagnosed reported a significant prevalence of GI symptoms, which impacted on their work and other daily activities, although in some instances to a lesser degree than medically diagnosed individuals. All IBS sufferers face the challenge of their condition on a daily basis and this study highlights the huge unmet therapeutic need in IBS.


Aliment Pharmacol Ther. 2005; 21 (11): 1365-1375. ©2005 Blackwell Publishing





A. P. S. Hungin ,* L. Chang ,† G. R. Locke ,‡ E. H. Dennis ,§ V. Barghout §

*Centre for Integrated Health Care Research, Wolfson Research Institute, University of Durham, Stockton-on-Tees, UK

†UCLA, Los Angeles, CA

‡Mayo Clinic College of Medicine, Rochester, NY

§Novartis Pharmaceuticals Corp., East Hanover, NJ


Aliment Pharmacol Ther. 2005; 21 (11): 1365-1375. ©2005 Blackwell Publishing


http://www.medscape.com/viewarticle/506173_1


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IBS—The Irritation of Inflammation new
      #198978 - 07/24/05 02:16 PM
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Gastroenterology - July 2005 • Volume 129 • Number 1

IBS—The Irritation of Inflammation

David G. Thompson

Irritable bowel syndrome (IBS) continues to be a major problem for clinical gastroenterologists worldwide and imposes considerable personal and social burdens. As a syndrome detailed understanding of its etiology and pathophysiology is lacking and, despite the welcome arrival of promising new pharmaceutical agents, most drug therapies to date have failed to make a major impact on the quality of life for sufferers. Therefore, an essential problem is to understand what lies behind the development of symptoms in IBS. There remains a tendency for investigators exploring the nature of IBS to divide themselves, in Cartesian fashion, into those who seek a cause for the problem in the mind and those who seek a cause in the gastrointestinal tract. Such a division is undoubtedly artificial and often seems dependent on the philosophical viewpoint of the clinician and of the patient. Perhaps unsurprisingly, the prevailing views of both patient and physician usually coalesce to determine explanations of causality and approaches to therapy.

For those seeking evidence of psychological factors, it now seems the case that health-seeking behavior is more prevalent in the chronic tertiary care-level attendees with IBS, and that depression and anxiety are more likely to increase the severity of pain reporting.1,2 However, do such psychological factors actually determine the development of symptoms or simply amplify, and prolong, them? If a primary psychological cause of symptoms in most individuals is not the fundamental factor, then what is? Over recent decades, many etiologic factors have been suggested, many of them coming and going with the passage of time and with the rise and fall of medical fashion. Most recently, the major etiologic proposals have been enteric and sensory neuropathy, allergy to food, and infection. All, of course, could share the common factor of a disordered inflammatory response to an otherwise benign external insult, leading to chronic symptoms in the absence of overt inflammation.

In support of this concept of postinflammatory dysfunction, it is now clear that, when epidemics of gastrointestinal infection are followed up, a cohort of patients continues to have chronic symptoms together with more prolonged inflammatory responses.3,4 In addition, the severity of symptoms seems to relate to the psychological state of the individual at follow-up.5 Taking such clinical observations into experimental models to obtain a mechanistic explanation of the pathophysiological processes behind IBS is, of course, difficult. However, the group at McMaster University have been steadfastly exploring this area during the past 2 decades, expanding our understanding of the interrelationships between gastrointestinal function and inflammation, and moving the field forward when others have watched critically from the sidelines. What Collins et al have done over the years is to use a rodent model of intestinal inflammation using Trichinella spiralis infection, with and without reexposure to Trichinella antigens, and to characterize in detail not only the inflammatory process operating in the model but also the physiological responsiveness of intestinal smooth muscles to the inflammatory process. In their latest studies published in this issue of GASTROENTEROLOGY,6 the group have again confirmed that T spiralis induces an increase in Th-2 cytokines and transforming growth factor (TGF) &#946;1. In addition, by repeatedly studying the animals for up to 1 month after the exposure to the inflammatory trigger, they have shown that, although the Th-2 cytokines appear to return to normal levels, TGF&#946;1 remains elevated in the tissue.

Therefore, what is now better understood is how the prolonged effects of short-term infection/inflammation actually operate. Studying the small intestinal longitudinal smooth muscle of infected animals, the group also describe what appears to be the chain of events driving postinfective smooth muscle hyperactivity. This comprises the sequence of elevation of Th-2 cytokines leading to TGF&#946; elevation, which in turn elevates cyclooxygenase-2 and prostaglandin E2 to increase smooth muscle excitability.

Thus, this interesting new article serves to extend our understanding of the relationships between intestinal inflammation in response to Trichinella and to provide a more detailed molecular basis for the observations that the group have made over the years. However, for the clinical gastroenterologist, the major questions arising from this article is whether the inflammatory sequence they have so elegantly described in an animal model can be used to forward our understanding of IBS and whether therapies could be designed that interfere with these cytokine-activated process and, thereby, either prevent the development of or alleviate symptoms.

In considering such questions, it is again necessary to address the awkward and unanswered problem in clinical IBS (ie, why do most patients develop their symptoms in the first place?). Although it is clear that a proportion of patients who suffer significant infection caused by Campylobacter do have longstanding diarrhea despite the disappearance of the organism, there seems to be little firm evidence that the symptoms continue after the return of mucosal inflammation to normal. It also remains to be established if, in the majority of patients who do not report gastrointestinal infection as the initiating factor in their symptoms, infection is indeed the underlying causative factor. Mucosal biopsies taken up to 1 year after infection caused by Campylobacter do continue to show inflammatory changes and an increase in enteroendocrine cell number4; however, it has understandably not been possible to show that smooth muscle from such patients shows the hypercontractility shown in the Trichinella model.

So what needs to be done next? Collins' group have now extended their observations to over a month after infection, so a demonstration of what happens even longer term seems appropriate. It is particularly important to know whether the smooth muscle effects can persist long after the disappearance of all indicators of inflammation or whether in the Trichinella model a continued inflammatory drive has to be present for continued muscle dysfunction. Exploration of this matter would seem to be feasible, as well as being of great importance, because if it is possible to show that function can be permanently altered without continued inflammation and if the mechanism for this physiological scarring can be identified, then such mechanisms could be explored in patients with chronic IBS symptoms unheralded by infection.

The work of Collins' group also serves to provide a challenge to those clinical scientists researching IBS, and to pharmaceutical companies seeking to provide new therapies.

The challenge to the clinical investigator is immense because the use of proxies for studying smooth muscle hyperexcitability in patients has fallen out of current clinical fashion, being generally uncomfortable to deliver and variable in their effects. Another major challenge for the clinical investigator will be to know how to identify the difference between normality and abnormality of colonic mucosal inflammation in the absence of any obvious histopathologic appearances. A molecular approach is an obvious one to adopt, and extending and developing the approach used by the Collins group into human mucosal tissue seems feasible.

A third issue that now needs to be explored by the clinical investigator is to determine whether the subtle variations in the inflammatory response that exist in the population relate to the chronicity of inflammation and the duration of symptoms after infection. Such an approach provides a huge opportunity for reclassifying abdominal symptoms against genotypic and phenotypic measures. The lessons currently being learned about these relationships and disease in inflammatory bowel disease are likely to have much to teach us about IBS.

The challenge for those trying to develop pharmaceuticals for the many patients with unexplained abdominal symptoms is equally large because it is necessary to know whether drugs that can modify the inflammatory process might be helpful to all or just some patients with IBS. Collins et al7 have already shown in their animal model that antiinflammatory medication in the form of dexamethasone does have a powerful moderating effect on smooth muscle function. However, in one study conducted in humans using corticosteroids in patients after infection by Campylobacter, no evidence for efficacy was found.8

Further observations of potential clinical interest are the ability of cyclooxygenase-2 antagonists to reduce the pathologic smooth muscle hypercontractility that suggests that nonsteroidal antiinflammatory drugs might alleviate gastrointestinal symptoms and the use of probiotics. Now that the soluble products of Lactobacillus paracasei have recently been shown to modulate the inflammatory response in the Trichinella model,9 the time appears to be right for a similar, empiric study in humans.

http://www2.gastrojournal.org/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0016508505010656

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Abdominal Radiography Not Useful in Constipated Children new
      #198979 - 07/24/05 02:30 PM
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Abdominal Radiography Not Useful in Constipated Children

NEW YORK (Reuters Health) Jul 13 - Findings from a review of published reports indicate that abdominal radiography does not help diagnose constipation in children when the clinical picture is unclear.

In theory, constipation can be diagnosed with plain abdominal x-rays by looking for the presence of fecal retention. However, previous studies have yielded conflicting results regarding the utility of such radiographs in clinical practice.

To clarify the value of radiography in diagnosing constipation in children, Dr. Marjolein Y. Berger, from Erasmus Medical Centre in the Netherlands, and colleagues reviewed relevant studies located with a MEDLINE search. However, of 392 publications that were identified, just 6 studies met inclusion criteria of which only two were deemed high quality.

The researchers' findings appear in the July issue of the Archives of Pediatrics and

Adolescent Medicine.

There was conflicting data regarding an association between constipation symptoms and x-ray findings, the authors note. Similarly, the link between digital rectal exam finding and the x-ray results was unclear. Lastly, rebound tenderness did not correlate with the radiography results either.

"The recommendation to perform a plain abdominal radiograph in case of doubt of the presence of constipation in a child cannot be supported by this systematic review," the investigators conclude.

Arch Pediatr Adolesc Med 2005;159:671-678.


http://www.medscape.com/viewarticle/508296?src=mp

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Dyspepsia and Irritable Bowel Syndrome After a Salmonella Gastroenteritis Outbreak new
      #198984 - 07/24/05 02:48 PM
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Gastroenterology - July 2005 • Volume 129 • Number 1

Dyspepsia and Irritable Bowel Syndrome After a Salmonella Gastroenteritis Outbreak: One-Year Follow-up Cohort Study

Background & Aims:

It has been reported that some patients develop functional digestive disorders, particularly irritable bowel syndrome (IBS), after acute gastroenteritis (AGE). However, the presence of dyspepsia has not been specifically addressed. We prospectively evaluated development of dyspepsia and IBS during a 1-year follow-up in a cohort of adult patients affected by a Salmonella enteritidis AGE outbreak.

Methods:

Questionnaires were sent to 1878 potential participants at baseline and 3, 6, and 12 months; 677 had experienced a Salmonella enteritidis AGE on June 23, 2002, and 1201 had not (randomly selected controls, matched for village of residence, age, and sex). At 12 months, 271 patients and 335 controls returned the questionnaires. Data permitted the establishment of dyspepsia and IBS diagnosis by Rome II criteria. Results: Before the AGE outbreak, the prevalence of dyspepsia was similar in cases and controls (2.5% vs 3.8%); the prevalence of IBS was also similar (2.9% vs 2.3%). At 3, 6, and 12 months, the prevalence of both dyspepsia and IBS had increased significantly in exposed compared with unexposed subjects. Overlap between dyspepsia and IBS was frequent. At 1 year, the relative risk for development of dyspepsia was 5.2 (95% confidence interval, 2.7–9.8) and for IBS was 7.8 (95% confidence interval, 3.1–19.7). Prolonged abdominal pain and vomiting during AGE were positive predictors of dyspepsia. No predictive factors for IBS were found.

Conclusions:

Salmonella gastroenteritis is a significant risk factor not only for IBS but also for dyspepsia; at 1 year of follow-up, 1 in 7 and 1 in 10 subjects developed dyspepsia or IBS, respectively.

http://www2.gastrojournal.org/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=abs&id=as0016508505006955&nav=abs

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Gastrointestinal infections can have lasting consequences as IBS new
      #203372 - 08/07/05 04:08 PM
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Ontario and Newfoundland incidents show gastrointestinal infections can have lasting consequences

Canadian outbreaks of two different gastrointestinal infections show the illnesses come with long-term health problems such as irritable bowel syndrome (IBS).
IBS puzzles doctors because medical tests usually don't show any abnormalities in the intestine, despite the presence of abdominal pain, diarrhea, constipation and bloating.

The two incidents -- the water-borne bacterial outbreak in Walkerton, Ont., in May 2000 and a food-borne viral outbreak at a scientific meeting in Newfoundland -- are providing researchers with an unprecedented look at what happens once the infections pass.

"It's a tragic opportunity, obviously we recognize that," says Dr. John Marshall, a gastroenterologist at McMaster University in Hamilton. "But it's an unusual opportunity to learn about the long-term outcomes of this sort of event."

The circumstances surrounding the Walkerton outbreak are well-known. Municipal water contaminated with E. coli bacteria killed seven local residents and made thousands of others sick. Some of them are still sick, according to Marshall's report.

He and his colleagues studied more than 2,000 Walkerton residents two to three years after the outbreak. One-third of those who got sick during the outbreak still had symptoms of IBS, including persistent diarrhea and abdominal pain. Just 10 per cent of people who did not get sick were found to have IBS.

The results lend a new note of credibility to the continuing health woes of Walkerton residents, Marshall says. "We need to bring legitimacy to this sort of complaint, because a lot of people -- certainly in Walkerton -- who've had irritable bowel syndrome find themselves a bit dismissed by the medical system because they don't have any identifiable abnormality."

As the researchers were collecting data on the Walkerton crisis, another outbreak occurred -- this time viral -- at the 2002 meeting of the Canadian Society of Gastroenterology Nurses and Associates.

Marshall and his team followed up on 100 people present during the meeting, 75 of whom fell ill at the time. Two years later, 20 per cent of those who got sick reported continuing symptoms of IBS and had higher rates of constipation and bloating, but not diarrhea.

In comparing the two outbreaks, Marshall notes the IBS seemed to clear up sooner after the viral infection than after the bacterial infection.

The new information will help guide doctors in counselling people who have suffered a bout of acute gastroenteritis, Marshall says. "We need to know how long this lasts and what proportion of people go back to normal over time. That's what every patient wants to know. When will this go away?"

http://www.macleans.ca/topstories/health/article.jsp?content=20050728_101720_5392

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Physiological Mechanisms Underlying Perceptions of Nausea and Stomach Fullness new
      #203380 - 08/07/05 04:33 PM
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Sickness and Satiety: Physiological Mechanisms Underlying Perceptions of Nausea and Stomach Fullness

Max E Levine PhD

Department of Internal Medicine Section of Gastroenterology, Medical Center Boulevard, Wake Forest University School of Medicine, Winston-Salem, NC, 27157, USA.

Current Gastroenterology Reports 2005, 7:280-288

Published 1 August 2005

Abstract

The pathophysiology of nausea and the physiological mechanisms underlying perceptions of stomach emptiness and fullness are not clearly understood, but several potentially important factors have been identified. Gastric dysrhythmias are believed to contribute to the subjective experience of nausea and may also be involved with perceptions of stomach emptiness, hunger, and even dyspepsia symptoms like bloating and early satiety.

Normal gastric neuromuscular function is more evident in the absence of nausea and is also thought to be related to feelings of satiety or comfortable stomach fullness. Autonomic and endocrine influences may also play a critical role in the pathophysiology of nausea and abnormal perceptions of stomach emptiness or fullness. Achieving a better understanding of the gastric neuromuscular and neurohormonal influences on perceptions arising from the viscera may prove invaluable in the development of novel treatments for such conditions as unexplained nausea, functional dyspepsia, and obesity.

http://www.biomedcentral.com/1522-8037/7/280/abstract

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Role of Carbon Dioxide-Releasing Suppositories in the Treatment of Chronic Functional Constipation new
      #207544 - 08/22/05 04:32 PM
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Role of Carbon Dioxide-Releasing Suppositories in the Treatment of Chronic Functional Constipation

A Double-Blind, Randomised, Placebo-Controlled Trial
Posted 08/10/2005

M. Lazzaroni; V. Casini; G. Bianchi Porro

Abstract and Introduction
Abstract

Objective: Treatment of chronic functional constipation is difficult. Both oral and topical laxatives may fail to adequately relieve symptoms, and there is risk of adverse effects such as functional or structural changes in the intestine, together with electrolyte disturbances. The aim of this study was to evaluate the efficacy and safety of a suppository that combines sodium bicarbonate and potassium bitartrate in a polyethylene glycol base to generate approximately 175mL of carbon dioxide (CO2). This release distends the rectal ampulla, thereby stimulating peristalsis and a subsequent bowel movement.

Patients and Methods:
This was a prospective, crossover, double-blind, randomised, placebo-controlled, sequential study of outpatients with chronic functional constipation. Each patient received two suppositories of identical appearance, containing active drug or placebo. The sequence of active drug-placebo (sequence 1) or placebo-active drug (sequence 2) was randomised in groups of eight. The second suppository was taken 7 days after the first. The following parameters were evaluated and scored: evacuation time, type of evacuation, feeling of emptying of the rectal ampulla, stool characteristics, anal complaints, abdominal pain and overall patient assessment.

Results:
A total of 29 patients entered the study. According to a restricted sequential plan, a statistical significance (p < 0.05) in favour of the active drug was reached after 26 patients. A positive response within 30 minutes of introduction of the suppository occurred in 51.7% and 6.9% of patients treated with the active drug and placebo, respectively (p = 0.0003). Normal evacuation occurred in 65.5% and 24.1% of patients treated with the active drug and placebo, respectively (p = 0.004). Normal stool consistency was found in 44.8% and 7.2% of patients treated with the active drug and placebo, respectively (p = 0.04). Patient assessment of treatment as satisfactory occurred in 51.7% and 20.7% of subjects treated with the active drug and placebo, respectively (p = 0.029). Only a trend in favour of the active drug was observed with regard to feeling of incomplete evacuation, and active drug was comparable to placebo with regard to anal and abdominal tolerability

Conclusion:
The CO2-releasing suppository may represent an alternative to rectal laxatives for the relief of chronic functional constipation. The data obtained in this study indicate that CO2-releasing suppositories may be usefully and safely employed in the treatment of patients at risk for electrolyte disorders such as the elderly or patients with renal or cardiovascular disorders.



M. Lazzaroni, V. Casini and G. Bianchi Porro, Gastrointestinal Unit, L. Sacco University Hospital, Milan, Italy


Disclosure: The authors have no potential conflicts of interest that are directly relevant to the contents of this article.


Clin Drug Invest. 2005;25(8):499-505. ©2005 Adis Data Information BV

http://www.medscape.com/viewarticle/509551?src=mp

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How Do Symptoms in Chronic Constipation and IBS With Constipation Differ? new
      #207555 - 08/22/05 04:51 PM
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How Do Symptoms in Chronic Constipation and IBS With Constipation Differ?

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

IBS is characterized by abdominal discomfort or pain, bloating, and disturbed defecation. This disturbed defecation can take the form of constipation (IBS-C), diarrhea (IBS-D), or mixed/alternating bowel habits (IBS-M) with roughly equivalent distribution of the 3 subtypes. The Rome criteria for IBS were developed by an international group of experts to provide a uniform means of identifying patients for clinical trials, though more recently, their use in clinical practice has been encouraged. The Rome II criteria for IBS include at least 12 weeks (which need not be consecutive), in the preceding 12 months, of abdominal discomfort or pain that is accompanied by at least 2 of the following symptoms: the abdominal discomfort or pain is (a) relieved with defecation, (b) associated with a change in the frequency of defecation, and/or (c) associated with a change in the form or appearance of the stool.

In contrast to IBS, the Rome Committee defined functional constipation as 2 or more of the following: straining during more than 25% of defecations; lumpy or hard stools at more than 25% of defecations; a sensation of incomplete evacuation during more than 25% of defecations; manual maneuvers to facilitate more than 25% of defecations; and/or fewer than 3 defecations per week for at least 12 weeks in the past 12 months.

There can be no doubt that there is substantial overlap between CC and IBS-C, but the cardinal feature for diagnosis and the most bothersome symptom in patients with IBS-C is abdominal discomfort or pain. However, it is important to note the absence of abdominal pain or discomfort from the Rome definition for CC. It can be argued that depending on the enthusiasm of the interviewer, many patients with severe constipation will have a history of at least mild abdominal pain or discomfort. However, in IBS, the abdominal discomfort or pain should be a critical symptom, while in patients with CC, abdominal discomfort or pain is typically only an aside to the stool-related complaints.

http://www.medscape.com/viewarticle/487948_4

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Irritable Bowel Syndrome: Toward an Understanding of Severity new
      #210442 - 09/01/05 11:19 AM
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Clinical Gastroenterology and Hepatology
Volume 3, Issue 8 , August 2005, Pages 717-725

Irritable Bowel Syndrome: Toward an Understanding of Severity

Anthony Lembo, Vanessa Z. Ameen‡ and Douglas A. Drossman

Beth Israel Deaconess Medical Center, Boston, Massachusetts
‡GlaxoSmithKline, Research Triangle Park, North Carolina
UNC Center for Functional GI and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina

Irritable bowel syndrome (IBS) is a chronic disorder with symptoms that range in severity from mild and intermittent to severe and continuous. Although severity is a guiding factor in clinical decision making related to diagnosis and treatment, current guidelines related to IBS do not address the issue of severity. Recent data suggest that severity as a multidimensional concept, not fully explained by intensity of symptoms, has important clinical implications including health care utilization and health-related quality of life. Components of IBS severity include symptom intensity, time of assessment, whether the patient or physician makes the severity determination, the type of scale used to measure severity, and the degree of disability or impairment. Currently no consensus definition of IBS severity exists, although 2 validated scales of IBS severity have recently been published. Review of the literature suggests that the prevalence of severe or very severe IBS is higher than previously estimated with a range from 3%–69%. Individual IBS symptoms are important but are not sufficient to explain severity. Rather, severity has multiple components including health-related quality of life, psychosocial factors, health care utilization behaviors, and burden of illness. However, studies have not been adequately designed to determine the relative values of these factors in IBS severity.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GGW-4GV2755-9&_user=10&_handle=V-WA-A-W-WC-MsSAYVA-UUW-U-AAWDWECCVA-AAWVYDZBVA-WECDUEZWB-WC-U&_fmt=summary&_coverDate=08%2F31%2F2005&_rdoc=9&_orig=browse&_srch=%23toc%2320161%232005%23999969991%23603702!&_cdi=20161&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=669d2c4ee640b4aa481d7379c5afbf35

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Increased Prevalence of Obesity in Children With Functional Constipation new
      #212985 - 09/13/05 12:45 PM
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PEDIATRICS Vol. 116 No. 3 September 2005, pp. e377-e380 (doi:10.1542/peds.2005-0490)

Increased Prevalence of Obesity in Children With Functional Constipation Evaluated in an Academic Medical Center
Objective. The rapidly increasing prevalence of obesity in children is the most important problem facing pediatricians today. A recent study suggested an association of obesity and constipation in children but lacked a control group for comparison. The objectives of this study were to evaluate the prevalence of obesity in a large cohort of children with functional constipation and to compare it with a control group representative of the general population.
Methods. Retrospective chart review was performed on 719 children, between the ages of 4 and <18 years, with chronic functional constipation seen in the general pediatric and pediatric gastroenterology clinics between July 2002 and June 2004. Data collected included age, gender, BMI, and signs and symptoms of constipation including fecal incontinence. Obesity was classified as a BMI of >95th percentile and severe obesity as a BMI of 5 kg/m2 above the 95th percentile for age and gender. The control group consisted of all 930 children (4 to <18 years of age) presenting to the pediatric clinic for a well-child visit between January and June 2004. The 2 and t tests were used for analysis.

Results. Overall prevalence of obesity was significantly higher in constipated children (22.4%) compared with control children (11.7%), and this higher prevalence was also seen for severe obesity. The prevalence rates of obesity were significantly higher in constipated males (25%) than in constipated females (19%) and were significantly higher compared with the control males (13.5%) and control females (9.8%). Constipated boys in all 3 age groups had significantly higher rates of obesity than the control boys; the constipated girls had significantly higher obesity rates for the age groups between 8 and <18 years. Fecal incontinence (encopresis) was present in 334 of 719 (46%) constipated children. The prevalence of obesity was similar in constipated children with and without fecal incontinence.

Conclusions. There is a significantly higher prevalence of obesity in children with constipation compared with age- and gender-matched controls. This higher prevalence is present in both boys (4 to <18 years of age) and girls (8 to <18 years of age) with constipation and is not related to the presence of fecal incontinence among constipated children. The higher prevalence of obesity may be a result of dietary factors, activity level, or hormonal influences and needs additional evaluation.



--------------------------------------------------------------------------------
Dinesh S. Pashankar, MD, MRCP* and Vera Loening-Baucke, MD

http://pediatrics.aappublications.org/cgi/content/abstract/116/3/e377

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IBS and Functional Dyspepsia: Different Diseases or a Single Disorder With Different Manifestations? new
      #212994 - 09/13/05 01:03 PM
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Irritable Bowel Syndrome and Functional Dyspepsia: Different Diseases or a Single Disorder With Different Manifestations?

Posted 08/29/2005

Laura Noddin, MD; Michael Callahan, PhD; Brian E. Lacy, MD, PhD

Introduction
Functional gastrointestinal disorders (FGIDs) are common, chronic ailments that affect millions of adults on a daily basis. FGIDs are characterized by recurrent symptoms (ie, abdominal pain or discomfort, bloating, nausea, vomiting, early satiety, constipation, or diarrhea) that indicate a dysfunctional GI tract despite that an organic reason for the symptom generation is not identified on diagnostic studies.

It is estimated that 40% of all gastroenterology clinic visits are for FGIDs,[1] and a recent survey of generalists and gastroenterologists found that nearly one third of their patient population had symptoms of irritable bowel syndrome (IBS).[2] Many patients with IBS have dyspepsia; likewise, many patients with dyspepsia also have overlapping symptoms of IBS. These 2 groups of patients are similar in that symptoms are typically chronic in nature, may wax and wane, are aggravated by psychosocial stressors, and are often worsened by meals. In addition, both disorders are considered difficult to diagnose by many physicians and in the absence of warning signs or "red flags," extensive testing is unlikely to be helpful. These similarities raise the issue of whether IBS and dyspepsia are just different manifestations of the same disorder or whether they represent distinct clinical entities. Elucidating this clinical dilemma is important because it may improve our ability to diagnose and treat these common disorders.

At present, the ROME II committee classifies IBS as a distinctly separate functional bowel disorder from dyspepsia.[3] IBS is characterized by lower abdominal pain or discomfort in association with disordered defecation ( Table 1 ). Dyspepsia presents as recurrent upper abdominal pain or discomfort associated with symptoms of early satiety, fullness, bloating, and nausea ( Table 2 ). Because upper GI function regularly affects lower GI tract function (ie, the gastro-colic reflex), and lower GI function routinely affects upper GI function (ie, constipation slows gastric emptying), it should not be surprising that these 2 areas are intimately linked.[4]

This article reviews the prevalence, natural history, etiology, pathogenesis, and treatment of these 2 common FGIDs, and discusses whether these disorders are different manifestations of the same disorder or whether they are truly distinct clinical entities.

Laura Noddin, MD, Department of Medicine, Dartmouth Medical School, Hanover, New Hampshire

Michael Callahan, PhD, Regional Scientific Director, Novartis Pharmaceuticals, East Hanover, New Jersey

Brian E. Lacy, MD, PhD, Associate Professor of Medicine, Dartmouth Medical School, Hanover, New Hampshire; Director, GI Motility Laboratory, Division of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire


Disclosure: Laura Noddin, MD, has disclosed no relevant financial relationships.

Disclosure: Michael Callahan, PhD, has disclosed that he is an employee of Novartis Pharmaceuticals, East Hanover, New Jersey, and holds stock options in the Company.

Disclosure: Brian E. Lacy, MD, PhD, has disclosed that he has received grants for clinical research from Novartis Pharmaceuticals, AstraZeneca, and GlaxoSmithKline.


Medscape General Medicine. 2005;7(3) ©2005 Medscape

To read this article in full, please click here:

http://www.medscape.com/viewarticle/506798?src=mp

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Guidelines for the Management of Dyspepsia new
      #215258 - 09/22/05 04:35 PM
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The American Journal of Gastroenterology
Volume 0 Issue 0 - October 2005
doi:10.1111/j.1572-0241.2005.00225.x


Guidelines for the Management of Dyspepsia

Nicholas J. Talley, M.D., Ph.D., F.A.C.G.1, Nimish Vakil, M.D., F.A.C.G.2, and the Practice Parameters Committee of the American College of Gastroenterology

Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper abdomen; patients with predominant or frequent (more than once a week) heartburn or acid regurgitation, should be considered to have gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic patients over 55 yr of age, or those with alarm features should undergo prompt esophagogastroduodenoscopy (EGD).

In all other patients, there are two approximately equivalent options: (i) test and treat for Helicobacter pylori (H. pylori) using a validated noninvasive test and a trial of acid suppression if eradication is successful but symptoms do not resolve or (ii) an empiric trial of acid suppression with a proton pump inhibitor (PPI) for 48 wk. The test-and-treat option is preferable in populations with a moderate to high prevalence of H. pylori infection (10%); empirical PPI is an initial option in low prevalence situations.

If initial acid suppression fails after 24 wk, it is reasonable to consider changing drug class or dosing. If the patient fails to respond or relapses rapidly on stopping antisecretory therapy, then the test-and-treat strategy is best applied before consideration of referral for EGD. Prokinetics are not currently recommended as first-line therapy for uninvestigated dyspepsia. EGD is not mandatory in those who remain symptomatic as the yield is low; the decision to endoscope or not must be based on clinical judgement. In patients who do respond to initial therapy, stop treatment after 48 wk; if symptoms recur, another course of the same treatment is justified.

The management of functional dyspepsia is challenging when initial antisecretory therapy and H. pylori eradication fails. There are very limited data to support the use of low-dose tricyclic antidepressants or psychological treatments in functional dyspepsia.

(Am J Gastroenterol 2005;100:114)

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1572-0241.2005.00225.x

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Abdominal Bloating new
      #215262 - 09/22/05 04:46 PM
HeatherAdministrator

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Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
doi:10.1053/j.gastro.2005.06.062

Copyright © 2005 American Gastroenterological Association Published by Elsevier Inc.

Abdominal Bloating

Fernando Azpiroz, and Juan–R. Malagelada

Digestive System Research Unit, Hospital General Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain

Received 5 August 2004; accepted 24 November 2004. Available online 6 September 2005.

Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect.

Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception.

All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception.

Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods.

Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.


Supported in part by the National Institutes of Health (grant DK57064), the Spanish Ministry of Education (grant BFI 2002-03413), and the Instituto Carlos III (grant C03/02).

Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFX-4H2162R-1G&_user=10&_handle=V-WA-A-W-DD-MsSWYWW-UUW-U-AAWEAYVAVY-AAWZDZVEVY-BBCBAECAD-DD-U&_fmt=summary&_coverDate=09%2F30%2F2005&_rdoc=42&_orig=browse&_srch=%23toc%236806%232005%23998709996%23605535!&_cdi=6806&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7663fa40aa8f7dc09ad26193f30710b2

--------------------
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Abdominal Bloating - Four Factors new
      #215264 - 09/22/05 04:47 PM
HeatherAdministrator

Reged: 12/09/02
Posts: 7788
Loc: Seattle, WA

Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078
doi:10.1053/j.gastro.2005.06.062

Copyright © 2005 American Gastroenterological Association Published by Elsevier Inc.

Abdominal Bloating

Fernando Azpiroz, and Juan–R. Malagelada

Digestive System Research Unit, Hospital General Vall d'Hebron, Autonomous University of Barcelona, Barcelona, Spain

Received 5 August 2004; accepted 24 November 2004. Available online 6 September 2005.

Abdominal bloating is a common and significant clinical problem that remains to be scientifically addressed. Bloating is one of the most bothersome complaints in patients with various functional gut disorders. However, in the current standard classification, abdominal bloating is merely regarded as a secondary descriptor, which masks its real clinical effect.

Four factors are involved in the pathophysiology of bloating: a subjective sensation of abdominal bloating, objective abdominal distention, volume of intra-abdominal contents, and muscular activity of the abdominal wall. The primer to elicit subjective bloating may be any of the other 3 factors, or the sensation may be related to distorted perception.

All of these mechanisms may play an independent role or may be interrelated. Gas transit studies have evidenced that patients with bloating have impaired reflex control of gut handling of contents. Segmental pooling, either of gas or of solid/liquid components, may induce a bloating sensation, particularly in patients with altered gut perception.

Furthermore, altered viscerosomatic reflexes may contribute to abdominal wall protrusion and objective distention, even without major intra-abdominal volume increment. Bloating probably is a heterogeneous condition produced by a combination of pathophysiological mechanisms that differ among individual patients and that in most cases are subtle and undetectable by conventional methods.

Further advances in the pathophysiology and clinical forms of bloating are warranted to develop mechanistic strategies rather than the current empiric treatment strategies for comprehensive and effective management of this problem.


Supported in part by the National Institutes of Health (grant DK57064), the Spanish Ministry of Education (grant BFI 2002-03413), and the Instituto Carlos III (grant C03/02).

Gastroenterology
Volume 129, Issue 3 , September 2005, Pages 1060-1078

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WFX-4H2162R-1G&_user=10&_handle=V-WA-A-W-DD-MsSWYWW-UUW-U-AAWEAYVAVY-AAWZDZVEVY-BBCBAECAD-DD-U&_fmt=summary&_coverDate=09%2F30%2F2005&_rdoc=42&_orig=browse&_srch=%23toc%236806%232005%23998709996%23605535!&_cdi=6806&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=7663fa40aa8f7dc09ad26193f30710b2

--------------------
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The Impact of Somatization on the Use of Gastrointestinal Health-Care Resources in Patients with IBS new
      #215265 - 09/22/05 04:51 PM
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The American Journal of Gastroenterology
Volume 0 Issue 0 - October 2005
doi:10.1111/j.1572-0241.2005.00269.x


The Impact of Somatization on the Use of Gastrointestinal Health-Care Resources in Patients with Irritable Bowel Syndrome

Brennan M.R. Spiegel, M.D., M.S.H.S.14, Fasiha Kanwal, M.D., M.S.H.S.13, Bruce Naliboff, Ph.D.4, and Emeran Mayer, M.D.2,4

BACKGROUND: It is unclear why patients with irritable bowel syndrome (IBS) consume a disproportionate amount of health-care resources versus matched controls. One possibility is the presence of comorbid somatizationa process marked by multiple unexplained somatic complaints that is highly prevalent in IBS. We sought to determine whether higher levels of somatization are associated with higher levels of gastrointestinal (GI) resource utilization in IBS.

METHODS: A total of 1,410 patients >18 yr with IBS were evaluated at a university-based clinic. Subjects completed a symptom questionnaire, the SCL-90R psychometric checklist, and the SF-36 Health Survey. We measured two outcomes: (1) a 1-yr direct GI health-care costs and (2) a 1-yr number of GI physician visits. Our primary regressor was somatization as measured by the somatization subscale of the SCL-90R. We performed regression analyses to measure the adjusted influence of somatization on GI resource utilization.

RESULTS: In the full sample of patients, there were no differences in the likelihood of expending versus not expending previous GI health-care costs among groups with varying levels of somatization. Similarly, there were no differences in either the likelihood of visiting a GI physician or the number of overall physician visits among patients with varying levels of somatization. However, in the subset of patients expending at least $1.00 in GI costs in the previous year (53% of cohort), there was a significantly higher cost of care for subjects with high versus low levels of somatization.

CONCLUSIONS: IBS patients with high levels of somatization are not more likely to seek GI care compared to patients with low levels of somatization. However, once they are evaluated for care, patients with high somatization expend significantly more GI health-care costs. This suggests that somatization is positively associated with health-care costs in IBS, and that the association may be driven more by physicians than patients.

(Am J Gastroenterol 2005;100:112)

http://www.blackwell-synergy.com/doi/abs/10.1111/j.1572-0241.2005.00269.x

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Bronchial Hyperresponsiveness in Irritable Bowel Syndrome new
      #218944 - 10/11/05 01:16 PM
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Bronchial Hyperresponsiveness in Irritable Bowel Syndrome

Authors: Jun, Dae1; Lee, Oh2; Yoon, Ho3; Lee, Hang1; Yoon, Byung1; Choi, Ho1; Lee, Min1; Lee, Dong1; Kee, Choon1

Source: Digestive Diseases and Sciences, Volume 50, Number 9, September 2005, pp. 1688-1691(4)

Publisher: Kluwer Academic Publishers

< previous article ' next article > View Table of Contents

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Abstract:

Extraintestinal symptoms are often found in patients with irritable bowel syndrome (IBS). Recent studies suggest that IBS is associated with bronchial hyperresponsiveness. But it is still arguable that the bronchial hyperresponsiveness is associated with IBS patients. The purpose of this study is to investigate the possible relationship between IBS and bronchial hyperresponsiveness. Forty-two patients with IBS and 42 control subjects were included in this study. All patients underwent pulmonary function, methacholine challenge, and skin prick tests. There was no statistical difference between the two groups with respect to percentage of all pulmonary function test parameters, including FEV1%, FCV%, FVC/FEV1, and FEF25 - 75%. Only two persons in the alternating-type IBS patient group and one person in the control group tested positive in the methacholine provocation test. But all PC20 values were above 16 mg/ml. These results do not demonstrate a relationship between bronchial hyperresponsiveness and IBS. However, a relationship might exist in a subpopulation of IBS patients.

http://www.ingentaconnect.com/content/klu/ddas/2005/00000050/00000009/00002916;jsessionid=p8p8fwgtpbpy.victoria

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Childhood Abdominal Pain May Progress to Adult Irritable Bowel Syndrome new
      #218948 - 10/11/05 01:36 PM
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Childhood Abdominal Pain May Progress to Adult Irritable Bowel Syndrome




NEW YORK (Reuters Health) Sept 29 - Childhood abdominal pain is a common complaint, which may progress to adult irritable bowel syndrome (IBS) in some children, according to a study in the September issue of the American Journal of Gastroenterology.

"The natural history of childhood abdominal pain and its association with adult IBS remain poorly described," Dr. Nicholas J. Talley, of the Mayo Clinic College of Medicine, Rochester, Minnesota, and colleagues write.

To investigate, they assessed the characteristics of childhood abdominal pain over the first 11 years of life in some 1,000 children born in Dunedin, New Zealand in 1972, and examined the association of childhood abdominal pain with IBS at 26 years.

Three measures were used to describe history of childhood abdominal pain: medical service encounters for childhood abdominal pain, parental reports of stomach pain, and a composite measure including both medical encounters and parental report. Three time frames were examined: ages 0 to 7, 7 to 9, and 9 to 11 years. Data were available for 912 subjects.

A history of abdominal pain was documented in 18.1% of children. Childhood abdominal pain was more common in females than in males. Among males, the prevalence of childhood abdominal pain peaked at age 7 to 9 years, but the prevalence of childhood abdominal pain remained stable across assessments for females.

IBS at age 26 years was about 2 or 3 times more common among subjects with a history of childhood abdominal pain between the ages of 7 and 9 years compared with those with no history, depending on the assessment method.

Adjustment for sex, socioeconomic status, psychiatric disorder at age 26, childhood emotional distress, or maternal malaise did not alter this association.

"The emergence of multiple stressors in the home and school environment may present a plausible mechanism to account for these findings," Dr. Talley's team suggests. "The 7 to 9 year age period follows closely from the school starting age in many cultures, and children who are predisposed to stress-related disorders may be at particular risk of developing symptomatic complaints at this point."

Am J Gastroenterol 2005;100:2071-2078.


http://www.medscape.com/viewarticle/513761

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Functional Constipation Linked to Obesity in Children new
      #218949 - 10/11/05 01:43 PM
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Functional Constipation Linked to Obesity in Children

By Anthony J. Brown, MD

NEW YORK (Reuters Health) Sept 21 - Children with functional constipation are about twice as likely to be obese as their peers without this problem, according to a report in the September issue of Pediatrics.

"When a clinician sees a child with constipation, they should remember to evaluate them for obesity," lead author Dr. Dinesh S. Pashankar, from Yale University School of Medicine in New Haven, Connecticut, told Reuters Health. "As most people are aware, obesity is an increasing problem among children and unless there's an issue, like constipation, many obese children simply won't be seen by a clinician."

The new findings also have psychiatric implications, Dr. Pashankar emphasized. Individually, "obesity and constipation can cause behavioral issues and depression, but together the problem is likely to be more severe. Clinicians need to be aware of that."

In the current study, the researchers compared the prevalence of obesity among 719 children with functional constipation and among 930 control children.

The rate of obesity among the constipated children was 22.4%, nearly double the rate seen in control children -- 11.7%. The association between constipation and obesity was noted in both boys and girls and was not related to the presence of encopresis in constipated children.

The new findings generally support those of a previous study, which examined this topic but did not include a control group, Dr. Pashankar pointed out.

As to the mechanism linking obesity and constipation, Dr. Pashankar said that diet is likely a major factor. "Less fiber intake probably results in greater caloric intake and together these dietary patterns cause both problems."

Pediatrics 2005;116:e377-e380.

http://www.medscape.com/viewarticle/513186?src=mp

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Brain activation responses to auditory stimuli in IBS new
      #221825 - 10/28/05 11:42 AM
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Neurogastroenterology and Motility
Volume 0 Issue 0 - October 2005
doi:10.1111/j.1365-2982.2005.00720.x


Brain activation responses to subliminal or supraliminal rectal stimuli and to auditory stimuli in irritable bowel syndrome

v. andresen*, d. r. bach*, a. poellinger, c. tsrouya*, a. stroh, a. foerschler§, p. georgiewa, c. zimmer¶ & h. mönnikes*

Abstract

Visceral hypersensitivity in irritable bowel syndrome (IBS) has been associated with altered cerebral activations in response to visceral stimuli. It is unclear whether these processing alterations are specific for visceral sensation.

In this study we aimed to determine by functional magnetic resonance imaging (fMRI) whether cerebral processing of supraliminal and subliminal rectal stimuli and of auditory stimuli is altered in IBS. In eight IBS patients and eight healthy controls, fMRI activations were recorded during auditory and rectal stimulation.

Intensities of rectal balloon distension were adapted to the individual threshold of first perception (IPT): subliminal (IPT 10 mmHg), liminal (IPT), or supraliminal (IPT +10 mmHg). IBS patients relative to controls responded with lower activations of the prefrontal cortex (PFC) and anterior cingulate cortex (ACC) to both subliminal and supraliminal stimulation and with higher activation of the hippocampus (HC) to supraliminal stimulation.

In IBS patients, not in controls, ACC and HC were also activated by auditory stimulation. In IBS patients, decreased ACC and PFC activation with subliminal and supraliminal rectal stimuli and increased HC activation with supraliminal stimuli suggest disturbances of the associative and emotional processing of visceral sensation.

Hyperreactivity to auditory stimuli suggests that altered sensory processing in IBS may not be restricted to visceral sensation.


http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2982.2005.00720.x

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Colonic Immune Activity and Blood T Lymphocytes in Patients With Irritable Bowel Syndrome new
      #221827 - 10/28/05 11:48 AM
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Clinical Gastroenterology and Hepatology
Volume 3, Issue 10 , October 2005, Pages 980-986

doi:10.1016/S1542-3565(05)00410-6

Copyright © 2005 American Gastroenterological Association Published by Elsevier Ltd.

A Controlled Study of Colonic Immune Activity and Blood T Lymphocytes in Patients With Irritable Bowel Syndrome

Lena Öhman , , Stefan Isaksson, Anna Lundgren§, Magnus Simrén and Henrik Sjövall

Department of Internal Medicine, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden
Department of Clinical Immunology, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden
Department of Medical Microbiology and Immunology, The Sahlgrenska Academy at Göteborg University, Göteborg, Sweden

Available online 6 October 2005.


Background & Aims: The mechanisms behind irritable bowel syndrome (IBS) are incompletely understood. Recently several studies have suggested a low-grade colonic inflammation as initiator of the gut dysfunctions recorded in this patient group. The aim of this study was to characterize the phenotype and homing properties of colonic and peripheral blood lymphocytes in patients with IBS.

Methods: Patients with IBS (n = 33), defined by the Rome II criteria, were compared with UC patients (n = 23) and control subjects (n = 15) without gastrointestinal symptoms. Colonic and peripheral blood lymphocytes were analyzed by flow cytometry. Secretion of IFN-&#947; from intestinal biopsies was determined by enzyme-linked immunosorbent assay, and immunohistochemical staining of colonic biopsies was performed. Results: IBS patients displayed an increased frequency of peripheral blood CD4+ and CD8+ T cells expressing the gut homing integrin &#946;7. Accordingly, IBS and UC patients had an augmented frequency of lamina propria CD8+ T cells in the ascending colon as compared with control subjects. The frequency of intestinal T cells expressing integrin &#946;7+ was unaltered in IBS and UC patients, although the expression of mucosal addressin cell adhesion molecule–1+ endothelium, the ligand for integrin &#946;7, was increased in the ascending colon of IBS and UC patients as compared with control subjects. Conclusions: Patients with IBS exhibit an enhanced immune activity in the gut and an increased frequency of integrin &#946;7+ T lymphocytes in the peripheral blood.

Our data further support the hypothesis of IBS being at least partially an inflammatory disorder.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7GGW-4H8FVBB-J&_user=10&_handle=V-WA-A-W-WD-MsSAYWW-UUA-U-AABAZEZWZZ-AAWEWDDUZZ-BEYWDYBWD-WD-U&_fmt=summary&_coverDate=10%2F31%2F2005&_rdoc=16&_orig=browse&_srch=%23toc%2320161%232005%23999969989%23607610!&_cdi=20161&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=238c088ffd280cc3f19386caee0a95f8

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Irritable Bowel Syndrome Study Shows That Targeted Antibiotics Lead To Long-lasting Improvement new
      #224504 - 11/12/05 01:00 PM
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Source: Cedars-Sinai Medical Center

Date: 2005-11-09

Irritable Bowel Syndrome Study Shows That Targeted Antibiotics Lead To Long-lasting Improvement In Symptoms

Researchers at Cedars-Sinai Medical Center have found that a nonabsorbable antibiotic – one that stays in the gut – may be an effective long-term treatment for irritable bowel syndrome (IBS), a disease affecting more than an estimated 20 percent of Americans. The findings, which showed that participants benefited from the antibiotic use even after the course of treatment ended, support previously published research identifying small intestine bacterial overgrowth (SIBO) as a possible cause of the disease.

The research was presented at the recent American College of Gastroenterology's annual meeting in Honolulu, HI.

"This study is important as it is the first to show that the use of targeted antibiotics results in a more significant and long-lasting improvement in IBS symptoms," said Mark Pimentel, M.D., first author on the study and director of the GI Motility Program at Cedars-Sinai. "These results clearly show that antibiotics offer a new treatment approach – and a new hope – for people with IBS."

The randomized, double blind study involved 87 patients. Those on the rifaximin experienced a 37 percent overall improvement of their IBS symptoms as compared to 23 percent on the placebo. Among study subjects whose primary symptom was diarrhea, those on the antibiotic showed more than twice the improvement of those on the placebo (49 percent vs. 23 percent). Patients received the drug (or placebo) for 10 days and were then followed for a total of 10 weeks. Participants kept a stool diary, took a questionnaire and were given methane breath tests. The positive effects of the drug were shown to continue throughout most of the 10-week study, not just during the actual antibiotic course.

Because the cause of IBS has been elusive, treatments for the disease have historically focused on reducing its symptoms – diarrhea and constipation – by giving medications that either slow or speed up the digestive process. In 2000, Pimentel linked bloating, the most common symptom of IBS, to bacterial fermentation, showing that small intestine bacteria overgrowth (SIBO) may be the causative factor in IBS (The American Journal of Gastroenterology, Dec. 2000).

To show evidence of small intestine bacterial overgrowth, participants in both studies were given a lactulose breath test, which monitors the level of hydrogen and methane (the gases emitted by fermented bacteria) on the breath. In the first study, an abnormal breath methane profile was shown to be 100 percent predictive of constipation-predominant IBS. In the current study, the correlation between the amount of methane and the amount of constipation was confirmed, another key finding.

"We were pleased – but not surprised – with the results of this study," said Pimentel. "The next step is to start larger, multi-centered studies to confirm the positive results of this study, which suggest that people can benefit from targeted antibiotic treatment for their IBS."

Irritable Bowel Syndrome is an intestinal disorder that causes abdominal pain or discomfort, cramping or bloating and diarrhea and constipation. It is a long-term condition that usually begins in adolescence or in early adult life. Episodes may be mild or severe and may be exacerbated by stress. It is one of the top ten most frequently diagnosed conditions among U.S. physicians and affects women more often than men.


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Other authors from Cedars-Sinai include Sandy Park, B.A., Yuthana Kong M.P.H. and Robert Wade. Sunanda V. Kane from the University of Chicago also participated in the study.

Rifaximin is made by Salix Pharmaceuticals, Inc. Funding for the study was provided by Salix Pharmaceuticals, Inc.


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This story has been adapted from a news release issued by Cedars-Sinai Medical Center.

http://www.sciencedaily.com/releases/2005/11/051109181127.htm


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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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The Genetics of Irritable Bowel Syndrome new
      #224507 - 11/12/05 01:10 PM
HeatherAdministrator

Reged: 12/09/02
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The Genetics of Irritable Bowel Syndrome

doi:10.1016/S1542-3565(05)00184-9
Copyright © 2005 American Gastroenterological Association Published by Elsevier Ltd.
Clinical genomics

The Genetics of Irritable Bowel Syndrome

Yuri A. Saito , Gloria M. Petersen‡, G. Richard Locke III; and Nicholas J. Talley

Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Mayo Clinic and Foundation, Rochester, Minnesota, USA
‡Division of Epidemiology, Mayo Clinic and Foundation, Rochester, Minnesota, USA

Available online 2