Crossed fused ectopic kidney in a patient with irritable bowel syndrome with diarrhea: a case report

A prospective assessment of bowel habit in irritable bowel syndrome in women: Defining an alternator

Irritable bowel syndrome (IBS) and chronic idiopathic constipation ((CIC) also referred to as functional constipation) are two of the most common functional gastrointestinal disorders worldwide. IBS is a global problem, with anywhere from 5 to 15 % of the general population experiencing symptoms that would satisfy a defi nition of IBS ( 1,2 ). In a systematic review on the global prevalence of IBS, Lovell and Ford ( 1 ) documented a pooled prevalence of 11 % with all regions of the world suff ering from this disorder at similar rates. Given its prevalence, the frequency of symptoms, and their associated debility for many patients and the fact that IBS typically occurs in younger adulthood, an important period for furthering education, embarking on careers, and / or raising families, the socioeconomic impact of IBS is considerable. Th ese indirect medical costs are frequently compounded by the direct medical costs related to additional medical tests and the use of various medical and nonmedical remedies that may have limited impact. CIC is equally common; in another systematic review, Suares and Ford ( 3 ) reported a pooled prevalence of 14 % , and also noted that constipation was more common in females, in older subjects, and those of lower socioeconomic status ( 3 ). Chronic constipation has also been linked to impaired quality of life ( 4 ), most notably among the elderly ( 5 ). Neither IBS nor CIC are associated with abnormal radiologic or endoscopic abnormalities, nor are they associated with a reliable biomarker; diagnosis currently rests entirely, therefore, on clinical grounds. Although a number of clinical defi nitions of both IBS and CIC have been proposed, the criteria developed through the Rome process, currently in its third iteration, have been those most widely employed in clinical trials and, therefore, most relevant to any review of the literature on the management of these disorders. According to Rome III, IBS is defi ned on the basis of the presence of:

Functional Bowel Disorders

Impact of Bile Acid Diarrhea in Patients With Diarrhea-Predominant Irritable Bowel Syndrome on Symptoms and Quality of Life

Postprandial Changes in Small Bowel Water Content in Healthy Subjects and Patients With Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) condition involving numerous potential causative factors (e.g. alterations in gut microbiota, motility, brain–gut axis). Several interventions are available for the management of patients with IBS, but no universal management algorithm currently exists. The aim of this article is to review interventions that may be considered in the management of patients with IBS with diarrhea (IBS-D). Nonpharmacological interventions include dietary and lifestyle modification, which are generally used as first-line therapy. Probiotics have demonstrated efficacy and safety in patients with IBS, but studies are inconsistent in strains examined, dosing, and treatment duration. Psychological therapies (e.g. cognitive behavioral therapy, hypnotherapy) also may improve IBS symptoms. Pharmacological interventions for the management of IBS-D include the US Food and Drug Administration–approved agents eluxadoline, rifaximin, and alosetron, as well as loperamide, smooth muscle antispasmodics, bile acid sequestrants, and antidepressants (i.e. tricyclic antidepressants, selective serotonin reuptake inhibitors). Eluxadoline and rifaximin have been shown to improve abdominal pain and stool consistency in patients with IBS-D. In addition, data indicate that alosetron improves IBS symptoms; however, it is approved only for women with severe IBS-D. Of the three approved agents, rifaximin has the most favorable safety profile. The risk–benefit ratio is an important consideration with every medication, but is especially important in the treatment of functional GI disorders such as IBS-D. Thus, the most troublesome symptoms, quality of life, symptom intensity, and individual patient preferences should be considered when formulating a management plan for patients with IBS-D.

Objective — to study the frequency of the syndrome of intestinal bacterial overgrowth (SIBO) and to establish the effects of its eradication on the clinical course of various subtypes of the irritable bowel syndrome (IBS).
 Materials and methods. The examinations in an open comparative randomized study involved 88 patients with IBS (35 men, 53 women) aged 26 to 56 years (mean age — 40 ± 14 years). The IBS diagnosis in all patients was established on the basis of Roma criteria IV. The IBS with diarrhea (IBS‑D) was established in the majority of patients (47 subjects, 53.4 %), a mixed subtype of IBS (IBS‑M) was revealed in 30 (34.1 %) patients, and IBS with constipation (IBS‑C) in 11 (12.5 %). The following IBS duration was defined: less than 5 years in 37 (42 %) of patients, 5 ‑ 10 years in 35 (39.8 %) subjects, more than 10 years in 16 (18.2 %) patients. The IBS course was mild in 30 (34.1 %) patients, mild to moderate in 45 (51.1 %) and severe disease was in 13 (14.8 %). The control group consisted of 30 clinically healthy people (18 women, 12 men, the mean age (33 ± 12) years). Diagnosis of SIBO was performed using the H2‑breath test with lactulose (H2‑LDT).
 Results. The overall frequency of SIBO detection (positive H2‑LDT) in patients with IBS (73.9 %) significantly exceeded its frequency in the controls (6.6 %, p < 0.005). The frequency of SIBO was significantly higher in IBS‑D and IBS‑M (78.7 % and 73.3 %, respectively) compared to IBS‑C (54.3 %, p < 0.005). Also, SIBO frequency was significantly higher in women with a history of the disease up to 5 years, in most patients a moderate course of IBS‑D was observed. The SIBO eradication after treatment with rifaximin was achieved in 73.8 % of cases, and eradication frequency in IBS‑D patients (78.4 %) significantly exceeded this parameter in patients with IBS‑C (66.6 %). Moreover, it was established that rifaximin at a dose of 1600 mg/day for 14 days was slightly more effective (eradication in 76.6 % of cases) than rifaximin at a dose of 1200 mg/day (eradication in 71.4 % of cases, p = 0.63).
 Conclusions. The results of the study indicate that SIBO is very often present in patients with IBS, and its elimination is accompanied by an increase in both clinical and anti‑relapse effects. Rifaximin is an effective agent for the eradication of SIBO, and increase of its dosage (from 1200 mg/day to 1600 mg/day) correlates with some increase in clinical and antibacterial efficacy. Clinical improvement and reduction of recurrence rates after eradication of SIBO suggests that the latter may play a pathogenetic role in IBS.

This month in Gastroenterology

BACKGROUND: Irritable bowel syndrome with diarrhea (IBS-D) is a chronic disorder of gut-brain interaction that negatively affects work productivity and health-related quality of life (HRQOL). IBS-D therapeutic options are limited and include loperamide, an over-the-counter μ-opioid receptor agonist commonly used as an antidiarrheal agent, and eluxadoline, a mixed μ- and κ-opioid receptor agonist and δ-opioid receptor antagonist approved in the United States for the treatment of IBS-D in adults. OBJECTIVE: To characterize the effect of eluxadoline on work productivity and HRQOL in patients with IBS-D with previous inadequate response to loperamide. METHODS: The Work Productivity and Activity Impairment Questionnaire for IBS-D (WPAI:IBS-D), Centers for Disease Control and Prevention Healthy Days Core Module (CDC HRQOL-4), and EuroQoL-5 Dimension (EQ-5D) instruments were administered at baseline and week 12 of a phase 4 clinical trial (RELIEF), assessing the efficacy and safety of eluxadoline treatment in adults with IBS-D reporting previous inadequate response to loperamide. Changes from baseline to week 12 for each assessment were evaluated using an analysis of covariance model. Indirect costs were calculated by converting overall work productivity losses into monetary values. RESULTS: A total of 346 patients were randomized to either eluxadoline (n = 172) or placebo (n = 174). From baseline to week 12, compared with placebo, twice-daily treatment with eluxadoline resulted in significantly greater reductions in absenteeism (2.6%; P = 0.046). Numerically greater decreases in presenteeism, overall work productivity loss, and daily activity impairment were also observed in patients receiving eluxadoline compared with those receiving placebo (P = not significant for each). Numerical reductions in overall work productivity loss from baseline to week 12 translate to approximately 2.4 hours per patient per week (123 hours annually) and correspond to an avoided overall work loss of $4,503 annually for an employee with IBS-D treated with eluxadoline. In addition, from baseline to week 12, treatment with eluxadoline led to a significantly greater reduction in the number of unhealthy days experienced (-1.7 days; P = 0.042), as well as numerical improvements in EQ-5D measures in comparison with placebo (P = not significant for each). CONCLUSIONS: In patients with IBS-D reporting inadequate response to loperamide, eluxadoline treatment was associated with significant reductions in absenteeism and the number of unhealthy days experienced. Eluxadoline treatment of IBS-D may lead to significant cost savings via mitigation of losses in work productivity. DISCLOSURES: This study was sponsored by Allergan plc (before acquisition by AbbVie, Inc.). Allergan plc and/or AbbVie, Inc., was involved in the study design, collection, analysis, interpretation of the data, writing of the report, and the decision to submit the report for publication. Abel and Burslem are employees of AbbVie, Inc., and own stock/stock options. Brenner has served as a consultant, speaker, and/or advisor for Allergan plc (before acquisition by AbbVie, Inc.), Alnylam, Alpha Sigma, Arena, Bayer, Ironwood Pharmaceuticals, Salix Pharmaceuticals, Shire, Synergy, and Takeda Pharmaceuticals. He is also supported in research by an unrestricted gift from the Irene D. Pritzker Foundation. Sayuk has served as a consultant and speaker for Allergan plc (before acquisition by AbbVie, Inc.), Gi Health Foundation, Ironwood Pharmaceuticals, Salix Pharmaceuticals, and Synergy. Portions of the current work were presented at AMCP Nexus; October 22-25, 2018; Orlando, FL.

Introduction: Symptoms of irritable bowel syndrome with diarrhea (IBS-D) impose a significant burden to patients. Our study examined disease burden and care-seeking behavior of patients with IBS-D. Methods: A cross-sectional, on-line health survey collected data during 8/2020-12/2021 from US adults. IBS-D patients were defined using Rome IV criteria. Health outcomes comparing IBS-D patients to controls included anxiety and depression screeners, health-related quality of life (HRQoL) and productivity measures. Care, treatment and symptom burden were assessed for IBS-D patients. Differences in anxiety, depression, HRQoL, and productivity between IBS-D patients and the general population were assessed with a 1:1 matched sample by sex, age, race, region and Charlson Comorbidity Index score. Categorical data were described by percentage and continuous data by mean and standard deviation. Means were compared with ANOVA and proportions with chi-square tests. Results: Data was collected from 29,359 participants. Matching IBS-D participants resulted in 669 patients and 669 controls. Most patients were female (74.6%), White (84.0%), with a mean age of 41.9 years. IBS-D patients had significantly higher proportions of moderate to severe anxiety and depression (p < .001) and significantly lower HRQoL vs controls (p < .001). Health impact on work productivity and daily activity was significantly higher among IBS-D patients vs controls (Table). Of IBS-D patients, 91.5% sought care for their symptoms, 59.3% within the past year. Of those having an ER visit/hospitalization in the past year (17.3%), abdominal pain was the most reported reason (87.1%). 65.9% of IBS-D patients reported currently taking an Rx and/or an OTC for their symptoms (13.2% Rx alone, 13.9% Rx and OTC, and 38.9% OTC alone). Abdominal pain and abdominal discomfort were the symptoms most experienced (71.0% and 70.9%, respectively). Abdominal pain was reported to be the most bothersome (34.5%) (Figure). IBS-D patients currently taking an Rx with/without an OTC were more satisfied with the control of bowel (39.2% vs 21.5%) and abdominal (40.3% vs 22.7%) symptoms than those currently taking an OTC alone. Conclusion: This large survey study demonstrates that the health impact of IBS-D is high. Nearly 1 in 5 patients sought care at an ER for their symptoms. Abdominal pain and discomfort are common bothersome symptoms with patients reporting better control with Rx medications compared to OTC agents.Figure 1.: Symptom Experience, Frequency and Bothersomeness Table 1. - Characteristics of the Rome IV IBS-D Cohort vs Controls (1) WPAI fielded 12/20-12/21: Rome IV IBS-D cohort n=463; control n=397. (2) GAD-7: Generalized Anxiety Disorder, 7-item; range: 0-21. (3) PHQ-9: Patient Health Questionnaire, 9-item; range: 0-29. (4) Veterans RAND 12-item Health Survey (VR12). (5) Question fielded 12/20-12/21: Rome IV IBS-D cohort n=251; control n=233 Rome IV IBS-D Cohort(N=669) Control(N=669) Sig. Female 74.6% 74.6% 1.000 Age, mean (SD) 41.9 (15.0) 41.9 (15.0) 0.990 Black or African American 7.8% 7.8% 1.000 White 84.0% 84.0% Other 8.2% 8.2% Proportion of Hispanic, Latino or Spanish origin 7.8% 8.5% 0.617 Northeast 17.2% 17.2% 1.000 Midwest 22.6% 22.6% South 42.8% 42.8% West 17.5% 17.5% Charlson Comorbidity Index (CCI) score, mean (SD) 0.6 (1.1) 0.6 (1.1) 1.000 Body Mass Index (BMI) (lbs/in2), mean (SD) 30.2 (9.0) 27.9 (7.4) < 0.001 Proportion employed per Work Productivity and Impairment (WPAI) (1) 54.2% 58.7% 0.187 Median household income (Census derived from zip code), mean (SD) 65,468(28,360) 65,459(26,647) 0.996 Anxiety (GAD-7 [2]) score, mean (SD) 9.9 (6.1) 6.8 (5.8) < 0.001 Depression (PHQ-9 [3]) score, mean (SD) 11.4 (7.3) 7.9 (7.1) < 0.001 Chronic pain 61.4% 38.6% < 0.001 Migraine 64.2% 35.8% < 0.001 Insomnia 67.7% 32.3% < 0.001 GERD 75.9% 24.1% < 0.001 VR-12 Mental Component Summary (MCS [4]), mean (SD) 36.7 (12.5) 43.9 (11.8) < 0.001 VR-12 Physical Component Summary (PCS [4]), mean (SD) 40.3 (11.2) 44.4 (10.6) < 0.001 VR-12 Health utility (VR-6D [4]), mean (SD) 0.60 (0.11) 0.67 (.12) < 0.001 Health problems affected work productivity rating (0-10 scale), mean, SD (5) 3.1 (2.9) 2.1 (2.8) < 0.001 Health problems affected daily activities rating (0-10 scale), mean, SD (1) 4.3 (3.2) 2.6 (3.1) < 0.001

Background/AimsFood interaction, including food hypersensitivity, plays a key role in the pathogenesis of irritable bowel syndrome with diarrhea (IBS-D). Since only a few studies have been reported about the relationship between food hypersensitivity and IBS-D, we elucidate the prevalence of serological food hypersensitivity in patients with IBS-D and the characteristics of gastrointestinal symptoms and serum cytokine profiles in patients with IBS-D and serological food hypersensitivity.MethodsImmunoglobulin E (Ig E)-mediated serological food hypersensitivity and serum cytokine levels were evaluated using the multiple allergen simultaneous test evaluating food allergen-specific serum IgE and Luminex Milliplex Panel containing multiple fluorescence-labeled beads. Class 2 or above was considered as IgE-mediated food hypersensitivity positive. The gastrointestinal symptom rating scale was used to evaluate symptoms.ResultsWe enrolled 92 subjects, including 60 with IBS-D and 32 healthy controls. The percentages of patients with IgE-mediated serological food hypersensitivity were not significantly different between the groups (controls = 28.1% and IBS-D = 33.3%). Serum IL-1β, IL-6, IL-8, macrophage inflammatory protein-1alpha, and TNF-α levels were higher in patients with IBS-D than in controls. Serum concentration of TNF-α (43.4 vs 21.8 pg/mL, P = 0.009) was higher in patients with IBS-D without IgE-mediated serological food hypersensitivity than those with food hypersensitivity.ConclusionsOne-third of Japanese patients with IBS-D showed IgE-mediated serological food hypersensitivity. The serum cytokine profile differed and was characterized by lower inflammatory cytokine levels in IBS-D with IgE-mediated serological food hypersensitivity. Serological test regarding IgE-mediated food hypersensitivity can detect a certain cluster of IBS-D.

Objective To explore the clinical effect of application of empowerment theory on patients with irritable bowel syndrome with diarrhea (IBS-D).Methods Sixty-four patients with IBS-D were chosen and randomly divided into two groups,each with 32 cases.The control group received routine nursing care,and the experimental group received empowerment theory for nursing intervention on the basis of routine nursing care.The curative effect and treating compliance in the two groups were compared,and the quality of life before and after intervention was assessed by IBS-QOL.Results The curative effect was 84.3％ in the experimental group after intervention,and 59.5％ in the control group,and the difference was statistically significant (x2 =4.95,P ＜ 0.05).The score of treating compliance was (36.12 ± 5.84) in the experimental group after intervention,and (29.51 ± 5.36) in the control group,and the difference was statistically significant (t =4.717,P ＜ 0.01).The scores of IBS-QOL in all factors between two groups were no statistically significant before intervention (P ＞0.05).The scores of IBS-QOL in all factors excluding picky eaters dimension in the experimental group after intervention were higher than those of the control group,and the differences were statistically significant (P ＜0.05).Conclusions Empowerment theory helps to improve the patients' quality of life and treating compliance,and enhance the curative effects. Key words: Diarrhea; Irritable bowel syndrome ; Quality of life ; Empowerment theory

Introduction: Bile acid (BA) diarrhea (BAD) affects up to 30% of patients with irritable bowel syndrome with diarrhea (IBS-D). In a cohort of 194 patients with IBS-D, 43 had BAD (serum 7αC4 >52ng/mL) and, as a group, had faster colonic transit, lower microbial α diversity, and a different microbial compositional profile based on β diversity compared to IBS-D without altered BA metabolism (ABAM); 70 microbial species were differentially abundant between the two groups, with 61/70 decreased in BAD (PMID: 35580964). However, the effect of colonic transit on the relationship between BAs and the microbiome was not evaluated. Our aim was to compare the microbiome composition in the same cohort of patients with IBS-D (total 183) with and without rapid colonic transit as measured by the geometric center at 24 hours (GC24) before and after adjusting for ABAM (elevated serum 7αC4). Methods: Participants with Rome III positive IBS-D provided a random single stool sample and measurements of fasting serum 7αC4 and colonic transit by scintigraphy as part of an institutional review board approved study. Patients with GC >3.45 (90th percentile of normal) were considered to have rapid transit. SHOGUN was used to perform taxonomic assignment of reads passing quality control. Microbiome analysis included α diversity, β diversity, and differential abundance. Results: Patients with rapid colonic transit had borderline lower α diversity (InvSimpson, p=0.07) and a borderline different compositional profile based on β diversity (Jaccard, p=0.07) compared to patients without rapid transit. There were 6 genera and 14 species (Table) including Clostridium polynesiense and species belonging to the Ruminococcaciae and Lachnospiraceae families that were decreased in patients with rapid colonic transit. After adjustment of the analysis for age, sex, BMI, and serum 7αC4, there was no significant difference in α or β diversity (Figure) between the two groups. Moreover, these differences in differential abundance of microbiota at the genus and species levels were not maintained after adjustment, except for Clostridium polynesiense which was decreased with rapid colonic transit. Conclusion: Altered fecal microbiome composition in patients with IBS-D and rapid colonic transit are significantly impacted by a biomarker of bile acid synthesis, serum 7αC4, rather than resulting from the rapid transit.Figure 1.: Microbial alpha (left) and beta (right) diversity in patients with IBS-D with and without rapid colonic transit after adjustment for age, sex, BMI, and serum 7αC4. Table 1. - Differentially abundant species in patients with IBS-D with or without rapid transit before and after adjustment for age, sex, BMI, and serum 7αC4 Log 2-Fold Change ± Standard Error Before adjustment Mobiluncus mulieris -0.60 ± 0.17 Intestinimonas butyriciproducens -1.12 ± 0.28 Intestinimonas massiliensis -0.82 ± 0.21 Pseudoflavonifractor capillosus -0.75 ± 0.20 Anaerosalibacter massiliensis -0.92 ± 0.27 Anaerofustis stercorihominis -1.79 ± 0.48 Lachnospiraceae bacterium MC2017 -0.99 ± 0.28 Oscillibacter sp. KLE 1745 -1.13 ± 0.35 Anaerotruncus colihominis -0.75 ± 0.20 Megasphaera genomosp. Type 1 -1.32 ± 0.38 Clostridium polynesiense -1.62 ± 0.32 Clostridium cellulosi -0.94 ± 0.29 Ruminococcaceae bacterium AE2021 -0.61 ± 0.17 Caloramator australicus -0.35 ± 0.11 After adjustment Clostridium polynesiense -1.34 ± 0.33

ObjectiveThere are altered mucosal functions in irritable bowel syndrome with diarrhoea (IBS-D); ~30% of patients with IBS-D have abnormal bile acid (BA) metabolism (ABAM) and diarrhoea (summarised as BAD).AimTo compare...

Background: Available stool form scales do not optimally capture the continuum of stool consistency experienced by patients with irritable bowel syndrome with diarrhea (IBS-D). This paper describes the development of a new measure to assess stool form and consistency for IBS-D. Methods: Descriptors for a new scale were selected by comparing spontaneous descriptions of stools from patients with IBS-D (Rome III) with spontaneous patient descriptions of images in the Bristol Stool Form Scale (BSFS) and an adapted BSFS. New images were prepared by an artist based on the final descriptors and literature images. The new Astellas Stool Form Scale (ASFS) was assessed in cognitive interviews. Results: Spontaneous reports of stool descriptors from 50 patients with IBS-D were broadly grouped based on conceptual equivalence. From these, 8 final stool descriptors were selected, ranging from “like marbles or hard rocks” to “just liquid,” and an image was created for each descriptor. In 20 cognitive interviews, 75% of patients with IBS-D indicated that descriptors matched the appropriate images, 95% of patients indicated that there were enough images to depict each stool type, and 70% of patients indicated that all images were clear. Conclusion: The ASFS, developed using spontaneous patient reports and rigorous qualitative methods, was well understood by patients with IBS-D and was relevant to their experience of stool form and consistency with IBS-D. Further evaluation is ongoing to confirm its utility in clinical research and in the clinical setting as a tool to monitor change in patients with IBS-D and to assess treatments.