Irritable Bowel Syndrome Severity Research Articles

New and emerging therapies for the treatment of irritable bowel syndrome: an update for gastroenterologists.

Irritable bowel syndrome is a functional bowel disorder with gastrointestinal symptoms (e.g. abdominal pain, straining, urgency, incomplete evacuation, nausea, and bloating) that occur alongside bowel function alterations (i.e. constipation, diarrhea, or both). Patients with irritable bowel syndrome may also experience comorbid anxiety and depression. Irritable bowel syndrome is common, with a prevalence estimated between 3% and 28%, affecting patient health and quality of life. Patients with moderate or severe irritable bowel syndrome generally seek medical care, whereas those with milder symptoms may choose self-management. Most patients with irritable bowel syndrome receive outpatient care, but irritable bowel syndrome-related hospitalizations do occur. The pathophysiology of irritable bowel syndrome is multifactorial (i.e. genetics, immune components, changes in the gut microbiota, disturbances in physiologic stress response systems, and psychosocial factors). Management of irritable bowel syndrome can include lifestyle changes, dietary interventions, counseling, psychologic medication, and agents that affect gastrointestinal motility. A number of therapies have emerged in recent years with clinical trial data demonstrating efficacy and safety for patients with irritable bowel syndrome, including agents that target gastrointestinal motility (i.e. linaclotide), gastrointestinal opioid receptors (i.e. asimadoline, eluxadoline), and gut microbiota (i.e. rifaximin). Linaclotide has been shown to significantly improve stool frequency and abdominal pain compared with placebo in constipation-predominant irritable bowel syndrome (number needed to treat, 5.1). Asimadoline shows efficacy in patients with moderate-to-severe irritable bowel syndrome-related pain. Rifaximin provided adequate relief of global irritable bowel syndrome symptoms versus placebo for a significantly greater percentage of patients with diarrhea-predominant irritable bowel syndrome (p < 0.001). Management that encompasses all aspects of irritable bowel syndrome (gastrointestinal symptoms) and comorbid psychologic symptoms (e.g. anxiety or depression) is important for improving overall patient health and well-being.

Cost-effectiveness analysis of sacral nerve stimulation as treatment for severe irritable bowel syndrome.

Early results from sacral nerve stimulation (SNS) for severe irritable bowel syndrome (IBS) are promising but estimates of cost-effectiveness are lacking. Our object was to perform a cost-effectiveness analysis for SNS as an alternative to no treatment of IBS. This retrospective analysis was based on the results from a randomized controlled crossover study with a cost-utility analysis performed on patient-level data and modelling of censored data over a projected period of time of up to 20years. The analysis was conducted on an intention-to-treat approach. For estimation of the uncertainty of the incremental cost-effectiveness ratio a bias corrected bootstrap analysis was performed. Cost-effectiveness was not reached for 4years after permanent implantation (£31270 per quality-adjusted life years), which was the upper limit for patient follow-up, but our data imply a cost-effectiveness from a 7-year perspective onwards. The study indicates the SNS treatment for IBS is cost effective from a 7-year perspective onwards.

Differences of microbiota in small bowel and faeces between irritable bowel syndrome patients and healthy subjects

Objective Several studies suggested that colonic microbiota have impacts on irritable bowel syndrome (IBS) patients. However, the knowledge about the association of small intestine (SI) microbiota with IBS is limited. We aimed to investigate the gut microbiota composition of SI and stool in IBS patients. Materials and methods Biopsies of jejunum mucosa by balloon-assisted enteroscopy and faecal samples from 28 IBS patients and 19 healthy controls were analysed by next-generation sequencing method. Results The three major phyla in SI microbiota of case/control groups were Proteobacteria (32.8/47.7%), Bacteroidetes (25.2/15.3%), and Firmicutes (19.8/11.2%), and those of stool were Bacteroidetes (41.3/45.8%), Firmicutes (40.7/38.2%), and Proteobacteria (15.4/7.1%). Analysis based on the family level, IBS patients had a higher proportion of Veillonellaceae (mean proportion 6.49% versus 2.68%, p = 0.046) in stool than controls. Prevotellaceae was more abundant in IBS patients than in control group (14.27% versus 6.13%, p = 0.023), while Mycobacteriaceae (0.06% versus 0.17%, p = 0.024) and Neisseriaceae (6.40% versus 8.94%, p = 0.038) was less abundant in IBS patients’ jejunal mucosa than those in controls. This less abundant jejunal Neisseriaceae was associated with more severe IBS (p = 0.03). The ratio of Firmicutes to Bacteroidetes in the stool of IBS-diarrhoea type patients was approximately three-fold higher, and the ratio of Firmicutes to Actinobacter in SI of IBS-mixed type patients was about nine-fold higher than healthy subjects. Conclusion Higher abundance of colonic Veillonellaceae and SI Prevotellaceae, and lower amount of oral cavity normal flora in proximal SI were found in IBS patients. We may manipulate these bacteria in IBS patients in future studies (ClinicalTrial.gov Number NCT01679730).

Lactulose Challenge Determines Visceral Sensitivity and Severity of Symptoms in Patients With Irritable Bowel Syndrome

Patients with irritable bowel syndrome (IBS) can be assigned to groups with different gastrointestinal (GI) symptoms based on results from a combined nutrient and lactulose challenge. We aimed to identify factors that predict outcomes to this challenge and to determine whether this can be used in noninvasive assessment of visceral sensitivity in patients with IBS. We performed a prospective study of 100 patients with IBS diagnosed according to Rome III criteria (all subtypes) and seen at a secondary or tertiary care center. After an overnight fast, subjects were given a liquid breakfast (400 mL; Nutridrink) that contained 25 g lactulose. Before the challenge, we assessed visceral sensitivity (via rectal barostat), oro-anal transit time, and fecal microbiota composition (via 16S ribosomal RNA pyrosequencing); we determined IBS severity using questionnaires. The intensity of 8 GI symptoms, the level of digestive comfort, and the amount of exhaled H2 and CH4 in breath were measured before and during a 4-hour period after the liquid breakfast. Based on the intensity of 8 GI symptoms and level of digestive comfort during the challenge, patients were assigned to groups with high-intensity GI symptoms (HGS; n = 39) or low-intensity GI symptoms (LGS; n = 61); patients with HGS had more severe IBS (P < .0001), higher somatization (P < .01), and lower quality of life (P < .05-.01) than patients with LGS. Patients with HGS also had significantly higher rectal sensitivity to random phasic distensions (P < .05-.001, compared with patients with LGS). There were no significant differences between groups in fecal microbiota composition, exhaled gas in breath, or oro-anal transit time. We found, in a prospective study, that results from a lactulose challenge test could be used to determine visceral sensitivity and severity of IBS. The intensity of patient symptoms did not correlate with the composition of the fecal microbiota. The lactulose challenge test may help better characterize patients with IBS and evaluate the efficacy of new treatments. ClinicalTrial.gov no: NCT01252550.

Digestive Symptoms in Healthy People and Subjects With Irritable Bowel Syndrome: Validation of Symptom Frequency Questionnaire.

Goals:The aim of this study was to validate the ability of symptom frequency questionnaire to differentiate between irritable bowel syndrome (IBS) patients and healthy subjects.Background:A digestive symptom frequency questionnaire (DSFQ) was previously used in a food efficacy trial in a non-IBS population with mild gastrointestinal symptoms.Study:We compared 2 well-defined populations: 100 IBS patients fulfilling Rome III criteria (mean age 32 y; range, 18 to 59 y), and 100 sex-matched and age-matched healthy subjects. Frequency of individual digestive symptoms (abdominal pain/discomfort, bloating, flatulence, borborygmi) was assessed using a 5-point Likert scale (from none to everyday of the week) and the IBS severity with the IBS-SSS questionnaire. Health-Related Quality of life (HRQoL) was assessed with the Food and Benefits Assessment (FBA) and Functional Digestive Disorders Quality of Life (FDDQL) questionnaires. The digestive (dis)comfort dimension of these questionnaires was considered as the main dimension for HRQoL.Results:The DSFQ discriminated IBS from healthy subjects with a significant difference (P<0.001) between groups (estimated mean difference=5.58; 95% CI, 4.91-6.28). On the basis of the ROC curve (AUC=0.9479), a cutoff value of 5 gives a sensitivity of 92% and a specificity of 84%, with a positive likelihood ratio of 5.75. Composite score of symptoms correlated strongly (P<0.0001) with digestive discomfort measured by FDDQL (−0.816), digestive comfort measured by FBA (−0.789), and the IBS-SSS score (0.762).Conclusions:Measurement of digestive symptom frequency by means of the DSFQ can differentiate IBS from healthy subjects, and shows a good correlation with other validated questionnaires (clinical trial #NCT01457378).

A novel reverse phase high-performance liquid chromatography (RP-HPLC–UV) method for the estimation of alosetron HCl and its validation

A novel simple, sensitive, and rapid isocratic reverse phase high-performance liquid chromatographic (RP-HPLC) method was developed for the quantitative determination of alosetron HCl, a 5-HT3 antagonist used in the treatment of severe irritable bowel syndrome (IBS) in females. The optimized chromatographic separation was achieved using a stationary phase of Phenomenex® kromasil C-18 (250 mm × 4.6 mm; 5 μm particle size) column, and mobile phase of 0.025 M disodium hydrogen orthophosphate buffer, pH adjusted to 3.0 with orthophosphoric acid, and acetonitrile in the ratio of 65:35 (v/v) with a flow rate of 1 mL min−1. The UV detection was carried out at 217 nm. The developed method provided linear responses within the concentration range 100–2000 ng mL−1, and regression analysis showed a correlation coefficient value (r2) of 0.997. The HPLC method was validated as per International Conference on Harmonization (ICH) guidelines with respect to selectivity, precision, linearity, and robustness. Limit of detec...

753 Identification of a Gut Microbial Signature Linked to Severity of Irritable Bowel Syndrome

753 Identification of a Gut Microbial Signature Linked to Severity of Irritable Bowel Syndrome

Mo1282 Attachment Styles in Patients With Irritable Bowel Syndrome (IBS), and Their Relationship With IBS Severity and Subtypes

Mo1282 Attachment Styles in Patients With Irritable Bowel Syndrome (IBS), and Their Relationship With IBS Severity and Subtypes

Mo2048 Altered Relation of Autonomic Response and Pituitary-Adrenal Response During Colorectal Distention With Corticotropin-Releasing Hormone in Irritable Bowel Syndrome

Background Searching biomarkers of irritable bowel syndrome (IBS) is emerging topic. Previous studies searched limited biomarkers and largely ignored real exacerbation of IBS symptoms in patient's life. We hypothesized that we can identify biomarkers of IBS which are associated with changes in IBS symptoms using urinary metabolomics.Methods Subjects were 25 IBS patients (33.0 ± 2.1 y.o., 15 male, 10 female) diagnosed with Rome III criteria (12 with diarrhea, 11 mixed, and 2 with constipation) and ageand sexmatched healthy controls. Subjects completed ordinate scales containing abdominal pain and discomfort everyday for 28 days. Simultaneously urinary samples were collected at the first day, the day with exacerbation, and the 28th day with questionnaires including IBS Severity Index (IBS-SI) and IBS Quality of Life (IBS-QOL). Urinary samples were immediately frozen, stored, and later analyzed with ultraperformance liquid chromatography and mass spectrometry. After correction with creatinine, data were analyzed statistically with generalized estimating equation (GEE) using SPSS ver. 21.0 followed by multiple regression analysis with IBS symptoms as dependent variables and metabolites as independent variables. Results We first identified 191 metabolome markers. GEE revealed significant 44 markers with group (IBS vs controls) effect and/or time effect and/or group time interaction. IBS patients showed significantly lower kynurenic acid (p < 0.005), xanthurenic acid (p < 0.001), homovanillic acid (p < 0.005), vanillylmandelic acid (p < 0.005) and glycylglycine (p < 0.001) than controls. IBS patients showed significantly higher quinolinic acid (p < 0.01), 3-methoxytyamine (p < 0.05), xylose (p < 0.005), 2'-deoxyguanosine (p < 0.001), 2'-deoxyadenosine (p < 0.05), and N-acetylarginine (p < 0.05) than controls. Multiple regression analysis disclosed xylose as significant predictor of abdominal pain (R2 = 0.859, b = 0.59, p < 0.0001). Conclusion These findings support our hypothesis and suggest that increased urinary xylose level reflects increased mucosal permeability in IBS patients. Moreover, increased quinolinic acid and decreased kynurenic and xanthurenic acids in IBS patients may cause toxicity of the glutamatergic neurons expressing NMDA receptors both in the brain and the gut.

Mo2047 Identifying Functionally Meaningful Biomarkers in Irritable Bowel Syndrome

Background Searching biomarkers of irritable bowel syndrome (IBS) is emerging topic. Previous studies searched limited biomarkers and largely ignored real exacerbation of IBS symptoms in patient's life. We hypothesized that we can identify biomarkers of IBS which are associated with changes in IBS symptoms using urinary metabolomics.Methods Subjects were 25 IBS patients (33.0 ± 2.1 y.o., 15 male, 10 female) diagnosed with Rome III criteria (12 with diarrhea, 11 mixed, and 2 with constipation) and ageand sexmatched healthy controls. Subjects completed ordinate scales containing abdominal pain and discomfort everyday for 28 days. Simultaneously urinary samples were collected at the first day, the day with exacerbation, and the 28th day with questionnaires including IBS Severity Index (IBS-SI) and IBS Quality of Life (IBS-QOL). Urinary samples were immediately frozen, stored, and later analyzed with ultraperformance liquid chromatography and mass spectrometry. After correction with creatinine, data were analyzed statistically with generalized estimating equation (GEE) using SPSS ver. 21.0 followed by multiple regression analysis with IBS symptoms as dependent variables and metabolites as independent variables. Results We first identified 191 metabolome markers. GEE revealed significant 44 markers with group (IBS vs controls) effect and/or time effect and/or group time interaction. IBS patients showed significantly lower kynurenic acid (p < 0.005), xanthurenic acid (p < 0.001), homovanillic acid (p < 0.005), vanillylmandelic acid (p < 0.005) and glycylglycine (p < 0.001) than controls. IBS patients showed significantly higher quinolinic acid (p < 0.01), 3-methoxytyamine (p < 0.05), xylose (p < 0.005), 2'-deoxyguanosine (p < 0.001), 2'-deoxyadenosine (p < 0.05), and N-acetylarginine (p < 0.05) than controls. Multiple regression analysis disclosed xylose as significant predictor of abdominal pain (R2 = 0.859, b = 0.59, p < 0.0001). Conclusion These findings support our hypothesis and suggest that increased urinary xylose level reflects increased mucosal permeability in IBS patients. Moreover, increased quinolinic acid and decreased kynurenic and xanthurenic acids in IBS patients may cause toxicity of the glutamatergic neurons expressing NMDA receptors both in the brain and the gut.

A cross-cultural investigation of attachment style, catastrophizing, negative pain beliefs, and symptom severity in irritable bowel syndrome.

Little information exists regarding whether psychosocial variables in irritable bowel syndrome (IBS) vary by geographic location. Adult attachment is an important psychological concept rooted in childhood relationship experience that has not been previously studied in IBS. Catastrophizing and negative pain beliefs have been described in IBS and may be affected by attachment. In this cross-cultural study, we determined: (i) whether attachment differs between IBS patients and controls, (ii) whether geographic location has a significant effect on attachment style, catastrophizing and negative pain beliefs, and (iii) how all three variables correlate with IBS symptom severity. 463 IBS patients, with moderate to severe symptom scores, and 192 healthy controls completed validated questionnaires about attachment, catastrophizing, negative pain beliefs and IBS-SSS in nine locations, USA (New York, Los Angeles), Mexico, Italy (Rome, Bari), Romania, Iran, India, and China. Attachment anxiety and avoidance scores were significantly higher in IBS patients than in controls (p < 0.001). This was particularly true for the fearful-avoidant attachment category, especially in China and Romania. Path analysis showed that attachment anxiety and avoidance had indirect effects on IBS-SSS through catastrophizing (p < 0.0001) and negative pain beliefs (p = 0.005). All three psychosocial measures varied significantly depending on location. In the IBS population studied, attachment style was significantly different in IBS compared to a control population. Geographic differences in attachment, catastrophizing and negative pain beliefs were documented and their correlation with symptom severity and thus, research of psychosocial variables in IBS should take into account the location of the population studied.

Symptom-association probability between meal ingestion and abdominal pain in patients with irritable bowel syndrome. Does somatization play a role?

Patients with irritable bowel syndrome (IBS) complain of postprandial abdominal pain, but it is still unknown how much of this association is due to chance. Somatization enhances the perception of symptoms after a meal. We assessed: (i) the proportion of meal-related pain periods and the symptom-association probability (SAP) between the two variables in IBS patients; and (ii) how this association is affected by somatization. Seventy IBS patients recorded the times of meals and abdominal pain in a 10-day diary card. The proportion of postmeal pain periods was calculated in relation to the total number of 90-min periods with pain. Fisher's exact test was used to calculate the probability (p) of an association within a time window of 90 min, and the SAP was calculated as (1 - p) × 100%. The IBS Symptom Severity Scale, the SCL90-R for psychological symptoms, and the SF-36 for the quality of life were completed. The proportion of postmeal pain periods was 42 ± 27%. SAP was significant (p < 0.05) in 32 patients (45%). Somatization was altered in 30 patients (47%), who were younger and had more severe IBS and a poorer quality of life. Somatization did not influence the association between meal ingestion and abdominal pain. Meal ingestion and abdominal pain are significantly associated in 45% of IBS patients. Somatization influences IBS severity and the patients' quality of life, but not the strength of the association between eating and pain.

Psychological therapies in patients with irritable bowel syndrome: a systematic review and meta-analysis of randomized controlled trials.

Background. Irritable bowel syndrome (IBS) is a poorly understood disease with few effective treatments. Psychosocial factors are believed to contribute to the pathogenesis of IBS. Objective. To evaluate the evidence for psychological therapies in IBS treatment. Methods. We searched six medical databases through February 6, 2014, for randomized controlled trials (RCTs) of psychological therapies for the treatment of IBS. Two independent reviewers identified the RCTs, extracted the data, and assessed trial quality. We used the random-effect model to pool standardized mean difference (SMD) and 95% confidence interval (CI) across trials. Results. 15 RCTs that mostly evaluated cognitive behavioral therapy were included. Psychological therapies were associated with improvement in IBS symptoms severity scales (SMD −0.618; 95% CI: −0.853 to −0.383), IBS-Quality of Life (SMD 0.604; 95% CI: 0.440 to 0.768), and abdominal pain (SMD −0.282; 95% CI: −0.562 to −0.001). No statistically significant effect was observed on diarrhea or constipation. Limitations. The trials were at increased risk of bias and the overall sample size was small leading to imprecision. Conclusion. Psychological therapies may improve the quality of life and symptom severity in IBS. The effect size noted is moderate to large and is clinically meaningful.

Intervention to increase physical activity in irritable bowel syndrome shows long-term positive effects.

To assess the long-term effects of physical activity on irritable bowel syndrome (IBS) symptoms and on quality of life, fatigue, depression and anxiety. Seventy-six patients from a previous randomized controlled interventional study on increased physical activity in IBS were asked to participate in this long-term follow-up study. The included patients attended one visit in which they filled out questionnaires and they underwent a submaximal cycle ergometer test. The primary end point was the change in the IBS Severity Scoring System (IBS-SSS) at baseline, i.e., before the intervention and at follow-up. The secondary endpoints were changes in quality of life, fatigue, depression and anxiety. A total of 39 [32 women, median age 45 (28-61) years] patients were included in this follow-up. Median follow-up time was 5.2 (range: 3.8-6.2) years. The IBS symptoms were improved compared with baseline [IBS-SSS: 276 (169-360) vs 218 (82-328), P = 0.001]. This was also true for the majority of the dimensions of psychological symptoms such as disease specific quality of life, fatigue, depression and anxiety. The reported time of physical activity during the week before the visit had increased from 3.2 (0.0-10.0) h at baseline to 5.2 (0.0-15.0) h at follow-up, P = 0.019. The most common activities reported were walking, aerobics and cycling. There was no significant difference in the oxygen uptake 31.8 (19.7-45.8) mL per min per kg at baseline vs 34.6 (19.0-54.6) mL/min per kg at follow-up. An intervention to increase physical activity has positive long-term effects on IBS symptoms and psychological symptoms.

Osteopathy decreases the severity of IBS-like symptoms associated with Crohn's disease in patients in remission.

Osteopathy may decrease the severity of irritable bowel syndrome (IBS). About 35% of patients with quiescent Crohn's disease (CD) continue to suffer from IBS-like symptoms with impaired quality of life (Qol). We aimed to evaluate the effect of osteopathy on the severity of IBS-like symptoms in quiescent CD patients. We prospectively included 38 patients with CD on remission over 12 months while receiving infliximab every 8 weeks. Patients were randomized 2/ 1 to receive three sessions of standardized osteopathy (n=25) at 15, 30, and 45 days after the last infusion of infliximab or simple follow-up. The severity of IBS-like symptoms, psychological factors, and its impact on Qol were assessed using questionnaires. Compared with baseline, the severity of IBS-like symptoms was significantly reduced in patients receiving osteopathy. The decrease was significantly more pronounced in patients receiving osteopathy at day 30 [-38.4 (-76.1 to 10.2) vs. 32.2 (-16.6 to 41.6), P=0.01], day 45 [-36.7 (-74.4 to 25.3) vs. 32.2 (-16.6 to 41.6), P=0.04], and day 60 [-39.5 (-60.9 to -9.2) vs. 6.1 (-38.7 to 28.5), P=0.05] with a concomitant increase in Qol (P=0.09 at day 30, P=0.02 at day 45, P=0.3 at day 60). Compared with baseline, the severity of fatigue was significantly reduced in patients receiving osteopathy, whereas depression and anxiety remained unchanged. Three sessions of osteopathy reduced the severity of IBS-like symptoms associated with CD in remission. Osteopathy should be viewed as a helpful therapeutic option to reduce the severity of abdominal pain and discomfort in patients with CD but in remission with IBS-like symptoms.

The severity of irritable bowel syndrome or the presence of fibromyalgia influencing the perception of visceral and somatic stimuli.

BackgroundFibromyalgia Syndrome (FMS) is a frequent comorbidity in Irritable Bowel Syndrome (IBS) patients with a higher functional bowel disorder severity index (FBDSI). We tested the possibility that mild to severe IBS patients without FMS would have a graduated visceral and somatic perception, and the presence of FMS would further enhance somatic, but conversely attenuate visceral perception.Our aim was to study visceral and somatic sensitivity in mild IBS patients and in severe IBS patients with or without FMS.MethodsEleven mild IBS and 19 severe IBS with and without FMS patients were studied. Somatic and visceral stimuli were applied in each patient by means of electrical stimulations at active and control sites and by means of an electronic barostat in the rectum. Thresholds for discomfort and perception cumulative scores were measured.ResultsMild and severe IBS patients without FMS demonstrated a significantly lower somatic perception cumulative score than severe IBS patients with FMS at active site. Conversely only severe IBS patients without FMS had significantly lower visceral thresholds for discomfort than mild IBS patients and severe IBS patients with FMS.ConclusionsThe presence of co-existing FMS or greater FBDSI affects somatic and visceral perception in a graded fashion across IBS patients.

Perception of lactose intolerance in irritable bowel syndrome patients.

The importance of lactose malabsorption in irritable bowel syndrome (IBS) is not well defined and these patients often complain of lactose intolerance. To objectively measure lactose malabsorption, a hydrogen breath test (HBT) can be performed, but a discrepancy emerges between the results of the HBT and the symptomatic response during the HBT. To determine in a group of IBS patients whether self-perceived lactose intolerance and the symptomatic response to lactose HBT were conditioned by other factors besides the presence of lactose malabsorption. Oral challenge to lactose (50 g) was tested in 51 IBS patients to assess HBT malabsorption and the symptomatic response to lactose intolerance was scored on a validated questionnaire. Allergological screening for common inhalants and food allergens (including cow's milk) was performed. The presence of psychological factors (e.g. anxiety, depression, fatigue) was evaluated using validated questionnaires. A total of 21 out of 51 patients (41.1%) were self-perceived to be lactose intolerant, 24/51 (47%) had a positive HBT, and 14/51 (27.4%) presented with symptoms of lactose intolerance during HBT. The serological screening for inhalant and food allergens was positive in 6/21 (28.6%) and 4/21 (19%) of patients who self-perceived lactose intolerance and in 5/14 (37.5%) and 3/14 (21.4%) in intolerant patients symptomatic during HBT. Only 1/51 (1.9%) presented evidence of IgE-mediated hypersensitivity to cow's milk. Patients who experienced symptoms of lactose intolerance during HBT presented more severe IBS symptoms [326 (296-398) vs. 215 (126-295) P=0.05] and a higher score of anxiety, depression, and fatigue. Factors influencing the symptoms of lactose intolerance during HBT resulted in an increase in hydrogen produced and in the severity of IBS. In a cohort of 51 IBS patients, the symptoms of lactose intolerance during HBT were influenced by the capacity to absorb lactose and the severity of IBS. Other factors, such as the psychological status or an adverse reaction to milk, merit consideration as potential cofactors involved in lactose perception and tolerance.

Linaclotide: a guide to its use in irritable bowel syndrome with constipation in the EU

Linaclotide (Constella®) is a novel first-in-class agent for the treatment of adults with moderate to severe irritable bowel syndrome with constipation. It is a synthetic peptide and a potent guanylate cyclase C receptor agonist that acts locally in the gastrointestinal tract to stimulate fluid secretion, increase colonic transit and reduce abdominal pain. Relative to placebo, oral linaclotide 290 µg/once daily significantly improved abdominal symptoms (including bloating and pain/discomfort), bowel function and health-related quality of life in two phase 3 trials. Linaclotide was generally well tolerated for up to 26 weeks.

Avoiding analgesic escalation and excessive healthcare utilization in severe irritable bowel syndrome: a role for intramuscular anticholinergics?

In patients with severe irritable bowel syndrome (IBS), abdominal pain can be the predominant symptom impacting on all aspects of their lives and resulting in excessive healthcare utilization. Furthermore, the use of analgesics can become excessive in this group of patients, sometimes leading to opiate dependency. Typically, the pain is often described as spastic in nature and we have speculated that parenteral anticholinergics might provide effective relief when all other measures have failed. For several years, we have therefore been asking general practitioners to consider teaching such patients to administer intramuscular hyoscine butylbromide for pain episodes and this study is an audit of this approach. Patients in whom the use of intramuscular hyoscine butylbromide had been recommended to their general practitioner in the last three years were interviewed over the telephone in order to document the efficacy of this approach as well as any potential disadvantages. A total of 122 general practitioners were advised to try this approach, with 58 agreeing to teach the technique and prescribe the medication. Of the 58 patients who used the medication, 50 (86%) found it gave them pain relief, which was complete in six (10%), substantial in 36 (62%) and mild in eight (14%), with 15 (26%) decreasing the use of analgesics and 13 (32%) of the 41 taking opiates able to reduce or stop them completely. Side effects were few and largely consisted of those associated with anticholinergics. Only four patients stopped medication because of side effects and no major skin reactions were reported. The use of intramuscular hyoscine butylbromide shows promise in the management of IBS when severe unmanageable abdominal pain is a major problem. This approach appears to be safe and has the potential to reduce analgesic escalation, opiate dependency and attendances at accident and emergency departments.

Alexithymia and gastrointestinal-specific anxiety in moderate to severe irritable bowel syndrome

ObjectiveGastrointestinal-specific anxiety (GSA) and alexithymia are two psychological constructs that may contribute to severity of irritable bowel syndrome (IBS). We aimed to investigate their independent contribution in predicting the level of severity in a group of patients with moderate to severe IBS. MethodA sample of 177 consecutive IBS patients (49.2% with moderate and 50.8% with severe IBS), diagnosed with Rome III criteria, were evaluated for IBS symptoms, alexithymia, GSA, psychological distress, and psychosocial functioning with validated scales. ResultsIBS severity was highly associated to both alexithymia (r=0.61) and GSA (r=0.66), that were also associated to each other (r=0.64). Severe IBS patients scored significantly different than moderate IBS patients to all scales in the expected direction. Multiple and hierarchical regression analyses showed that IBS severity was predicted at a similar degree by alexithymia and GSA, controlled for IBS symptoms, psychological distress, and psychosocial functioning. Effect sizes showed that the highest IBS severity scores were obtained by patients with high alexithymia alone (d=1.16) or combined with higher GSA (d=1.45). ConclusionAlexithymia and GSA were closely related to each other and associated to IBS severity, thus suggesting a common basis of emotional dysregulation. However, alexithymia (particularly the facets of difficulty identifying and describing feelings) resulted to be a stronger predictor of IBS severity than GSA, thus suggesting that impaired affective awareness may reflect on the clinical manifestations of IBS.