Demonstration of differences in colonic volumes, transit, chyme consistency, and response to psyllium between healthy and constipated subjects using magnetic resonance imaging.

BACKGROUND: In functional gastrointestinal disorders a lack of objective biomarkers limits evaluation of underlying mechanisms. We aimed to demonstrate the utility of magnetic resonance imaging for this task using psyllium, an effective constipation treatment, in patients and controls. METHODS: Two crossover studies: (i) adults without constipation (controls, n = 9) took three treatments in randomized order for 6 days - maltodextrin (placebo), psyllium 3.5 g t.d.s and 7 g t.d.s., (ii) adults with chronic constipation (patients, n = 20) took placebo and psyllium 7 g t.d.s. for 6 days. MRI was performed fasting and postprandially on day 6. Measurements included small bowel and ascending colon water content, colonic volume, transit time, and MR relaxometry (T1, T2) to assess colonic chyme. Stool water percentage was measured. RESULTS: 7 g psyllium t.d.s. increased fasting colonic volumes in controls from median 372 mL (IQR 284-601) to 578 mL (IQR 510-882), and in patients from median 831 mL (IQR 745-934) to 1104 mL (847-1316), P < .05. Mean postprandial small bowel water was higher in controls and patients after 7 g psyllium t.d.s. vs placebo. Whole gut transit was slower in patients than controls (P < .05). T1 of the descending colon chyme (fasting) was lower in patients (213 ms, 176-420) than controls (440 ms, 352-884, P < .05) on placebo, but increased by 7 g psyllium t.d.s. (590 ms, 446-1338), P < .001. Descending colon T1 correlated with baseline stool water content and stool frequency on treatment. CONCLUSIONS AND INFERENCES: MRI measurements can objectively demonstrate the mode of action of therapy targeting intestinal fluid content in constipation.

Electro-acupuncture relieves chronic visceral hyperalgesia in rats.

Acupuncture treatment is one of the most desirable choices for the management of pain including chronic visceral pain, but its scientific evidence and laws of action are not very clear at this point. In this study, we examined the immediate and cumulative effects of electro-acupuncture (EA) on chronic visceral pain induced by colorectal distention (CRD) stimuli in rats using an irritable bowel syndrome (IBS) model (a chronic visceral hypersensitivity model). The results demonstrated that EA could significantly depress both abnormally increased abdominal withdrawal reflex (AWR) scores and the magnitude of electromyograms (EMGs) recorded from the rectus abdominis in response to CRD stimulation at strengths of 20, 40, 60, and 80 mmHg. Repeated EA treatment for 14 days showed that the effects of EA on both abnormal AWRs and EMGs appeared 2-4 days after the start of the EA application session, gradually enhanced to its maximum within 8-12 days, and lasted 5 days after EA treatment stopped. These data provide evidence that visceral pain associated with the rat IBS model can be effectively treated by EA and opens up the possibility of clinical treatment of chronic visceral pain with acupuncture.

Reversal of visceral and cutaneous hyperalgesia by local rectal anesthesia in irritable bowel syndrome (IBS) patients.

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal illnesses and is characterized by altered visceral perception. The aim of the study was to determine if local anesthetic blockade of peripheral visceral nociceptive input reduces both visceral and cutaneous secondary hyperalgesia in IBS patients. Ten women with IBS (mean age 30+/-10 years) and ten control subjects (all women) (mean age 29+/-7 years) rated pain intensity and unpleasantness to distension of the rectum (35 mmHg) and thermal stimulation (47 degrees C) of the foot before and after rectal administration of either lidocaine jelly or saline jelly in a double blind crossover design. Intrarectal lidocaine (300 mg) reduced reported rectal and cutaneous pain in all of the IBS patients. The effects were statistically much greater than those of placebo and most of the effects were present within 5-15 min after the onset of the treatment. In the control subjects, rectal lidocaine did not decrease pain report from visceral and cutaneous stimuli. The results of this study support the hypothesis that local anesthetic blockade of peripheral impulse input from the rectum/colon reduces both visceral and cutaneous secondary hyperalgesia in IBS patients. The results provide further evidence that visceral hyperalgesia and secondary cutaneous hyperalgesia in IBS reflects central sensitization mechanisms that are dynamically maintained by tonic impulse input from the rectum/colon. Rectal administration of lidocaine jelly may also be a safe and effective means of reducing pain symptoms in IBS patients.

Sense of coherence and quality of life in women with and without irritable bowel syndrome.

BACKGROUND: Despite ongoing physical and psychological distress, little is known about sense of coherence (SOC) and holistic quality of life (QOL) in women with irritable bowel syndrome (IBS). OBJECTIVES: The purposes of this study were to (a) describe and compare SOC and holistic QOL of women with and without IBS, and (b) examine the relationships among SOC, holistic QOL, and gastrointestinal (GI) and psychological distress symptoms. METHOD: A two-group comparison design was used to test the study hypotheses that women with IBS would have lower SOC and holistic QOL than control women without IBS, and that SOC and holistic QOL would be inversely related to GI and psychological distress. A total of 324 women were studied (n= 235 with IBS, n= 89 controls). Measures included the 13-item SOC Questionnaire, Modified Flanagan QOL Scale, Bowel Disease Questionnaire, and Symptom-Checklist-90-R. RESULTS: Both SOC and holistic QOL were lower in women with IBS (p <.001). Correlations between SOC and global distress, depression, anxiety, and somatization without GI symptoms were moderately and inversely related (r= -.64, -.64, -.53, and -.31, respectively; p <.001) in the total sample. Relationships between holistic QOL and psychological distress indicators were universally of lower magnitude (r= -.56 to -.27, p <.001). The only GI symptom indicator significantly related to SOC and holistic QOL was alternating constipation and diarrhea (tau= -.21 and -.17, respectively; p <.001). DISCUSSION: Women with IBS have a reduced SOC and holistic QOL when compared to women without IBS. It remains to be determined whether interventions targeted at enhancing SOC and holistic QOL can impact the psychological distress associated with IBS.

Health-related quality of life and health care costs in severe, refractory irritable bowel syndrome.

BACKGROUND: The irritable bowel syndrome (IBS) may lead to considerable impairment of health-related quality of life and high health care costs. It is not clear whether these poor outcomes directly result from severe bowel symptoms or reflect a coexisting psychiatric disorder. OBJECTIVE: To determine whether bowel symptom severity and psychological symptoms directly influence health-related quality of life and health care costs. DESIGN: Cross-sectional survey. SETTING: Secondary and tertiary gastroenterology clinics. PATIENTS: 257 patients with severe IBS who did not respond to usual treatments and were recruited for a trial of psychological treatment. MEASUREMENTS: Predictors were abdominal pain, entries in a diary of 10 IBS symptoms, and measures of psychological symptoms. Outcomes were inability to work, health-related quality of life (measured by Medical Outcomes Survey 36-item short-form questionnaire [SF-36] physical component summary scores), and health care and productivity costs. Predictor and outcome measures were compared by using multiple regression and logistic regression analyses. RESULTS: Abdominal pain occurred on average 24 days per month and activities were restricted on 145 days of the previous 12 months. The mean (+/-SD) Hamilton depression score was 11.3 +/- 6.1. The SF-36 physical component summary score was low (37.7 +/- 10.6), and the patients had incurred high health care costs ($1743 +/- $2263) over the previous year. Global severity and somatization scores on the Symptom Checklist 90 Revised, abdominal pain, and Hamilton depression scores independently contributed to the physical component score of the SF-36 (adjusted R(2) = 35.2%), but only psychological scores were associated with disability due to ill health. These variables did not accurately predict health care or other costs (adjusted R(2) = 9.3%). History of sexual abuse was not an independent predictor of outcome. CONCLUSIONS: Both abdominal and psychological symptoms are independently associated with impaired health-related quality of life in patients with severe IBS. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with these symptoms, alleviation of them will not necessarily lead to reduced costs.

Dolor abdominal recurrente: un trastorno somatomorfo / Recurrent abdominal pain: a somatomorf disorder

El dolor abdominal recurrente es un problema común en pediatría. La etiología es desconocida, aunque se relaciona con un origen psicosomático. En este trabajo analizamos el dolor abdominal recurrente como trastorno somatomorfo indiferenciado, según los criterios del DSM-IV, y estudiamos los factores psicológicos asociados a la etiología, fisiopatología, diagnóstico y tratamiento (AU)

Enteric-coated, pH-dependent peppermint oil capsules for the treatment of irritable bowel syndrome in children.

In a randomized, double-blind controlled trial, 42 children with irritable bowel syndrome (IBS) were given pH-dependent, enteric-coated peppermint oil capsules or placebo. After 2 weeks, 75% of those receiving peppermint oil had reduced severity of pain associated with IBS. Peppermint oil may be used as a therapeutic agent during the symptomatic phase of IBS.

Arrowroot as a treatment for diarrhoea in irritable bowel syndrome patients: a pilot study.

OBJECTIVES: Arrowroot is an old-fashioned remedy for diarrhoea, but no clinical studies have been done to evaluate its effectiveness. The aim of this pilot study was to assess its efficacy as a treatment for diarrhoea in 11 patients, all of whom had irritable bowel syndrome with diarrhoea as a feature. METHODS: The patients were interviewed and a questionnaire completed on entry into the trial. They then took 10 mL arrowroot powder three times a day for one month and discontinued the treatment for the subsequent month. Questionnaires were completed after one month on treatment and at the end of the trial after one month off treatment. RESULTS: Arrowroot reduced diarrhoea and had a long-term effect on constipation. It also eased abdominal pain. CONCLUSION: Arrowroot is an effective treatment for diarrhoea. Its action could be explained by several theories which relate to an increase in faecal bulk and thus a more efficient bowel action. The number of patients was small, and further studies are needed to substantiate preliminary results.

Perceptual hyperreactivity to auditory stimuli in patients with irritable bowel syndrome.

BACKGROUND: Patients with irritable bowel syndrome (IBS) have abnormal perception of visceral stimuli; however, no study has so far investigated the perception of non-visceral stimuli in IBS. In the present study we used event-related potentials (ERP) to study whether IBS patients differed from healthy controls in processing of auditory stimuli and, if so, how this was influenced by emotions. METHODS: We compared ERPs to auditory stimuli in 40 female diarrhoea-predominant IBS patients without current psychiatric illness with those in 20 healthy controls. Tones were used as standard and target stimuli, and words with emotional content as distractors. Characteristics of the first negative wave (N100) and mean amplitudes in 50-msec time intervals between 150 and 600 msec were assessed. RESULTS: At the frontal midline electrode IBS patients had significantly enhanced N100 amplitude to all stimuli, persisting after adjustment for age, current emotions, and personality traits. They additionally had enhanced waves 200-300 msec and 400-500 msec after stimulus. The latter differences disappeared after adjustment for emotions and personality traits. CONCLUSIONS: In the frontal brain region, IBS patients seem to have a hyperreactivity to auditory stimuli compared with controls. Later elements (P300, N400) of stimulus processing were influenced by emotions and personality traits. These may possibly contribute to changes in intestinal motility caused by stress. The study indicates that aberrant brain functioning may be an element of the irritable bowel syndrome. It may elucidate a mechanism for brain-gut interaction by which psychosocial stress may influence visceral pain perception in non-psychiatric subjects with an intestinal motility disorder and also the efficacy of psychiatric treatment on IBS symptoms.

Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome.

OBJECTIVE: The influence of the gastrointestinal (GI) microflora in patients with irritable bowel syndrome (IBS) has not been clearly elucidated. This study was undertaken to see if patients with IBS have an imbalance in their normal colonic flora, as some bacterial taxa are more prone to gas production than others. We also wanted to study whether the flora could be altered by exogenous supplementation. In a previous study we have characterized the mucosa-associated lactobacilli in healthy individuals and found some strains with good colonizing ability. Upon colonization, they seemed to reduce gas formation. METHODS: The study comprised 60 patients with IBS and a normal colonoscopy or barium enema. Patients fulfilling the Rome criteria, without a history of malabsorption, and with normal blood tests underwent a sigmoidoscopy with biopsy. They were randomized into two groups, one receiving 400 ml per day of a rose-hip drink containing 5 x 10(7) cfu/ml of Lactobacillus plantarum (DSM 9843) and 0.009 g/ml oat flour, and the other group receiving a plain rose-hip drink, comparable in color, texture, and taste. The administration lasted for 4 wk. The patients recorded their own GI function, starting 2 wk before the study and continuing throughout the study period. Twelve months after the end of the study all patients were asked to complete the same questionnaire regarding their symptomatology as at the start of the study. RESULTS: All patients tolerated the products well. The patients receiving Lb. plantarum had these bacteria on rectal biopsies. There were no major changes of Enterobacteriaceae in either group, before or after the study, but the Enterococci increased in the placebo group and remained unchanged in the test group. Flatulence was rapidly and significantly reduced in the test group compared with the placebo group (number of days with abundant gas production, test group 6.5 before, 3.1 after vs 7.4 before and 5.6 after for the placebo group). Abdominal pain was reduced in both groups. At the 12-month follow-up, patients in the test group maintained a better overall GI function than control patients. There was no difference between the groups regarding bloating. Fifty-nine percent of the test group patients had a continuous intake of fermented products, whereas the corresponding figure for the control patients was 73%. CONCLUSIONS: The results of the study indicate that the administration of Lb. plantarum with known probiotic properties decreased pain and flatulence in patients with IBS. The fiber content of the test solution was minimal and it is unlikely that the fiber content could have had any effect. This type of probiotic therapy warrants further studies in IBS patients.

How to deal with chronic constipation. A stepwise method of establishing and treating the source of the problem.

Chronic constipation is a common medical complaint encountered often in a primary care setting. Most patients can be treated successfully with simple measures, including education, bowel habit training, increased fluid and fiber intake, and use of laxatives. Chronic constipation is usually considered idiopathic, but secondary causes should be excluded. In about 1% of patients with severe, intractable constipation, further diagnostic testing (e.g., endoscopy, colonic transit study) is needed. Patients with colonic inertia can be treated with judicious use of laxatives, but surgery may be necessary in a few cases. Patients with outlet inertia should be referred for biofeedback treatment.

Computerised biofeedback games: a new method for teaching stress management and its use in irritable bowel syndrome.

OBJECTIVES: To develop and test a computer biofeedback game designed to teach deep relaxation to patients with a stress related disorder and to assess whether relaxation can improve symptomatic episodes. STUDY DESIGN AND SETTING: An open, prospective, single centre study. Department of Gastroenterology, Royal Free Hospital, London. SUBJECTS: Forty patients with irritable bowel syndrome refractory to conventional medical treatment. MAIN OUTCOME MEASURES: Development of a computer aided biofeedback apparatus directed at the gut for teaching relaxation to patients with irritable bowel syndrome. The patients' ability to complete a computer game involving biofeedback modulated by a physiological loop that related changes in stress (monitored by electrodermal activity) to animated computer graphics. The degree to which deep relaxation was achieved was measured numerically by a progressive reduction in the sensitivity level of the biofeedback loop. The success of relaxation in ameliorating physical symptoms of irritable bowel syndrome was assessed by daily diaries in which global and weighted bowel symptom scores were entered. RESULTS: A computer biofeedback game based on animated gut imagery was successfully developed. Most patients learned to achieve progressively deeper levels of relaxation after four 30 minute biofeedback sessions (mean difference in sensitivity level 2.0 (95% confidence interval 0.96 to 2.93), p < 0.001). Use of 'dosed' relaxation when bowel symptoms were troublesome was helpful in 50% of patients. It reduced the global symptom score (mean difference 0.5 (0.02 to 0.32), p < 0.04) and the bowel symptom score (mean difference 0.8 (0.04 to 1.58), p < 0.04). At long term follow up, 64% of patients who had been helped by dosed relaxation continued to use the technique, although they had had no further contact with the hospital. CONCLUSIONS: This computer biofeedback game taught deep relaxation rapidly and effectively. Half the patients with refractory irritable bowel syndrome found the technique helpful on most occasions on which it was used. Computer biofeedback games may offer a simple, inexpensive strategy for managing other stress related medical disorders.

The treatment of irritable bowel syndrome with hypnotherapy.

Previous research from the United Kingdom has shown hypnotherapy to be effective in the treatment of irritable bowel syndrome (IBS). The current study provides a systematic replication of this work in the United States. Six matched pairs of IBS patients were randomly assigned to either a gut-directed hypnotherapy (n = 6) or to a symptom monitoring wait-list control condition (n = 6) in a multiple baseline across subjects design. Those assigned to the control condition were later crossed over to the treatment condition. Subjects were matched on concurrent psychiatric diagnoses, susceptibility to hypnosis, and various demographic features. On a composite measure of primary IBS symptoms, treatment was superior (p = .016) to symptom monitoring. Results from the entire treated sample (n = 11; one subject was removed from analysis) indicate that the individual symptoms of abdominal pain, constipation, and flatulence improved significantly. State and trait anxiety scores were also seen to decrease significantly. Results at the 2-month follow-up point indicated good maintenance of treatment gains. No significant correlation was found between initial susceptibility to hypnosis and treatment gain. A positive relationship was found between the incidence of psychiatric diagnosis and overall level of improvement.

Electromanometry of the rectosigmoid in colonic diverticulosis.

In order to better understand the rectosigmoid motor activity in diverticular disease of the colon, we studied 186 patients, grouped according to their intestinal habit, the presence of diverticular disease and previous crisis of sigmoid diverticulitis. The intestinal habit was classified as: normal habit, irritable colon syndrome, diarrhea and constipation. The group of diverticulosis was classified by their intestinal habit and by diverticula localization (localized or generalized). The presence of systemic diseases or drug ingestion that could modify intestinal motility, were considered criteria for exclusion. The manometric study was preceded by food stimulus, with 650 kcal meal, by mechanic intestinal cleansing, with 500 ml of saline solution enema and by one hour resting period. A manometric catheter, was introduced by rectosigmoidoscopy, with open ended orifices situated at the sigmoid and upper rectum, respectively. The catheter was perfused by a capillary infusion system and the bowel pressures were registered for 30 minutes, in a thermal paper physiograph. We analyzed the % of activity, mean amplitude and motility index, by non parametric tests. No significant difference was observed between sexes. Difference or close to it were found for the groups with constipation, with or without diverticulosis, and for the latter in its subdivisions (localized, generalized and sigmoid diverticulitis). The rectal motor activity was similar in all groups. There was no difference for diverticulosis and its subdivision, when we take into account the several kinds of intestinal habits and the diverticula localization. The motility index averages showed low values for the sigmoid diverticulitis fact that suggests some dysfunction of this segment (hypocontractility). The key factor differentiating the groups was the presence of constipation and no influence was noted regarding the localization of diverticula or previous inflammatory process on intraluminal pressures. The fact that no difference was found in the mean amplitude or % of activity among patients with or without diverticulosis, suggests that the high pressures in a colonic segment, may not be responsible for the diverticular disease, and there must be other factors, besides motility, accounting for the development of the different forms of this disease.

Evaluation of patients who meet clinical criteria for irritable bowel syndrome.

OBJECTIVE: To determine which test would yield the most useful clinical data in evaluation of irritable bowel syndrome (IBS). METHODS: One hundred ninety-six patients who met the International Congress of Gastroenterology criteria for irritable bowel syndrome were prospectively evaluated with hematological, biochemical, and metabolic laboratory testing, as well as a structural evaluation of the colon. RESULTS: complete blood count, sedimentation rate (ESR), serum chemistries, thyroid profile, and urinalysis were normal or yielded no useful clinical information. Stool examinations for parasites were also normal. Structural evaluations (barium enema, x-ray, and flexible sigmoidoscopy or colonoscopy) revealed abnormalities, including colon cancer (1), polyps (9), colitis (1), melanosis coli (2), diverticulosis (17), and hemorrhoids (11). Forty-eight subjects (25.8%) had lactose maldigestion confirmed by H2 breath lactose testing. Prior to formal testing, 25 (52%) of these subjects were unaware of the relationship between lactose-containing foods and their symptoms. CONCLUSIONS: 1) ESR, thyroid profiles, and parasite examinations had no diagnostic yield in this study and, without specific clinical indication from history and physical examination, should not be part of the "routine" IBS evaluation. 2) Lactose hydrogen breath testing is encouraged for patients with and without milk intolerance who present with IBS.

[Esophageal achalasia of chagasic origin: report of a case diagnosed in the pre-symptomatic stage]. / Achalasia esofágica de origen chagásico: a propósito de un caso diagnosticado en etapa pre-sintomática.

A 42 year old male that presented with functional gastrointestinal symptoms is presented. X ray examination showed an esophageal diameter of 3 cm, measured 6 cm above the gastroesophageal junction. This finding, according to previous experiences of the authors, is highly suggestive of Chagasic esophageal involvement. The patient resided in a highly endemic area for Chagas disease; hemagglutination, latex agglutination and ELISA serological tests for Chagas disease were positive. The manometric study of the esophagus confirmed the diagnosis showing an elevated lower esophageal sphincter pressure and hypomotility and poor amplitude contractions of the esophageal body. Barium enema and EKG were normal. Upper gastrointestinal endoscopy disclosed an erosive gastritis that could explain the patients' symptomatology. The antiquity of Chagas infection was estimated in 18 years. This case represents an example of early diagnosis of esophageal involvement in the course of Chagas disease.

A controlled trial of psychological treatment for the irritable bowel syndrome.

One hundred two patients with irritable bowel syndrome were studied in a controlled trial of psychological treatment involving psychotherapy, relaxation, and standard medical treatment compared with standard medical treatment alone. Patients were only selected if their symptoms had not improved with standard medical treatment over the previous 6 months. At 3 months, the treatment group showed significantly greater improvement than the controls on both gastroenterologists' and patients' ratings of diarrhea and abdominal pain, but constipation changed little. Good prognostic factors included overt psychiatric symptoms and intermittent pain exacerbated by stress, whereas those with constant abdominal pain were helped little by this treatment. This study has demonstrated that psychological treatment is feasible and effective in two thirds of those patients with irritable bowel syndrome who do not respond to standard medical treatment.

Treatment of the spastic pelvic floor syndrome with biofeedback.

The spastic pelvic floor syndrome is a functional disorder based on contraction instead of relaxation of the pelvic floor muscle during straining, which inhibits defecation and gives rise to constipation. Until now no adequate treatment has been found for this condition. The treatment described here is aimed at teaching patients to relax their pelvic floor muscle during straining. Treatment consists of a training program with EMG feedback, followed by simulation of the defecation process, using oatmeal porridge. Patients are then given instructions to generalize the relaxation response in their daily lives. Treatment was completely successful in seven of ten patients. The three remaining patients learned to strain in the correct manner, but could not achieve generalization. Two of them underwent subtotal colectomy because of delayed colonic transit times, which subsequently resulted in normal evacuation. In the third patient, the generalization was most likely hampered by psychologic problems, for which she now receives psychotherapy.

Food sensitivity, a search for underlying causes. Case study of 12 patients.

Twelve cases of multiple food sensitivity were studied. All had responded to food elimination and a number were receiving sublingual food desensitization drops. An underlying cause was postulated and looked for. The method used was an electrical recording technique called the segmental electrogram. All of the cases were seen to have a primary colonic dysfunction which has been described as Dysbiosis. It was assumed that the colonic dysfunction was due to abnormal intestinal flora and this was corrected by a repopulation of the bowel with normal commensals and the simultaneous stimulation of liver and pancreatic function. This resulted in all of the patients losing at least a number of their sensitivities and those who were on sublingual desensitization drops were able to stop these drops and tolerate the foods without any further problem. It has postulated that much of multiple food and chemical sensitivity is due to underlying causes of which Dysbiosis is one.

Psychological aspects of irritable bowel syndrome.

The literature on psychological aspects of Irritable Bowel Syndrome (IBS) is reviewed. Psychiatric and/or psychometric assessment of IBS samples has consistently revealed a high prevalence of psychological symptoms by comparison with non-psychiatric patient and healthy control groups. Various psychological factors have been implicated in the aetiology of IBS and in the decision to seek medical help, including psychoneurotic personality traits, abnormal illness behaviour and life event stress. Controlled studies of psychological intervention for IBS, while scarce, suggest that supportive psychotherapy and hypnotherapy may be helpful. The long-term efficacy of such treatments remains to be demonstrated.