Progress with treating the microbial dysbiosis associated with irritable bowel syndrome.

PURPOSE OF REVIEW: Microbial dysbiosis is receiving increasing attention as possibly being important in the pathophysiology of irritable bowel syndrome. This review will summarize the most recent literature addressing attempts to explore and target the microbiome in patients with irritable bowel syndrome. RECENT FINDINGS: Manipulation of the intestinal microbiota in irritable bowel syndrome is receiving increasing attention. Traditionally, dietary manipulation has been utilized. There is now evidence that a low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet has not only been able to improve symptoms, but may have an effect on the gut microbiota. Probiotics are a safe and attractive option for the manipulation of the microbiota. There have been a number of well-designed trials examining the efficacy of certain strains of bacteria, and even yeasts are receiving attention. The role of antibiotics remains controversial and it seems likely that their use should currently be limited to those individuals with small intestinal bacterial overgrowth. Interest in the role of faecal microbiota transplantation for the treatment of a number of gastrointestinal conditions has intensified and irritable bowel syndrome is no exception. SUMMARY: The manipulation of the microbial dysbiosis is gaining momentum. Further research, however, is required in order to identify the most appropriate treatment option for each individual patient.

SKYPE HYPNOTHERAPY FOR IRRITABLE BOWEL SYNDROME: Effectiveness and Comparison with Face-to-Face Treatment.

Gut-focused hypnotherapy is an effective treatment for irritable bowel syndrome but is not widely available. This study assessed whether providing hypnotherapy by Skype might partially overcome this problem. Using a 50-point or more reduction in the IBS Symptom Severity Score as the primary outcome measure, 65% of subjects responded to Skype hypnotherapy with all other outcomes significantly improving. The primary outcome figure for face-to-face hypnotherapy was 76%. When other outcome scores for Skype and face-to-face treatment were compared, the mean changes were these: symptom severity (-94.1 vs. -129.2), noncolonic score (-52.3 vs. -64.8), quality of life (+56.4 vs. +66.2), anxiety (-3.3 vs. -3.0), depression (-1.7 vs. -2.5), and a 30% or more pain reduction (44% vs. 62%). Skype hypnotherapy is effective but slightly less so than face-to-face treatment. However, many patients would have been unable to access treatment without the Skype option.

The short-term effects of posterior tibial nerve stimulation on anorectal physiology in patients with faecal incontinence: a single centre experience.

BACKGROUND: Posterior tibial nerve stimulation (PTNS) is a novel treatment for patients with faecal incontinence (FI) and may be effective in selected patients; however, its mechanism of action is unknown. We sought to determine the effects of PTNS on anorectal physiological parameters. METHODS: Fifty patients with FI underwent 30 min of PTNS treatment, weekly for 12 weeks. High-resolution anorectal manometry, bowel diaries and Vaizey questionnaires were performed before and after treatment. Successful treatment was determined as a greater than 50% reduction in FI episodes. RESULTS: Fifty patients with FI were studied; 39 women, median age 62 years (range 30-82). Compared with pretreatment, there were reductions in episodes of urgency (16.0 versus 11.4, p = 0.006), overall FI (14.5 versus 9.1, p = 0.001), urge FI (5.4 versus 3.2, p = 0.016) and passive FI (9.1 versus 5.9, p = 0.008). Vaizey score was reduced (16.1 versus 14.5, p = 0.002). Rectal sensory volumes (ml) decreased (onset 40.3 versus 32.6, p = 0.014, call 75.7 versus 57.5, p < 0.001, urge 104.1 versus 87.4, p = 0.004). There was no significant change in anal canal pressures (mmHg) (maximum resting pressure 41.4 versus 44.2, p = 0.39, maximum squeeze pressure, 78.7 versus 88.2, p = 0.15, incremental squeeze pressure 37.2 versus 44.1, p = 0.22). Reduction in FI episodes did not correlate with changes in physiological parameters (p > 0.05). Treatment success of 44% was independent of changes in manometric parameters (p > 0.05). CONCLUSIONS: PTNS has a measureable physiological effect on rectal sensory volumes without an effect on anal canal pressures. It also reduces FI episodes; however, this effect is independent of changing physiology, suggesting that PTNS has a complex mechanism of action.

Immunoglobulin E in irritable bowel syndrome: another target for treatment? A case report and literature review.

Irritable bowel syndrome (IBS) is notoriously difficult to treat and this situation is unlikely to change until the pathophysiology is better understood. There is no doubt that IBS is a multifactorial condition but it is likely that the relative contribution of the various factors involved varies from patient to patient. Consequently, in some individuals one mechanism may have such a strong effect that its elimination may lead to a substantial improvement in symptoms. This paper describes a patient with severe asthma and IBS where the administration of an anti-Immunoglobulin E (IgE) monoclonal antibody not only improved her asthma but also resulted in an almost complete resolution of her IBS symptoms. This observation suggests that some form of allergic process, which may be mediated by IgE, might be driving IBS in some patients and there is evidence from the literature that atopy is more common in this condition. Therefore, in patients with IBS and atopy where the response to standard treatment is poor, it may be worth considering targeting the allergic diathesis. Possible approaches include skin testing with food antigens followed by an appropriate exclusion diet or pharmacological mast cell stabilization.

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

OBJECTIVES: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.