The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis

Management Options for Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is associated with diverse pathophysiologic mechanisms. These mechanisms include increased abnormal colonic motility or transit, intestinal or colorectal sensation, increased colonic bile acid concentration, and superficial colonic mucosal inflammation, as well as epithelial barrier dysfunction, neurohormonal up-regulation, and activation of secretory processes in the epithelial layer. Novel approaches to treatment include lifestyle modification, changes in diet, probiotics, and pharmacotherapy directed to the motility, sensation, and intraluminal milieu of patients with IBS. Despite recent advances, there is a need for development of new treatments to relieve pain in IBS without deleterious central or other adverse effects.

Efficacy of Secretagogues in Patients With Irritable Bowel Syndrome With Constipation: Systematic Review and Network Meta-analysis

BACKGROUND & AIMS

Several secretagogues have been approved for the treatment of irritable bowel syndrome with constipation (IBS-C). However, their relative efficacy is unclear because there have been no head-to-head randomized controlled trials. We conducted a network meta-analysis to compare their efficacies in patients with IBS-C.

METHODS

We searched MEDLINE, EMBASE, EMBASE Classic, and the Cochrane Central Register of Controlled Trials through June 2018 to identify randomized controlled trials assessing the efficacy of secretagogues in adults with IBS-C. Trials included in the analysis reported a dichotomous assessment of overall response to therapy, and data were pooled using a random-effects model. Efficacy and safety of secretagogues were reported as a pooled relative risk with 95% confidence interval to summarize the effect of each comparison tested, and treatments were ranked according to their P score.

RESULTS

We identified 15 eligible randomized controlled trials of secretagogues that included 8462 patients. Linaclotide, lubiprostone, plecanatide, and tenapanor were superior to placebo for the treatment of IBS-C. Linaclotide (290 μg once daily) was ranked first in efficacy based on the end point recommended by the Food and Drug Administration for trials in IBS-C, the primary end point used in each trial, abdominal pain, and complete spontaneous bowel movements. Tenapanor (50 mg twice daily) was ranked first for decreasing bloating. Total numbers of adverse events were significantly larger with linaclotide (290 and 500 μg once daily) and plecanatide (3 mg once daily) compared with placebo. However, plecanatide 6 mg once daily ranked first for safety. Diarrhea was significantly more common with all drugs, except lubiprostone (8 μg twice daily). Nausea was significantly more common in patients who received lubiprostone.

CONCLUSIONS

In a network analysis of randomized controlled trials of secretagogues for IBS-C, we found all drugs to be superior to placebo. Efficacy was similar among individual drugs and dosages for most end points. However, data were extracted at the 12-week time point, so the long-term relative efficacy of these drugs is unknown.

Comparison and Assessment of Flixweed and Fig Effects on Irritable Bowel Syndrome with Predominant Constipation: A Single-Blind Randomized Clinical Trial

BACKGROUND

Irritable bowel syndrome with predominant constipation (IBS-C) is a common digestive disorder. The current therapy is inadequate and evidence regarding the effect of herbal therapies on the relief of affected individuals is insufficient. The aim of this study was to investigate the beneficial effects of flixweed and fig consumption on IBS-C symptoms.

METHODS

150 patients with IBS-C were enrolled in this randomized, controlled trial. All patients were randomly assigned to three groups and received an intervention for four months. The IBS severity score system and quality-of-life questionnaires were used for evaluating IBS-C symptoms. C-reactive protein levels, frequency of defecation and hard stool were also assessed.

RESULTS

Consumption of flixweed or fig, compared to a control group, caused a significant improvement in IBS symptoms including frequency of pain, distention, frequency of defecation and hard stool. Also, the findings showed a significant increase in quality of life, as well as satisfaction with overall bowel habits. However, flixweed and fig intake had no significant effects on abdominal pain severity and C-reactive protein levels.

CONCLUSIONS

In conclusion, consumption of flixweed or fig for four months would be a useful therapy for alleviating IBS-C symptoms and can be a beneficial option for first-line treatment.

Association Between Ultra-Processed Food Consumption and Functional Gastrointestinal Disorders: Results From the French NutriNet-Santé Cohort

OBJECTIVES

Ultra-processed foods (UPF) consumption has increased over the last decades and is raising concerns about potential adverse health effects. Our objective was to assess the association between UPF consumption and four functional gastrointestinal disorders (FGIDs): irritable bowel syndrome (IBS), functional constipation (FC), functional diarrhea (FDh), and functional dyspepsia (FDy), in a large sample of French adults.

METHODS

We analyzed dietary data of 33,343 participants from the web-based NutriNet-Santé cohort, who completed at least three 24 h food records, prior to a Rome III self-administered questionnaire. Proportion (in weight) of UPF in the diet (UPFp) was computed for each subject. The association between UPFp quartiles and FGIDs was estimated by multivariable logistic regression.

RESULTS

Participants included in the analysis were mainly women (76.4%), and the mean age was 50.4 (SD = 14.0) years. UPF accounted for 16.0% of food consumed in weight, corresponding to 33.0% of total energy intake. UPF consumption was associated with younger age, living alone, lower incomes, higher BMI, and lower physical activity level (all p < 0.0001). A total of 3516 participants reported IBS (10.5%), 1785 FC (5.4%), 1303 FDy (3.9%), and 396 FDh (1.1%). After adjusting for confounding factors, an increase in UPFp was associated with a higher risk of IBS (_aOR _{Q4 vs. Q1} [95% CI]: 1.25 [1.12-1.39], p-trend < 0.0001).

CONCLUSIONS

This study suggests an association between UPF and IBS. Further longitudinal studies are needed to confirm those results and understand the relative impact of the nutritional composition and specific characteristics of UPF in this relationship.

Pharmabiotic Manipulation of the Microbiota in Gastrointestinal Disorders: A Clinical Perspective

The advent and widespread availability of high-throughput technology has revolutionized the assessment of the communities of microorganisms that inhabit the gastrointestinal tract––the gut microbiota. As our understanding of the role of the microbiota in health and human disease increases, so also do efforts to prevent and treat disease through the modulation of the microbiota. Several strategies are available to us and range from time honored approaches, such as antibiotics and probiotics, to changes in diet, the administration of prebiotics as food supplements, and fecal microbiota transplantation. Of these, diet is perhaps the most pervasive but often ignored modulator of the microbiota, and a failure to recognize its impact complicates the interpretation of many microbiota studies. The impacts of antibiotics on the microbiota are more complex than originally thought and, though antibiotics can be life-saving, their effects on commensal bacterial populations can be clinically significant. Though there have been many studies of, and even more claims made for, probiotics, the majority of available studies suffer from significant deficits in study design and execution and many claims remain to be substantiated. Though holding much promise, the study of prebiotics in human disease is still in its infancy. Possibilities other than the administration of live organisms have been identified through efforts to mine the microbiota for novel therapeutics and include: dead organisms, bacterial components, small molecules elaborated by bacteria, and even bacterial DNA. Accordingly, the term pharmabiotic has been introduced to encompass the full range of therapeutic possibilities that the microbiota offers.

Use of Dietary Management in Irritable Bowel Syndrome: Results of a Survey of Over 1500 United States Gastroenterologists

Background/Aims

Dietary therapy is increasingly used to manage gastrointestinal (GI) symptoms in patients with irritable bowel syndrome (IBS). We aim to gauge United States gastroenterologists’ perceptions of dietary therapies for IBS.

Methods

We distributed a 22-question survey to members of the American College of Gastroenterology. The survey was developed by gastroenterologists and survey methodologists. We collected information pertaining to demographics, providers’ interpretation of their patients’ views on dietary therapy, and gastroenterologists’ perceptions on dietary therapy, and nutritional counseling in IBS.

Results

One thousand five hundred and sixty-two (14%) surveys were collected. Nearly 60% of participants reported that patients commonly associate food with GI symptoms. IBS patients most commonly use a trial and error approach followed by a lactose-free and gluten-free diet, and rarely use a low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet on their own. Over half of providers recommend diet therapy to > 75% of IBS patients and most commonly recommend a low FODMAP diet. Only 21% of gastroenterologists commonly refer IBS patients to registered dietitians, and only 30% use GI dietitians. Female providers were more likely than males to recommend dietary changes as the primary mode of therapy (OR, 1.43 [1.09–1.88]; P = 0.009).

Conclusions

Our national survey identified enthusiasm for diet treatment of IBS. While patients infrequently tried a low FODMAP diet on their own, GI providers commonly recommended this diet. Only a minority of GI providers refer their IBS patients to a registered dietitian for nutrition counseling and few refer patients to dietitians with specialized GI training. Female providers were more enthusiastic about diet therapies than males.

Long-term results of linaclotide in the treatment of constipation-type irritable bowel syndrome

BACKGROUND

constipation-predominant irritable bowel syndrome (C-IBS) is a prevalent, complex and multifactorial disorder that represents a challenge in terms of diagnosis and therapeutic management.

OBJECTIVE

to evaluate the effectiveness, safety and treatment satisfaction of linaclotide in C-IBS patients.

METHODS

prospective, single-center and observational study conducted in patients diagnosed with C-IBS. The patients were treated with linaclotide (Constella®, Allergan Inc., Irvine, CA), once-daily via an oral capsule of 290-μg, 30 minutes before breakfast. The primary effectiveness endpoint was the number of bowel movements per week. The secondary endpoints included treatment satisfaction and changes from baseline in frequency and severity of symptoms (abdominal pain and bloating). This was assessed via an 11-point visual analog scale (VAS) reported by the patients in a daily register.

RESULTS

thirty female patients were consecutively included. The median follow-up time was 18 months. The mean (standard deviation [SD]) number of weekly bowel movements significantly increased from 0.9 (0.6) at baseline to 4.7 (3.9) at the end of follow-up, p < 0.0001. Abdominal pain significantly decreased from 5.7 (2.3) at baseline to 3.1 (2.8) at the end of the follow-up period, p < 0.0001. Similarly, bloating significantly decreased from 6.8 (1.6) to 2.9 (2.5) at the beginning and end of the treatment period, respectively, p < 0.0001. The mean (SD) degree of satisfaction at the end of the study was 6.7 (3.0).

CONCLUSIONS

long-term linaclotide treatment in patients with C-IBS is effective and safe in the clinical setting.

Clinical Practice Guidelines for Irritable Bowel Syndrome in Korea, 2017 Revised Edition

In 2011, the Korean Society of Neurogastroenterology and Motility (KSNM) published clinical practice guidelines on the management of irritable bowel syndrome (IBS) based on a systematic review of the literature. The KSNM planned to update the clinical practice guidelines to support primary physicians, reduce the socioeconomic burden of IBS, and reflect advances in the pathophysiology and management of IBS. The present revised version of the guidelines is in continuity with the previous version and targets adults diagnosed with, or suspected to have, IBS. A librarian created a literature search query, and a systematic review was conducted to identify candidate guidelines. Feasible documents were verified based on predetermined inclusion and exclusion criteria. The candidate seed guidelines were fully evaluated by the Guidelines Development Committee using the Appraisal of Guidelines for Research and Evaluation II quality assessment tool. After selecting 7 seed guidelines, the committee prepared evidence summaries to generate data exaction tables. These summaries comprised the 4 main themes of this version of the guidelines: colonoscopy; a diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols; probiotics; and rifaximin. To adopt the core recommendations of the guidelines, the Delphi technique (ie, a panel of experts on IBS) was used. To enhance dissemination of the clinical practice guidelines, a Korean version will be made available, and a food calendar for patients with IBS is produced.

The Role of Diet in the Treatment of Irritable Bowel Syndrome: A Systematic Review

Irritable bowel syndrome (IBS) is a multifaceted illness involving maladaptive shifts in the gut microbiota that affect the enteric nervous and immune systems, mucosal barrier function, the balance of neurotransmitters and hormones, and emotional well-being. There is abundant evidence indicating that certain foods elicit symptoms in IBS. Numerous elimination-type diets have been shown to alleviate symptoms. However, among these, the most controversial is a group of foods called fructo, oligo-, di-, and monosaccharides and polyols (FODMAPs). This paper reviews the role of diet and systematically analyze the literature for the role of FODMAPs in IBS.

Dietary therapies for functional bowel symptoms: Recent advances, challenges, and future directions

BACKGROUND

Functional gastrointestinal symptoms in irritable bowel syndrome (IBS) and quiescent inflammatory bowel disease (IBD) cause significant morbidity and a reduction in quality of life. Multiple dietary therapies are now available to treat these symptoms, but supporting evidence for many is limited. In addition to a further need for studies demonstrating efficacy and mechanism of action of dietary therapies, the risk of nutritional inadequacy, alterations to the microbiome and changes in quality of life are key concerns requiring elucidation. Identifying predictors of response to dietary therapy is an important goal as management could be tailored to the individual to target specific dietary components, and thereby reduce the level of dietary restriction necessary.

PURPOSE

This review discusses the available dietary therapies to treat symptoms in patients with IBS and patients with quiescent IBD suffering from IBS symptoms, with the aim to understand where current dietary evidence lies and how to move forward in dietary research in this field.

Characterizing Normal Bowel Frequency and Consistency in a Representative Sample of Adults in the United States (NHANES)

OBJECTIVES

Our current understanding of normal bowel patterns in the United States (US) is limited. Available studies have included individuals with both normal and abnormal bowel patterns, making it difficult to characterize normal bowel patterns in the US. The current study aims to (1) examine frequency and consistency in individuals with self-reported normal bowel habits and (2) determine demographic factors associated with self-reported normalcy.

METHODS

This study used data from adult participants who completed bowel health questions as part of the National Health and Nutrition Examination Survey (NHANES) in 2009-2010 and who reported normal bowel patterns (N=4,775). Data regarding self-perceived bowel health; stool frequency; stool consistency (using the Bristol Stool Form Scale (BSFS)); and demographic factors were analyzed.

RESULTS

95.9% of the sample reported between 3 and 21 BMs per week. Among men, 90% reported a BSFS between 3 and 5, while for women it was 2-6. After controlling for age, the following demographic variables were associated with normalcy: male sex, higher education, higher income, <2 daily medications, and high daily fiber intake. Hispanic ethnicity was significantly associated with abnormal self-reported bowel habits.

CONCLUSIONS

This is the first study to evaluate normal bowel frequency and consistency in a representative sample of adults in the US. The current findings bolster the common "3 and 3" metric of normal frequency (3 BMs/day to 3 BMs/week) while also suggesting different criteria for normal consistency for men and women. Finally, this study provides novel information about demographic factors associated with normal frequency and consistency.

A Novel Prebiotic Blend Product Prevents Irritable Bowel Syndrome in Mice by Improving Gut Microbiota and Modulating Immune Response

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder yet it still lacks effective prevention therapies. The aim of this study is to determine whether a novel prebiotic blend (PB) composed of fructo-oligosaccharide (FOS), galactooligosaccharide (GOS), inulin and anthocyanins could be effective in preventing the development of IBS. We explored the possible mechanisms both in animal and in cells. Post-infectious IBS models in C57BL/6 mice were established and were pretreated with the PB, PB and probiotic strains 8 weeks in advance of infection. Eight weeks after infection, intestinal tissues were collected for assessing histomorphology, visceral sensitivity, barrier function, pro-inflammatory cytokines expression and proteomics analysis. Fecal samples were also collected for microbiota analysis. The pro-inflammatory cytokines expression in Caco-2 cells were evaluated after co-incubation with PB and Salmonella typhimurium 14028. The results showed that PB significantly decreased the pro-inflammatory cytokines both in infected Caco-2 cells and PI-IBS models. The loss of body weight, decreased expression of tight junction protein Occludin (OCLN), and changes of the microbiota composition induced by infections could be greatly improved by PB intervention (p < 0.05). The proteomics analysis revealed that this function was associated with Peroxisome proliferator-activated receptor (PPAR)γ pathway.

Research Gaps in Diet and Nutrition in Inflammatory Bowel Disease. A Topical Review by D-ECCO Working Group [Dietitians of ECCO]

Although the current doctrine of IBD pathogenesis proposes an interaction between environmental factors and gut microbiota in genetically susceptible individuals, dietary exposures have attracted recent interest and are, at least in part, likely to explain the rapid rise in disease incidence and prevalence. The D-ECCO working group along with other ECCO experts with expertise in nutrition, microbiology, physiology, and medicine reviewed the evidence investigating the role of diet and nutritional therapy in the onset, perpetuation, and management of IBD. A narrative topical review is presented where evidence pertinent to the topic is summarised collectively under three main thematic domains: i] the role of diet as an environmental factor in IBD aetiology; ii] the role of diet as induction and maintenance therapy in IBD; and iii] assessment of nutritional status and supportive nutritional therapy in IBD. A summary of research gaps for each of these thematic domains is proposed, which is anticipated to be agenda-setting for future research in the area of diet and nutrition in IBD.

Irritable bowel syndrome and diet: where are we in 2018?

PURPOSE OF REVIEW

The aim is to review the most recent advances in the evidence supporting the use of various dietary interventions for the management of irritable bowel syndrome (IBS).

RECENT FINDINGS

There is insufficient evidence of the effect of fibres other than psyllium in IBS, whereas the recent studies on prebiotics suggest a limited effect in IBS. Recent probiotic trials continue to provide varying results, with some probiotic strains exhibiting beneficial effects, whereas others show no effect. Recent trials have also confirmed the clinical effectiveness of a diet low in fermentable oligosaccharides, disaccharides, monosaccharides and polyols (i.e. low FODMAP diet) in IBS. Although gluten sensitivity has also been recently investigated, its presence cannot be confirmed yet because of the presence of other potential contributing compounds in wheat. Studies also suggest a potential beneficial effect of peppermint oil, which warrants further research.

SUMMARY

It is clear that a low FODMAP diet has a beneficial effect in a majority of patients with IBS. Probiotics also have great potential in the management of IBS; however, it is still unclear which strains and doses are the most beneficial. Further research is needed on the effect of different fibres, or combinations of fibres, in IBS.

Diagnosis and management of irritable bowel syndrome: a guide for the generalist

Irritable bowel syndrome (IBS) and other functional gastrointestinal disorders (FGIDs) are so prevalent they cannot reasonably have their diagnoses and management based within specialty care. However, delayed diagnosis, lengthy wait times for specialist review, overinvestigation and lack of clear diagnostic communication are common. The intrusive symptoms of IBS and other FGIDs impair patient functioning and reduce quality of life, and come with significant costs to individual patients and the health care system, which could be reduced with timely diagnosis and effective management. IBS, in particular, is no longer a diagnosis of exclusion, and there are now effective dietary and psychological therapies that may be accessed without specialist referral. The faecal calprotectin test is widely available, yet not on the Medical Benefits Schedule, and a normal test result reliably discriminates between people with IBS and patients who warrant specialist referral.

Motivations for Botanical Use by Socioeconomically Diverse, Urban Adults: Does Evidence Support Motivation?

OBJECTIVE

The study objectives were to characterize botanical dietary supplement (BDS) use and to compare the motivations for botanical supplement (BS) use to the efficacy of the botanical in a socioeconomically and racially diverse urban adult population.

METHODS

Subjects were from the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study, a 20-year prospective health disparities study with African American and white adults from Baltimore, Maryland. All study participants completed two dietary recalls and a dietary supplement (DS) questionnaire in Wave 3 (n = 2140). Diet quality was evaluated by the Healthy Eating Index-2010 and the Mean Adequacy Ratio for 17 micronutrients. A comparison of reported motivations to efficacy reported in the literature of single BS was conducted.

RESULTS

Approximately 50% (1062/2140) of participants took DS. Of these, 8% (n = 178) reported taking either BS or BDS. It was found that BDS users had better diet quality than DS users as well as nonusers of DS. The top three motivations for BDS users were to improve overall health, to maintain health, and to supplement the diet. There is limited evidence for the efficacy of most BS. Review of the efficacy of the 15 BS reported by ≥5% of the study population revealed beneficial health roles for only fiber, gingko biloba extract EGb 761, and hawthorn berry.

CONCLUSION

To the authors' knowledge, this study is the first to report a better quality diet with BDS use for a racially diverse urban population. Yet, improvement in diet is needed because overall quality did not achieve current recommendations. To improve overall health, it may be beneficial for this population to focus on dietary modifications to reduce the risks associated with chronic diseases. In general, the reported motivations for BS use were not supported by clinical evidence.

Irritable bowel syndrome diagnosis and management: A simplified algorithm for clinical practice

BACKGROUND

Effective management of irritable bowel syndrome (IBS), a common functional gastrointestinal disorder, can be challenging for physicians because of the lack of simple diagnostic tests and the wide variety of treatment approaches available.

OBJECTIVE

The objective of this article is to outline a simple algorithm for day-to-day clinical practice to help physicians navigate key stages to reaching a positive IBS diagnosis and guidance on how to prioritise the use of specific management strategies.

METHODS

This algorithm was based on the opinion of an expert panel evaluating current evidence.

RESULTS

The key principles forming the foundation of this evidence-supported algorithm are: confidently naming and explaining an IBS diagnosis for the patient, followed by assessment of key patient characteristics likely to influence the choice of therapy, such as predominant symptoms, and exploring the patient agenda and preferences. Consultation should always include education and reassurance with an explanatory model of IBS tailored to the patient. Individualised lifestyle changes, dietary modifications, pharmacological therapies, psychological strategies or a combination of interventions may be used to optimise treatment for each patient.

CONCLUSION

The simple visual tools developed here navigate the key stages to reaching a positive diagnosis of IBS, and provide a stepwise approach to patient-centred management targeted towards the most bothersome symptoms. Establishing a strong patient-physician relationship is central to all stages of the patient journey from diagnosis to effective management.

Western Dietary Pattern Is Associated with Irritable Bowel Syndrome in the French NutriNet Cohort

Background: Diet appears to play a key role in the pathogenesis of the irritable bowel syndrome (IBS). Some dietary patterns (DP) could increase the risk of triggering or worsening IBS symptoms. This cross-sectional study aimed to assess the association between a posteriori derived DP and IBS in a large French population, the web-based NutriNet-Santé cohort. Methods: Study population included participants of the NutriNet-Santé study who completed a questionnaire based on Rome III criteria assessing IBS. A principal component analysis (PCA) was performed to identify major DPs based on 29 food groups' consumption. Associations between DP quintiles and IBS were investigated with multivariable logistic regressions. Results: 44,350 participants were included, with 2423 (5.5%) presenting IBS. Three major DP were extracted using PCA, "healthy," "western," and "traditional." After adjustments on confounders, the "western" DP was positively associated with IBS (OR _{Q5 vs. Q1} = 1.38, 95% CI 1.19-1.61, p trend < 0.0001) and the "traditional" DP was positively associated with IBS in women (OR _{Q5 vs. Q1} = 1.29 95% CI 1.08-1.54, p trend = 0.001). Conclusions: In this study, a "western" DP-highly correlated with the consumption of fatty and sugary products and snacks-was associated with a moderate increased risk of IBS.

Association between self-reported vegetarian diet and the irritable bowel syndrome in the French NutriNet cohort

BACKGROUND

There is growing interest in using diet counselling in the management of patients with irritable bowel syndrome (IBS). Among new emerging diets, vegetarian diets (VD) seem to be experiencing an important popularity, partly because of their alleged health benefits. A recent study performed among a rural Indian population showed that predominant VD could be associated with IBS.

OBJECTIVE

This cross-sectional study aimed at assessing the association between the VD and IBS, among a large French cohort, the NutriNet-santé study.

METHODS

Subjects participating in the NutriNet-Santé cohort study completed a questionnaire based on Rome III criteria (N = 41,682). Anthropometrics, socio-demographical and lifestyle data, including VD, were collected prior to the completion of Rome III questionnaire via self-administered questionnaires. Association between VD and IBS and its subtypes was investigated through multivariate logistic regression.

RESULTS

The included subjects were mainly women (78.0%) and the mean age was 49.8±14.3 years. Among these individuals, 2,264 (5.4%) presented an IBS, and 805 (1.9%) reported a VD. Overall, VD was not associated with IBS or subtypes. A stable VD (i.e. self-declared at least three times) was associated with IBS (aOR 2.60 95%CI [1.37-4.91]), IBS mixed (aOR 2.97 95%CI [1.20-7.36]) and IBS diarrhoea (aOR 2.77 95%CI [1.01-7.59]).

CONCLUSIONS

This study suggests that a long term VD could be associated with IBS. Nevertheless, further studies are needed to confirm these results, and investigate the multiple aspects of the vegetarian diet, possibly related to the IBS.

[Pharmacotherapy in Patients with Chronic Constipation]

Chronic constipation is one of the most common digestive diseases frequently observed in a clinical setting. It has been known to cause considerable damage to the quality of life of patients. Despite recent developments, there are considerable limitations in the use of constipation-modulating agents in Korea. Chloride channel inhibitors, such as lubiprostone and linaclotide, have not been introduced in Korea yet, and prucalopride and several kinds of polyethylene glycol are not covered under medical insurance. This article assesses medicines that are clinically available for the management of constipation in Korea, with a brief review of agents that have recently developed around the world.

The low FODMAP diet: recent advances in understanding its mechanisms and efficacy in IBS

There is an intensifying interest in the interaction between diet and the functional GI symptoms experienced in IBS. Recent studies have used MRI to demonstrate that short-chain fermentable carbohydrates increase small intestinal water volume and colonic gas production that, in those with visceral hypersensitivity, induces functional GI symptoms. Dietary restriction of short-chain fermentable carbohydrates (the low fermentable oligosaccharide, disaccharide, monosaccharide and polyol (FODMAP) diet) is now increasingly used in the clinical setting. Initial research evaluating the efficacy of the low FODMAP diet was limited by retrospective study design and lack of comparator groups, but more recently well-designed clinical trials have been published. There are currently at least 10 randomised controlled trials or randomised comparative trials showing the low FODMAP diet leads to clinical response in 50%-80% of patients with IBS, in particular with improvements in bloating, flatulence, diarrhoea and global symptoms. However, in conjunction with the beneficial clinical impact, recent studies have also demonstrated that the low FODMAP diet leads to profound changes in the microbiota and metabolome, the duration and clinical relevance of which are as yet unknown. This review aims to present recent advances in the understanding of the mechanisms by which the low FODMAP diet impacts on symptoms in IBS, recent evidence for its efficacy, current findings regarding the consequences of the diet on the microbiome and recommendations for areas for future research.

Dietary fiber in irritable bowel syndrome (Review)

Irritable bowel syndrome (IBS) is a common chronic gastrointestinal disorder. It is widely believed that IBS is caused by a deficient intake of dietary fiber, and most physicians recommend that patients with IBS increase their intake of dietary fiber in order to relieve their symptoms. However, different types of dietary fiber exhibit marked differences in physical and chemical properties, and the associated health benefits are specific for each fiber type. Short-chain soluble and highly fermentable dietary fiber, such as oligosaccharides results in rapid gas production that can cause abdominal pain/discomfort, abdominal bloating/distension and flatulence in patients with IBS. By contrast, long-chain, intermediate viscous, soluble and moderately fermentable dietary fiber, such as psyllium results in a low gas production and the absence of the symptoms related to excessive gas production. The effects of type of fiber have been documented in the management of IBS, and it is known to improve the overall symptoms in patients with IBS. Dietary fiber acts on the gastrointestinal tract through several mechanisms, including increased fecal mass with mechanical stimulation/irritation of the colonic mucosa with increasing secretion and peristalsis, and the actions of fermentation byproducts, particularly short-chain fatty acids, on the intestinal microbiota, immune system and the neuroendocrine system of the gastrointestinal tract. Fiber supplementation, particularly psyllium, is both safe and effective in improving IBS symptoms globally. Dietary fiber also has other health benefits, such as lowering blood cholesterol levels, improving glycemic control and body weight management.

The challenges of control groups, placebos and blinding in clinical trials of dietary interventions

High-quality placebo-controlled evidence for food, nutrient or dietary advice interventions is vital for verifying the role of diet in optimising health or for the management of disease. This could be argued to be especially important where the benefits of dietary intervention are coupled with potential risks such as compromising nutrient intake, particularly in the case of exclusion diets. The objective of the present paper is to explore the challenges associated with clinical trials in dietary research, review the types of controls used and present the advantages and disadvantages of each, including issues regarding placebos and blinding. Placebo-controlled trials in nutrient interventions are relatively straightforward, as in general placebos can be easily produced. However, the challenges associated with conducting placebo-controlled food interventions and dietary advice interventions are protean, and this has led to a paucity of placebo-controlled food and dietary advice trials compared with drug trials. This review appraises the types of controls used in dietary intervention trials and provides recommendations and nine essential criteria for the design and development of sham diets for use in studies evaluating the effect of dietary advice, along with practical guidance regarding their evaluation. The rationale for these criteria predominantly relate to avoiding altering the outcome of interest in those delivered the sham intervention in these types of studies, while not compromising blinding.

Diet in irritable bowel syndrome: What to recommend, not what to forbid to patients!

A substantial proportion of patients with irritable bowel syndrome (IBS) associate their symptoms with the ingestion of specific foods. Therefore, in recent years, scientific research has increasingly focused on the role of diet in IBS and dietary management is now considered an important tool in IBS treatment. This article reviews the main dietary approaches in IBS emphasizing evidence from experimental and observational studies and summarizing the main diet and lifestyle recommendations provided by dietary guidelines and scientific literature. Despite the limited evidence for a beneficial role, general advice on healthy eating and lifestyle is recommended as the first-line approach in the dietary management of IBS. Standard recommendations include adhering to a regular meal pattern, reducing intake of insoluble fibers, alcohol, caffeine, spicy foods, and fat, as well as performing regular physical activity and ensuring a good hydration. Second-line dietary approach should be considered where IBS symptoms persist and recommendations include following a low FODMAP diet, to be delivered only by a healthcare professional with expertise in dietary management. The efficacy of this diet is supported by a growing body of evidence. In contrast, the role of lactose or gluten dietary restriction in the treatment of IBS remains subject to ongoing research with a lack of high-quality evidence. Likewise, further clinical trials are needed to conclude the efficacy of probiotics on IBS symptoms.

Irritable Bowel Syndrome

: Irritable bowel syndrome (IBS) is a common, chronic gastrointestinal (GI) condition characterized by disturbances in bowel habits and abdominal pain in the absence of known organic pathology. IBS reduces quality of life and is costly to treat. It is diagnosed using the symptom-based Rome criteria for functional GI disorders, which was recently updated and released as Rome IV. Both physiologic and psychological variables play a role in the etiology of IBS and perpetuate symptoms. Although research has shed light on IBS pathophysiology, therapeutic interventions remain symptom driven, employing both pharmacologic and nonpharmacologic approaches. Here, the authors review the epidemiology and pathophysiology of IBS, summarize diagnostic and treatment strategies, and discuss implications for nursing practice.

Integrative Medicine for Gastrointestinal Disease

Gastrointestinal conditions are prevalent in the population and account for significant morbidity and health care costs. Patients with gastrointestinal conditions use integrative medicine. There is growing evidence that integrative medicine approaches can improve symptoms and affect physiology and disease course. This article reviews data on some common and well-studied approaches, including mind-body therapies, acupuncture, diet, probiotics, and dietary supplements and herbs. Although clear recommendations can be made for some conditions, in others there are challenges in translating these findings owing to small study size, lack of standardization, and trial heterogeneity.

Probiotics, fibre and herbal medicinal products for functional and inflammatory bowel disorders

Functional bowel disorders (FBD), mainly irritable bowel syndrome (IBS) and functional constipation (FC, also called chronic idiopathic constipation), are very common worldwide. Inflammatory bowel disease (IBD), including ulcerative colitis and Crohn's disease, although less common, has a strong impact on patients' quality of life, as well as being highly expensive for our healthcare. A definite cure for those disorders is still yet to come. Over the years, several therapeutic approaches complementary or alternative to traditional pharmacological treatments, including probiotics, prebiotics, synbiotics, fibre and herbal medicinal products, have been investigated for the management of both groups of diseases. However, most available studies are biased by several drawbacks, including small samples and poor methodological quality. Probiotics, in particular Saccharomyces boulardii and Lactobacilli (among which Lactobacillus rhamnosus), synbiotics, psyllium, and some herbal medicinal products, primarily peppermint oil, seem to be effective in ameliorating IBS symptoms. Synbiotics and fibre seem to be beneficial in FC patients. The probiotic combination VSL#3 may be effective in inducing remission in patients with mild-to-moderate ulcerative colitis, in whom Escherichia coli Nissle 1917 seems to be as effective as mesalamine in maintaining remission. No definite conclusions can be drawn as to the efficacy of fibre and herbal medicinal products in IBD patients due to the low number of studies and the lack of randomized controlled trials that replicate the results obtained in the individual studies conducted so far. Thus, further, well-designed studies are needed to address the real role of these therapeutic options in the management of both FBD and IBD.

LINKED ARTICLES

This article is part of a themed section on Principles of Pharmacological Research of Nutraceuticals. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.11/issuetoc.

Low-FODMAP diet reduces irritable bowel symptoms in patients with inflammatory bowel disease

AIM

To investigate the effect of a low-FODMAP diet on irritable bowel syndrome (IBS)-like symptoms in patients with inflammatory bowel disease (IBD).

METHODS

This was a randomised controlled open-label trial of patients with IBD in remission or with mild-to-moderate disease and coexisting IBS-like symptoms (Rome III) randomly assigned to a Low-FODMAP diet (LFD) or a normal diet (ND) for 6 wk between June 2012 and December 2013. Patients completed the IBS symptom severity system (IBS-SSS) and short IBD quality of life questionnaire (SIBDQ) at weeks 0 and 6. The primary end-point was response rates (at least 50-point reduction) in IBS-SSS at week 6 between groups; secondary end-point was the impact on quality of life.

RESULTS

Eighty-nine patients, 67 (75%) women, median age 40, range 20-70 years were randomised: 44 to LFD group and 45 to ND, from which 78 patients completed the study period and were included in the final analysis (37 LFD and 41 ND). There was a significantly larger proportion of responders in the LFD group (n = 30, 81%) than in the ND group (n = 19, 46%); (OR = 5.30; 95%CI: 1.81-15.55, P < 0.01). At week 6, the LFD group showed a significantly lower median IBS-SSS (median 115; inter-quartile range [IQR] 33-169) than ND group (median 170, IQR 91-288), P = 0.02. Furthermore, the LFD group had a significantly greater increase in SIBDQ (median 60, IQR 51-65) than the ND group (median 50, IQR 39-60), P < 0.01.

CONCLUSION

In a prospective study, a low-FODMAP diet reduced IBS-like symptoms and increased quality of life in patients with IBD in remission.

Psyllium Fiber Reduces Abdominal Pain in Children With Irritable Bowel Syndrome in a Randomized, Double-Blind Trial

BACKGROUND & AIMS

We sought to determine the efficacy of psyllium fiber treatment on abdominal pain and stool patterns in children with irritable bowel syndrome (IBS). We evaluated effects on breath hydrogen and methane production, gut permeability, and microbiome composition. We also investigated whether psychological characteristics of children or parents affected the response to treatment.

METHODS

We performed a randomized, double-blind trial of 103 children (mean age, 13 ± 3 y) with IBS seen at primary or tertiary care settings. After 2 weeks on their habitual diet, children began an 8-day diet excluding carbohydrates thought to cause symptoms of IBS. Children with ≥75% improvement in abdominal pain were excluded (n = 17). Children were assigned randomly to groups given psyllium (n = 37) or placebo (maltodextrin, n = 47) for 6 weeks. Two-week pain and stool diaries were compared at baseline and during the final 2 weeks of treatment. We assessed breath hydrogen and methane production, intestinal permeability, and the composition of the microbiome before and after administration of psyllium or placebo. Psychological characteristics of children were measured at baseline.

RESULTS

Children in the psyllium group had a greater reduction in the mean number of pain episodes than children in the placebo group (mean reduction of 8.2 ± 1.2 after receiving psyllium vs mean reduction of 4.1 ± 1.3 after receiving placebo; P = .03); the level of pain intensity did not differ between the groups. Psychological characteristics were not associated with response. At the end of the study period, the percentage of stools that were normal (Bristol scale scores, 3-5), breath hydrogen or methane production, intestinal permeability, and microbiome composition were similar between groups.

CONCLUSIONS

Psyllium fiber reduced the number of abdominal pain episodes in children with IBS, independent of psychological factors. Psyllium did not alter breath hydrogen or methane production, gut permeability, or microbiome composition. ClinicalTrials.gov no: NCT00526903.

When the low FODMAP diet does not work

Irritable bowel syndrome (IBS) is heterogeneous. Patients need proper assessment and explanation of IBS pathophysiology and appropriate therapies. A low FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) diet effectively reduces symptoms in 75% of patients. Best treatment for those nonresponsive will depend on the pathophysiological basis for symptom genesis, with the following possible abnormalities: (i) Visceral hypersensitivity and/or enhanced gut-brain communication: a low FODMAP diet is mainly targeted for this patient group. A dietitian may also recommend antispasmodic agents, including peppermint oil. Another dietary treatment is a low food chemical diet, although this diet is often extremely limited, and therefore, not suited for some populations. Psychological therapies are also clinically beneficial. (ii) Altered motility: in patients with fast transit, a dietitian may recommend a reduction in all FODMAPs or targeted monosaccharides and disaccharides, which are more osmotic in nature. If not effective, patients may benefit from psyllium, which has an exceptional water-holding capacity aimed to promote more formed stools. Patients with slow or uncoordinated transit are often more difficult to treat. Dietary interventions have some success and usually comprise a combination of adequate fiber and fluid, osmotic laxatives, and stimulating agents such as caffeine, senna, and exercise. (iii) Altered microbiome: supplementary probiotics and prebiotics have weak evidence of efficacy with some notable exceptions. A dietitian may trial supplementary Bifidobacterium infantis or oligosaccharides, usually as an adjunct therapy. Guidance from a dietitian will encompass dietary methods to treat IBS but additionally identify where dietary treatment is not indicated to ensure that diet is correctly used and patients are not nutritionally or psychologically compromised.

Role of Fiber in Symptomatic Uncomplicated Diverticular Disease: A Systematic Review

Symptomatic uncomplicated diverticular disease (SUDD) is a syndrome characterized by recurrent abdominal symptoms in patients with colonic diverticula. There is some evidence that a high-fiber diet or supplemental fibers may reduce symptoms in SUDD patients and a high-fiber diet is commonly suggested for these patients. This systematic review aims to update the evidence on the efficacy of fiber treatment in SUDD, in terms of a reduction in symptoms and the prevention of acute diverticulitis. According to PRISMA, we identified studies on SUDD patients treated with fibers (PubMed and Scopus). The quality of these studies was evaluated by the Jadad scale. The main outcome measures were a reduction of abdominal symptoms and the prevention of acute diverticulitis. Nineteen studies were included, nine with dietary fiber and 10 with supplemental fiber, with a high heterogeneity concerning the quantity and quality of fibers employed. Single studies suggest that fibers, both dietary and supplemental, could be beneficial in SUDD, even if the quality is very low, with just one study yielding an optimal score. The presence of substantial methodological limitations, the heterogeneity of the therapeutic regimens employed, and the lack of ad hoc designed studies, did not permit a summary of the outcome measure. Thus, the benefit of dietary or supplemental fiber in SUDD patients still needs to be established.

Current and emergent pharmacologic treatments for irritable bowel syndrome with diarrhea: evidence-based treatment in practice

Irritable bowel syndrome with diarrhea (IBS-D) is a common, chronic functional gastrointestinal disorder with symptoms that can be distressing for patients and often result in substantially impaired quality of life. This review focuses on providing clinicians with information on practical, evidence-based treatment for IBS-D. Current therapies commonly used for the treatment of IBS-D, including pharmacologic and nonpharmacologic interventions, are briefly reviewed, followed by discussion of the emergent pharmacologic treatments (rifaximin and eluxadoline) and medical foods (IBgard® and EnteraGam®). Given the lack of a standard treatment algorithm for IBS-D and the emergence of new pharmacologic therapies, treatment needs to be tailored to the individual patient and take into account the severity of disease. In this context, the latter part of this manuscript examines how treatments for IBS-D can be used in clinical practice by presenting three patient case scenarios with varying degrees of IBS-D severity. For each case, the patient's medical history and clinical presentation are related to the Rome Foundation multidimensional clinical profile (MDCP) and potential treatment options with current and emergent therapies are reviewed. The interplay of gastrointestinal symptoms and their psychosocial impact, as well as the importance of a patient-centered approach to therapy, are discussed. Consideration is given to the potential need for combination therapies and how emergent treatments could fit into the treatment pathway for mild, moderate, and severe cases of IBS-D in clinical practice.

Management of the multiple symptoms of irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders. A stepwise management approach is advocated for patients with IBS. For a substantial proportion of patients with mild symptoms, general management principles, including making a confident diagnosis and offering explanation, reassurance, and dietary and lifestyle advice, are sufficient. However, many patients continue to have moderate-to-severe symptoms and are not satisfied solely with this approach. In these patients, use of pharmacotherapy on the basis of the predominant symptom (constipation, diarrhoea, pain, or bloating) or combination of symptoms is the next step. For patients with symptoms that are refractory to these initial treatment options and those who have comorbid conditions or psychological symptoms, a combination of therapies should be used, and the use of psychotropic drugs and psychological treatment alternatives is often effective. Finally, the key to successful treatment of patients with IBS is a good physician-patient relationship and use of person-centred care principles.

Dietary Interventions and Irritable Bowel Syndrome: A Review of the Evidence

Irritable bowel syndrome (IBS) is the best studied of the functional gastrointestinal disorders. It is a highly prevalent disorder characterized by symptoms of abdominal pain, bloating, and disordered bowel habits, which may include constipation, diarrhea, or both. IBS has a significant negative impact on patients, both financially and with regard to their quality-of-life. At present, there is no cure for IBS, and while there are a number of pharmacological therapies available to treat IBS symptoms, they are not uniformly effective. For this reason, many patients and providers are turning to dietary interventions in an attempt to ameliorate IBS symptoms. At first glance, this approach appears reasonable as dietary interventions are generally safe and side effects, including potential adverse reactions with medications, are rare. However, although dietary interventions for IBS are frequently recommended, there is a paucity of data to support their use. The goals of this article are to answer key questions about diets currently recommended for the treatment of IBS, using the best available data from the literature.

Microbiota Transfer Therapy alters gut ecosystem and improves gastrointestinal and autism symptoms: an open-label study

BACKGROUND

Autism spectrum disorders (ASD) are complex neurobiological disorders that impair social interactions and communication and lead to restricted, repetitive, and stereotyped patterns of behavior, interests, and activities. The causes of these disorders remain poorly understood, but gut microbiota, the 1013 bacteria in the human intestines, have been implicated because children with ASD often suffer gastrointestinal (GI) problems that correlate with ASD severity. Several previous studies have reported abnormal gut bacteria in children with ASD. The gut microbiome-ASD connection has been tested in a mouse model of ASD, where the microbiome was mechanistically linked to abnormal metabolites and behavior. Similarly, a study of children with ASD found that oral non-absorbable antibiotic treatment improved GI and ASD symptoms, albeit temporarily. Here, a small open-label clinical trial evaluated the impact of Microbiota Transfer Therapy (MTT) on gut microbiota composition and GI and ASD symptoms of 18 ASD-diagnosed children.

RESULTS

MTT involved a 2-week antibiotic treatment, a bowel cleanse, and then an extended fecal microbiota transplant (FMT) using a high initial dose followed by daily and lower maintenance doses for 7-8 weeks. The Gastrointestinal Symptom Rating Scale revealed an approximately 80% reduction of GI symptoms at the end of treatment, including significant improvements in symptoms of constipation, diarrhea, indigestion, and abdominal pain. Improvements persisted 8 weeks after treatment. Similarly, clinical assessments showed that behavioral ASD symptoms improved significantly and remained improved 8 weeks after treatment ended. Bacterial and phagedeep sequencing analyses revealed successful partial engraftment of donor microbiota and beneficial changes in the gut environment. Specifically, overall bacterial diversity and the abundance of Bifidobacterium, Prevotella, and Desulfovibrio among other taxa increased following MTT, and these changes persisted after treatment stopped (followed for 8 weeks).

CONCLUSIONS

This exploratory, extended-duration treatment protocol thus appears to be a promising approach to alter the gut microbiome and virome and improve GI and behavioral symptoms of ASD. Improvements in GI symptoms, ASD symptoms, and the microbiome all persisted for at least 8 weeks after treatment ended, suggesting a long-term impact.

TRIAL REGISTRATION

This trial was registered on the ClinicalTrials.gov, with the registration number  NCT02504554.

The Role of the Gastrointestinal Microbiota in Visceral Pain

A growing body of preclinical and clinical evidence supports a relationship between the complexity and diversity of the microorganisms that inhabit our gut (human gastrointestinal microbiota) and health status. Under normal homeostatic conditions this microbial population helps maintain intestinal peristalsis, mucosal integrity, pH balance, immune priming and protection against invading pathogens. Furthermore, these microbes can influence centrally regulated emotional behaviour through mechanisms including microbially derived bioactive molecules (amino acid metabolites, short-chain fatty acids, neuropeptides and neurotransmitters), mucosal immune and enteroendocrine cell activation, as well as vagal nerve stimulation.The microbiota-gut-brain axis comprises a dynamic matrix of tissues and organs including the brain, autonomic nervous system, glands, gut, immune cells and gastrointestinal microbiota that communicate in a complex multidirectional manner to maintain homeostasis and resist perturbation to the system. Changes to the microbial environment, as a consequence of illness, stress or injury, can lead to a broad spectrum of physiological and behavioural effects locally including a decrease in gut barrier integrity, altered gut motility, inflammatory mediator release as well as nociceptive and distension receptor sensitisation. Centrally mediated events including hypothalamic-pituitary-adrenal (HPA) axis, neuroinflammatory events and neurotransmitter systems are concomitantly altered. Thus, both central and peripheral pathways associated with pain manifestation and perception are altered as a consequence of the microbiota-gut-brain axis imbalance.In this chapter the involvement of the gastrointestinal microbiota in visceral pain is reviewed. We focus on the anatomical and physiological nodes whereby microbiota may be mediating pain response, and address the potential for manipulating gastrointestinal microbiota as a therapeutic target for visceral pain.

Irritable Bowel Syndrome: Pathophysiology and Current Therapeutic Approaches

Irritable bowel syndrome (IBS) is a prevalent condition affecting 10-20% of adults in most countries; IBS results in significant morbidity and health care costs. IBS is a disorder of the brain-gut axis, and recent insights into the pathophysiological mechanisms include altered bile acid metabolism, neurohormonal regulation, immune dysfunction, alterations in the epithelial barrier, and secretory properties of the gut. There remains a significant unmet need for effective treatments, particularly for the pain component of IBS, although the introduction of drugs directed at secretion, motility, and a nonabsorbable antibiotic provides an option for the bowel dysfunction in IBS.

Rifaximin for the treatment of diarrhea-predominant irritable bowel syndrome

Irritable bowel syndrome (IBS) is a chronic, functional bowel disorder characterized by abdominal pain or discomfort and altered bowel habit. The pathophysiology is unclear, but may include altered gut motility, visceral hypersensitivity, abnormal central pain processing, chronic low-grade intestinal inflammation, or disturbances in the gut microbiome. These etiological mechanisms, alongside environmental factors such as stress and anxiety, vary between individuals and represent potential targets for treatment. Rifaximin is a poorly absorbed oral antibiotic proposed to act on the gut microenvironment, used in the treatment of travelers' diarrhea and hepatic encephalopathy. Clinical trials suggest the drug can reduce global IBS symptoms and improve bloating, abdominal pain, and stool consistency in some patients with non-constipated IBS, leading to Food and Drug Administration approval in the United States. This article considers the pharmacology of rifaximin, the evidence for its use in IBS, and the safety and tolerability of the drug.

Randomised clinical trial: low-FODMAP rye bread vs. regular rye bread to relieve the symptoms of irritable bowel syndrome

BACKGROUND

Grains are high in FODMAPs (Fermentable Oligo-, Di-, Monosaccharides And Polyols) and often considered as triggers of IBS symptoms.

AIM

To evaluate if rye bread low in FODMAPs would be better tolerated than regular rye bread in subjects with IBS.

METHODS

The study was conducted as a randomised double blind controlled cross-over study (n = 87). Participants were supplied with both regular rye bread and low-FODMAP rye bread for 4 weeks. Symptoms were measured with a symptom severity scoring system (IBS-SSS) and visual analogue scale (VAS) assessments of individual symptoms. Quality of life was monitored. Colonic fermentation was measured by the breath hydrogen test and dietary intake by food diaries.

RESULTS

Dietary fibre intake increased during both study periods compared to baseline. Many signs of IBS i.e. flatulence, abdominal pain, cramps and stomach rumbling were milder on the low-FODMAP rye bread (P-values: 0.04; 0.049; 0.01 and 0.001). The mean of VAS measurements was favourable towards LF bread [-3 (95% CI): -6 to -1, P = 0.02] but no differences were detected in IBS-SSS or quality of life. The AUC of breath hydrogen values was significantly lower during the low-FODMAP bread period (median 52.9 vs. 72.6; P = 0.01).

CONCLUSIONS

Low-FODMAP rye bread helps IBS patients to control their symptoms and reduces gastrointestinal gas accumulation. However, replacing regular rye bread by low-FODMAP bread without concomitant broader dietary changes does not improve quality of life or IBS-SSS. Nonetheless, inclusion of low-FODMAP rye bread in diet might be one way that IBS patients could increase their fibre intake.

Response of irritable bowel syndrome with constipation patients administered a combined quebracho/conker tree/M. balsamea Willd extract

The aim of this case series was to retrospectively examine the symptom response of irritable bowel syndrome with constipation (IBS-C) patients administered an herbal extract in a real-world setting. Twenty-four IBS-C patients in a community office practice were provided a combination over-the-counter dietary supplement composed of quebracho (150 mg), conker tree (470 mg) and M. balsamea Willd (0.2 mL) extracts (Atrantil™) and chose to take the formulation for a minimum of 2 wk in an attempt to manage their symptoms. Patient responses to the supplement were assessed by visual analogue scale (VAS) for abdominal pain, constipation and bloating at baseline and at 2 wk as part of standard-of-care. Patient scores from VAS assessments recorded in medical chart data were retrospectively compiled and assessed for the effects of the combined extract on symptoms. Sign tests were used to compare changes from baseline to 2 wk of taking the extract. Significance was defined as P < 0.05. Twenty-one of 24 patients (88%) responded to the dietary supplement as measured by individual improvements in VAS scores for abdominal pain, bloating and constipation symptoms comparing scores prior to administration of the extract against those reported after 2 wk. There were also significant improvements in individual as well as mean VAS scores after 2 wk of administration of the combined extract compared to baseline for abdominal pain [8.0 (6.5, 9.0) vs 2.0 (1.0, 3.0), P < 0.001], bloating [8.0 (7.0, 9.0) vs 1.0 (1.0, 2.0), P < 0.001] and constipation [6.0 (3.0, 8.0) vs 2.0 (1.0, 3.0), P < 0.001], respectively. In addition, 21 of 24 patients expressed improved quality of life while taking the formulation. There were no reported side effects to administration of the dietary supplement in this practice population suggesting excellent tolerance of the formulation. This pilot retrospective analysis of symptom scores from patients before and after consuming a quebracho/conker tree/M. balsamea Willd extract may support the formulation’s use in IBS-C.

THE INTESTINAL MICROBIOTA AND THE ROLE OF PROBIOTICS IN IRRITABLE BOWEL SYNDROME: a review

Irritable bowel syndrome is a common, chronic relapsing gastrointestinal disorder that affects 7%-22% of the population worldwide. According to Rome III Criteria, the disorder is defined by the coexistence of abdominal discomfort or pain associated with an alteration in bowel habits. Its pathophysiology is not completely understood but, in addition to some important abnormalities, the disturbed intestinal microbiota has also been described supported by several strands of evidence. The treatment of irritable bowel syndrome is based upon several therapeutic approaches but few have been successful or without adverse events and more recently the gut microbiota and the use of probiotics have emerged as a factor to be considered. Probiotics are live micro-organisms which when consumed in adequate amounts confer a health benefit to the host, such as Lactic bacteria among others. An important scientific rationale has emerged for the use of probiotics in irritable bowel syndrome, although the data regarding different species are still limited. Not all probiotics are beneficial: it is important to select the specific strain which should be supported by good evidence base. The mechanisms of action of probiotics are described and the main strains are quoted.