Review article: gut-directed hypnotherapy in the management of irritable bowel syndrome and inflammatory bowel disease

Case Study: An Integrative Modification of Gut-Directed Hypnotherapy for a Patient with Intermittent Flares of Long-Standing Irritable Bowel Syndrome

This article presents a case of a patient whose treatment for irritable bowel syndrome (IBS) involved a modification of gut-directed hypnotherapy (GDH). It was delivered in a nonstandard schedule and integrated concepts from other therapeutic modalities, primarily mindfulness meditation and narrative therapy. A review of the literature on GDH and prior modifications, as well as other iterations of integrative hypnosis, will be provided. Along with describing the case, a rationale for the treatment and examples of the modification will be presented.

Comparison of Digitally Delivered Gut-Directed Hypnotherapy Program With an Active Control for Irritable Bowel Syndrome

INTRODUCTION

Gut-directed hypnotherapy (GDH) treats irritable bowel syndrome (IBS), but its accessibility is limited. This problem may be overcome by digital delivery. The aim of this study was to perform a randomized control trial comparing the efficacy of a digitally delivered program with and without GDH in IBS.

METHODS

Adults with IBS were randomized to a 42-session daily digital program with the GDH Program (Nerva) or without (Active Control). Questionnaires were completed to assess gastrointestinal symptoms through IBS Symptom Severity Scale (IBS-SSS), quality of life, and psychological symptoms (Depression Anxiety and Stress Scale-21) at regular intervals during the program and 6 months following the conclusion on the intervention. The primary end point was the proportion of participants with ≥50-point decrease in IBS-SSS between the interventions at the end of the program.

RESULTS

Of 240/244 randomized participants, 121 received GDH Program-the median age 38 (range 20-65) years, 90% female, IBS-SSS 321 (interquartile range 273-367)-and 119 Active Control-36 (21-65), 91% female, IBS-SSS 303 (255-360). At program completion, 81% met the primary end point with GDH Program vs 63% Active Control ( P = 0.002). IBS-SSS was median 208 (interquartile range 154-265) with GDH and 244 (190-308) with control ( P = 0.004), 30% reduction in pain was reported by 71% compared with 35% ( P < 0.001), and IBS quality of life improved by 14 (6-25) compared with 7 (1-15), respectively ( P < 0.001). Psychological status improved similarly in both groups.

DISCUSSION

A digitally delivered GDH Program provided to patients with IBS was superior to the active control, with greater improvement in both gastrointestinal symptoms and quality of life and provides an equitable alternative to face-to-face behavioral strategies.

Current state of the non-pharmacological management of irritable bowel syndrome: an up-to-date review of the literature

Irritable bowel syndrome (IBS) is a complex disorder of gut-brain interaction (DGBI) that is thought to affect a significant proportion of the population. As a result of the nature of IBS, it is hard to predict treatment efficacy as all individuals respond differently, and thus multidisciplinary treatment has become increasingly of interest as it targets multiple aspects of IBS at the same time. Here, we aim to review the literature of both multidisciplinary and single-discipline therapy for IBS. Ovid MEDLINE was utilised with a systematic search to find relevant randomised controlled trials. The population included adults with a Rome diagnosis of IBS and an intervention that was either multidisciplinary care, diet, psychotherapy, gut-directed hypnotherapy (GDH) or physiotherapy. Multidisciplinary care studies found an overall significant improvement, while dietary treatment was varied. A low fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet was the only one to improve symptoms, while gluten-free and fibre diets had mixed evidence for their efficacy. Novel diets, including a tritordeum-based diet and low tryptophan diet, significantly improved symptoms. Cognitive behavioural therapy was found to be efficacious when compared to controls, as was psychoeducation. GDH was also found to be efficacious, but 83.3% of studies examined a refractory IBS population. There is a lack of literature looking at how multidisciplinary care and different combinations of disciplines work to treat those with IBS in secondary care. Further studies are required for a greater understanding of how multidisciplinary care may be utilised to better manage IBS.

Chronic Abdominal Pain in Patients with Inflammatory Bowel Disease in Remission: A Continuing Challenge for Clinicians

Inflammatory bowel disease (IBD) is a chronic condition that includes ulcerative colitis and Crohn's disease. It is characterized by a relapsing and remitting pattern that negatively impacts quality of life (QoL). Current goals of treatment involve symptomatic, biochemical, and endoscopic remission in a treat-to-target approach. Despite effective treatment and remission of IBD, many patients report frequent and isolated abdominal pain. A wide range of etiologies exist, including surgery-related, infections, pelvic conditions, immune-related, and systemic illnesses. Disorders of the gut-brain interaction (DGBI), frequently characterized by abdominal pain, are increasingly recognized in IBD patients, including those with quiescent disease. Various mechanisms are involved and numerous non-pharmacologic and pharmacologic therapies have been proposed. Hereby, we outline the pertinent findings of the literature on management of chronic abdominal pain, focusing on quiescent IBD.

A Review of Pharmacologic and Non-Pharmacologic Therapies in the Management of Irritable Bowel Syndrome: Current Recommendations and Evidence

Irritable bowel syndrome (IBS) is a highly prevalent and debilitating disorder of gut-brain interaction (DGBI) affecting millions globally. It imposes a significant burden on healthcare systems and is a leading cause of workplace absenteeism. IBS is classified into several subtypes based on predominant presenting symptoms, including IBS with constipation (IBS-C) and IBS with diarrhea (IBS-D), with each requiring targeted approaches to treatment. Some treatments, such as psychotherapy, dietary intervention, and medications like tricyclic antidepressants, are nonspecific and recommended for managing IBS symptoms across all subtypes. In contrast, therapies like secretagogues for IBS-C and eluxadoline or rifaximin for IBS-D are subtype-specific. However, many IBS treatments carry conditional recommendations and are based on low-certainty evidence, emphasizing the need for further research to expand the available treatment options. This review compares the latest IBS management guidelines from the American Gastroenterological Association (AGA), American College of Gastroenterology (ACG), British Society of Gastroenterology (BSG), and European Society for Neurogastroenterology and Motility (ESNM). Pharmacologic and non-pharmacologic therapies, including established and emerging interventions, will be explored to provide a comprehensive guide to management.

Can Hypnotherapy Be Considered a Valuable Component in the Management of Inflammatory Bowel Disease? Insights from a Comprehensive Review

Despite advancements in medication,managing inflammatory bowel disease (IBD) remains challenging, necessitatingalternative control methods. Gut-directed hypnotherapy, known for alleviating irritable bowel syndrome (IBS), is debated as an IBD management method. Anextensive search across PubMed, Cochrane Library, and Clinicaltrials.govuncovered five randomized trials and two case series involving IBD patients undergoing hypnotherapy. A small trial reported statistically significant remission at one year (p = .04), but larger trials, including one with 63 patients, showed no significant gastrointestinal improvements. The first case series noted post-intervention reduction in the mediators of inflammation in rectal mucosal, without long-term monitoring. The second case series observed the absence of flare episodes in 12 of 13 ulcerative colitis patients during follow-up, possibly influenced by the simultaneous use of two drugs alongside hypnotherapy. Psychological outcomes, demonstrated no significant differences between hypnotherapy and control groups. While current literature doesn't decisively support hypnotherapy for managing IBD symptoms, it underscores the importance of further research, including randomized clinical trials, to thoroughly assess its effectiveness in this context.

Unmet needs of drugs for irritable bowel syndrome and inflammatory bowel diseases: interest of vagus nerve stimulation and hypnosis

The gut and the brain communicate bidirectionally through the autonomic nervous system. The vagus nerve is a key component of this gut-brain axis, and has numerous properties such as anti-inflammatory, antinociceptive, anti-depressive effects. A perturbation of this gut-brain communication is involved in the pathogeny of functional digestive disorders, such as irritable bowel syndrome, and inflammatory bowel diseases. Stress plays a role in the pathogeny of these diseases, which are biopsychosocial models. There are presently unmet needs of pharmacological treatments of these chronic debilitating diseases. Treatments are not devoid of side effects, cost-effective, do not cure the diseases, can lose effects over time, thus explaining the poor satisfaction of patients, their lack of compliance, and their interest for non-drug therapies. The gut-brain axis can be targeted for therapeutic purposes in irritable bowel syndrome and inflammatory bowel disease through non-drug therapies, such as hypnosis and vagus nerve stimulation, opening up possibilities for responding to patient expectations.

The Interaction between Stress and Inflammatory Bowel Disease in Pediatric and Adult Patients

Background: Inflammatory bowel diseases (IBDs) have seen an exponential increase in incidence, particularly among pediatric patients. Psychological stress is a significant risk factor influencing the disease course. This review assesses the interaction between stress and disease progression, focusing on articles that quantified inflammatory markers in IBD patients exposed to varying degrees of psychological stress. Methods: A systematic narrative literature review was conducted, focusing on the interaction between IBD and stress among adult and pediatric patients, as well as animal subjects. The research involved searching PubMed, Scopus, Medline, and Cochrane Library databases from 2000 to December 2023. Results: The interplay between the intestinal immunity response, the nervous system, and psychological disorders, known as the gut-brain axis, plays a major role in IBD pathophysiology. Various types of stressors alter gut mucosal integrity through different pathways, increasing gut mucosa permeability and promoting bacterial translocation. A denser microbial load in the gut wall emphasizes cytokine production, worsening the disease course. The risk of developing depression and anxiety is higher in IBD patients compared with the general population, and stress is a significant trigger for inducing acute flares of the disease. Conclusions: Further large studies should be conducted to assess the relationship between stressors, psychological disorders, and their impact on the course of IBD. Clinicians involved in the medical care of IBD patients should aim to implement stress reduction practices in addition to pharmacological therapies.

Development and Current State of Digital Therapeutics for Irritable Bowel Syndrome

BACKGROUND & AIMS

Irritable bowel syndrome (IBS) is a common, debilitating disorder characterized by abdominal pain and disordered bowel habits. Current pharmacologic treatments often provide incomplete symptom relief and may be poorly tolerated. Furthermore, alleviation of gastrointestinal symptoms does not always translate into improved quality of life for IBS patients. Current treatment guidelines recommend brain-gut behavior therapy (BGBT) in conjunction with other IBS therapies, and, in randomized controlled trials, BGBT has been shown to improve symptoms, patient satisfaction, functioning, and quality of life. Access to BGBT is limited by lack of adequately trained gastrointestinal psychologists, patient time constraints, and cost. Furthermore, clinician knowledge that BGBT is specific, and different from psychotherapy approaches for common mental health disorders, may limit referrals even where available. This review provides an overview of the pathophysiology of IBS, disease burden, unmet therapeutic needs, evidence base of novel digital therapeutics for IBS, and guidance on the introduction and appropriateness of these interventions for patients.

METHODS

We searched the literature for available published data relating to the use of novel digital therapeutics to provide cognitive behavioral therapy and gut-directed hypnotherapy in the treatment of irritable bowel syndrome.

RESULTS

Clinical trial data support the development and utility of digital therapeutics designed to deliver self-guided cognitive behavioral therapy and hypnotherapy for the treatment of IBS.

CONCLUSIONS

BGBTs are effective, guideline-recommended treatments for IBS. Digital therapeutic devices offer accessible, cost-effective treatment options for delivery of adjunctive BGBT for the treatment of IBS. The decision to recommend digital BGBTs should be guided by careful patient assessment that includes mental health screening and risk assessment.

The effect of eye movement desensitization and reprocessing (EMDR) on abdominal pain in patients with irritable bowel syndrome (IBS): a study protocol for a randomized controlled trial (EMDR4IBS)

BACKGROUND

Irritable bowel syndrome (IBS) is a highly prevalent disorder for which treatment options such as medication, diets, and hypnotherapy either have shown limited effect or relieve symptoms in only a limited subset of patients. Abdominal pain is the key criterion for the diagnosis and is deemed the most distressing IBS symptom, and the most disruptive of everyday life. A growing body of research demonstrates the effect of Eye Movement Desensitization and Reprocessing (EMDR) on chronic pain. EMDR is known as a safe and successful treatment for disorders in which unresolved traumatic memories play a role in the cause or maintenance of symptoms. In IBS, activated memories may increase pain through pain flashbacks and the stress generated by unresolved memories. The aim of this study is to ascertain whether applying EMDR to traumatic memories including pain memories will reduce abdominal pain in IBS patients.

METHODS

This study is a randomized controlled trial which will be conducted at a city hospital in the Netherlands. Adult patients with considerable IBS pain (pain intensity at least 60/100 during at least 5/10 days) will be randomly assigned to either EMDR therapy or the wait list. We aim to include 34 participants. The EMDR condition comprises seven sessions, around 90 min in length delivered weekly, the first of which is a case conceptualization session. All participants will be assessed at baseline, post-treatment, and at 3 months follow-up. The primary outcome measure is pain intensity on a Likert scale which is self-reported daily during a 2-week period. Secondary outcomes include similar daily ratings on other IBS symptoms and reported hindrance of valued activities, and also standardized questionnaires on IBS symptoms and Quality of Life. Data will be analyzed by a Linear Mixed Effects Model for repeated measures.

DISCUSSION

The results are expected to gain insight into the effectiveness of EMDR treatment on abdominal pain in IBS. As there are very few effective treatment options for IBS-related abdominal pain, this study could have important implications for clinical practice.

TRIAL REGISTRATION

Human ethics committee MEC-U NL71740.100.20. International Clinical Trial Registry Platform: NL8894. Prospectively registered on 28 January 2020.

Psychological treatments for irritable bowel syndrome: a comprehensive systematic review and meta-analysis

A wide range of psychological treatments have been found to reduce the symptoms of irritable bowel syndrome (IBS) but their relative effects are unclear. In this systematic review and meta-analysis, we determined the effects of psychological treatments for IBS, including subtypes of cognitive behavior therapy, versus attention controls. We searched 11 databases (March 2022) for studies of psychological treatments for IBS, reported in journal articles, books, dissertations, and conference abstracts. The resulting database comprised 9 outcome domains from 118 studies published in 1983-2022. Using data from 62 studies and 6496 participants, we estimated the effect of treatment type on improvement in composite IBS severity using random-effects meta-regression. In comparison with the attention controls, there was a significant added effect of exposure therapy (g = 0.52, 95% CI = 0.17-0.88) and hypnotherapy (g = 0.36, 95% CI = 0.06-0.67) when controlling for the pre- to post-assessment duration. When additional potential confounders were included, exposure therapy but not hypnotherapy retained a significant added effect. Effects were also larger with a longer duration, individual treatment, questionnaire (non-diary) outcomes, and recruitment outside of routine care. Heterogeneity was substantial. Tentatively, exposure therapy appears to be a particularly promising treatment for IBS. More direct comparisons in randomized controlled trials are needed. OSF.io identifier: 5yh9a.

Virtual adjunctive gut-directed hypnotherapy for people with Crohn's disease: A randomized controlled pilot and feasibility trial

BACKGROUND

Gut-directed hypnotherapy appears to be a promising adjunctive treatment for people with Crohn's disease. The primary objective of this pilot trial was to evaluate feasibility and acceptability of virtually delivered hypnotherapy to determine the parameters for a future definitive trial.

METHODS

This prospective, single-site, randomized controlled pilot and feasibility trial compared a 7-week course of virtually delivered adjunctive gut-directed hypnotherapy to standard medical treatment only for adults with Crohn's disease. Primary outcomes were study feasibility and intervention acceptability. Secondary outcomes were objective disease activity and patient-reported outcomes. Assessments took place at five time-points: baseline, post-intervention, and follow-up three-, six-, and 12-months post-intervention.

KEY RESULTS

Recruitment took place between July 2020 and August 2021 at a tertiary hospital. Recruitment was initially slow and subsequently expanded to community settings. Thirty-seven participants were enrolled in the trial: 95% were retained at post-intervention and 76% at 12-months. Completion of online assessments was high (97-100% across all time-points) whilst objective data collection was low (34-44%). Most intervention participants completed all hypnotherapy sessions (88%) and reported being extremely satisfied (73%), despite 60% experiencing technical issues.

CONCLUSION & INFERENCES

Virtually delivered hypnotherapy was acceptable to participants. Certain aspects of the trial including online assessment were feasible, while recruitment and objective data collection were challenges. Undertaking a future definitive trial will require broader recruitment scope and significant funding for widespread objective data collection.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ANZCTR#1260000348954.

Chronic abdominal pain in inflammatory bowel disease: a practical guide

Pain is common in inflammatory bowel disease (IBD), yet many patients feel their pain is not addressed by healthcare professionals. Listening to a patient's concerns about pain, assessing symptoms and acknowledging the impact these have on daily life remain crucial steps in addressing pain in IBD. While acute pain may be effectively controlled by pain medication, chronic pain is more complex and often pharmacological therapies, particularly opioids, are ineffective. Low-dose tricyclic antidepressants and psychological approaches, including cognitive-behavioural therapy, have shown some promise in offering effective pain management while lifestyle changes such as a trial of low-fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet in those with overlapping irritable bowel syndrome may also reduce pain. Patients benefit from a long-term, trusting relationship with their healthcare professional to allow a holistic approach combining pharmacological, psychological, lifestyle and dietary approaches to chronic pain. We present a practical review to facilitate management of chronic abdominal pain in IBD.

Hypnotherapy for chronic pelvic pain: A scoping systematic review and meta-analysis

BACKGROUND

Chronic pelvic pain (CPP) is typically managed with anti-inflammatory analgesics and opioids; however, these do not adequately manage the pain or address the associated negative impact on quality of life. Hypnotherapy has been found to reduce pain associated with a range of disorders, including some with symptoms of chronic pain.

AIM

The aim of this review is to systematically scope research investigating the use of hypnosis on chronic pelvic pain, quality of life, anxiety, depression and fatigue.

METHOD

The scoping review was guided by the method described by Arksey and O'Mallee [1]. A systematic search was conducted in six databases. The Covidence Risk of Bias tool and the National Institutes of Health (NIH) quality assessment tool were used.

RESULTS

Nine studies (four RCT's and five case series) were suitable for inclusion. Meta-analysis of the RCT's found no significant difference in pain or quality of life for the intervention group compared to controls. Only one study reported a reduction in pain after hypnotherapy and did not outperform controls. These results are limited due to lack of a standardised intervention and heterogeneity of the included studies.

CONCLUSION

There is a need for further research using well designed randomized controlled trials with validated measures of pain, quality of life, anxiety, depression and fatigue. Hypnotherapy interventions utilised in further research should be grounded in evidence-based best practice for dealing with pain.

IBD-related mental health disorders: where do we go from here?

Inflammatory bowel disease is a complex and debilitating disease which is known to cause mental burden for patients. Even though few studies look at mental health disease in this cohort of patients, there is growing evidence of a correlation between disease activity and prevalence of mental health conditions such as anxiety, depression and post-traumatic stress disorder. In this literature review, the relationship between inflammatory bowel disease and mental health disorders is explored, with an emphasis on recognition, screening and therapeutic options and special considerations for these complex comorbidities. The relationship between medical and psychological disease is not often considered and less well understood and there is a need for further research in these fields. Patients would have much to gain both medically and psychologically from a multidisciplinary approach to this chronic disease association.

The neurobiology of irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most prevalent disorder of brain-gut interactions that affects between 5 and 10% of the general population worldwide. The current symptom criteria restrict the diagnosis to recurrent abdominal pain associated with altered bowel habits, but the majority of patients also report non-painful abdominal discomfort, associated psychiatric conditions (anxiety and depression), as well as other visceral and somatic pain-related symptoms. For decades, IBS was considered an intestinal motility disorder, and more recently a gut disorder. However, based on an extensive body of reported information about central, peripheral mechanisms and genetic factors involved in the pathophysiology of IBS symptoms, a comprehensive disease model of brain-gut-microbiome interactions has emerged, which can explain altered bowel habits, chronic abdominal pain, and psychiatric comorbidities. In this review, we will first describe novel insights into several key components of brain-gut microbiome interactions, starting with reported alterations in the gut connectome and enteric nervous system, and a list of distinct functional and structural brain signatures, and comparing them to the proposed brain alterations in anxiety disorders. We will then point out the emerging correlations between the brain networks with the genomic, gastrointestinal, immune, and gut microbiome-related parameters. We will incorporate this new information into a systems-based disease model of IBS. Finally, we will discuss the implications of such a model for the improved understanding of the disorder and the development of more effective treatment approaches in the future.

Patients' experiences with virtual group gut-directed hypnotherapy: A qualitative study

Background

Hypnotherapy is a useful treatment for a variety of gastrointestinal conditions. While there is strong evidence for delivering other treatments virtually and in groups, there is no research thus far on delivering hypnotherapy in this format. Given the growth of both psychogastroenterology and telehealth, these methods should be explored as they have great potential for increasing access and cost-effectiveness of intervention.

Aims

This qualitative study was developed to help understand patients experiences in virtual, group-based, gut-directed hypnotherapy (GDH) in two different institutions.

Methods

Authors developed a qualitative interview with the assistance of two patient partners and then recruited patients from New York University and Dartmouth Health to participate. Interviews were completed one-on-one with patients who started and then completed GDH (≥5 visits) and who did not complete GDH (≤3 visits). Data were coded and then analyzed using thematic analysis.

Results

Twenty-one patients from NYU and Dartmouth participated in qualitative interviews. Broadly, patients reported coming to GDH because they believed in the importance of the mind-body connection or were desperate for treatment. Regardless of why patients came to GDH, they generally reported positive outcomes for GI symptoms and for other physical and mental health conditions. Most patients appreciated the group and virtual formats, though some concerns about inflexible schedules and lack of anonymity were voiced. Despite these concerns, there was broad support for virtual, group-based GDH and general excitement for behavioral health programming.

Conclusion

Virtual, group-based GDH is an acceptable treatment for patients from rural and urban settings. Given the possible improvements in access and cost-effectiveness that this treatment modality can provide, GI practices may want to consider it in lieu of or in addition to the traditional one-on-one treatment format. Barriers and facilitators and recommendations for practice are discussed.

Psychological distress in inflammatory bowel disease

INTRODUCTION

Mental health disorders are common in inflammatory bowel disease (IBD) and affect patients' quality of life, impacting on disease outcomes and health care-related costs.

AREAS COVERED

Even if psychological issues in IBD patients are highly burdened in terms of quality of life, psychiatric comorbidities still receive less attention into routine care than the physical symptoms of the disease. The present review provides an overview of recent literature, focusing on the association between perceived stress and IBD outcomes. For this purpose, the epidemiology of more common psychological comorbidities in IBD and their potential effect on the onset and disease course have been examined. Moreover, therapeutic interventions in the management of these patients have also been evaluated.

EXPERT OPINION

Screening of patients at high risk of psychological issues is currently an unmet, clinical need in the management of IBD. Under-diagnosed and under-treated mental health disorders in IBD patients may impact outcomes, leading to increased disability and health-care utilization and associated costs. A patient-tailored, integrated model of care in the management of IBD is required to optimize disease outcomes and improve patients' quality of life.

Hypnotherapy and IBS: Implicit, long-term stress memory in the ENS?

The association between irritable bowel syndrome (IBS) and psychiatric and mood disorders may be more fundamental than was previously believed. Prenatal, perinatal, postnatal, and early-age conditions can have a key role in the development of IBS. Subthreshold mental disorders (SMDs) could also be a significant source of countless diverse diseases and may be a cause of IBS development. We hypothesize that stress-induced implicit memories may persist throughout life by epigenetic processes in the enteric nervous system (ENS). These stress-induced implicit memories may play an essential role in the emergence and maintenance of IBS. In recent decades, numerous studies have proven that hypnosis can improve the primary symptoms of IBS and also reduce noncolonic symptoms such as anxiety and depression and improve quality of life and cognitive function. These significant beneficial effects of hypnosis on IBS may be because hypnosis allows access to unconscious brain processes.

[Hypnotherapy for Irritable Bowel Syndrome]

Irritable bowel syndrome (IBS) is a functional disorder of the lower digestive tract. Based on the biopsychosocial model, there is a wide range of therapeutic interventions to deal with the symptoms of IBS and to improve the quality of life of those who are affected. In this context, hypnotherapy and in particular gut-directed hypnosis represents a psychotherapeutic intervention with great empirical evidence for its efficacy.

Heart Rate Variability-An Index of the Efficacy of Complementary Therapies in Irritable Bowel Syndrome: A Systematic Review

Irritable bowel syndrome (IBS), as a functional and psychosomatic disease, reduces the quality of life and increases the risk of developing mental disorders. Deregulation of the autonomic nervous system (ANS) is one of the main causes of the disease. The objective of the present study was to identify the studies in which measurements of heart rate variability (HRV) were performed before and after therapeutic intervention, and to evaluate the effectiveness of IBS therapy in terms of a reduction of IBS symptoms and changes in autonomic tone. A systematic review of the literature was carried out in accordance with PRISMA standards. Six databases were searched for articles published before 2022: PubMed®, MEDLINE®, EBSCO, Cochrane, Scopus, and Web of Science. Inclusion criteria were experimental design, diagnosis of IBS (medical and/or diagnosis in accordance with the Rome Criteria), non-pharmacological intervention, and HRV measurement before and after the intervention. The quality of the studies was assessed by JBI Critical appraisal. In total, 455 studies were identified, of which, sixwere included in the review. Expected changes in HRV (increase in parasympathetic activity) were observed in four of the six studies (interventions studied: ear acupressure, transcutaneous auricular vagusnerve stimulation, cognitive behavioral therapy with relaxation elements, yoga). In the same studies, therapeutic interventions significantly reduced the symptoms of IBS. The present review indicated that interventions under investigation improve the efficiency of the ANS and reduce the symptoms of IBS. It is advisable to include HRV measurements as a measure of the effectiveness of interventions in IBS therapy, and to assess autonomic changes as a moderator of the effectiveness of IBS therapy.

Skills or Pills: Randomized Trial Comparing Hypnotherapy to Medical Treatment in Children With Functional Nausea

BACKGROUND & AIMS

The potential effectiveness of gut-directed hypnotherapy (HT) is unknown for pediatric chronic nausea. This randomized controlled trial compared HT with standard medical treatment (SMT).

METHODS

One hundred children (ages, 8-18 y) with chronic nausea and fulfilling functional nausea (FN) or functional dyspepsia (FD) criteria were allocated randomly (1:1) to HT or SMT, with a 3-month intervention period. Outcomes were assessed at baseline, at the halfway point, after treatment, and at the 6- and 12-month follow-up evaluation. Children scored nausea symptoms in a 7-day diary. The primary outcome was treatment success, defined as a reduction in nausea of 50% or more, at the 12-month follow-up evaluation. Secondary outcomes included adequate relief of nausea.

RESULTS

After treatment and at the 6-month follow-up evaluation, there was a trend toward higher treatment success in the HT group compared with the SMT group (45% vs 26%, P = .052; and 57% vs 40%, P = .099, respectively). At 12 months, treatment success was similar in both groups (60% in the HT group and 55% in the SMT group; P = .667). In the FN group, significantly higher success rates were found for HT, but no differences were found in patients with FD. Adequate relief was significantly higher in the HT group than in the SMT group at the 6-month follow-up evaluation (children: 81% vs 55%, P = .014; parents: 79% vs 53%; P = .016), but not at the 12-month follow-up evaluation.

CONCLUSIONS

HT and SMT were effective in reducing nausea symptoms in children with FN and FD. In children with FN, HT was more effective than SMT during and after the first 6 months of treatment. Therefore, HT and SMT, applied separately or in combination, should be offered to children with FN as a treatment option (Clinical trials registration number: NTR5814).

Psychological interventions for inflammatory bowel disease: a systematic review and component network meta-analysis protocol

INTRODUCTION

Patients with inflammatory bowel diseases (IBD) often report psychological problems, unemployment, disability, sick leave and compromised quality of life. The effect of psychological interventions on health-related outcomes in IBD is controversial as previous reviews faced the obstacle of high heterogeneity among provided multimodular interventions. The heterogeneity can be addressed with network meta-analysis (NMA) and (multi)component NMA (CNMA). We aim to investigate whether psychological interventions can improve quality of life, clinical and social outcomes in IBD using NMA and CNMA. This is the study protocol.

METHODS AND ANALYSIS

We will consider randomised, quasi-randomised and non-randomised controlled trials, including cluster randomised and cross-over trials with 2 months of minimum follow-up. The conditions to be studied comprise Crohn's disease and ulcerative colitis in children, adolescents and adults. We will include any psychological intervention aiming to change the health status of the study participant.We will search Medline, Embase, Web of Science, CENTRAL, LILACS, Psyndex, PsycINFO, Google Scholar and trial registries from inception (the search will be updated before the review completion). Two authors will independently screen all references based on titles and abstracts. For data extraction, standard forms are developed and tested before extraction. All information will be assessed independently by at least two reviewers, and disagreements solved by consensus discussion or a third rater if necessary.The data synthesis will include a pairwise meta-analysis supported by meta-regression. We will conduct NMA (all treatments will constitute single nodes of the network) and CNMA (we will define all treatments as sums of core components, eg, cognitive +behaviour, or cognitive +behaviour + relaxation, and additionally consider interactions) using the R Package netmeta.

ETHICS AND DISSEMINATION

No ethical approval is required. Reports will include the final report to the funder, conference presentation, peer-reviewed publication and a patient report.

PROSPERO REGISTRATION NUMBER

CRD42021250446.

Hypnotherapy for persons with Irritable Bowel Syndrome: A three-arm randomized controlled trial

The current study sought to (1) compare the efficacies of Ericksonian hypnotherapy, traditional hypnotherapy, and educational talk in treating irritable bowel syndrome (IBS), and to (2) evaluate the impacts of hypnotic susceptibility on participants' responses to hypnotherapy. The study adopted a three-arm randomized controlled trial design and achieved an effective sample size of 144. Self-reported psychological questionnaires were used to assess participants' IBS symptom severity, health-related quality of life, and coping patterns at baseline, immediately post-intervention, and 3 months after intervention. The evaluation focused primarily on IBS symptom severity and health-related quality of life, as well as on the illness coping patterns of symptom catastrophizing and symptoms-related social hypervigilance.The findings showed that significant improvements in IBS symptom severity occurred in all three types of study groups immediately after completion of the intervention (p < .05, η_ρ² = .20). However, only the traditional hypnotherapy groups and the Ericksonian hypnotherapy groups still had a notably significant decrease in symptoms 3 months after the intervention, whereas the educational talk groups had dropped back to pre-treatment symptom levels at the 3-month follow-up. The amplitude of change of symptom catastrophizing in the traditional hypnotherapy groups was stronger than that in the Ericksonian hypnotherapy groups after completion of the intervention, and the two types of hypnotherapy groups were significantly lower in symptom catastrophizing both immediately after the intervention and also 3 months post-intervention (p < .001, η_ρ² = .17). The other coping mechanism studied, symptoms-related social hypervigilance, showed a significant decline only in the Ericksonian hypnotherapy groups (ps < .001, η_ρ² = .45). Interestingly, in the traditional hypnotherapy groups, persons with higher hypnotic susceptibility showed significant improvement in symptom severity, health-related quality of life, and coping patterns following treatment. Notably, the effects from Ericksonian hypnotherapy for IBS diverged from the effects from traditional hypnotherapy. Finally, both Ericksonian hypnotherapy and traditional hypnotherapy appeared to have greater positive effects than educational talk did, but at different levels.

Review article: the patients' experience with irritable bowel syndrome and their search for education and support

BACKGROUND & AIMS

METHODS: The author looked at the impact of IBS with a review of the scientific evidence with the following aims: a) to study the effect of IBS on a patient's quality of life, health care utilization rates and the importance of education on their condition and associated treatments b) to characterize the influence of sociocultural factors, health care literacy and the role that education has in improving clinical outcomes and c) to make recommendations of how to effectively provide education to patients about their diagnosis and treatment options in order to improve symptoms and clinical outcomes.

RESULTS

Evidence supports the fact that interventions targeting patient-provider interactions in order to provide validated and evidence based education options can improve health outcomes, the patient and provider experience, and reduce costs. Effectively communicating the rationale of the brain-gut axis, as well as treatments such as the benefits of neuromodulators or behavioral health treatments can improve patient satisfaction and clinical outcomes.

CONCLUSIONS

The author concluded that effective patient education can improve the patient-provider relationship and health outcomes. The author also provides info-graphics and a listing of vetted, scientifically backed educational resources for patients to utilize for self management.

Local immune response as novel disease mechanism underlying abdominal pain in patients with irritable bowel syndrome

OBJECTIVES

Irritable bowel syndrome (IBS) is the most frequently diagnosed functional gastrointestinal disorder, with a prevalence of up to 25% of the global population. IBS patients suffer from abnormal abdominal pain, or visceral hypersensitivity (VHS), associated with altered bowel habits in the absence of an organic detectable cause. The pathophysiology of the disease is incompletely understood, but the dysregulation of the brain-gut axis is well established in IBS.

METHODS

IBS onset is mainly triggered by infectious gastroenteritis, psychological factors, and dietary factors, but genetic predispositions and intestinal dysbiosis might also play a role. Additionally, immune activation, and particularly chronic mast cell activation, have been shown to underlie the development of abdominal pain in IBS.

RESULTS

By releasing increased levels of mediators, including histamine, mast cells sensitize enteric nociceptors and lead to VHS development. The mechanisms underlying aberrant mast cell activation in IBS are still under investigation, but we recently showed that a local break in oral tolerance to food antigens led to IgE-mediated mast cell activation and food-induced abdominal pain in preclinical models and in IBS patients.

CONCLUSION

The concept of food-mediated VHS highlights the potential of therapies targeting upstream mechanisms of mast cell sensitization to treat IBS.

Influence of trauma on clinical outcomes, quality of life and healthcare resource utilization following psychogastroenterology intervention

INTRODUCTION

Patients with disorders of gut-brain interaction (DGBI) are more likely to report a history of psychological trauma, including abuse, compared with controls. The purpose of this study was to evaluate the prevalence of trauma amongst patients in a GI behavioral health program and assess the impact of trauma on GI-specific quality of life, psychological distress, and healthcare utilization.

METHODS

We conducted a retrospective analysis for 205 patients who completed treatment in the GI behavioral health program. Measures included the IBS-QOL and the Brief Symptom Inventory-18 (BSI-18), as well as a retrospective chart review to examine healthcare utilization (HCU).

RESULTS

Patients with a trauma history had significantly greater psychological distress on the BSI-18 compared with controls (63.32 vs 57.40, p < .001). Patients with trauma also endorsed significantly poorer GI-specific QOL compared with controls (54.57 vs 64.15, p = .001). Patients with and without trauma demonstrated improvements in distress and GI-specific QOL following behavioral treatment. Comparison of one year pre and post treatment HCU revealed a mean decrease in HCU from 6.87 contacts to 4.21 contacts per year.

CONCLUSIONS

In a sample of GI behavioral health patients, those with a history of trauma endorsed higher levels of distress and poorer GI-specific QOL at baseline. Both groups benefitted equally from behavioral treatment. The impact of GI behavioral treatment on patient mental health, GI-specific quality of life and HCU lends support to the assessment of patient trauma history by gastroenterologists in order to provide more comprehensive treatment for their GI health.

Evaluation of the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) on patients with centrally mediated abdominal pain syndrome: a randomized controlled trial

BACKGROUND

Centrally mediated abdominal pain syndrome (CAPS) is characterized by continuous or frequently recurring abdominal pain and can result in functional loss across several life domains. The efficacy of the present management methods has not been established yet. We performed a prospective randomized controlled trial to explore the short-term efficacy of local analgesic (lidocaine) and opioid analgesic (sufentanil) in patients with CAPS.

METHODS

We consecutively enrolled 130 patients who met the Rome IV CAPS criteria and divided them into the sufentanil + lidocaine (S + L) group and sufentanil (S) group. Patients completed the pain rating scales, including the numeric rating scale (NRS) and verbal rating scale (VRS), 60 min before colonoscopy. All the patients were initially administered sufentanil. In the S + L group, we sprayed a 5 ml solution of lidocaine on the surface of ascending, transverse, descending, and sigmoid colon during colonoscope withdrawal, while 5 ml saline was sprayed in the S group. Follow up was performed 1 day, 3 days, 1 week, 2 weeks, 1 month, and 3 months after colonoscopy, to complete the pain scaling.

RESULTS

A comparison of the NRS and VRS showed that there were no significant differences between the S + L and S groups and within each group (p > 0.05).

CONCLUSIONS

Local analgesic lidocaine and opioid analgesic sufentanil showed negative efficacy during short-term observation. The opioid receptor blocker sufentanil did not worsen symptoms in patients with CAPS after colonoscopy under general anesthesia in the short term.[chictr.org.cn, Chinese Clinical Trial Identifier, ChiCTR-IOR-16008187].

Altered brain structural connectivity in patients with longstanding gut inflammation is correlated with psychological symptoms and disease duration

OBJECTIVE

We aimed to identify differences in network properties of white matter microstructure between asymptomatic ulcerative colitis (UC) participants who had a history of chronic gut inflammation, healthy controls (HCs) and a disease control group without gut inflammation (irritable bowel syndrome; IBS).

DESIGN

Diffusion weighted imaging was conducted in age and sex-matched participants with UC, IBS, and HCs (N = 74 each), together with measures of gastrointestinal and psychological symptom severity. Using streamline connectivity matrices and graph theory, we aimed to quantify group differences in brain network connectivity. Regions showing group connectivity differences were correlated with measures showing group behavioral and clinical differences.

RESULTS

UC participants exhibited greater centrality in regions of the somatosensory network and default mode network, but lower centrality in the posterior insula and globus pallidus compared to HCs (q < 0.05). Hub analyses revealed compromised hubness of the pallidus in UC and IBS compared to HCs which was replaced by increased hubness of the postcentral sulcus. Surprisingly, few differences in network matrices between UC and IBS were identified. In UC, centrality measures in the secondary somatosensory cortex were associated with depression (q < 0.03), symptom related anxiety (q < 0.04), trait anxiety (q < 0.03), and symptom duration (q < 0.05).

CONCLUSION

A history of UC is associated with neuroplastic changes in several brain networks, which are associated with symptoms of depression, trait and symptom-related anxiety, as well as symptom duration. When viewed together with the results from IBS subjects, these findings suggest that chronic gut inflammation as well as abdominal pain have a lasting impact on brain network organization, which may play a role in symptoms reported by UC patients, even when gut inflammation has subsided.

Systematic review, meta-analysis with subgroup analysis of hypnotherapy for irritable bowel syndrome, effect of intervention characteristics

BACKGROUND

Hypnotherapy has been shown to be effective at relieving global gastrointestinal symptoms (GGS) in irritable bowel syndrome (IBS). This study examines the impact of hypnotherapy delivery and participant characteristics on IBS outcomes.

METHODS

This systematic review searched CINAHL, Cochrane Library, Conference Citation Index, Embase, PubMed, PsycARTICLES, PsychINFO, Science Citation index-expanded, Social Science Citation Index. Titles and abstracts, then full-text articles were screened against inclusion criteria: trials with a concurrent comparator of hypnotherapy in adults with IBS diagnosed using Manning or ROME criteria, which provided symptom data. Included studies were extracted and assessed for bias using Cochrane Collaboration 2011 guidance. Random-effects meta-analysis was conducted with sub-group analysis to assess the impact of delivery characteristics on outcomes.

RESULTS

Twelve trials were included, 7 in the meta-analyses. Hypnotherapy reduced the risk of GGS, but this was not statistically significant, (standardised mean difference (SMD) 0.24, [-0.06, 0.54], I² 66 %). Higher frequency of sessions (≥1/week) reduced GGS (SMD 0.45 [0.23,0.67] I² 0 %), as did higher volumes of intervention (≥8 sessions with ≥6 h of contact) (SMD 0.51 [0.27,0.76] I² 0 %) and group interventions (SMD 0.45 [0.03, 0.88] I² 62 %). Only volume of intervention produced a significant effect between the subgroups.

CONCLUSION

This review suggests that high volume hypnotherapy is more beneficial than low and should be adopted for GDH. Both high frequency and group interventions are effective in reducing GGS in IBS. However, the sample size is small and more studies are needed to confirm this.

The Brain-Gut Axis: Psychological Functioning and Inflammatory Bowel Diseases

The brain-gut axis represents a complex bi-directional system comprising multiple interconnections between the neuroendocrine pathways, the autonomous nervous system and the gastrointestinal tract. Inflammatory bowel disease (IBD), comprising Crohn's disease and ulcerative colitis, is a chronic, relapsing-remitting inflammatory disorder of the gastrointestinal tract with a multifactorial etiology. Depression and anxiety are prevalent among patients with chronic disorders characterized by a strong immune component, such as diabetes mellitus, cancer, multiple sclerosis, rheumatoid arthritis and IBD. Although psychological problems are an important aspect of morbidity and of impaired quality of life in patients with IBD, depression and anxiety continue to be under-diagnosed. There is lack of evidence regarding the exact mechanisms by which depression, anxiety and cognitive dysfunction may occur in these patients, and whether psychological disorders are the result of disease activity or determinants of the IBD occurrence. In this comprehensive review, we summarize the role of the brain-gut axis in the psychological functioning of patients with IBD, and discuss current preclinical and clinical data on the topic and therapeutic strategies potentially useful for the clinical management of these patients. Personalized pathways of psychological supports are needed to improve the quality of life in patients with IBD.

Hypnotherapy for Irritable Bowel Syndrome-Type Symptoms in Patients with Quiescent Inflammatory Bowel Disease: A Randomized, Controlled Trial

BACKGROUND AND AIMS

Many inflammatory bowel disease [IBD] patients in remission have persisting symptoms, compatible with irritable bowel syndrome [IBS-type symptoms]. We aimed to compare the effectiveness of gut-directed hypnotherapy vs standard medical treatment [SMT] for IBS-type symptoms in IBD patients.

METHODS

In this multicentre, randomized, controlled, open-label trial, patients aged 12-65 years with IBD in clinical remission [global assessment] and biochemical remission [faecal calprotectin ≤100 µg/g, or ≤200 µg/g without inflammation at endoscopy] with IBS according to Rome III criteria were randomized to hypnotherapy or SMT. Primary outcome was the proportion with ≥50% reduction on a visual analog scale for symptom severity, as measured with the Irritable Bowel Syndrome Severity Scoring System [IBS-SSS] at week 40 [i.e. 6 months after finishing the intervention], compared to baseline. Secondary outcomes included total IBS-SSS score, quality of life, adequate relief, IBS-related cognitions, and depression and anxiety scores.

RESULTS

Eighty patients were included, of whom 70 received at least one session of the allocated treatment and were included in the modified intention-to-treat-population. Seven patients were excluded because of missing baseline data required for the primary outcome. The primary outcome was met in nine [27%] of 33 patients randomized to SMT and nine [30%] of 30 patients randomized to hypnotherapy [p = 0.81]. Adequate relief was reported in 60% and 40% of subjects, respectively. Exploratory analyses of secondary outcomes revealed no apparent differences between the two treatment groups.

CONCLUSIONS

Hypnotherapy was not superior to SMT in the treatment of IBS-type symptoms in IBD patients. Both treatment strategies are reasonable options from a clinical perspective.

Hypnosis in Treatment of Atopic Dermatitis: A Clinical Study

Atopic dermatitis (AD) is a multifactorial disease that may have a psychosomatic component. In this study, the authors aimed to measure the effect of hypnosis on AD in a clinical setting. Patients with AD who never had systemic treatment were offered hypnosis sessions. Twenty-seven patients with AD and a mean age of 34.5 years participated in a mean of six hypnosis sessions (range 2 to 16). AD severity can be assessed with the Eczema Area and Severity Index (EASI). EASI score was calculated during the first and last hypnosis sessions for 21 patients. Eczema improved or resolved in 26 of the 27 patients. Mean EASI score for the 21 patients evaluated was 12 at the first session and 2.8 at the last session. Hypnosis may be useful in AD and may overcome the need for systemic treatments for some patients.

Management of Irritable Bowel Syndrome: Physician-Dietitian Collaboration

Irritable bowel syndrome (IBS) affects 10%-15% of adults in the United States and 12% of the worldwide population. Gastroenterologists as well as primary care practitioners are likely to be the first resource for patients with gastrointestinal (GI) symptoms. IBS is difficult to diagnose, as it is a functional GI disorder, determined after ruling out a myriad of other diagnoses. The 2016 Rome IV criteria define IBS as "a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits. Disordered bowel habits are typically present (ie, constipation, diarrhea, or a mix of constipation and diarrhea), as are symptoms of abdominal bloating/distension occurring over at least 6 months and not less than 3 months." Treatment of IBS historically has been through medical management; however, nutrition management of IBS using the FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) elimination diet is now a recommended, first-line therapy. FODMAPs are short-chain, poorly absorbed carbohydrates that are associated with symptoms in people with IBS. This diet intervention can be quite challenging, and therefore, patients should meet with a qualified dietitian who can provide the complex diet information in a practicable form. Physician-dietitian collaboration is invaluable for IBS patients to achieve a successful outcome.

Irritable Bowel Syndrome: News from an Old Disorder

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder, which can affect all members of a society, regardless of age, sex, race or socioeconomic status. Because of its high prevalence and chronic nature, it represents a significant economic burden. In fact, these patients have a relevant impairment of their quality of life, which limits their work productivity and daily social activities, especially when it is associated with other disorders, such as anxiety and depression. The diagnosis of IBS relies on symptom-based diagnostic criteria with normal results on a limited number of complementary tests that rule out other possible diagnoses. The aetiology of this condition is incompletely established. However, evidence suggests that it is a multifactorial disorder with several different mechanisms that have been implicated as responsible for the symptoms. Since the treatment strategy is usually based on predominant symptoms and their severity, it is important to recognise the underlying mechanisms in order to successfully relief the visceral pain and altered bowel habits. The aim of this non-systematic review of the literature was to explore the pathophysiology and treatment options of IBS, highlighting the most recent evidence, from the new Rome IV criteria to the new drug armamentarium.

Managing Pain and Psychosocial Care in IBD: a Primer for the Practicing Gastroenterologist

PURPOSE OF REVIEW

This review focuses on the relationship between trauma and pain in inflammatory bowel disease (IBD), and offers effective treatment strategies.

RECENT FINDINGS

Recent evidence points to bidirectional pathways between psychiatric disorders and IBD. The impact of trauma and development of post-traumatic stress symptoms on IBD disease course is beginning to be appreciated including its relationship with pain. First-line treatments for both psychiatric and chronic pain disorders include behavioral interventions such as cognitive behavioral therapy, hypnosis, and mindfulness, and there is emerging evidence studying Acceptance and Commitment Therapy and telehealth interventions. Pharmacological treatments using neuromodulators can also be beneficial. An integrated care team, such as a subspecialty medical home model, can provide the best patient experience and address comprehensive care needs efficiently and effectively. Psychosocial factors impact IBD course and necessitate effective management. Despite the significant limitations of research, particularly lack of clinical trials examining behavioral and pharmacotherapy interventions in IBD, effective treatments exist and are best utilized in an integrated care setting.

Complementary and Alternative Medicine for Functional Gastrointestinal Disorders

The relevance of functional gastrointestinal (GI) disorders and their impact on quality of life for many patients has become an increasingly important topic in gastroenterology. A gastroenterologist can expect to see 40% of patients for motility and functional GI disorders, thus highlighting the necessity for physicians to have a strong foundation of knowledge in treatment strategies for these patients with complex disorders. A significant number of patients who suffer with functional GI disorders turn to complementary and alternative therapies to maintain control over their symptoms and often are happy with therapeutic results. This narrative presents information and treatment algorithms for the gastroenterologist to better understand and use some of the most common complementary and alternative therapies for patients with functional dyspepsia, nausea and vomiting, and irritable bowel syndrome.

Low FODMAP Diet: Evidence, Doubts, and Hopes

Food is often considered to be a precipitating factor of irritable bowel syndrome (IBS) symptoms. In recent years, there has been a growing interest in FODMAPs (Fermentable Oligo-, Di-, Mono-saccharides, And Polyols), which can be found in many common foods. A low FODMAP diet (LFD) is increasingly suggested for IBS treatment. However, long-term, large, randomized controlled studies are still lacking, and certainties and doubts regarding LFDs have grown, often in a disorderly and confused manner. Some potential LFD limitations and concerns have been raised, including nutritional adequacy, cost, and difficulty in teaching the diet and maintaining it. Most of these limitations can be solved with the involvement of a skilled nutritionist, who can clearly explain the different phases of the LFD and ensure nutritional adequacy and compliance. Further studies should focus on new methods of teaching and learning the LFD and on predictors of response. Moreover, particular interest should be focused on the possible use of LFD in gastrointestinal diseases other than functional disorders and, possibly, also in non-gastrointestinal diseases. The aim of the present review was to clarify the effective and appropriate indications and limitations of an LFD and to discuss its possible future uses.

Effects of Low-FODMAPS Diet on Irritable Bowel Syndrome Symptoms and Gut Microbiome

Patients with irritable bowel syndrome (IBS) suffer from abdominal pain, bloating, and abnormal defecation. Reducing the dietary intake of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) has been shown to be beneficial in reducing IBS symptoms. However, diet modification plays an important role in the composition of colonic microbiota. Currently, the effects of a FODMAP diet on the composition of the gut microbiome are not known. We conducted a systematic review to determine (1) the effectiveness of low-FODMAPs diet to reduce symptoms of patients with IBS and (2) the association between a low-FOMAPs diet and the composition of gut microbiome. Four electronic databases were searched using key words "IBS" or "irritable bowel syndrome," and "FODMAP" or "FODMAPs" or "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols," and "microbiome." Two reviewers (H.S. and Y.T.L.) selected and reviewed articles according to our inclusion criteria. A total of 87 articles were reviewed and 7 met inclusion criteria. Based on the systematic review, low FODMAPs appear to reduce gastrointestinal symptoms for a least a subset of patients with IBS. However, due to the heterogeneity of reviewed studies, the influence on patients' gut microbiome composition and/or microbiota metabolites requires additional studies.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults

Ulcerative colitis and Crohn's disease are the principal forms of inflammatory bowel disease. Both represent chronic inflammation of the gastrointestinal tract, which displays heterogeneity in inflammatory and symptomatic burden between patients and within individuals over time. Optimal management relies on understanding and tailoring evidence-based interventions by clinicians in partnership with patients. This guideline for management of inflammatory bowel disease in adults over 16 years of age was developed by Stakeholders representing UK physicians (British Society of Gastroenterology), surgeons (Association of Coloproctology of Great Britain and Ireland), specialist nurses (Royal College of Nursing), paediatricians (British Society of Paediatric Gastroenterology, Hepatology and Nutrition), dietitians (British Dietetic Association), radiologists (British Society of Gastrointestinal and Abdominal Radiology), general practitioners (Primary Care Society for Gastroenterology) and patients (Crohn's and Colitis UK). A systematic review of 88 247 publications and a Delphi consensus process involving 81 multidisciplinary clinicians and patients was undertaken to develop 168 evidence- and expert opinion-based recommendations for pharmacological, non-pharmacological and surgical interventions, as well as optimal service delivery in the management of both ulcerative colitis and Crohn's disease. Comprehensive up-to-date guidance is provided regarding indications for, initiation and monitoring of immunosuppressive therapies, nutrition interventions, pre-, peri- and postoperative management, as well as structure and function of the multidisciplinary team and integration between primary and secondary care. Twenty research priorities to inform future clinical management are presented, alongside objective measurement of priority importance, determined by 2379 electronic survey responses from individuals living with ulcerative colitis and Crohn's disease, including patients, their families and friends.

Management of irritable bowel syndrome with diarrhea: a review of nonpharmacological and pharmacological interventions

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

Nuances of the psychogastroenterology patient: A predictive model for gastrointestinal quality of life improvement

BACKGROUND

Gastrointestinal conditions are multifactorial in nature, and certain patients can benefit greatly from brain-gut psychotherapies delivered by mental health professionals who specialize in psychogastroenterology. This study aimed to identify features associated with improvements in GI-specific quality of life scores following behavioral health interventions (BHI). The second aim was to create a psychogastroenterology referral care pathway incorporating identified characteristics for greatest benefit from GI-specific behavioral therapy.

METHODS

We performed a prospective observational study of 101 (63 women; median age, 45 years) gastroenterology patients referred for psychogastroenterology consultation at a single center. Patients attended an average of seven sessions with a single GI psychologist where evidence-based brain-gut psychotherapies were employed. GI-specific quality of life (IBS-QOL) and psychological distress (BSI-18) were assessed before and after BHI. Patients completed self-reported questionnaires. We performed a multivariable analysis to determine predictors associated with IBS-QOL score improvement.

KEY RESULTS

A total of 53 (52.5%) patients experienced improvement in IBS-QOL score. Patients with improved IBS-QOL scores had significantly higher baseline BSI general domain T-scores (61.9 vs. 56.9, P = 0.002). Female gender (odds ratio [OR], 3.2), pretreatment BSI somatization T-score ≥63 (OR, 3.7), and a diagnosis of depression (OR, 4.2) were associated with greater odds of IBS-QOL score improvement following BHI.

CONCLUSIONS AND INFERENCES

We identified factors associated with response to GI-specific BHI to aid in optimizing the utilization of psychogastroenterology services and provide referring providers with information to inform treatment recommendations. Female patients with disorders of gut-brain interaction (DGBIs), high somatization, and depression should be considered a priority for brain-gut psychotherapies.

Using Twitter to Understand the Human Bowel Disease Community: Exploratory Analysis of Key Topics

BACKGROUND

Nowadays, the use of social media is part of daily life, with more and more people, including governments and health organizations, using at least one platform regularly. Social media enables users to interact among large groups of people that share the same interests and suffer the same afflictions. Notably, these channels promote the ability to find and share information about health and medical conditions.

OBJECTIVE

This study aimed to characterize the bowel disease (BD) community on Twitter, in particular how patients understand, discuss, feel, and react to the condition. The main questions were as follows: Which are the main communities and most influential users?; Where are the main content providers from?; What are the key biomedical and scientific topics under discussion? How are topics interrelated in patient communications?; How do external events influence user activity?; What kind of external sources of information are being promoted?

METHODS

To answer these questions, a dataset of tweets containing terms related to BD conditions was collected from February to August 2018, accounting for a total of 24,634 tweets from 13,295 different users. Tweet preprocessing entailed the extraction of textual contents, hyperlinks, hashtags, time, location, and user information. Missing and incomplete information about the user profiles was completed using different analysis techniques. Semantic tweet topic analysis was supported by a lexicon-based entity recognizer. Furthermore, sentiment analysis enabled a closer look into the opinions expressed in the tweets, namely, gaining a deeper understanding of patients' feelings and experiences.

RESULTS

Health organizations received most of the communication, whereas BD patients and experts in bowel conditions and nutrition were among those tweeting the most. In general, the BD community was mainly discussing symptoms, BD-related diseases, and diet-based treatments. Diarrhea and constipation were the most commonly mentioned symptoms, and cancer, anxiety disorder, depression, and chronic inflammations were frequently part of BD-related tweets. Most patient tweets discussed the bad side of BD conditions and other related conditions, namely, depression, diarrhea, and fibromyalgia. In turn, gluten-free diets and probiotic supplements were often mentioned in patient tweets expressing positive emotions. However, for the most part, tweets containing mentions to foods and diets showed a similar distribution of negative and positive sentiments because the effects of certain food components (eg, fiber, iron, and magnesium) were perceived differently, depending on the state of the disease and other personal conditions of the patients. The benefits of medical cannabis for the treatment of different chronic diseases were also highlighted.

CONCLUSIONS

This study evidences that Twitter is becoming an influential space for conversation about bowel conditions, namely, patient opinions about associated symptoms and treatments. So, further qualitative and quantitative content analyses hold the potential to support decision making among health-related stakeholders, including the planning of awareness campaigns.

Gut-focused hypnotherapy for Functional Gastrointestinal Disorders: Evidence-base, practical aspects, and the Manchester Protocol

BACKGROUND

Despite their high prevalence and advances in the field of neurogastroenterology, there remain few effective treatment options for functional gastrointestinal disorders (FGIDs). It is recognized that approximately 25% of sufferers will have symptoms refractory to existing therapies, causing significant adverse effects on quality of life and increased healthcare utilization and morbidity. Gut-focused hypnotherapy, when delivered by trained therapists, has been shown to be highly effective in severe refractory FGIDs. However, hypnotherapy continues to be surrounded by much misunderstanding and skepticism.

PURPOSE

The purpose of this review is to provide a contemporary overview of the principles of gut-focused hypnotherapy, its effects on gut-brain interactions, and the evidence-base for its efficacy in severe FGIDs. As supplementary material, we have included a hypnotherapy protocol, providing the reader with an insight into the practical aspects of delivery, and as a guide, an example of a script of a gut-focused hypnotherapy session.

Irritable Bowel Syndrome: What Treatments Really Work

Irritable bowel syndrome (IBS) is present in patients with symptoms of chronic abdominal pain and altered bowel habits but no identifiable organic etiology. Rome IV classification groups patients based on predominant stool pattern. Low-FODMAP diets have been helpful in providing symptom relief, as have cognitive behavioral and mind-body techniques that help patients manage symptoms. Targeted symptomatic relief for the patient's predominant symptoms provides relief in addition to effective older medications that are inexpensive and reliable. Newer treatments for IBS-D, such as eluxadoline, and IBS-C, with linaclotide, lubiprostone, plecanatide, also can provide durable relief.