Pharmacological Therapies and Their Clinical Targets in Irritable Bowel Syndrome With Diarrhea

Depression in Diarrhea-Predominant IBS Patients: Exploring the Link Between Gut Barrier Dysfunction and Erythrocyte Polyunsaturated Fatty Acid Levels

Background: Patients with irritable bowel syndrome (IBS) often experience comorbid psychological conditions, notably depression and anxiety. Evidence suggests that these conditions are linked to gut barrier dysfunction, dysbiosis, and chronic inflammation. All these factors are central to IBS pathophysiology and mood disturbances. Polyunsaturated fatty acids (PUFAs) play crucial roles in modulating inflammation and depression. This study examined the associations among intestinal permeability, PUFA profiles, low-grade inflammation, and depression severity in IBS patients with diarrhea (IBS-D). Methods: Forty-three IBS-D patients (7 men, 36 women; 44.56 ± 1.52 years) were categorized into depressed (IBS-D(d+)) and non-depressed (IBS-D(d-)) groups according to scores on the depression subscale of the Symptom Checklist-90-Revised (SCL-90-R). Biomarkers of small intestinal permeability (s-IP) were assessed in urine and blood, alongside erythrocyte membrane PUFA composition, dysbiosis, and inflammation indices. Results: IBS-D (d+) patients exhibited elevated s-IP and altered PUFA metabolism compared to their IBS-D (d-) counterparts. Additionally, in the first group, omega-3 PUFA concentrations inversely correlated with s-IP biomarkers, while the omega-6/omega-3 ratio showed a positive correlation. Moreover, depression severity is significantly associated with s-IP markers and omega-3 PUFA levels. Lastly, IBS-D (d+) patients exhibited higher levels of dysbiosis and pro-inflammatory cytokines than IBS-D (d-) patients. Conclusions: These findings highlight the interplay between intestinal barrier integrity and PUFA metabolism in IBS-D patients with depression, suggesting that s-IP markers and erythrocyte PUFA profiles could represent novel therapeutic targets for managing depression in this population. This study was registered on ClinicalTrials.gov (NCT03423069), with a date of registration of 30 January 2018.

Self-administered active versus sham acupressure for diarrhea predominant irritable bowel syndrome: a nurse-led randomized clinical trial

BACKGROUND

Diarrhea-predominant irritable bowel syndrome (IBS-D) significantly impacts patients' quality of life, with existing treatments offering limited relief. Self-administered acupressure presents a potential non-invasive, cost-effective treatment option that could alleviate symptoms and enhance health outcomes in these patients.

AIM

This randomized controlled trial aimed to evaluate the effect of active acupressure compared to sham acupressure on primary and secondary outcomes among IBS-D patients.

METHOD

The study included 63 patients with IBS-D, recruited from Alexandria Main University Hospital, Egypt. Participants were randomized into either an active acupressure group or a sham acupressure group. Both groups underwent two days of training, followed by four weeks of intervention. The active group applied pressure to specific therapeutic acupoints, while the sham group used non-therapeutic points. Outcomes were assessed at baseline, week 2, and week 4.

RESULTS

The active acupressure group showed a significant reduction in symptom severity, improved stool consistency, and frequency, and greater adequate symptom relief by week 4 compared to the sham group. Psychological outcomes, including anxiety and depression, also improved significantly in the active group. Additionally, the active group reported reduced use of rescue medications.

CONCLUSION

Active acupressure is an effective nursing intervention for alleviating symptoms of IBS-D, particularly when applied consistently over time. It improves both physical and psychological outcomes, offering a valuable non-pharmacological treatment option.

IMPLICATIONS

Nurses can integrate self-administered acupressure into IBS-D care plans, teaching patients this technique to manage symptoms independently, thus enhancing their quality of life (QOL) and reducing reliance on conventional medications. This intervention aligns with holistic nursing care and offers a cost-effective, patient-friendly solution for managing IBS-D.

TRIAL REGISTRATION

This study was prospectively registered as a randomized controlled trial in https://clinicaltrials.gov/ Registration Date: January 7, 2023, Registration Number: NCT05702255.

Chinese herbal formula Tongxie Yaofang granules for diarrhoea-predominant irritable bowel syndrome: a randomised, double-blind, placebo-controlled, phase II trial

OBJECTIVES

To assess the therapeutic effects and safety of Tongxie Yaofang (TXYF) granules vs placebo as an alternative treatment for diarrhoea-predominant irritable bowel syndrome (IBS-D). We hypothesised that TXYF would improve clinical responses among patients with IBS-D.

DESIGN

A randomised, double-blind, placebo-controlled, phase II, superiority trial.

SETTING

Outpatients attending the Fangshan Hospital, Beijing University of Chinese Medicine, Beijing, China.

PARTICIPANTS

96 eligible participants included men and women ranging from late adolescence to middle adulthood (18-65 years), diagnosed with IBS-D according to the Rome IV criteria. In addition, they were required to have an irritable bowel syndrome symptom severity score (IBS-SSS) of at least 75.

INTERVENTIONS

TXYF granules (3.7 g) twice daily (taken orally before meals) or placebo for 8 weeks.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the response rate measured by the change in IBS-SSS compared with baseline at week 8. Secondary outcomes included stool frequency; stool consistency at weeks 4, 8 and 20; and quality of life, anxiety and depression at week 8; and safety was monitored throughout the trial.

RESULTS

The TXYF and placebo groups each comprised 48 participants. The response rate was not significantly different at week 8 between the two groups (the unadjusted treatment effect estimate (intention-to-treat analysis) was 1.12 (95% CI (0.89, 1.41)), p=0.348). Both groups had a high and similar rate of symptom reduction (79.2% (38/48) vs 70.8% (34/48)). There were no statistically significant differences between the two groups on secondary outcomes, although both groups showed substantial improvements. Adverse events in the TXYF and placebo groups were one (sinus arrhythmia) and two (elevated transaminases, weakly positive faecal occult blood), respectively. No serious adverse events occurred.

CONCLUSIONS

Despite showing clinically meaningful improvements in IBS-D symptoms and a reasonable safety profile after 8 weeks, no significant differences were observed between the TXYF and placebo groups. This suggests that the severity of IBS-D symptoms in both treatment arms might have decreased over time, regardless of the treatment, and highlights the need to investigate the relationship between IBS-D and patient psychology. Future large-scale, rigorously designed trials with longer treatment and follow-up periods are essential to evaluate the therapeutic effects and safety of TXYF, and to explore the psychological factors.

TRIAL REGISTRATION NUMBER

ISRCTN12453166.

A Comprehensive Overview of the Current Status and Advancements in Various Treatment Strategies against Epilepsy

Epilepsy affects more than 70 million individuals of all ages worldwide and remains one of the most severe chronic noncommunicable neurological diseases globally. Several neurotransmitters, membrane protein channels, receptors, enzymes, and, more recently noted, various pathways, such as inflammatory and mTORC complexes, play significant roles in the initiation and propagation of seizures. Over the past two decades, significant developments have been made in the diagnosis and treatment of epilepsy. Various pharmacological drugs with diverse mechanisms of action and other treatment options have been developed to control seizures and treat epilepsy. These options include surgical treatment, nanomedicine, gene therapy, natural products, nervous stimulation, a ketogenic diet, gut microbiota, etc., which are in various developmental stages. Despite a plethora of drugs and other treatment options, one-third of affected individuals are resistant to current medications, while the majority of approved drugs have severe side effects, and significant changes can occur, such as pharmacoresistance, effects on cognition, long-term problems, drug interactions, risks of poor adherence, specific effects for certain medications, and psychological complications. Therefore, the development of new drugs and other treatment options that have no or minimal adverse effects is needed to combat this deadly disease. In this Review, we comprehensively summarize and explain all of the treatment options that have been approved or are in developmental stages for epilepsy as well as their status in clinical trials and advancements.

Efficacy of acupuncture treatment for diarrhea-predominant irritable bowel syndrome with comorbid anxiety and depression: A meta-analysis and systematic review

BACKGROUND

Presently, a diverse range of Western medical interventions are accessible for the management of irritable bowel syndrome with diarrhea (IBS-D) concomitant with comorbid anxiety and depression. However, the concomitant adverse effects have also surfaced, exerting strain on healthcare resources and the socio-economic structure. In recent times, the benefits of acupuncture in the management of IBS-D with coexisting anxiety and depression have become progressively evident. Nevertheless, a paucity of evidence-based medicine exists to substantiate the utilization of acupuncture for the treatment of IBS-D with anxiety and depression. The objective of this study is to examine the effectiveness of acupuncture as an intervention for IBS-D with comorbid anxiety and depression.

METHODS

We searched 7 databases, including the Chinese Journal Full-text Database, Wanfang Academic Journals Full-text Database, VIP Chinese Scientific Journals Full-text Database, China Biomedical Literature Database, PubMed, Embase, and Cochrane Library, for randomized controlled trials (RCTs) related to acupuncture treatment for IBS with anxiety and depression, published from database inception to August 1, 2023. RevMan 5.4 and Stata 17.0 software were used for meta-analysis of relevant outcome measures.

RESULTS

This study included a total of 16 RCTs, involving 1305 IBS-D patients (691 in the experimental group and 614 in the control group). The meta-analysis results showed that compared to oral medication, acupuncture therapy improved HAMD scores (MD = 0.88, 95% CI = [0.68, 1.07], P < .00001), HAMA scores (MD = 2.32, 95% CI = [1.70, 2.93], P < .00001), self-rating anxiety scale scores (MD = 11.67, 95% CI = [10.85, 12.49], P < .00001), SDS scores (MD = 9.84, 95% CI = [8.52, 11.16], P < .00001), IBS-SSS scores (MD = 37.48, 95% CI = [12.17, 62.78], P = .004), overall response rate (MD = 1.27, 95% CI = [1.20, 1.35], P < .00001), and relapse rate (MD = 0.27, 95% CI = [0.16, 0.47], P < .00001) in patients with IBS-D comorbid with anxiety and depression.

CONCLUSION

Acupuncture treatment has a definite and beneficial effect on IBS-D patients with comorbid anxiety and depression.

Multiple Aspects of Irritable Bowel Syndrome and the Role of the Immune System: An Overview of Systematic Reviews with a Focus on Polyphenols

Irritable bowel syndrome (IBS) is a complex and often debilitating condition that significantly impacts the gastrointestinal system and the overall quality of life of those affected. IBS is characterized by a variety of distressing symptoms, including cramping, abdominal pain, and irregular bowel movements, underlined by an intricate interplay of immune system dysfunction in its pathology. Numerous studies highlight an increased cellular immune response, with elevated levels of proinflammatory cytokines, mucosal alterations due to immune imbalance, and visceral hypersensitivity. Notably, studies indicate increased levels of proinflammatory cytokines, immune imbalances that lead to mucosal changes, and heightened visceral sensitivity. The roles of effector and regulatory T cells are particularly intriguing, as their modification appears to amplify inflammation and may even contribute to autoimmune disorders. This overview of systematic reviews explores the connections between IBS and immune responses, with a focus on immune cell alterations and proliferation of lymphocytes and mast cells in affected individuals. Furthermore, we explore various aspects of IBS management, including its pharmacological approaches. A systematic search of PubMed and Web of Science yielded 676 articles, which were ultimately narrowed down to 9 key studies that met our inclusion criteria. These studies collectively underscore the activation of the immune system with the degranulation of the mast cells in patients with IBS, where the release of inflammatory mediators can compromise intestinal permeability, exacerbating symptoms further. Additionally, we examine the multifaceted management strategies for IBS, emphasizing the potential therapeutic benefits of dietary polyphenols as antioxidants. The present study aims to enhance our understanding of IBS and offer insights into more effective treatment strategies for this challenging condition.

Sinisan Alleviates Stress-Induced Intestinal Dysfunction and Depressive-like Behaviors in Mice with Irritable Bowel Syndrome by Enhancing the Intestinal Barrier and Modulating Central 5-Hydroxytryptamine

Irritable bowel syndrome (IBS) is a common chronic functional bowel disorder and is strongly associated with an increased risk of depression and anxiety. The brain-gut axis plays an important role in the pathophysiologic changes in IBS, yet effective treatments for IBS are still lacking. Sinisan, originating from the Treatise on Typhoid Fever by the medical sage Zhang Zhongjing, is a classic formula in the Eight Methods of Traditional Chinese Medicine (TCM) that focuses on dispersing the liver and regulating the spleen, relieving depression and transmitting evils, and has been widely used in the treatment of liver-depression and spleen-deficiency, diarrhea, and related liver and stomach disorders. However, the therapeutic effect of sinisan in IBS has not been clarified. The aim of this study was to investigate the effects of sinisan on stress-induced intestinal dysfunction and depressive behavior in IBS mice. We established a diarrhea-predominant irritable bowel syndrome (IBS-D) mouse model using a 4% acetic acid enema combined with restraint stress, and analyzed the results using behavioral tests, relevant test kits, hematoxylin-eosin (HE) staining, immunofluorescence (IF), Western blot (WB), and quantitative fluorescence polymerase chain reaction (qRT-PCR). The results showed that sinisan administration significantly alleviated intestinal dysfunction and depressive-like behaviors in IBS-D mice, improved mild colonic inflammation and intestinal mucosal permeability, up-regulated the expression of tight junction proteins ZO-1 and occludin. Sinisan significantly alleviated intestinal dysfunction and depressive-like behaviors in IBS-D mice by decreasing the expression of TNF-α, promoting the expression of tight junction proteins (occludin, ZO-1) expression, and inhibiting the Tlr4/Myd88 signaling pathway, thereby attenuating the inflammatory response, protecting the intestinal barrier, and alleviating symptoms in the IBS-D mouse model. Taken together, sinisan may ameliorate intestinal inflammation and the intestinal barrier by regulating 5-HT expression and the Tlr4/Myd88 pathway, thereby alleviating stress-induced intestinal dysfunction and depressive behaviors in IBS-D mice.

Efficacy of acupuncture in refractory irritable bowel syndrome patients: a randomized controlled trial

Previous studies have confirmed that acupuncture for irritable bowel syndrome (IBS) provided an additional benefit over usual care alone. Therefore, we performed a multicenter, randomized, sham-controlled trial to assess the efficacy and safety of acupuncture versus sham acupuncture for refractory IBS in patients in the context of conventional treatments. Patients in the acupuncture and sham acupuncture groups received real or sham acupuncture treatment in 3 sessions per week for a total of 12 sessions. The primary outcome was a change in the IBS-Symptom Severity Scale (IBS-SSS) score from baseline to week 4. A total of 521 participants were screened, and 170 patients (85 patients per group) were enrolled and included in the intention-to-treat analysis. Baseline characteristics were comparable across the two groups. From baseline to 4 weeks, the IBS-SSS total score decreased by 140.0 (95% CI: 126.0 to 153.9) in the acupuncture group and 64.4 (95% CI: 50.4 to 78.3) in the sham acupuncture group. The between-group difference was 75.6 (95% CI: 55.8 to 95.4). Acupuncture efficacy was maintained during the 4-week follow-up period. There were no serious adverse events. In conclusion, acupuncture provided benefits when combined with treatment as usual, providing more options for the treatment of refractory IBS.

Pharmacokinetic considerations for drugs that treat diarrhea-predominant irritable bowel syndrome: what's new?

INTRODUCTION

Irritable bowel syndrome (IBS), which presents a significant healthcare and socioeconomic burden, is one of the main issues in the field of therapy. Hence, it is imperative to tackle this matter by evaluating the safety and efficacy of the available treatments and determining the ideal approach for each patient.

AREAS COVERED

We reviewed the pharmacokinetics and safety of pharmacologic interventions administered in diarrhea-predominant IBS (IBS-D) patients. PubMed, Google Scholar and the USFDA databases were searched up to November 2023 to include all updated information on eluxadoline, alosetron, and rifaximin.

EXPERT OPINION

The most effective way to treat IBS-D is to focus on managing the most common symptoms. However, healthcare providers face a challenge when it comes to identifying the right treatment for each patient, and the root cause of this is the diversity of IBS-D population. Studies have shown that there are differences in how men and women metabolize drugs, which may lead to gender-specific adverse reactions. Women tend to have higher drug concentrations in their bloodstream and take longer to eliminate them. Therefore, healthcare providers may need to reduce the dosage for female patients. Integrating IBS care into sustainable development efforts can indirectly contribute to achieving SDGs and promote health and well-being for all.

Development and Validation of a High-Performance Liquid Chromatography Method to Quantify Marker Compounds in Lysimachia vulgaris var. davurica and Its Effects in Diarrhea-Predominant Irritable Bowel Syndrome

Irritable bowel syndrome (IBS), a common gastrointestinal disorder worldwide, is characterized by chronic abdominal pain, bloating, and disordered defecation. IBS is associated with several factors, including visceral hypersensitivity, gut motility, and gut-brain interaction disorders. Because currently available pharmacological treatments cannot adequately improve symptoms and may cause adverse effects, the use of herbal therapies for managing IBS is increasing. Lysimachia vulgaris var. davurica (LV) is a medicinal plant used in traditional medicine to treat diarrhea. However, information on whether LV can effectively improve diarrhea-predominant IBS (IBS-D) remains limited. In this study, using an experimental mouse model of IBS-D, we elucidated the effects of the LV extract. The methanol extract of LV decreased fecal pellet output in the restraint stress- or 5-hydroxytryptamine (5-HT)-induced IBS mouse model and inhibited 5-HT-mediated [Ca2+]i increase in a dose-dependent manner. Furthermore, we developed and validated a high-performance liquid chromatography method using two marker compounds, namely, chlorogenic acid and rutin, for quality control analysis. Our study results suggest the feasibility of the methanol extract of LV for developing therapeutic agents to treat IBS-D by acting as a 5-HT3 receptor antagonist.

Drugs of the future for diarrhea-predominant irritable bowel syndrome: an overview of current investigational drugs

INTRODUCTION

Irritable bowel syndrome (IBS) has a significant impact on society and quality of life. Current treatments are ineffective, and new investigational drugs are necessary.

AREAS COVERED

Numerous potential therapies are developing, targeting different areas such as cannabinoid signaling, opioid receptors, tachykinin (NK2) receptors, β3-adrenergic receptors, intestinal microbiota, inflammation, and 5HT receptors. Clinical trial evidence has shown that loperamide, eluxadoline, alosetron, ramosetron, bile acid sequestrants, and rifaximin can modulate GI alterations and benefit patients with IBS-D. Among the potential therapies, ibodutant, ibudilast, blautix, BOS-589, solabegron, vibegron, olorinab, ebastine, and ORP-101 have demonstrated possible effects but remain confirmed.

EXPERT OPINION

Individuals with IBS-D require cost-effective treatment options that do not impede their productivity or that of their caregivers. This is necessary for consistent healthcare and improved quality of life. Therefore, we should focus on developing new, efficient, and affordable medications for IBS-D. The government, insurers, and society must recognize this need and collaborate to ensure its fulfillment.

A follow-up study of anxiety and depressive symptoms in irritable bowel syndrome

Background

Irritable bowel syndrome (IBS) is a functional gastrointestinal (GI) disorder and is closely linked to stress. Psychiatric morbidities such as anxiety and depression are common in IBS. Long-term follow-up studies on anxiety and depressive symptoms in IBS and the impact of treatment are lacking in the Indian scenario.

Aims

This study aimed to assess the various subtypes of IBS according to the Rome IV criteria, assess anxiety and depressive symptoms in patients with IBS at baseline and also at various phases of follow-up over one year, and see the impact of the treatment of both IBS and associated anxiety and depressive symptoms if present, in the severity of IBS and other psychiatric symptoms.

Materials and Methods

Patients with IBS, aged between 18 and 65 years, were enrolled for the study. Subtypes and severity of IBS were assessed. Anxiety and depressive symptoms were assessed by the Hamilton Rating Scale for Anxiety (HAM-A) and the Hamilton Rating Scale for Depression (HAM-D), respectively. The patients were treated with conventional treatment of IBS with concomitant treatment of anxiety and depressive symptoms and were followed up for 1 year.

Results

Thirty-seven patients completed a 1-year follow-up. The mean age was 38.4 ± 11.6 years. The majority were males (81%), and IBS-D (84%) was the most common subtype. Stressful life events (67.6%) and chronic stressors (64.9%) were present in the majority of the patients. The patients had moderate-to-severe anxiety at baseline (HAM-A score 27.8 ± 6.4) and moderate-to-severe depression at baseline (HAM-D score 19.7 ± 6.6). The improvement over 1 year was statistically significant (P = 0.000, two-tailed). A positive correlation between the severity score of IBS and HAM-D (r = 0.604) and HAM-A (r = 0.536) scores was present.

Conclusion

There is a high prevalence of anxiety and depression in patients with IBS. With adequate treatment of both IBS and concomitant anxiety-depressive symptoms, there is a significant decrease in the severity of IBS, anxiety, and depression.

Triptolide attenuates irritable bowel syndrome via inhibiting ODC1

BACKGROUND

Irritable bowel syndrome (IBS) is a chronic disorder of the gut-brain axis with significant morbidity. Triptolide, an active compound extracted from Tripterygium wilfordii Hook F (TwHF), has been widely used as a major medicinal herb in the treatment of inflammatory disease.

METHODS

The chronic-acute combined stress (CAS) stimulation was used to establish IBS rat model. The model rats were then gavaged with triptolide. Forced swimming, marble-burying, fecal weight and abdominal withdrawal reflex (AWR) score were recorded. Pathologic changes in the ileal and colonic tissues were validated by hematoxylin and eosin staining. The inflammatory cytokines and Ornithine Decarboxylase-1 (ODC1) in the ileal and colonic tissues were performed by ELISA and WB.

RESULTS

Triptolide didn't have antidepressant- and antianxiety- effects in rats caused by CAS, but decreased fecal weight and AWR score. In addition, Triptolide reduced the release of IL-1, IL-6, and TNF-α and the expression of ODC1 in the ileum and colon.

CONCLUSION

The therapeutic efficacy of triptolide for IBS induced by CAS was revealed in this study, which may be related to the reduction of ODC1.

Gut Microbiome-Brain Alliance: A Landscape View into Mental and Gastrointestinal Health and Disorders

Gut microbiota includes a vast collection of microorganisms residing within the gastrointestinal tract. It is broadly recognized that the gut and brain are in constant bidirectional communication, of which gut microbiota and its metabolic production are a major component, and form the so-called gut microbiome-brain axis. Disturbances of microbiota homeostasis caused by imbalance in their functional composition and metabolic activities, known as dysbiosis, cause dysregulation of these pathways and trigger changes in the blood-brain barrier permeability, thereby causing pathological malfunctions, including neurological and functional gastrointestinal disorders. In turn, the brain can affect the structure and function of gut microbiota through the autonomic nervous system by regulating gut motility, intestinal transit and secretion, and gut permeability. Here, we examine data from the CAS Content Collection, the largest collection of published scientific information, and analyze the publication landscape of recent research. We review the advances in knowledge related to the human gut microbiome, its complexity and functionality, its communication with the central nervous system, and the effect of the gut microbiome-brain axis on mental and gut health. We discuss correlations between gut microbiota composition and various diseases, specifically gastrointestinal and mental disorders. We also explore gut microbiota metabolites with regard to their impact on the brain and gut function and associated diseases. Finally, we assess clinical applications of gut-microbiota-related substances and metabolites with their development pipelines. We hope this review can serve as a useful resource in understanding the current knowledge on this emerging field in an effort to further solving of the remaining challenges and fulfilling its potential.

Effects of Glutamine, Curcumin and Fish Bioactive Peptides Alone or in Combination on Intestinal Permeability in a Chronic-Restraint Stress Model

Irritable bowel syndrome (IBS), a multifactorial intestinal disorder, is often associated with a disruption in intestinal permeability as well as an increased expression of pro-inflammatory markers. The aim of this study was to first test the impact of treatment with glutamine (Gln), a food supplement containing natural curcumin extracts and polyunsaturated n-3 fatty acids (Cur); bioactive peptides from a fish protein hydrolysate (Ga); and a probiotic mixture containing Bacillus coagulans, Lactobacillus acidophilus, Lactobacillus gasseri and Lactobacillus helveticus. These compounds were tested alone on a stress-based IBS model, the chronic-restraint stress model (CRS). The combination of Gln, Cur and Ga (GCG) was also tested. Eight-week-old C57Bl/6 male mice were exposed to restraint stress for two hours every day for four days and received different compounds every day one week before and during the CRS procedure. Plasma corticosterone levels were measured as a marker of stress, and colonic permeability was evaluated ex vivo in Ussing chambers. Changes in the gene expression of tight junction proteins (occludin, claudin-1 and ZO 1) and inflammatory cytokines (IL1β, TNFα, CXCL1 and IL10) were assessed using RT-qPCR. The CRS model led to an increase in plasma corticosterone and an increase in colonic permeability compared with unstressed animals. No change in plasma corticosterone concentrations was observed in response to CRS with the different treatments (Gln, Cur, Ga or GCG). Stressed animals treated with Gln, Cur and Ga alone and in combination showed a decrease in colonic permeability when compared to the CRS group, while the probiotic mixture resulted in an opposite response. The Ga treatment induced an increase in the expression of the anti-inflammatory cytokine IL-10, and the GCG treatment was able to decrease the expression of CXCL1, suggesting the synergistic effect of the combined mixture. In conclusion, this study demonstrated that a combined administration of glutamine, a food supplement containing curcumin and polyunsaturated n-3 fatty acids, and bioactive peptides from a fish hydrolysate was able to reduce colonic hyperpermeability and reduce the inflammatory marker CXCL1 in a stress-based model of IBS and could be of interest to patients suffering from IBS.

A Review of Xyloglucan: Self-Aggregation, Hydrogel Formation, Mucoadhesion and Uses in Medical Devices

The present paper reviews the self-aggregation, gel-forming and adsorption properties of xyloglucan (XG), and its main applications as a medical device for wound dressings, mucosal protection and ocular lubrication, as well as its uses as an excipient. XG is a branched polysaccharide composed of a central backbone of D-glucose units linked by β(1→4)-glycosidic bonds, decorated with D-xylose units through α(1→6) glycosidic bonds, and with some D-galactose units anchored to these D-xylose units via β(1→2) bonds. XG forms self-aggregates with a hierarchically ordered morphology in aqueous solutions, leading to the formation of nanofibers. Consequently, XG is a hydrogel-forming polymer able to retain large amounts of water. Inside the human digestive tract, XG is enzymatically degalactosylated, but the backbone with xylose side chains remains stable until excretion. Degalactosylated XG undergoes a fully reversible sol–gel transition, forming hydrogels between upper and lower critical temperatures. XG adsorbs on intestinal mucosa and creates a diffusion barrier that reduces permeability and also prevents bacterial infections by reducing their infiltration. Therefore, orally administered XG is considered a mucosa protectant.

Efficacy of Jawarish Shahi a herbal formulation in irritable bowel syndrome: An open-labeled single-arm clinical trial

Background and aim

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders characterized by chronic recurrent abdominal pain related to a change in bowel habit or defecation frequency and commonly accompanied by anxiety and depression affecting about 10% population globally. Jawarish Shahi (JS) is a special dosage form prepared for gastrointestinal disorders in Unani medicine containing Phyllanthus emblica L., Terminalia chebula Retz., Coriandrum sativum L., Elettaria cardamomum (L.) Maton and Salix caprea L. Considering the antioxidant, immunomodulatory, antispasmodic analgesic, antidiarrheal, antisecretory, laxative, anti-inflammatory, anxiolytic, and antidepressant properties, the present study was aimed to evaluate the efficacy of JS in IBS.

Experimental procedure

This single-arm open-labeled clinical trial was conducted on 26 male and female patients of IBS according to Rome IV criteria, aged 18-50 years with moderate symptoms. JS was given 7 g orally twice a day after meal with water for 45 days. IBS Severity Scoring Scale (IBS-SSS) was used for efficacy outcomes and the difference was analyzed from baseline to the subsequent follow-ups.

Results

Data analysis of subsequent followup showed a significant decrease in IBS-SSS scores except for 2nd followup, scores decreased from 229.50 ± 75.91 to 203.12 ± 71.71 (p < 0.1018), 150.61 ± 55.32 (p < 0.0001), and 123.76 ± 54.81 (p < 0.0001) at 0, 15th, 30th, 45th day of follow up respectively.

Conclusion

The present study revealed that JS is safe and effective in reducing the overall symptoms of IBS in respect to its severity and impact on quality of life and can be used as an alternate as well as a complementary treatment in IBS.

Treatments targeting the luminal gut microbiota in patients with irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder of gut-brain interaction affecting 4% of the world's population. Patients with IBS experience chronic or recurrent abdominal pain in combination with altered bowel habits (diarrhea and/or constipation), and have reduced quality of life. Despite the high prevalence and substantial burden of IBS, its pathophysiology is incompletely understood and remains to be elucidated. The importance of the gut microenvironment has been highlighted in IBS, as there are signs that the gut microbiota of patients differs from healthy controls. Recent studies have aimed to alter the gut microbiota and thereby, attempted to alleviate gastrointestinal symptoms in IBS patients. We highlighted recent advances in common treatments that are targeting the luminal gut microbiota in IBS.

Belgian consensus on irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is characterised by recurrent abdominal pain related to defaecation or associated with altered stool frequency or consistency. Despite its prevalence, major uncertainties in the diagnostic and therapeutic management persist in clinical practice.

METHODS

A Delphi consensus was conducted by 20 experts from Belgium, and consisted of literature review and voting process on 78 statements. Grading of recommendations, assessment, development and evaluation criteria were applied to evaluate the quality of evidence. Consensus was defined as > 80 % agreement.

RESULTS

Consensus was reached for 50 statements. The Belgian consensus agreed as to the multifactorial aetiology of IBS. According to the consensus abdominal discomfort also represents a cardinal symptom, while bloating and abdominal distension often coexist. IBS needs subtyping based on stool pattern. The importance of a positive diagnosis, relying on history and clinical examination is underlined, while additional testing should remain limited, except when alarm features are present. Explanation of IBS represents a crucial part of patient management. Lifestyle modification, spasmolytics and water-solube fibres are considered first-line agents. The low FODMAP diet, selected probiotics, cognitive behavioural therapy and specific treatments targeting diarrhoea and constipation are considered appropriate. There is a consensus to restrict faecal microbiota transplantation and gluten-free diet, while other treatments are strongly discouraged.

CONCLUSIONS

A panel of Belgian gastroenterologists summarised the current evidence on the aetiology, symptoms, diagnosis and treatment of IBS with attention for the specificities of the Belgian healthcare system.

Montelukast suppresses the development of irritable bowel syndrome phenotype possibly through modulating NF-κB signaling in an experimental model

Irritable bowel syndrome (IBS) is a functional gut disorder with multi-factorial pathophysiology that causes recurring pain or discomfort in the abdomen, as well as altered bowel habits. Montelukast, a well-known cysteinyl leukotriene receptor 1 (CysLT1R) antagonist, is widely used for the anti-inflammatory management of asthma. The present study aimed to evaluate the effects of pharmacological inhibition of CysLT1R on acetic acid-induced diarrhea-predominant IBS (D-IBS) in rats. Behavioral pain responses to noxious mechanical stimulation were decreased in the montelukast-treated rats as compared to the model animals following colorectal distension (CRD)-induced visceral hypersensitivity. Stool frequency decreased dose-dependently by montelukast in IBS rats exposed to restraint stress. A significantly shorter immobility time was also observed in IBS rats who received montelukast vs IBS group in the forced swimming test (depression-like behavior). Furthermore, there were significant decreases in the NF-κB protein expression, inflammatory cytokine (TNF-α, and IL-1ß) levels, and histopathological inflammatory injuries concomitant with increased anti-inflammatory cytokine, IL-10, in montelukast-treated rats compared with the IBS group. Cysteinyl leukotriene production and CysLT1R mRNA expression showed no remarkable differences among the experimental groups. The present results suggest the possible beneficial effects of montelukast in the management of D-IBS symptoms. The molecular mechanism underlying such effects, at least to some extent, might be through modulating CysLT1R-mediated NF-κB signaling. Yet, more studies are required to demonstrate the clinical potential of this drug for IBS therapy.

Buspirone in the management of refractory irritable bowel syndrome: A case report

RATIONALE

Irritable bowel syndrome (IBS) is a chronic and debilitating functional disorder of the gastrointestinal tract manifested by abdominal pain and bowel habit dysregulation. The pathophysiology is complex and management targets symptom resolution. Therapeutic interventions range from dietary modification, psychological interventions, exercise, to the use of antispasmodics, antibiotics, and antidepressants. Anecdotal reports have suggested that buspirone may be beneficial in the treatment of functional dyspepsia and IBS and its physiological effect of reducing gastric tone provides a rational for its benefit.

PATIENT CONCERNS

A 28-year-old man with unremarkable past medical and psychiatric history presented with worsening abdominal pain, bloating, and bowel movement dysregulation of over 6-year duration.

DIAGNOSES

Physical examination revealed mild distension and discomfort on deep palpation. Thorough blood investigations, stool analysis and culture, and imaging were unremarkable except for the detection of mucus with stool. The patient was diagnosed with irritable bowel syndrome with mixed habits.

INTERVENTIONS

Dietary adjustment and a range of medications (mebeverine, simethicone, loperamide, rifaximin, sertraline and amitriptyline) yielded unsatisfactory response of were not tolerated. Buspirone was eventually introduced.

OUTCOMES

Buspirone was associated with a significant and sustained improvement in IBS symptoms and quality of life.

LESSONS

This case suggests that buspirone was effective in treating refractory IBS. Further research is needed to assess the role of buspirone in IBS management.

STW 5 Herbal Preparation Modulates Wnt3a and Claudin 1 Gene Expression in Zebrafish IBS-like Model

AIM

Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by chronic abdominal pain and stool irregularities. STW 5 has proven clinical efficacy in functional gastrointestinal disorders, including IBS, targeting pathways that suppress inflammation and protect the mucosa. Wnt signaling is known to modulate NF-kβ-dependent inflammatory cytokine production. This sparked the idea of evaluating the impact of STW 5 on the expression of inflammatory-response and Wnt/β catenin-target genes in an IBS-like model.

MAIN METHODS

We used zebrafish and dextran sodium sulfate (DSS) treatment to model IBS-like conditions in vivo and in vitro and examined the effects of subsequent STW 5 treatment on the intestines of DSS-treated fish and primary cultured intestinal and neuronal cells. Gross gut anatomy, histology, and the expression of Wnt-signaling and cytokine genes were analyzed in treated animals and/or cells, and in controls.

KEY FINDINGS

DSS treatment up-regulated the expression of interleukin-8, tumor necrosis factor-α, wnt3a, and claudin-1 in explanted zebrafish gut. Subsequent STW 5 treatment abolished both the macroscopic signs of gut inflammation, DSS-induced mucosecretory phenotype, and normalized the DSS-induced upregulated expression of il10 and Wnt signaling genes, such as wnt3a and cldn1 in explanted zebrafish gut. Under inflammatory conditions, STW 5 downregulated the expression of the pro-inflammatory cytokine genes il1β, il6, il8, and tnfα while it upregulated the expression of the anti-inflammatory genes il10 and wnt3a in enteric neuronal cells in vitro.

SIGNIFICANCE

Wnt signaling could be a novel target for the anti-inflammatory and intestinal permeability-restoring effects of STW 5, possibly explaining its clinical efficacy in IBS.

An Update on the Assessment and Management of Pediatric Abdominal Pain

Chronic abdominal pain is very common in children and adolescent and results in high personal and social costs. Most youth with chronic abdominal pain fulfill criteria for a functional abdominal pain disorder (FAPD) as defined by Rome criteria. These are complex conditions with a wide array of biological, psychological, and social factors contributing to the experience of pain. The purpose of the current review is to provide an overview of the pathophysiology of FAPDs and an up-to-date summary of the literature related to FAPDs in children and adolescents, with additional focus on several areas (eg, diet and probiotics) where patients and families frequently have questions or implement self-directed care. We also provide an approach to the assessment and treatment of pediatric FAPDs focusing on the robust literature regarding psychological interventions and much sparser literature regarding medication treatment.