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

Survey-Based Analysis of the Clinical Treatment Status of Irritable Bowel Syndrome in Korea

BACKGROUND

The quality-of-life of patients with irritable bowel syndrome is low; incorrect diagnosis/treatment causes economic burden and inappropriate consumption of medical resources. This survey-based study aimed to analyze the current status of irritable bowel syndrome treatment to examine differences in doctors' perceptions of the disease, and treatment patterns.

METHODS

From October 2019 to February 2020, the irritable bowel syndrome and Intestinal Function Research Study Group of the Korean Society of Neurogastroenterology and Motility conducted a survey on doctors working in primary, secondary, and tertiary healthcare institutions. The questionnaire included 37 items and was completed anonymously using the NAVER platform (a web-based platform), e-mails, and written forms.

RESULTS

A total of 272 doctors responded; respondents reported using the Rome IV diagnostic criteria (amended in 2016) for diagnosing and treating irritable bowel syndrome. Several differences were noted between the primary, secondary, and tertiary physicians' groups. The rate of colonoscopy was high in tertiary healthcare institutions. During a colonoscopy, the necessity of random biopsy was higher among physicians who worked at tertiary institutions. 'The patient did not adhere to the diet' as a reason for ineffectiveness using low-fermentable oligo-, di-, and mono-saccharides, and polyols diet treatment was higher among physicians in primary/secondary institutions, and 'There are individual differences in terms of effectiveness' was higher among physicians in tertiary institutions. In irritable bowel syndrome constipation predominant subtype, the use of serotonin type 3 receptor antagonist (ramosetron) and probiotics was higher in primary/secondary institutions, while serotonin type 4 receptor agonist was used more in tertiary institutions. In irritable bowel syndrome diarrhea predominant subtype, the use of antispasmodics was higher in primary/secondary institutions, while the use of serotonin type 3 receptor antagonist (ramosetron) was higher in tertiary institutions.

CONCLUSION

Notable differences were observed between physicians in primary/secondary and tertiary institiutions regarding the rate of colonoscopy, necessity of random biopsy, the reason for the ineffectiveness of low-fermentable oligo-, di-, and mono-saccharides, and polyols diet, and use of drug therapy in irritable bowel syndrome. In South Korea, irritable bowel syndrome is diagnosed and treated according to the Rome IV diagnostic criteria, revised in 2016.

Commonalities among dietary recommendations from 2010-2021 clinical practice guidelines: A meta-epidemiological study from the American College of Lifestyle Medicine

Clinical practice guidelines (CPGs) provide recommendations to clinicians based on current medical knowledge to guide and reduce variability in clinical care. With advances in nutrition science research, CPGs increasingly include dietary guidance; however, the degree of consistency in dietary recommendations across CPGs has not been investigated. Using a systematic review approach adapted for meta-epidemiological research, this study compared dietary guidance from current guidelines developed by governments, major medical professional societies, and large health stakeholder associations due to their often well-defined and standardized processes for guideline development. CPGs making recommendations for dietary patterns and food groups or components for generally healthy adults or those with pre-specified chronic diseases were eligible. Literature from January 2010-2022 was searched in five bibliographic databases and augmented by searches in point-of-care resource databases and relevant websites. Reporting followed an adapted Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and included narrative synthesis and summary tables. The protocol was pre-published on PROSPERO (CRD42021226281). Seventy-eight CPGs for major chronic conditions (autoimmune=7, cancers=5, cardiovascular-related=35, digestive=11, diabetes=12, weight-related=4, or multiple=3) and general health promotion (n=1) were included. Nearly all (91%) made dietary pattern recommendations, and roughly half (49%) endorsed patterns centered around plant foods. Overall, CPGs were most closely aligned in promoting consumption of major plant food groups (vegetables=74% of CPGs, fruit=69%, whole grains=58%) while discouraging intake of alcohol (62%) and salt or sodium (56%). CVD and diabetes CPGs were similarly aligned with additional messaging to consume legumes/pulses (60% of CVD CPGs; 75%, diabetes), nuts and seeds (67%, CVD), and low-fat dairy (60%, CVD). Diabetes guidelines discouraged sweets/added sugars (67%) and sweetened beverages (58%). This alignment across CPGs should boost clinician confidence in relaying such dietary guidance to patients in accordance with their relevant CPGs.

Probiotics therapy for adults with diarrhea-predominant irritable bowel syndrome: a systematic review and meta-analysis of 10 RCTs

PURPOSE

Accumulating evidence showed that probiotics therapy might be effective in treating diarrhea-predominant irritable bowel syndrome (IBS-D). This study aimed to evaluate the effectiveness and safety of probiotics therapy for the treatment of IBS-D.

METHODS

We performed a comprehensive literature search in eight electronic databases, and gray literature from inception to August 4, 2021. Randomized controlled trials (RCTs) of probiotics therapy for the treatment of IBS-D were included and the quality was assessed using the risk of bias tool recommended by the Cochrane Handbook version 5.1.0. RevMan 5.4 software was used to perform the meta-analysis on the outcomes of IBS-D symptoms, abdominal pain, quality of life, and abdominal distension. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the certainty of evidence.

RESULTS

Ten RCTs evaluating 943 patients were identified. Only one study had unclear risk of bias, while nine studies had a high risk of bias. The meta-analysis results showed that, compared to the placebo, probiotics therapy significantly decreased the score of IBS-D symptoms (SMD =  - 0.55, 95% CI: [- 0.83, - 0.27], P < 0.05), abdominal pain (SMD =  - 0.43, 95% CI: [- 0.57, - 0.29], P < 0.05), and abdominal distension (SMD =  - 0.45, 95%CI: [- 0.81, - 0.09], P < 0.05). There was no statistical difference in the quality of life. However, all the certainty of evidence was very low.

CONCLUSION

Very low certainty evidence showed that probiotics might be an effective treatment for improving the IBS-D symptoms, abdominal pain, and abdominal distension, in adult IBS-D patients. However, these conclusions should be supported by high-quality evidence.

Bile Acid and Gut Microbiota in Irritable Bowel Syndrome

Gut microbiota and their metabolites like bile acid (BA) have been investigated as causes of irritable bowel syndrome (IBS) symptoms. Primary BAs are synthesized and conjugated in the liver and released into the duodenum. BA biotransformation by gut microbiota begins in the intestine and results in production of a broad range of secondary BAs. Deconjugation is considered the gateway reaction for further modification and is mediated by bile salt hydrolase, which is widely expressed by the gut microbiota. However, gut bacteria that convert primary BAs to secondary BAs belong to a limited number of species, mainly Clostridiales. Like gut microbiota modify BA profile, BAs can shape gut microbiota via direct and indirect actions. BAs have prosecretory effects and regulates gut motility. BAs can also affect gut sensitivity. Because of the vital role of the gut microbiota and BAs in gut function, their bidirectional relationship may contribute to the pathophysiology of IBS. Individuals with IBS have been reported to have altered microbial profiles and modified BA profiles. A significant increase in fecal primary BA and a corresponding decrease in secondary BA have been observed in IBS with predominant diarrhea. In addition, primary BA was positively correlated with IBS symptoms. In IBS with predominant diarrhea, bacteria with reduced abundance mainly belonged to the genera in Ruminococcaceae and exhibited a negative correlation with primary BAs. Integrating the analysis of the gut microbiota and BAs could better understanding of IBS pathophysiology. The gap in this field needs to be further filled in the future.

How to Implement the 3-Phase FODMAP Diet Into Gastroenterological Practice

Background/Aims

The 3-phase fermentable oligo-, di-, mono-saccharides, and polyols (FODMAP) diet has shown a high level of efficacy in irritable bowel syndrome, largely based on dietitian delivered education. However, access to dietitians can be limited, and challenges exist when applying the diet to a wide range of cultures, such as limited FODMAP analysis of local foods. This review aims to discuss ways to optimally use the FODMAP diet in practice in a wide range of cultures, directed at gastroenterologists from a dietitian's perspective.

Methods

Recent literature was analysed via search databases including Medline, CINAHL, PubMed and Scopus.

Results

The dietetic process involves detailed assessment and follow-up through the 3 stages of the FODMAP diet (restriction, re-introduction, and long-term maintenance). Emerging evidence suggests the diet can be delivered by other health professionals such as the gastroenterologist or nurse, but training on how to do so successfully would be needed. Self-guided approaches through use of technology or specialised food delivery services may be an alternative when dietitians are not available, but efficacy data is limited. Regardless of delivery mode, nutritional and psychological risks of the diet must be mitigated. Additionally, culturally appropriate education must be provided, with accommodations necessary when the FODMAP content of local foods are unknown.

Conclusion

While the diet has shown improved irritable bowel syndrome outcomes across studies, it is important to acknowledge the essential role of dietitians in implementing, tailoring, and managing the diet to achieve the best outcome for each individual.

Physical activity for treatment of irritable bowel syndrome

BACKGROUND

Current recommendations for people with irritable bowel syndrome (IBS) to partake in physical activity are based on low-level evidence, do not incorporate evidence from all available randomised controlled trials (RCTs) and provide little information regarding potential adverse effects.

OBJECTIVES

To assess the benefits and harms of physical activity interventions in adults diagnosed with irritable bowel syndrome and to explore possible effect moderators including type, setting and nature of physical activity interventions.

SEARCH METHODS

We searched nine electronic databases including CENTRAL, MEDLINE and Embase to 5 November 2021. We handsearched reference lists and sought unpublished studies through trial registries.

SELECTION CRITERIA

We included RCTs involving adults (aged 18 years or older) diagnosed with IBS and conducted in any setting comparing a physical activity intervention with no intervention, usual care or wait-list control group or another physical activity intervention group and assessing a validated measure of symptoms, quality of life or bowel movement.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies for inclusion, extracted study data, and performed risk of bias and GRADE assessments to assess the certainty of evidence. We pooled studies that evaluated similar outcomes using a random-effects meta-analysis, and synthesised data from other studies narratively.

MAIN RESULTS

We included 11 RCTs with data for 622 participants. Most (10/11) were set in high- or middle- to high-income countries, with five involving supervised physical activity, three unsupervised activity and three a mix of supervised and unsupervised activity. No trial was at low risk of bias. Four trials specified a minimally important difference for at least one assessed outcome measure. Data for 10 trials were obtained from published journal articles, with data for one obtained from an unpublished Masters degree thesis. Irritable bowel syndrome symptoms Six RCTs assessed the effectiveness of a physical activity intervention compared with usual care on global symptoms of IBS. Meta-analysis of five studies showed an observed improvement in reported symptoms following physical activity (standardised mean difference (SMD) -0.93, 95% confidence interval (CI) -1.44 to -0.42; 185 participants). We rated the certainty of evidence for this outcome as very low due to unclear and high risk of bias, inconsistency and imprecision from sparse data. This means physical activity may improve IBS symptoms but the evidence is very uncertain. The results of the remaining study supported the meta-analysis but were at unclear risk of bias and sample size was small. Two studies assessed the effectiveness of a yoga intervention compared with a walking intervention on global IBS symptoms. Meta-analysis of these two studies found no conclusive evidence of an effect of yoga compared with walking on IBS symptoms (SMD -1.16, 95% CI -3.93 to 1.62; 124 participants). We rated the certainty of evidence as very low, meaning the evidence is very uncertain about the effect of yoga interventions compared with walking interventions on IBS symptoms. Two studies assessed the effectiveness of a physical activity intervention (yoga) compared with medication. One reported no observed difference in global IBS symptoms, though CIs were wide, suggesting uncertainty in the observed estimates and risk of bias was high (MD -1.20, 95% CI -2.65 to 0.25; 21 participants). We excluded IBS symptom data for the remaining study as it used a non-validated method. One study compared a yoga intervention with a dietary intervention and reported an observed improvement in symptoms with both interventions but neither intervention was superior to the other. Quality of life Five RCTs assessed the impact of physical activity on self-reported quality of life compared with usual care. Meta-analysis of data from four studies found no improvement in quality of life following a physical activity intervention (SMD 1.17, 95% CI -0.30 to 2.64; 134 participants; very low certainty due to risk of bias, inconsistency and imprecision). We rated the certainty of evidence as very low, meaning the evidence is very uncertain about the effect of physical activity interventions on quality-of-life outcomes in people with IBS. One study assessed the impact on quality of life of a yoga intervention compared with walking and observed an improvement in the yoga group (MD 53.45, 95% CI 38.85 to 68.05; 97 participants ).  One study reported no observed difference in quality of life between a yoga and a dietary intervention. Abdominal pain Two trials assessed the impact of physical activity compared with usual care on reported abdominal pain. Meta-analysis found no improvement in abdominal pain with physical activity compared with usual care (SMD 0.01, 95% CI -0.48 to 0.50; 64 participants). We rated the certainty of the evidence as very low due to risk of bias and imprecision, meaning the evidence is very uncertain about the effect of physical activity interventions on abdominal pain in people with IBS. One study assessing the impact of a yoga intervention compared with walking advice reported no observed differences between groups on abdominal pain. One study comparing a yoga intervention with a dietary intervention found neither intervention had a more beneficial impact than the other and both interventions did not conclusively reduce abdominal pain. There was insufficient evidence to adequately assess adverse effects associated with physical activity due to a lack of reporting in trials. One study reported a musculoskeletal injury in a yoga intervention group but this did not result in withdrawal from the study.

AUTHORS' CONCLUSIONS

Findings from a small body of evidence suggest that physical activity comprising of yoga, treadmill exercise or support to increase physical activity may improve symptoms but not quality of life or abdominal pain in people diagnosed with IBS but we have little confidence in these conclusions due to the very low certainty of evidence. The numbers of reported adverse events were low and the certainty of these findings was very low for all comparisons, so no conclusions can be drawn. Discussions with patients considering physical activity as part of symptom management should address the uncertainty in the evidence to ensure fully informed decisions. If deemed sufficiently important to patients and healthcare providers, higher quality research is needed to enable more certain conclusions.

Diet as a therapeutic tool in chronic gastrointestinal disorders: Lessons from the FODMAP journey

BACKGROUND AND AIM

Diet is a powerful tool in the management of gastrointestinal disorders, but developing diet therapies is fraught with challenge. This review discusses key lessons from the FODMAP diet journey.

METHODS

Published literature and clinical experience were reviewed.

RESULTS

Key to designing a varied, nutritionally adequate low-FODMAP diet was our accurate and comprehensive database of FODMAP composition, made universally accessible via our user-friendly, digital application. Our discovery that FODMAPs coexist with gluten in cereal products and subsequent gluten/fructan challenge studies in nonceliac gluten-sensitive populations highlighted issues of collinearity in the nutrient composition of food and confirmation bias in the interpretation of dietary studies. Despite numerous challenges in designing, funding, and executing dietary randomized controlled trials, efficacy of the low-FODMAP diet has been repeatedly demonstrated, and confirmed by real-world experience, giving this therapy credibility in the eyes of clinicians and researchers. Furthermore, real-world application of this diet saw the evolution of a safe and effective three-phased approach. Specialist dietitians must deliver this diet to optimize outcomes as they can target and tailor the therapy and to mitigate the key risks of compromising nutritional adequacy and precipitating disordered eating behaviors, skills outside the gastroenterologist's standard tool kit. While concurrent probiotics are ineffective, specific fiber supplements may improve short-term and long-term outcomes.

CONCLUSIONS

The FODMAP diet is highly effective, but optimal outcomes are contingent on the involvement of a gastroenterological dietitian who can assess, educate, and monitor patients and manage risks associated with implementation of this restrictive diet.

Probiotics in irritable bowel syndrome - is the quest for the right strain over? Rapid review of existing guidelines and recommendations

Irritable bowel syndrome (IBS) - functional gastrointestinal disorder (FGIDs) and disorder of gut-brain interaction (DGBIs) - has emerged as an important medical problem with an impact on health care systems, affecting patients' quality of life. The management of IBS consists of pharmacological and non-pharmacological treatments; however, the data of their long-term efficacy are scarce. Modulation of gastrointestinal microbiota, by means of probiotics and prebiotics, is often sought and advertised as a popular treatment modality in IBS. Faecal microbiota transplantation (FMT) awaits recommendations for IBS treatment and requires more methodological assessments. To date, numerous guidelines and recommendations have been published on the role of probiotics in IBS. Because no probiotic claim for probiotics in foods has yet been granted by the European Food and Safety Authority (EFSA), medical practitioners still recommend probiotics on the basis of available literature and recommendations released by independent health authorities. We aimed to summarize published formal recommendations and guidelines regarding the clinical effectiveness of available probiotic strains and conduct a random-effects meta-analysis of outcomes for which ≥ 2 studies contributed data on the same probiotic strain recommended to adults with IBS. Based on available and most recent guidelines, we report that probiotics, as a group, may be an effective treatment for global symptoms and abdominal pain in IBS, with the strongest effect for genus Lactobacillus. Our current and updated meta-analysis is in line with several reports documenting significant effects of Lactobacillus plantarum (Lp299v) in reducing the risk of global symptoms and their persistence, which could assist clinicians in making the choice for the right probiotic strain in IBS patients.

Long-term symptom severity in people with irritable bowel syndrome following dietetic treatment in primary care: A service evaluation

BACKGROUND

Evidence suggests that dietary interventions can improve symptoms in people with irritable bowel syndrome (IBS), although most data explore the short-term (immediate) impact. Data on long-term (>6 months) impact are limited, especially from primary care settings. The present study aimed to investigate the long-term effect of dietetic-led interventions for IBS delivered in primary care.

METHODS

A service evaluation of a dietetic-led IBS clinic was completed, analysing data on symptom severity, stool frequency and consistency, and healthcare input. Data were collected before and immediately after dietary intervention as part of patients' routine clinical appointments. Long-term data were collected via a postal questionnaire at least 11 months later.

RESULTS

In total, 211 patients responded to the long-term follow-up questionnaire at a median of 13 months (interquartile range 12-16 months) post follow-up appointment. Of these, 84% had been advised to follow a low FODMAP (i.e., fermentable oligosaccharides, disaccharides, monosaccharides and polyols carbohydrates) diet. All symptoms were reported significantly less frequently short term, and all except heartburn and acid regurgitation remained so over the long term. The four most commonly reported bowel symptoms reduced in frequency were abdominal pain (62%), bloating (50%), increased wind (48%) and urgency to open bowels (49%) (p < 0.001). The percentage of patients reporting satisfactory relief of gut symptoms was 10% at baseline and 55% at long-term follow-up (p < 0.001). Visits to a general practitioner were reduced (from 96% to 34%; p < 0.001), as were those to the gastroenterologist (from 37% to 12%; p = 0.002), during the year prior to long-term follow-up compared to the year prior to dietary intervention.

CONCLUSIONS

Patients with IBS who received dietetic-led interventions in primary care reported long-term symptoms improvements that may result in reduced healthcare usage.

Effect of Heat-killed Lactobacillus casei DKGF7 on a Rat Model of Irritable Bowel Syndrome

Non-viable bacteria, referred to as “paraprobiotics,” have attracted attention as potentially safer alternatives to probiotics. The aim of this study was to investigate the efficacy of heat-killed Lactobacillus casei DKGF7 on the symptomatic improvement of irritable bowel syndrome (IBS) in a rat disease model and to elucidate the underlying mechanisms that contribute to the beneficial effects of heat-killed probiotics. Seven male Wistar rats were induced with IBS by restraint stress and administered heat-killed L. casei DKGF7 for four weeks and then compared with seven rats in the control group. Stool consistency measured four weeks after initial treatment was the primary outcome measure. To investigate the mechanism of action of the heat-killed bacteria on IBS, we measured serum corticosterone levels, inflammatory cytokines in colon tissue, and expression of tight junction proteins (TJPs) in the epithelium. The treatment group showed significantly better stool consistency scores than the control group at week 4, as well as at every measured time point (all p values < 0.05). The treatment group showed lower serum corticosterone levels, lower colonic inflammatory cytokine levels, and higher expression of TJPs compared with the control group. Paraprobiotics such as heat-killed L. casei DKGF7 can improve stool consistency in a rat IBS model, which may indicate a potential therapeutic strategy for IBS treatment.

Effect of a Synbiotic Containing Lactobacillus paracasei and Opuntia humifusa on a Murine Model of Irritable Bowel Syndrome

The administration of a combination of probiotics and prebiotics is expected to be a promising strategy for improving irritable bowel syndrome (IBS) symptoms. This study aimed to investigate the efficacy of a synbiotic containing Lactobacillus paracasei and Opuntia humifusa extract for symptomatic improvement of IBS in a murine model and to evaluate the mechanism underlying the beneficial effects of this synbiotic. A total of 20 male Wistar rats aged 8 weeks with IBS induced by restraint stress were assigned into four groups and administered L. paracasei as a probiotic and O. humifusa extract as a prebiotic for 4 weeks. The primary outcome was stool consistency at week 4. To evaluate the mechanism underlying the beneficial effects of the synbiotic, fecal microbial analysis was conducted, and the serum corticosterone levels, tumor necrosis factor-α (TNF-α) levels in the colon tissue, and expression of tight junction proteins were investigated. All three treatment groups showed significantly lower scores for stool consistency than the control group at week 4 (all p < 0.001). When compared with the control group, the synbiotic groups showed a significantly greater abundance of L. paracasei in fecal microbial analysis, lower serum corticosterone levels, lower TNF-α levels in the colon tissue, and higher expression of tight junction proteins. This novel synbiotic containing L. paracasei and O. humifusa extract can improve the stool consistency in a murine model of IBS. It may be a promising treatment option for IBS, and human studies are warranted.

2019 Seoul Consensus on Esophageal Achalasia Guidelines

Esophageal achalasia is a primary motility disorder characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. Achalasia is a chronic disease that causes progressive irreversible loss of esophageal motor function. The recent development of high-resolution manometry has facilitated the diagnosis of achalasia, and determining the achalasia subtypes based on high-resolution manometry can be important when deciding on treatment methods. Peroral endoscopic myotomy is less invasive than surgery with comparable efficacy. The present guidelines (the "2019 Seoul Consensus on Esophageal Achalasia Guidelines") were developed based on evidence-based medicine; the Asian Neurogastroenterology and Motility Association and Korean Society of Neurogastroenterology and Motility served as the operating and development committees, respectively. The development of the guidelines began in June 2018, and a draft consensus based on the Delphi process was achieved in April 2019. The guidelines consist of 18 recommendations: 2 pertaining to the definition and epidemiology of achalasia, 6 pertaining to diagnoses, and 10 pertaining to treatments. The endoscopic treatment section is based on the latest evidence from meta-analyses. Clinicians (including gastroenterologists, upper gastrointestinal tract surgeons, general physicians, nurses, and other hospital workers) and patients could use these guidelines to make an informed decision on the management of achalasia.

Clinical Practice Guidelines for Functional Dyspepsia in Korea

Functional dyspepsia (FD) is a chronic upper gastrointestinal (GI) symptom complex that routine diagnostic work-up, such as endoscopy, blood laboratory analysis, or radiological examination, fails to identify a cause. It is highly prevalent in the World population, and its response to the various available therapeutic strategies is only modest because of the heterogenous nature of its pathogenesis. Therefore, FD represents a heavy medical burden for healthcare systems. We constituted a guideline development committee to review the existing guidelines on the management of functional dyspepsia. This committee drafted statements and conducted a systematic review and meta-analysis of various studies, guidelines, and randomized control trials. External review was also conducted by selected experts. These clinical practice guidelines for FD were developed based on evidence recently accumulated with the revised version of FD guidelines released in 2011 by the Korean Society of Neurogastroenterology and Motility. These guidelines apply to adults with chronic symptoms of FD and include the diagnostic role of endoscopy, Helicobacter pylori screening, and systematic review and meta-analyses of the various treatment options for FD (proton pump inhibitors, H.pylori eradication, and tricyclic antidepressants), especially according to the FD subtype. The purpose of these new guidelines is to aid the understanding, diagnosis, and treatment of FD, and the targets of the guidelines are clinicians, healthcare workers at the forefront of patient care, patients, and medical students. The guidelines will continue to be revised and updated periodically.

Irritable bowel syndrome and functional constipation management with integrative medicine: A systematic review

BACKGROUND

Irritable bowel syndrome (IBS) and functional constipation (FC) are two commonly encountered functional gastrointestinal disorders in clinical practice and are usually managed with Western medicines in cooperation with traditional Chinese medicine (TCM) interventions. Although clinical practice guidelines (CPGs) have been developed to assist clinicians with their decisions, there are still gaps in management with regard to integrative medicine (IM) recommendations.

AIM

To comprehensively review the currently available CPGs and to provide a reference for addressing the gaps in IBS and FC management.

METHODS

We searched mainstream English and Chinese databases and collected data from January 1990 to January 2019. The search was additionally enriched by manual searches and the use of publicly available resources. Based on the development method, the guidelines were classified into evidence-based (EB) guidelines, consensus-based (CB) guidelines, and consensus-based guidelines with no comprehensive consideration of the EB (CB-EB) guidelines. With regard to the recommendations, the strength of the interventions was uniformly converted to a 4-point grading scale.

RESULTS

Thirty CPGs met the inclusion criteria and were captured as data extraction sources. Most Western medicine (WM) CPGs were developed as EB guidelines. All TCM CPGs and most IM CPGs were identified as CB guidelines. Only the 2011 IBS and IM CPG was a CB-EB set of guidelines. Antispasmodics and peppermint oil for pain, loperamide for diarrhea, and linaclotide for constipation were relatively common in the treatment of IBS. Psyllium bulking agents, polyethylene glycol and lactulose as osmotic laxatives, bisacodyl and sodium picosulfate as stimulant laxatives, lubiprostone and linaclotide as prosecretory agents, and prucalopride were strongly recommended or recommended in FC. TCM interventions were suggested based on pattern differentiation, while the recommendation level was considered to be weak or insufficient.

CONCLUSION

WM CPGs generally provide a comprehensive management algorithm, although there are still some gaps that could be addressed with TCM. Specific high-quality trials are needed to enrich the evidence.

Bacillus spp. Spores-A Promising Treatment Option for Patients with Irritable Bowel Syndrome

Dysbiosis is a condition that can cause various clinical disorders, from gastrointestinal problems to allergies or even cancer. Resetting the microbiota using antibiotics and/or probiotics could be a possible therapy for many diseases. The aim of this study was to evaluate the effects of three treatment regimens in patients with irritable bowel syndrome (IBS). The regimens were short-term rifaximin treatment (10 days) followed by either a nutraceutical agent (G1) or a low- Fermentable, Oligo-, Di-, Monosaccharide and Polyol (FODMAP) diet (24 days) (G3) or treatment with MegaSporeBiotic a mixture of spores of five Bacillus spp. for medium-term (34 days) (G2). Ninety patients with IBS without constipation were enrolled and divided into three groups (G1, G2, G3). Patients in G1 and G3 were evaluated over four visits (baseline/first day (V1), 10 days (V2), 34 days (V3), 60 days (V4)), and, those in G2 over three visits (V1, V3, V4). Severity score, quality of life, and parameters from the rectal volume sensation test were determined. The results demonstrated that patients treated with MegaSporeBiotic, compared with those treated with rifaximin followed by nutraceutical or low-FODMAP diet, had similar severity scores and rectal volume sensation test results for all parameters tested and statistically significant improvement in measurements of quality of life.

Are probiotics useful in the treatment of chronic idiopathic constipation in adults? A review of existing systematic reviews, meta-analyses, and recommendations

Chronic idiopathic constipation (CIC) has emerged as common problem for contemporary gastroenterology and is one of the most frequent complaints in primary care. Chronic idiopathic constipation significantly affects patients' quality of life and has an impact on global health and economy. Functional gastrointestinal disorders and bowel disorders, according to Rome IV criteria, result from inappropriate gut-brain interactions. The pathophysiology is complex and poorly understood, with evidence accumulating that gut microbiota can be implicated in the development and function of the enteric nervous system. Gut bacteria modulate gut barrier function, short chain fatty acid synthesis, and bile acid metabolism, factors which play roles in the gut peristalsis regulation. The high prevalence of CIC, with poor treatment outcomes, warrants searches for new forms of therapy, including probiotic therapies. Probiotics are often recommended by medical practitioners, but evidence-based utility in adults with CIC is uncertain. Recommendations/guidelines are often based on results from individual studies, rather than meta-analyses or umbrella reviews. Additionally, meta-analyses often indicate a group of probiotics rather than individual strains, and they create difficulty for physicians in making therapeutic choices. More CIC patient randomised clinical studies utilising well-defined strains, or combinations, are necessary.

Efficacy of different probiotic protocols in irritable bowel syndrome: A network meta-analysis

BACKGROUND

Probiotics is a prevalence therapeutic method for irritable bowel syndrome (IBS), but there is lack of comparison in different protocols. We aim to differentiate the reasonable protocols by assessing the efficacy and safety through the combined way of traditional and network meta-analysis.

METHOD

PubMed, Medline, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases were searched from January 2006 to April 2019. The relative risk (RR) with a 95% confidence interval (CI) was used to combine dichotomous data of responders.

RESULT

Among 14 studies included 1695 patients were identified as suitable for inclusion. The proportion of responders was associated with the administration of multispecies probiotics (RR: 1.39; 95% CI: 1.19-1.61) and the dose of 10∼10 (RR: 2.08; 95% CI: 1.59-2.71). In network meta-analysis, the protocol of DUO had a significant effect for diarrhea type of IBS compared with placebo (RR: 7.46; 95% CI: 2.00-32.23). In the rest of 4 protocols, no significant difference was found in each other except F19 which appears inferior when compared with Pro (RR: 0.16; 95% CI: 0.03-0.88). Meanwhile, Pro showed a superior effect for undifferentiated-type IBS compared with placebo (RR: 7.16; 95% CI: 1.72-29.89). No probiotics-associated severe adverse event was reported in included studies.

CONCLUSION

Probiotics is a safety choice to improve the overall symptoms for IBS patient. The protocols with suitable dose combined of Lactobacillus and Bifidobacterium can have prepotent effects compared with single species or over-dosage protocols. Network meta-analysis shows that DUO may be the first recommendation for diarrhea-type IBS. In the remaining 4 regimes of this study, Pro has a high rank for undifferentiated-type IBS.

Sex-Gender Differences in Irritable Bowel Syndrome

Because of the sex-gender differences that are shown in a diversity of physiological and psychological factors, it can be speculated that the clinical presentation of symptoms as well as treatment strategies in women and men with irritable bowel syndrome (IBS) may differ. Studies have revealed that IBS is more common in women than men. As for the IBS subtype, IBS with constipation is significantly more prevalent among women than men. Sex hormones and gender differences may play important roles in the pathophysiology of IBS. However, its pathophysiologic mechanisms still remain largely unknown, and therapeutic implications are limited. Moreover, women IBS patients have been reported to feel more fatigue, depression, anxiety, and lower quality of life than men IBS patients. Furthermore, there has been evidence of differences in the appropriate treatment efficacy to IBS in men and women, although relatively few men are enrolled in most relevant clinical trials. A more sex-gender-oriented approach in the medical care setting could improve understanding of heterogeneous patients suffering from IBS. An individualized and multicomponent approach including sex and gender issues might help improve the treatment of IBS.

Guidelines on the management of irritable bowel syndrome: In memory of Professor Witold Bartnik

These guidelines constitute an update of the previous "Recommendations on the management of irritable bowel syndrome" issued in 2008. They have been developed by a Task Force organized by the Governing Board of the Polish Society of Gastroenterology. They discuss, with particular emphasis on new scientific data covering papers published since 2008, the aetiology, epidemiology, clinical presentation, diagnostic principles and criteria for the diagnosis, and recommendations for the treatment of irritable bowel syndrome (IBS). The English-language acronym for the syndrome (IBS) has become popular in medical and popular scientific language. It is also widely recognized by patients who identify with this diagnosis. Therefore, in the discussed guidelines, this is what we will use.