Tag Archives: irritable bowel syndrome

Low Quality Evidence for IBS Dietary Therapy

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A recent systematic review and meta-analysis (J Dionne et al. Am J Gastroenterol 2018; 113: 1290-1300) throws some shade on the effectiveness of dietary therapies for irritable bowel syndrome. Thanks to Ben Gold for this reference. The authors reviewed 1726 citations -only 9 were eligible for systematic review; two RCTs (n=111 participants) with gluten-free diet (GFD) and 7 RCTs (n=397) with low FODMAPs diet.

Key findings:

  • A GFD was associated with reduced global symptoms compared with control interventions (RR=0.42, CI 0.11-1.55) which was not statistically significant.  Thus, there is “insufficient evidence to recommend a GFD to reduce IBS symptoms.”
  • A low FODMAP diet was associated with reduced global symptoms compared with control interventions (RR=0.69, CI 0.54-0.88). The three RCTs with rigorous control diets found the least magnitude of effect. Thus, the overall quality of the data was “very low” according to the GRADE criteria.

Given the limited data supporting dietary therapy for IBS, the authors caution that in those who are placed on a low FODMAPs diet, that after a 2-6 week trial, those who “fail to improve should not continue the diet. ”

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Differential Microbiome Effects of Prebiotics and low FODMAPs

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A recent study (J-W Huaman et al. Gastroenterol 2018; 155: 1004-7) examined the effects of a prebiotic (Bimuno) and a low FODMAPs diet for the treatment of functional GI disorders and their effects on the microbiome.

This was a randomized controlled 4-week trial with a 2-week followup period.  Those who received the prebiotic (N=19) received a placebo diet (Mediterranean-type) and those who were randomized to a low FODMAP diet (n=21) were instructed to consume a placebo.  The prebiotic contained beat-galactooligosaccharide.

Key findings:

  • Both groups had significant reduction in GI symptoms, though low FODMAPs was the only treatment helpful for flatulence/borborygmi.
  • The symptom reduction persisted in the prebiotic group for the 2 -week follow-up period, whereas symptoms reappeared immediately in the low FODMAP group.
  • The two treatments had opposite effects on the intestinal microbiota –the prebiotic treatment led to an increase in bifidobacteria and a decrease in Bilophilia wadsworthia.

My take: (borrowed from editorial pg 960-2): This study “may indicate that the effect of the prebiotic is mediated through its effects on gut microbiota composition, whereas the effect of the low FODMAP diets is more related to the meal composition…than to its effects on gut microbiota composition.”

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From two of the missions in San Antonio

 

 

 

 

Chronic Fatigue and Irritable Bowel Syndrome -10 years after Giardia Infection!

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A recent study (S Litleskare et al. Clin Gastroenterol Hepatol 2018; 16: 1064-72) involved prospective follow-up of 1252 laboratory-confirmed cases of giardiasis from a 2004 outbreak in Norway.

Key findings:

  • Prevalence of irritable bowel syndrome (IBS) was 43% 10 years after the outbreak among 576 exposed individuals compared with 14% among 685 controls. Thus, the odds ration of developing IBS was 4.74 following Giardia exposure.
  • Chronic fatigue at 10 years was higher as well, reported in 26% in the exposed group compared with 11% in the control group.
  • The authors note that the change in IBS between 6 years and 10 years following the infection was 40% and 43% respectively and the change in chronic fatigue was 31% at 6 years and 26% at 10 years.

My take: Don’t get Giardia!! It may cause chronic fatigue and IBS 10 years after acquisition of an infection.  This study reinforces other studies which have shown that numerous enteric pathogens can increase the risk of IBS.  These other studies reported lower rates of IBS following infections, between 7-36%.

Moraine Lake, Banff

Why Did the Young Woman’s Heartburn Keep Getting Worse?

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Mystery NY Times Case: Why Did the Young Woman’s Heartburn Keep Getting Worse?

An excerpt:

The radiologist who read the scan made an interesting observation. In each of the three visits to the E.R., the patient’s blood had been tested. All three tests showed an elevated white-blood-cell count. That could suggest an infection — but in her tests a quarter of those white blood cells were a cell type known as eosinophils, which normally make up only a tiny fraction of the white blood cells in the circulation. ..

When the radiologist saw the elevated level of eosinophils, however, he recalled an unusual and relatively new disorder known as eosinophilic gastroenteritis (EGE). He added this rarity to the list of possible causes of the patient’s abnormal CT findings on his report…

EGE is thought to be an unusual type of allergic reaction to foods. Food exposure triggers the recruitment of eosinophils to the gut, but once they have a toehold, repeated exposure isn’t necessary to keep them there. The disorder was first described in a series of patients in the United States in 1993 but since then has been found to occur throughout the developed world. Because it’s a relatively new disease, and because our understanding of allergy is still emerging, it’s not well understood. As recognition of the disorder expands, so, too, do the number of cases. Patients are usually started on an elimination diet and given steroids to further suppress the immune system. An elimination diet — one in which the foods most frequently linked to allergic reactions, like milk, eggs and wheat, are not consumed — has been shown to be helpful up to 90 percent of the time.

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Gut-Brain Modulators for Functional GI Disorders: Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome

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A lengthy report (DA Drossman et al. Gastroenterol 2018; 154: 1140-71) thoroughly reviews the evidence for neuromodulators for functional GI disorders, including Irritable Bowel, Dyspepsia, Functional Heartburn, and Cyclic Vomiting Syndrome.

“Some general recommendations include: (1) low to modest dosages of tricyclic antidepressants provide the most convincing evidence of benefit for treating chronic gastrointestinal pain and painful FGIDs and serotonin noradrenergic reuptake inhibitors can also be recommended, though further studies are needed; (2) augmentation, that is, adding a second treatment (adding quetiapine, aripiprazole, buspirone α2δ ligand agents) is recommended when a single medication is unsuccessful or produces side effects at higher dosages; (3) treatment should be continued for 6-12 months to potentially prevent relapse; and (4) implementation of successful treatment requires effective communication skills to improve patient acceptance and adherence, and to optimize the patient-provider relationship.”

The report makes specific recommendations for several functional conditions (Table 4).

  • For dyspepsia, the authors recommend categorizing as either postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) as per Rome IV criteria.
  • They state that “Buspirone…may be used for PDS where early satiety, fullness and nausea predominate.”
  • “Mirtazapine is a good treatment option for PDS when there is chronic nausea and vomiting, or weight loss, and it may also help coexisting abdominal pain.”
  • For EPS, “studies mainly support the use of TCAs, either initially or after an unsuccessful response to a proton pump inhibitor.”

Figure 5 outlines general treatment advice:

  • SSRIs -“when anxiety, depression and phobic features are prominent with FGIDs”
  • TCAs -“first-line treatment when pain is dominant in FGIDs”
  • Tetracyclic antidepressant (mirtazapine, mianserin, trazodone) -“treatment of early satiety, nausea/vomiting, weight loss and disturbed sleep”
  • SNRIs (duloxetiine, venlafaxine, desvenlafaxin, milnacipran) -“treatment when pain is dominant in FGIDs or when side effects from TCAs preclude treatment”
  • Augmentation therapies are subsequently delineated including atyipical antipsychotics, pyschological treatments (like cognitive behavioral therapy) and hypnosis

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Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.

 

Another Study: Low FODMAPs Diet for Irritable Bowel Syndrome

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Another good study on the low FODMAPs diet for irritable bowel syndrome with diarrhea (IBS-D): S Eswaran et al. Clin Gastroenterol Hepatol 2017; 15: 1890-9

This was a propspective, single-blind trial of 92 patients (84 completed study) with IBS-D (65 women) comparing the low FODMAPs diet to a modified diet recommended by the National Institute for Health and Care Excellence (NICE) for 4 weeks. Key findings:

  • The low FODMAPs group had larger increase in IBS-QOL score (15.0 vs 5.0).  In addition, based on IBS-QOL a meaningful clinical response occurred in 52% compared with 21% in the mNICE group.
  • Activity impairment was significantly reduced in the low FODMAPs group; -22.89 compared with -9.44.  Anxiety scores decreased as well.

My take: This study indicates that the low FODMAPs diet helps patient with IBS-D, and not just with their GI symptoms.

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Low FODMAP –Real World Experience

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HM Staduacher et al. Gastroenterol October 2017; 153: 936–47

Key finding:

  • In this randomized, placebo-controlled study with 104 patients with irritable bowel syndrome (IBS), the researchers spent only 10 minutes per patient teaching the low FODMAPs diet; yet 57% reported adequate relief of symptoms.

AGA Journals blog summary: Can a Diet Low in FODMAP Reduce IBS Symptoms in the Real World?

An excerpt:

Heidi Maria Staudacher et al aimed to investigate the effects of a diet low in FODMAPs compared with a sham diet in patients with IBS, and determine the effects of a probiotic on diet-induced alterations in the microbiota.

They performed a 2×2 factorial trial of 104 patients with IBS. Patients were either given counselling to follow a sham diet or diet low in FODMAPs for 4 weeks, but not the actual foods. Patients also received a placebo or multistrain probiotic formulation, resulting in 4 groups (27 receiving sham diet/placebo, 26 receiving sham diet/probiotic, 24 receiving low-FODMAP diet/placebo, and 27 receiving low-FODMAP diet/probiotic)…

In the per-protocol analysis, a significantly higher proportion of patients on the low-FODMAP diet had adequate symptom relief (61%) than in the sham diet group (39%).

The total mean IBS severity score was significantly lower for patients on the low-FODMAP diet (173 ± 95) than the sham diet (224 ± 89), but there was no significantly difference between patients given probiotic (207 ± 98) or placebo (192 ± 93).

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#NASPGHAN 17 More Abstracts

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This link for the NASPGHAN abstracts :NASPGHAN 2017 Scientific Abstracts

The following slides are from some of the abstract posters. This first poster (next 5 pics) showed that symptom association with meals is not predictive of aspiration among a selected group of children who underwent swallow study evaluations. In the figures, the blue bars are children who passed the swallow study whereas the red bars indicate the children who failed the swallow study.

This next slide demonstrated that a six food diet for EoE could be administered blenderized via a gastrostomy tube.

The next slide showed that irritable bowel syndrome was more frequent (overall hazard ratio of 1.52) following a urinary tract infection in the first year of life.

The next pictures are from a poster discussing high rates of recurrent C difficile infection following fecal microbial transplantation in pediatric patients with inflammatory bowel disease (mainly ulcerative colitis).  An inference from this study would be that many cases of C difficile that were attributed as causing symptoms could in fact have been from a flare up of their IBD.  More details about the diagnosis of C difficile (based on PCR or ELISA) would be helpful

The next poster provides data from CHOP experience with Ustekinumab.  Overall, in this highly-selected (refrcactory) population the long term improvement was low; while one-third had steroid-free remission at week 8, this was not maintained at week 16 and week 24.  In addition, among the 22 patients, one developed transverse myelitis.

This study that follows (next two pics) documented the relative safety of liver biopsies (mainly percutaneous without interventional radiology) in the post-transplant period.  The two most serious adverse events, cholangitis and bile leak, helped identify biliary strictures.

The following collaborative study examined the neurocognitive status of children with Alagille syndrome.  Overall, this study shows that children with Alagille syndrome are at increased risk of low IQ compared to children with other cholestatic diseases.

 

 

#NASPGHAN17 Why Rome IV Criteria are important

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More information from this year’s annual NASPGHAN meeting.

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

The following slides highlight a terrific lecture by Carlo DiLorenzo (Nationwide Children’s Hospital).  Subsequently, I’ve included slides from Miranda van Tilburg (UNC); I was unable to attend her lecture and found some of the slides via twitter.

Key points:

  • Rome IV criteria are helpful, particularly with less common presentations like rumination
  • There has been an increase in nausea.  Morning nausea can be equated as a marker of anxiety until proven otherwise.
  • There is improved wording. “After appropriate medical evaluation, the symptoms cannot be attributed to another condition” may help facilitate the diagnosis of irritable bowel syndrome, for example, in patients with IBD who are in remission.

From Miranda Tilburg:

Small Pediatric Study: Probiotic Helping Some with Irritable Bowel Syndrome

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In a recent study (O Jadresin et al. JPGN 2017; 64: 925-9), 55 children with functional abdominal pain or irritable bowel syndrome were randomized (prospective, double-blind, placebo-controlled study) to either L reuteri DSM or placebo.

Key findings:

  • The intervention group had more days without pain: median 89.5 days vs. 51 days (P=.029)
  • Abdominal pain was less severe in the intervention group at some time points (second month, and fourth month)
  • The two groups did not differ with regard to duration of abdominal pain, stool type, or absence from school

Limitation: Small number of patients -the estimated samples size was not reached

My take: This study suggests that probiotics may help some pediatric patients with irritable bowel syndrome.  Trying to identify which patients should receive a probiotic and which probiotic should be selected remains unclear.

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