bunch of info

[Guest guest]

Some of us have several things wrong with

us. I have irritable bowel syndrome, that is something I forgot to

mention in my last list of crap that I have. Here is some info on that

and some other stuff.

Wolf

incognito

Subject: Irritable

Bowel Syndrome: From Epidemiology to Treatment

Irritable Bowel Syndrome: From Epidemiology to Treatment

J. Talley, MD, PhD

Introduction

The management of irritable bowel syndrome (IBS) and other functional

gastrointestinal disorders remains a significant challenge to the physician at

the front lines of disease management. At this year's meeting of the American College of Gastroenterology, new

information on the epidemiology, pathophysiology, and management of IBS and

related conditions was presented.

This report discusses some of the more key and interesting data

presented during this meeting, and thus provides the relevant context for

highlighting their implications on clinical practice.

Epidemiology, Impact, and Practice Variations

Symptom Complexes

One of the difficulties in managing patients with IBS remains the

multitude of symptoms that many describe either spontaneously or on systems

review. Sometimes this confounds management because such complaints may lead to

extensive evaluations, even if the patient clearly has a positive clinical

diagnosis of IBS and there are no alarm features present. However, the exact

prevalence of the combinations of different functional gastrointestinal symptom

complexes remains unclear.

To examine the prevalence of gastrointestinal symptoms, Tutega and

colleagues[1] reviewed 1069 employees of an integrated healthcare system in Salt Lake City, Utah,

623 of whom responded to a validated questionnaire. They found a striking

overlap between IBS and functional dyspepsia: 70% of individuals with IBS also

had functional dyspepsia, whereas 43% of subjects with dyspepsia also had IBS.

Moreover, more individuals with such overlap reported consulting a physician

than those who had IBS or dyspepsia alone.

In a community survey from Olmsted

County, Minnesota,

Locke and colleagues[2] evaluated a similar number of subjects drawn from the

general population. Six hundred fifty-seven of 935 eligible subjects responded

to a validated questionnaire. These study authors found that symptom complex

overlap was much more the rule than the exception in this community sample.

This applied to IBS with constipation as well as IBS with diarrhea in terms of

overlap with upper gastrointestinal tract symptoms. It is important to note

that there was no predominant pattern of overlap identified consistent with a

common underlying pathophysiology. Hence, artificial subdivision of these

functional gastrointestinal complaints may not be particularly helpful in terms

of management.

These data arguably challenge the subdivision of the functional

gastrointestinal disorders into finer and finer categories, which has been the

tendency over the past decade.[3]

Ethnic Differences

An area that has been understudied in IBS is the issue of ethnic

differences in disease manifestation and presentation. Wigington and

colleagues[4] studied black and white patients with IBS and evaluated the

symptomatic presentations. A similar prevalence of IBS was found among both

blacks and whites. However, there were some unexplained sociodemographic

differences between the groups. For example, blacks with IBS and diarrhea were

significantly more likely to have lower incomes compared with white patients,

who tended to have higher incomes. Age, sex, and education differences were not

observed, however.

Such differences may be explained by confounding. Alternatively, there

may be different etiologic explanations for IBS in different races (eg,

genetic) yet a common final pathway in terms of symptom expression. However,

confirmation of racial differences in IBS in the United States, which to date has

been largely ignored, is still required.

Bowel Pattern

One issue that remains controversial in IBS is subdivision into bowel

pattern subgroups. In particular, what defines an alternating bowel pattern is

unclear from the literature. Indeed, there is no definitive guidance from the Rome committees regarding

this issue. Simply defining patients not fitting into an arbitrary diarrhea or

constipation subgroup as an alternator may be overly simplistic and even

misleading.

In a study by Locke and coworkers,[5] the investigators aimed to

determine what individuals meant when they said that they had an alternating

bowel pattern, as based on a large community survey. A valid questionnaire was

mailed to 4029 randomly selected individuals in Olmsted County,

of whom 3022 eligible subjects provided data. Overall, 7.6% of the population

had a self-reported alternating bowel pattern, compared with 9.2% who stated

that their usual bowel pattern was constipation and 2.5% who said that their

usual bowel pattern was diarrhea. It was interesting to note that the feeling

of incomplete rectal evacuation and passage of mucus were significant

predictors of reporting an alternating bowel pattern in this general

population. Of those individuals who reported an alternating bowel pattern, 59%

met symptom criteria for constipation based on standard and accepted groupings

of individual symptoms, whereas 35% met symptom criteria for diarrhea and 20%

met criteria for both (25% met criteria for neither).ˆò

These findings suggest that " alternators " may not comprise a

distinct subgroup from constipation and diarrhea in this population. Further work

is needed to define an appropriate, clinically relevant subclassification of

IBS based on colonic symptoms. The latter could be very useful in terms of

making management strategies more logical and evidence-based.

Primary-Care vs Gastroenterology Clinics

The approach to management of IBS in practice has been little

evaluated. In particular, it is unclear how gastroenterologists and

primary-care physicians treat IBS in the United States.

Whitehead and colleagues[6] studied 1665 patients diagnosed with a

functional bowel disorder in both gastroenterology and primary-care clinics of

a large health maintenance organization; some interesting differences in

management were noted. Primary-care physicians more commonly prescribed

laxatives than did gastroenterologists. About one quarter of patients in both

settings were prescribed antidiarrheal agents and about one quarter were

prescribed antispasmodics, but only 1 in 10 were given antidepressants and 1 in

10 prescribed anxiolytics or muscle relaxants. Approximately one third of

patients had lifestyle changes suggested to them, or were advised to exercise

-- and this approach was similar in both clinical practice settings.

Gastroenterologists were more likely to tell their patients about the certainty

of diagnosis than were primary-care physicians, although this presumably

reflects standard practice in primary care. However, surprisingly,

gastroenterologists were less likely to explain the cause of

ˆò

Other data suggest that explanation, reassurance, and education are all

important in reducing subsequent visits to clinic for patients with IBS.[7]

Therefore, such differences in practice patterns may have real clinical

relevance. Gastroenterologists and primary-care physicians achieved only modest

patient satisfaction levels, which may be improved with the adoption of more

appropriate management strategies.

Pathogenesis

Postinfectious IBS

There continues to be major interest in postinfectious IBS. Marshall

and colleagues[8] investigated an outbreak of acute gastroenteritis (that was

attributed to a viral pathogen) and the subsequent development of IBS. This

study documented a large foodborne outbreak of severe acute gastroenteritis at

a meeting of the Canadian Society of Gastroenterology Nurses and Associates. The

attendees were subsequently surveyed and followed-up. The study authors

obtained a 71% response rate; 107 respondents (77%) described an acute enteric

illness during the outbreak. Among those subjects who had enteric illness, the

incidence rate of IBS at 3 months was 24%, although by 6 months the rate had

dropped to 14%, compared with 3% and 11% among controls, respectively.

Hence, although there was an increased incidence of IBS among subjects

at 3 months, by 6 months there was no difference in the rates. Vomiting

appeared to be indicative of some protection from the development of

postinfectious IBS, although this effect remains unexplained. These study

results are consistent with other published data that suggest that

postinfectious IBS is a distinct subgroup with more diarrhea and less

psychiatric illness.[9] It seems likely that infection can precipitate IBS in

individuals who are otherwise predisposed. Whether subclinical infection could

explain the increased incidence rates in the control patients as well is

unclear. Unfortunately, at this time there is no way to prevent the development

of IBS in individuals so exposed. A recent trial of high-dose prednisone failed

to demonstrate any benefits in postinfectious IBS.[10]

Relationship Between Menstrual Cycle and IBS Symptoms

Some women with IBS report an exacerbation of symptoms across the

menstrual cycle. Heitkamper and colleagues[11] studied 195 women with IBS who

reported that they often felt bloated and distended. The study authors used a

daily diary as well as a standardized questionnaire to assess bloating and

other gastrointestinal symptoms in menstruating women during perimenstrual and

non-perimenstrual days. Bloating was associated with menses-type symptoms; they

also noticed that bloating was worse on days with loose or hard stools. Could

these findings reflect abnormal visceral pain perception in different phases of

the menstrual cycle?

Wrzos and associates[12] evaluated 11 women, 5 of whom had IBS, and

induced distention with a rectal barostat to experimentally cause visceral-type

pain. They found that the thresholds for sensation were lower in patients with

IBS than in healthy volunteers as would be expected, with no differences in

somatic sensation. It was interesting to note that in the healthy volunteers --

but not in the patients with IBS -- there were lower pressure thresholds in the

follicular vs luteal phase for each sensation level. The level of anxiety was

not associated with the changes observed. Hormonal changes during the menstrual

cycle may therefore affect " normal " individuals differently from

those with IBS. Most likely, the threshold for pain sensation is set lower in

IBS and is not modulated by hormonal changes during menses.

Overall, these data suggest that menstrual cycle hormonal fluctuations

in IBS are unlikely to be a major explanation for changes in symptoms. Although

chemical castration of women with leuprolide has been proposed as a therapy for

IBS, trials with this agent had methodologic limitations and thus, such an

approach cannot be recommended.[13]

Serotonin Signaling

There remains major interest in serotonin signaling in IBS. Moses and

colleagues,[14] in a follow-up of previous work, evaluated serotonin (5-hydroxytryptamine;

5-HT) content, serotonin release, and serotonin transporter levels in patients

with IBS with either constipation or diarrhea, ulcerative colitis, and

controls. They found that 5-HT content in colonic biopsies was reduced in

patients with IBS as well as in patients with ulcerative colitis. There were

actually increased enterochromaffin cells (which store serotonin) in

individuals with IBS compared with controls. The presence of the 5-HT

transporter was reduced in patients with IBS, but also was reduced in those

with ulcerative colitis.

These data suggest that in the setting of IBS, more 5-HT is released,

but less can be removed because there is less transporter available.

Unfortunately, these findings are not specific to IBS. Moreover, the results no

longer seem to explain the differences between patients who present with IBS

and constipation and those who present with IBS with diarrhea, contradicting

earlier findings from the same group.[15] It is possible, however, that in

individuals with constipation there may be greater serotonin receptor

desensitization than in those with diarrhea despite the greater availability of

5-HT, which could explain the clinical differences between IBS with

constipation and IBS with diarrhea.

Treatment

5-HT4 Receptor Agonist Therapy (Tegaserod)

Tegaserod is approved by the United States Food and Drug Administration

for treatment of women with IBS and constipation, and in clinical trials, this

agent has been shown to be more efficacious than placebo for this condition as

well.[16] Other work has evaluated the role of tegaserod in chronic

constipation, which is distinct from IBS in terms of the absence of significant

abdominal pain linked to the defecation disturbance.

A large randomized controlled trial evaluating the use of tegaserod in

chronic constipation was reported on during this year's meeting.[17] Patients (n = 1264) with significant constipation,

defined as less than 3 complete spontaneous bowel movements per week and at

least 1 other constipation symptom, were enrolled in this study. They found a

significantly greater increase in the number of complete spontaneous bowel

movements on active treatment compared with placebo: 36% for 2 mg tegaserod

twice daily and 40% for 6 mg tegaserod twice daily, compared with 27% for

placebo.

This finding suggests that tegaserod* does provide a therapeutic

benefit in functional constipation -- although whether this applies

particularly to individuals with slow-transit constipation rather than patients

with pelvic-floor dysfunction was not evaluated. Furthermore, this study

population was 86% women; therefore, the benefit of the drug in men remains

unknown.

Hypnosis

Other novel approaches to management are also undergoing investigation.

Palsson and colleagues[18] looked at the value of hypnosis for treating IBS in

a pilot study.

Hypnosis was performed by a novel home-treatment course via an audio

compact disc recording. The investigators studied 19 patients with IBS and

found that 53% responded to treatment by the 3-month follow-up timepoint. The

control group comprised 57 patients with IBS from a separate study. Only 26% of

these controls responded by 3 months to standard medical care, although the

groups may not be directly comparable. Nonresponders to hypnosis tended to be

patients with higher anxiety scores. Previously, hypnosis has been shown to be

beneficial both in IBS and functional dyspepsia in randomized, controlled (but

not blinded) studies.[19] Hypnosis is therefore promising and additional work

is needed in this area, particularly if simple strategies can be used to save

on therapist time and costs.

Role of Diet

Another intriguing area that is currently undergoing more active

exploration, is the potential role of dietary modification in IBS. There has,

however, been a lack of population-based studies evaluating nutrient

consumption in individuals with and without IBS.

Saito and colleagues[20] presented their findings from a case-control

study conducted in Olmsted County comparing dietary consumption of specific

nutrients in subjects who had a presumed functional gastrointestinal disorder

with controls (ie, those without symptoms). A validated food frequency

questionnaire was applied. Patients

with functional gastrointestinal symptoms consumed a higher percentage of fat,

but there were no other major differences observed between the 2 groups,

although there was a modestly lower percentage of carbohydrate, vitamin C, and

sugar consumed by individuals with functional gastrointestinal complaints.

Drisko and colleagues[21] performed an open-label study evaluating 20

patients with a history of IBS with diarrhea who failed standard medical

treatment. Patients had a

food-elimination diet provided for 1 month based on the results of serum IgE

and IgG food and mold panels. In addition, probiotics were provided in months

2-5 during controlled food challenges. Of the 19 patients who completed the

trial, there was significant improvement in terms of pain, stool frequency, and

quality of life after the intervention. However, this was not a controlled

trial, and therefore the results require confirmation in randomized clinical

trials.

A controlled trial of food-elimination diet demonstrating promising

results was reported during Digestive Disease Week 2003.[22] In this study, 150

patients were randomized to either receive a diet excluding all foods to which

they had positive IgG antibodies or to a sham exclusion diet. The investigators

observed that symptom severity scores were significantly reduced in the active-therapy

arm. The role of withdrawal diets in IBS remains to be adequately documented,

but this strategy represents a nonpharmacologic approach to management that may

be useful.

Concluding Remarks

This year's meeting of the American

College of Gastroenterology

presented more information on IBS and its diverse manifestations. Within this

setting, it is no surprise that this condition continues to present a challenge

to the clinician in practice.

Unfortunately, the pathophysiology of IBS remains obscure and therefore

more work is needed to understand both postinfectious IBS and the role of

serotonin signaling. Advances in management have been slower than anticipated,

but efforts remain under way in testing novel therapeutic targets for this very

common disease entity.

* The United States Food and Drug Administration has not approved this

medication for this use.________________________________________________________________________

________________________________________________________________________

Effectiveness of Exercise in Management of Fibromyalgia

Posted 03/24/2004

Abstract and Introduction

Abstract

Purpose of Review: Exercise was established as an integral part of the

nonpharmacological treatment of fibromyalgia approximately 20 years ago. Since

then many studies have investigated the effects of exercise-either alone or in

combination with other interventions. This review will discuss the benefits of

exercise alone and provide practical suggestions on how patients can exercise

without causing a long-term exacerbation of their pain.

Recent Findings: Short-term exercise programs for individuals with

fibromyalgia have consistently improved physical function, especially physical

fitness, and reduced tenderpoint pain. Exercise has also produced improvements

in self-efficacy. These effects can persist for periods of up to 2 years but

may require participants to continue to exercise. Most exercise studies have

examined the effects of moderately intense aerobic exercise. Only in the past 2

years have muscle-strengthening programs, in isolation, been evaluated. To be

well tolerated, exercise programs must start at a level just below the capacity

of the participants and then progress slowly. Even with these precautions,

exercise may still produce tolerable, short-term increases in pain and fatigue

that should abate within the first few weeks of exercising.

Summary: Future studies should investigate the possible benefits of

low-intensity exercise and test strategies that may enhance long-term

compliance with exercise. Individuals with fibromyalgia also need to be able to

access community exercise programs that are appropriate for them. This may

require community instructors to receive instruction on exercise prescription

and progression for individuals with fibromyalgia.

Introduction

Fibromyalgia is a condition characterized by widespread pain and pain

at specific tender points.[1] Typically, individuals with fibromyalgia are also

inactive and unfit.[2,3] Exercise was established as an integral part of the

nonpharmacological treatment for individuals with fibromyalgia less than 20

years ago by the demonstration that patients randomized to 20 weeks of high-intensity

exercise had greater improvements in fitness, tender point pain thresholds, and

patient/physician global assessment ratings than patients randomized to 20

weeks of flexibility training.[4] Since then, an escalating number of

randomized controlled trials have evaluated the benefits of exercise for

individuals with fibromyalgia. Subsequent exercise trials have, by and large,

examined the benefit of moderately intense aerobic exercise, either alone, or

in combination with other interventions, such as muscle strengthening or

education. Only in the past 2 years have a limited number of studies examined

the effect of muscle strengtheˆò

This review summarizes the literature on exercise for individuals with fibromyalgia

and highlights relevant exercise studies that have been published between

January 2002 and September 2003.

Conclusion

Moderately intense aerobic exercise is beneficial for people with

fibromyalgia, particularly for improving their physical fitness and self

efficacy, and reducing their tender point pain. Further studies need to address

whether the benefits from low-intensity aerobic exercise, demonstrated in one

well-run study, can be replicated. Muscle strengthening, in isolation, has only

recently been tested for individuals with fibromyalgia and the benefits,

suggested by these studies, need to be replicated by other controlled studies.

Subsequent studies of strengthening should also continue to test whether

strengthening, in isolation, can improve outcomes besides physical function.

Follow-up studies suggest that long-term compliance with aerobic exercise will

produce an ongoing benefit for physical function, pain reduction, and self

efficacy. Since long-term compliance with exercise is difficult to achieve,

further studies need to test strategies to enhance long-term exercise

compliance for individuals with fibromyalgia.ˆò

Correspondence to E. Gowans, Department of Rehabilitation

Services, gw 1-553, University Health Network, Toronto General Hospital, 200

Street, Toronto, Ontario, Canada. Tel: , ext. 4408; fax: