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| ==Overview== | | ==Overview== |
| <ref name="pmid10811333">{{cite journal |vauthors=Nobaek S, Johansson ML, Molin G, Ahrné S, Jeppsson B |title=Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome |journal=Am. J. Gastroenterol. |volume=95 |issue=5 |pages=1231–8 |year=2000 |pmid=10811333 |doi=10.1111/j.1572-0241.2000.02015.x |url=}}</ref>
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| The fact that patients benefit from probiotics shows that the composition of gut microflora determines IBS. Administration of probiotics alters metabolism and composition of the microflora and decreases flatulence in patients.There is no treatment for [disease name]; the mainstay of therapy is supportive care.
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| The important role of psychological therapies that act on cerebral cortical sites and [[antidepressants]] as mainstays of therapy in IBS patients, further throws light on the involvement of the CNS in its pathophysiology. In addition to this, the role of [[Probiotic|probiotics]] in modifying signal processing in the brain also proves that IBS is a brain gut disorder.<ref name="pmid23474283">{{cite journal |vauthors=Tillisch K, Labus J, Kilpatrick L, Jiang Z, Stains J, Ebrat B, Guyonnet D, Legrain-Raspaud S, Trotin B, Naliboff B, Mayer EA |title=Consumption of fermented milk product with probiotic modulates brain activity |journal=Gastroenterology |volume=144 |issue=7 |pages=1394–401, 1401.e1–4 |year=2013 |pmid=23474283 |pmc=3839572 |doi=10.1053/j.gastro.2013.02.043 |url=}}</ref>
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| Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
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| The majority of cases of [disease name] are self-limited and require only supportive care.
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| [Disease name] is a medical emergency and requires prompt treatment.
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| The mainstay of treatment for [disease name] is [therapy].
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| The optimal therapy for [malignancy name] depends on the stage at diagnosis.
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| [Therapy] is recommended among all patients who develop [disease name].
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| Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
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| Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
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| Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
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| Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
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| ===Diet therapy===
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| The therapy for IBS is as follows: <ref name="pmid4436161">{{cite journal |vauthors=Briggs A, Yazdany S |title=Resistance of Bacillus spores to combined sporicidal treatments |journal=J. Appl. Bacteriol. |volume=37 |issue=4 |pages=623–31 |year=1974 |pmid=4436161 |doi= |url=}}</ref>
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| ====Low FODMAP diet====
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| Low [[FODMAP]] diet may help acording to a [[systematic review]] of [[randomized controlled trial]]s<ref name="pmid25982757">{{cite journal| author=Marsh A, Eslick EM, Eslick GD| title=Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. | journal=Eur J Nutr | year= 2016 | volume= 55 | issue= 3 | pages= 897-906 | pmid=25982757 | doi=10.1007/s00394-015-0922-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25982757 }} </ref> and a more recent trial<ref name="pmid27725652">{{cite journal| author=Eswaran SL, Chey WD, Han-Markey T, Ball S, Jackson K| title=A Randomized Controlled Trial Comparing the Low FODMAP Diet vs. Modified NICE Guidelines in US Adults with IBS-D. | journal=Am J Gastroenterol | year= 2016 | volume= | issue= | pages= | pmid=27725652 | doi=10.1038/ajg.2016.434 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27725652 }} </ref>. Included in the systematic review was a trial that combined low FODMAPs and high [[dietary fiber]].<ref name="pmid24076059">{{cite journal| author=Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG| title=A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. | journal=Gastroenterology | year= 2014 | volume= 146 | issue= 1 | pages= 67-75.e5 | pmid=24076059 | doi=10.1053/j.gastro.2013.09.046 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24076059 }} </ref>
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| ====High dietary fiber====
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| High [[dietary fiber]], especially soluble fiber (psyllium or ispaghula husks) can help according to a [[systematic review]] of [[randomized controlled trial]]s.<ref name="pmid25070054">{{cite journal| author=Moayyedi P, Quigley EM, Lacy BE, Lembo AJ, Saito YA, Schiller LR et al.| title=The effect of fiber supplementation on irritable bowel syndrome: a systematic review and meta-analysis. | journal=Am J Gastroenterol | year= 2014 | volume= 109 | issue= 9 | pages= 1367-74 | pmid=25070054 | doi=10.1038/ajg.2014.195 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25070054 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25402531 Review in: Ann Intern Med. 2014 Nov 18;161(10):JC10] </ref> This result is driven by a large [[randomized controlled trial]] that directly compared soluble and insoluble fiber.<ref name="pmid19713235">{{cite journal| author=Bijkerk CJ, de Wit NJ, Muris JW, Whorwell PJ, Knottnerus JA, Hoes AW| title=Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. | journal=BMJ | year= 2009 | volume= 339 | issue= | pages= b3154 | pmid=19713235 | doi=10.1136/bmj.b3154 | pmc=3272664 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19713235 }} [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083814 Review in: Ann Intern Med. 2010 Jan 19;152(2):JC1-11] </ref>
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| ===Medical therapy===
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| [[Clinical practice guideline]]s by the [[American College of Gastroenterology]] address the treatment of irritable bowel syndrome.<ref name="pmid25224526">{{cite journal| author=Weinberg DS, Smalley W, Heidelbaugh JJ, Sultan S| title=American gastroenterological association institute guideline on the pharmacological management of irritable bowel syndrome. | journal=Gastroenterology | year= 2014 | volume= 147 | issue= 5 | pages= 1146-8 | pmid=25224526 | doi=10.1053/j.gastro.2014.09.001 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25224526 }} </ref>
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| ====Initial treatments====
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| Medications may consist of stool softeners and [[laxative]]s in constipation-predominant IBS, and antidiarrheals (e.g., [[opioid]]or opioid [[analog (chemistry)|analog]]s such as [[loperamide]], [[diphenoxylate]] or [[codeine]] in diarrhea-predominant IBS for mild symptoms.<ref name="pmid15846668">{{cite journal | author = Quartero A, Meineche-Schmidt V, Muris J, Rubin G, de Wit N | title = Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome. | journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003460 | year = | id = PMID 15846668}}</ref><ref name="pmid15606387">{{cite journal| author = Lesbros-Pantoflickova D, Michetti P, Fried M, Beglinger C, Blum A | title = Meta-analysis: The treatment of irritable bowel syndrome. | journal = Aliment Pharmacol Ther | volume = 20 | issue = 11-12 | pages = 1253-69 | year = 2004 | id = PMID 15606387}}</ref><ref name="pmid10896640">{{cite journal | author = Jailwala J, Imperiale T, Kroenke K | title = Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials. | journal = Ann Intern Med | volume = 133 | issue = 2 | pages = 136-47 | year = 2000 | id = PMID 10896640}}</ref>
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| =====Laxatives=====
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| {{main|laxative}}
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| For patients who do not adequately respond to [[dietary fiber]], osmotic agents such as [[polyethylene glycol]], [[sorbitol]], and [[lactulose]] can help avoid 'cathartic colon' which has been associated with stimulant laxatives.<ref name="pmid9649012">{{cite journal | author = Joo J, Ehrenpreis E, Gonzalez L, Kaye M, Breno S, Wexner S, Zaitman D, Secrest K | title = Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited. | journal = J Clin Gastroenterol | volume = 26 |issue = 4 | pages = 283-6 | year = 1998 | id = PMID 9649012}}</ref> Among the osmotic laxatives, 17 to 26 grams/day of [[polyethylene glycol]] (PEG) has been well studied.
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| =====Antispasmodics=====
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| {{main|antispasmodic}}
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| The use of antispasmodic drugs (e.g. [[anticholinergic]]s such as [[hyoscyamine]] or [[dicyclomine]]) may help patients, especially those with cramps or diarrhea. A [[meta-analysis]] by the [[Cochrane Collaboration]] concludes that if 6 patients are treated with antispasmodics, 1 patient will benefit ([[number needed to treat]] = 6).<ref name="pmid15846668" /> Antispasmodics can be divided in two groups: neurotropics and musculotropics. Neurotropics, such as [[atropine]], act at the nerve fibre of the parasympathicus but also affect other nerves and have side effects. Musculotropics such as [[mebeverine]] act directly at the smooth muscle of the gastrointestinal tract, relieving spasm without affecting normal gut motility. Since this action is not mediated by the autonomic nervous system, the usual anticholinergic side effects are absent. Antispasmodic drugs are also available in combination with [[tranquilizers]] or [[barbiturates]], such as [[chlordiazepoxide]] and [[Donnatal]]. The value of the combination therapies has not been established.
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| ====Drugs affecting serotonin (5-HT)====
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| Drugs affecting [[serotonin]] (5-HT) in the intestines can help reduce symptoms.<ref name="pmid11755632">{{cite journal | author = Talley N | title = Serotoninergic neuroenteric modulators. | journal = Lancet | volume = 358 | issue = 9298 | pages = 2061-8 | year = 2001 | id = PMID 11755632}}</ref> Serotonin stimulates the gut motility and so agonists can help constipation predominate irritable bowel while antagonists can help diarrhea predominant irritable bowel:
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| =====Agonists=====
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| *[[Tegaserod]], a selective 5-HT4 agonist for IBS-C, is available for relieving IBS constipation in women and chronic idiopathic constipation in men and women. On March 30, 2007, the Food and Drug Administration (FDA) requested that Novartis Pharmaceuticals voluntarily discontinue marketing of Zelnorm (tegaserod) based on the recently identified finding of an increased risk of serious cardiovascular adverse events (heart problems) associated with use of the drug. Novartis agreed to voluntarily suspend marketing of the drug in the United States and in many other countries. On July 27, 2007 the Food and Drug Administration (FDA) approved a limited treatment IND program for Zelnorm in the USA to allow restricted access to the medication for patients in need if no comparable alternative drug or therapy is available to treat the disease. The USA FDA had issued two previous warnings about the serious consequences of Tegaserod. In 2005, Tegaserod was rejected as an IBS medication by the European Union. Tegaserod, marketed as Zelnorm in the United States, was the only agent approved to treat the multiple symptoms of IBS (in women only), including constipation, abdominal pain and bloating. A [[meta-analysis]] by the [[Cochrane Collaboration]] concludes that if 17 patients are treated with typical doses of [[tegaserod]], 1 patient will benefit ([[number needed to treat]] = 17).<ref name="pmid14974049">{{cite journal | author = Evans B, Clark W, Moore D, Whorwell P | title = Tegaserod for the treatment of irritable bowel syndrome. |journal = Cochrane Database Syst Rev | volume = | issue = | pages = CD003960 | year = | id = PMID 14974049}}</ref>
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| *[[Selective serotonin reuptake inhibitor]] [[anti-depressants]] (SSRIs), because of their serotonergic effect, would seem to help IBS, especially patients who are constipation predominant. Initial [[crossover studies]]<ref name="pmid16401691">{{cite journal |author = Tack J, Broekaert D, Fischler B, Oudenhove L, Gevers A, Janssens J | title = A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome. | journal = Gut | volume = 55 | issue = 8 | pages = 1095-103 |year = 2006 | id = PMID 16401691}}</ref> and [[randomized controlled trials]]<ref name="pmid16128675">{{cite journal | author = Vahedi H, Merat S, Rashidioon A, Ghoddoosi A, Malekzadeh R | title = The effect of fluoxetine in patients with pain and constipation-predominant irritable bowel syndrome: a double-blind randomized-controlled study. | journal = Aliment Pharmacol Ther |volume = 22 | issue = 5 | pages = 381-5 | year = 2005 | id = PMID 16128675}}</ref><ref name="pmid12557136">{{cite journal | author = Creed F, Fernandes L, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C, Thompson D, Tomenson B | title = The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. | journal = Gastroenterology | volume = 124 | issue = 2 | pages = 303-17 | year = 2003 | id = PMID 12557136}}</ref><ref>{{cite journal | author = Tabas G, Beaves M, Wang J, Friday P, Mardini H, Arnold G | title = Paroxetine to treat irritable bowel syndrome not responding to high-fiber diet: a double-blind, placebo-controlled trial. | journal = Am J Gastroenterol | volume = 99 | issue = 5 | pages = 914-20 | year = 2004 | id = PMID 15128360}}</ref> support this role.
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| =====Antagonists=====
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| * [[Alosetron]], a selective 5-HT3 antagonist for IBS-D, which is only available for women in the United States under a restricted access program, due to severe risks of [[adverse drug reaction|side-effect]]s if taken mistakenly by IBS-A or IBS-C sufferers.
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| * [[Cilansetron]], also a selective 5-HT3 antagonist, is undergoing further clinical studies in Europe for IBS-D sufferers. In 2005, Solvay Pharmaceuticals withdrew Cilansetron from the United States regulatory approval process after receiving a "not approvable" action letter from the FDA requesting additional clinical trials.
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| ====Secretagogues (for constipation)====
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| Linaclotide, a guanylate cyclase C agonist, can reduce symptoms according to a [[systematic review]] of trials. <ref name="pmid23644388">{{cite journal| author=Videlock EJ, Cheng V, Cremonini F| title=Effects of linaclotide in patients with irritable bowel syndrome with constipation or chronic constipation: a meta-analysis. | journal=Clin Gastroenterol Hepatol | year= 2013 | volume= 11 | issue= 9 | pages= 1084-1092.e3; quiz e68 | pmid=23644388 | doi=10.1016/j.cgh.2013.04.032 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23644388 }} </ref>
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| ====Other agents====
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| Anti-depressants include both [[tricyclic antidepressants]] (TCAs) and the newer [[selective serotonin reuptake inhibitors]] (SSRIs). In addition to improving symptoms via treating any co-existing depression, TCAs have anti-cholinergic actions while SSRIs are serotonergic. Thus in theory, TCAs would best treat diarrhea-predominant IBS while SSRIs would best treat constipation-predominant IBS. A [[meta-analysis]] of [[randomized controlled trials]] of mainly TCAs found 3 patients have to be treated with TCAs for one patient to improve ([[number needed to treat]] = 3).<ref name="pmid11059442">{{cite journal | author = Jackson J, O'Malley P, Tomkins G, Balden E, Santoro J, Kroenke K | title = Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. | journal = Am J Med | volume = 108 | issue = 1 | pages = 65-72 | year = 2000 | id = PMID}}</ref> A separate [[randomized controlled trial]] found that TCAs are best for patients with diarrhea-predominant IBS.<ref name="pmid12851867">{{cite journal | author = Drossman D, Toner B, Whitehead W, Diamant N, Dalton C, Duncan S, Emmott S, Proffitt V, Akman D, Frusciante K, Le T, Meyer K, Bradshaw B, Mikula K, Morris C, Blackman C, Hu Y, Jia H, Li J, Koch G, Bangdiwala S | title = Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders. |journal = Gastroenterology | volume = 125 | issue = 1 | pages = 19-31 | year = 2003 | id = PMID}}</ref>
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| Recent studies have suggested that [[rifaximin]] can be used as an effective treatment for abdominal bloating and [[flatulence]],<ref name="AmJGastro2006-Sharara">{{cite journal | author=Sharara AI, Aoun E, Abdul-Baki H, Mounzer R, Sidani S, Elhajj I | title=A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence| journal=Am J Gastroenterol | year=2006 | pages=326–33 | volume=101 | issue=2 | id=PMID}}</ref><ref name="pmid17043337">{{cite journal | author = Pimentel M, Park S, Mirocha J, Kane S, Kong Y | title = The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial. | journal = Ann Intern Med | volume = 145 | issue = 8 | pages = 557-63 | year = 2006 | id = PMID}}</ref> giving more credibility to the potential role of bacterial overgrowth in some patients with IBS.<ref name="AmJGastro2006-Quigley">{{cite journal | author=Quigley EM | title=Germs, gas and the gut; the evolving role of the enteric flora in IBS | journal=Am J Gastroenterol | year=2006 | pages=334–5 | volume=101 | issue=2 | id=PMID}}</ref>
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| The multi-herbal extract [[Iberogast]] was found to be significantly superior to placebo via both an abdominal pain scale and an IBS symptom score after four weeks of treatment.<ref name="Madisch2004">{{cite journal|journal=Aliment Pharmacol Ther|title=Treatment of irritable bowel syndrome with herbal preparations: results of a double-blind, randomized, placebo-controlled, multi-centre trial|author=Madisch A, Holtmann G, Plein K, Holz J|year=2004|volume=19|pages=271–9}}</ref>
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| Enteric coated [[peppermint]] oil capsules has been advocated for IBS symptoms in adults and children;<ref name="AmFamPhysician2005-Hadley">{{cite journal | author=Hadley SK, Gaarder SM | title=Treatment of irritable bowel syndrome |journal=Am Fam Physician | year=2005 | pages=2501–6 | volume=72 | issue=12 | id=PMID}}</ref> however, results from trials have been inconsistent.<ref name="pmid3527248">{{cite journal | author = Nash P, Gould S, Bernardo D | title = Peppermint oil does not relieve the pain of irritable bowel syndrome. | journal = Br J Clin Pract | volume = 40 | issue = 7 | pages = 292-3 | year = 1986 | id = PMID}}</ref><ref name="pmid9430014">{{cite journal | author = Liu J, Chen G, Yeh H, Huang C, Poon S | title = Enteric-coated peppermint-oil capsules in the treatment of irritable bowel syndrome: a prospective, randomized trial. | journal = J Gastroenterol |volume = 32 | issue = 6 | pages = 765-8 | year = 1997 | id = PMID}}</ref>
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| For severe diarrhea-predominant IBS, more potent [[opioids]] may be used, such as [[codeine]] or [[propoxyphene]]; refractory cases may even be treated with [[paregoric]], or, more rarely, [[laudanum|deodorized tincture of opium]] or [[morphine sulfate]]. The use of opioids remains controversial due to the lack of evidence supporting their benefit and the potential risk of [[tolerance]],[[physical dependence]] and [[addiction]].<ref>{{cite book |title=Principles and Practice of Pain Medicine |last=Warfield|first=Carol A. |coauthors=Zahid H. Bajwa |year=2003 |publisher=McGraw-Hill Professional |isbn=0071443495 }}</ref>
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| [[Cannabis]] has theoretical support for its role,<ref name="pmid16133420">{{cite journal | author = Massa F, Storr M, Lutz B | title = The endocannabinoid system in the physiology and pathophysiology of the gastrointestinal tract. | journal = J Mol Med | volume = 83 | issue = 12 | pages = 944-54 | year = 2005 | id = PMID}}</ref><ref name="pmid15159679">{{cite journal | author = Russo E | title = Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions? | journal = Neuro Endocrinol Lett | volume = 25 | issue = 1-2 |pages = 31-9 | year = | id = PMID}}</ref> but has not been subject of clinical studies. Although illegal in many counties, it has been prescribed to patients in nations such as [[Canada]]. Some of the argued benefits of cannabis are the reduction of pain and nausea, appetite stimulation, and assisting in falling asleep.
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| ==Medical Therapy== | | ==Medical Therapy== |