Summary
Background and aim
Current treatment for irritable bowel syndrome (IBS) is suboptimal. Fermentable oligo‐, di‐, mono‐saccharides and polyols (FODMAPs) may trigger gastrointestinal symptoms in ...IBS patients. Our aim was to determine whether a low FODMAP diet improves symptoms in IBS patients.
Methods
Irritable bowel syndrome patients, who had performed hydrogen/methane breath testing for fructose and lactose malabsorption and had received dietary advice regarding the low FODMAP diet, were included. The effect of low FODMAP diet was prospectively evaluated using a symptom questionnaire. Furthermore, questions about adherence and satisfaction with symptom improvement, dietary advice and diet were assessed.
Results
Ninety patients with a mean follow up of 15.7 months were studied. Most symptoms including abdominal pain, bloating, flatulence and diarrhoea significantly improved (p < 0.001 for all). 75.6%, 37.8% and 13.3% of patients had fructose, lactose malabsorption or small intestinal bacterial overgrowth respectively. Fructose malabsorption was significantly associated with symptom improvement (abdominal pain odds ratio (OR) 7.09 95% confidence interval (CI) 2.01–25.0, bloating OR 8.71 (95% CI 2.76–27.5), flatulence OR 7.64 (95% CI 2.53–23.0) and diarrhoea OR 3.39 (95% CI 1.17–9.78), p < 0.029 for all). Most patients (75.6%) were adherent to the diet, which was associated with symptom improvement (abdominal pain, bloating, flatulence and diarrhoea all significantly associated with adherence, r > 0.27, p < 0.011). Most patients (72.1%) were satisfied with their symptoms.
Conclusions
The low FODMAP diet shows efficacy for IBS patients. The current strategy of breath testing and dietary advice provides a good basis to understand and adhere to the diet.
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Summary
Background Functional gut symptoms are induced by inclusion and reduced by dietary restriction of poorly absorbed short‐chain carbohydrates (FODMAPs), but the mechanisms of action remain ...untested.
Aims To determine the effect of dietary FODMAPs on the content of water and fermentable substrates of ileal effluent.
Methods Twelve ileostomates without evidence of small intestinal disease undertook two 4‐day dietary periods, comprising diets differing only in FODMAP content in a randomized, cross‐over, single‐blinded intervention study. Daytime (14 h) ileal effluent was collected on day four of each diet. Patients rated effluent volume and consistency on a 10‐cm visual analogue scale. The FODMAP content of the diet and effluent was measured.
Results Ingested FODMAPs of 32% (range 6–73%) was recovered in the high FODMAP diet effluent. Effluent collection weight increased by a mean of 22% (95% CI, 5–39), water content by 20% (2–38%) and dry weight by 24% (4–43%) with the high compared to low FODMAP diet arm. Output increased by 95 (28–161) mL. Volunteers perceived effluent consistency was thicker (95% CI, 0.6–1.9) with the low FODMAP diet than with the high FODMAP diet (3.5–6.1; P = 0.006).
Conclusions These data support the hypothetical mechanism; FODMAPs increase delivery of water and fermentable substrates to the proximal colon.
Summary
Background
Crohn's disease recurs in the majority of patients after intestinal resection.
Aim
To compare the relative efficacy of thiopurines and anti‐TNF therapy in patients at high risk of ...disease recurrence.
Methods
As part of a larger study comparing post‐operative management strategies, patients at high risk of recurrence (smoker, perforating disease, ≥2nd operation) were treated after resection of all macroscopic disease with 3 months metronidazole together with either azathioprine 2 mg/kg/day or mercaptopurine 1.5 mg/kg/day. Thiopurine‐intolerant patients received adalimumab induction then 40 mg fortnightly. Patients underwent colonoscopy at 6 months with endoscopic recurrence assessed blind to treatment.
Results
A total of 101 patients 50% male; median (IQR) age 36 (25–46) years were included. There were no differences in disease history between thiopurine‐ and adalimumab‐treated patients. Fifteen patients withdrew prior to 6 months, five due to symptom recurrence (of whom four were colonoscoped). Endoscopic recurrence (Rutgeerts score i2–i4) occurred in 33 of 73 (45%) thiopurine vs. 6 of 28 (21%) adalimumab‐treated patients intention‐to‐treat (ITT); P = 0.028 or 24 of 62 (39%) vs. 3 of 24 (13%) respectively per‐protocol analysis (PPA); P = 0.020. Complete mucosal endoscopic normality (Rutgeerts i0) occurred in 17/73 (23%) vs. 15/28 (54%) (ITT; P = 0.003) and in 27% vs. 63% (PPA; P = 0.002). The most advanced disease (Rutgeerts i3 and i4) occurred in 8% vs. 4% (thiopurine vs. adalimumab).
Conclusions
In Crohn's disease patients at high risk of post‐operative recurrence adalimumab is superior to thiopurines in preventing early disease recurrence.
Background
Functional gastrointestinal disorders (FGIDs) are common and cause significant morbidity. Psychiatric comorbidities associated with FGIDs include anxiety and depression. However, little is ...understood about the factors that modulate this association. The aim of this study was to examine the association between FGIDs and depression and anxiety, and to determine the covariates influencing this association in a New Zealand cohort.
Methods
The Christchurch IBS cOhort to investigate Mechanisms FOr gut Relief and improved Transit (COMFORT) study is an observational case–control study that recruited FGID cases and healthy controls between 2016 and 2018. In addition to the collection of a wide range of biological samples, participants completed questionnaires concerning socioeconomic status, physical activity, smoking, alcohol intake, anxiety, and depression (the latter two measured using the Hospital Anxiety and Depression Score HADS). A multivariate analysis was performed using the significant covariates from the univariate analyses to test whether their effect was independently significant on anxiety and depression.
Key Results
A total of 315 participants (57 with diarrhea‐predominant IBS (IBS‐D), 30 with constipation‐predominant IBS (IBS‐C), 41 with mixed‐IBS (IBS‐M), 16 with functional diarrhea (FD), 42 with functional constipation (FC), and 129 controls); mean age 53 years (range 18–70 years), 221 (70%) female) completed the questionnaires. Anxiety (odds ratio OR 2.85 95% confidence interval CI 1.64–4.94, p < 0.01) and depression (OR 3.40 95% CI 1.35–8.55, p = 0.01) were strongly associated with FGID cases versus controls. Lower economic living status (p < 0.01) was an independent covariate associated with depression, while lower economic living status (p < 0.005) and abdominal pain (p = 0.005) were both independently associated with anxiety.
Conclusions & Inferences
In addition to the established associations between FGIDs and anxiety and depression, we have shown that the economic standard of living, pain, and IBS phenotype are significant independent covariates. This study demonstrates the range of lifestyle and demographic factors that modulate morbidity associated with FGIDs and may provide targets for intervention.
In this observational study, we demonstrate that economic living standard influenced the association between functional GI disorders and both anxiety and depression, whereas abdominal pain modified the association between functional GI disorders and anxiety.
Summary
Background Corticosteroids are a well‐established treatment for active Crohn’s disease and have been widely used for decades. It has become apparent, however, that a proportion of patients ...either fails to respond to corticosteroids or is unable to withdraw from them without relapsing. Furthermore, their use is associated with a range of side effects, such that long‐term treatment carries unacceptable risk.
Aim To review the evidence regarding the appropriate use of corticosteroids in Crohn’s disease, along with their side effects, safety and alternatives.
Methods To collect relevant articles, a PubMed search was performed from 1966 to November 2006 using the terms ‘steroid’, ‘corticosteroid’, ‘glucocorticoid’, ‘prednisolone’, ‘prednisone’, ‘methylprednislone’, ‘hydrocortisone’, ‘dexamethasone’ and ‘budesonide’ in combination with ‘Crohn(s) disease’. Relevant articles were reviewed, as were their reference lists to identify further articles.
Results When used correctly, corticosteroids are a highly effective, well tolerated, cheap and generally safe treatment for active Crohn’ disease. Nevertheless, approximately 50% of recipients will either fail to respond (steroid‐resistant) or will be steroid dependent at 1 year. Newer alternatives to corticosteroids are not, however, without risk themselves and, moreover, are not necessarily available universally.
Conclusions Steroids are used widely to treat Crohn’s disease, a situation that is unlikely to change in the near future. Accordingly, efforts should be made to ensure that they are used correctly and that their side effects are minimized. Reference is made to recently published guidelines and a simplified ‘users guide’ is presented.
Biomarkers have been proposed as surrogate treatment targets for the management of inflammatory bowel disease (IBD); however, their relationship with IBD-related complications remains unclear. This ...study investigated the utility of neutrophil biomarkers fecal calprotectin (fCal) and fecal myeloperoxidase (fMPO) in predicting a complicated IBD course.
Participants with IBD were followed for 24 months to assess for a complicated IBD course (incident corticosteroid use, medication escalation for clinical disease relapse, IBD-related hospitalizations/surgeries). Clinically active IBD was defined as Harvey-Bradshaw index >4 for Crohn's disease (CD) and simple clinical colitis activity index >5 for ulcerative colitis (UC). Area under the receiver-operating-characteristics curves (AUROC) and multivariable logistic regression assessed the performance of baseline symptom indices, fCal, and fMPO in predicting a complicated disease IBD course at 24 months.
One hundred and seventy-one participants were included (CD, n = 99; female, n = 90; median disease duration 13 years interquartile range, 5-22). Baseline fCal (250 μg/g; AUROC = 0.77; 95% confidence interval CI, 0.69-0.84) and fMPO (12 μg/g; AUROC = 0.77; 95% CI, 0.70-0.84) predicted a complicated IBD course. Fecal calprotectin (adjusted OR = 7.85; 95% CI, 3.38-18.26) and fMPO (adjusted OR = 4.43; 95% CI, 2.03-9.64) were associated with this end point after adjustment for other baseline variables including clinical disease activity. C-reactive protein (CRP) was inferior to fecal biomarkers and clinical symptoms (pdifference < .05) at predicting a complicated IBD course. A combination of baseline CRP, fCal/fMPO, and clinical symptoms provided the greatest precision at identifying a complicated IBD course.
Fecal biomarkers are independent predictors of IBD-related outcomes and are useful adjuncts to routine clinical care.
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