Irritable bowel syndrome: Difference between revisions

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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 16370407}}</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 3527248}}</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 9430014}}</ref>. Peppermint may exacerbate [[gastroesophageal reflux disease]].
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 16370407}}</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 3527248}}</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 9430014}}</ref>. Peppermint may exacerbate [[gastroesophageal reflux disease]].
Two [[randomized controlled trials]] show reduction in gas by subjects taking oral alpha-galactosidase (Beano) <ref name="pmid17151807">{{cite journal |author=Di Stefano M, Miceli E, Gotti S, Missanelli A, Mazzocchi S, Corazza G |title=The effect of oral alpha-galactosidase on intestinal gas production and gas-related symptoms |journal=Dig Dis Sci |volume=52 |issue=1 |pages=78-83 |year=2007 |id=PMID 17151807}}</ref> <ref name="pmid7964541">{{cite journal |author=Ganiats T, Norcross W, Halverson A, Burford P, Palinkas L |title=Does Beano prevent gas? A double-blind crossover study of oral alpha-galactosidase to treat dietary oligosaccharide intolerance |journal=J Fam Pract |volume=39 |issue=5 |pages=441-5 |year=1994 |id=PMID 7964541}}</ref>; however, alpha-galactosidase may interfere with the diabetic medication [[acarbose]] <ref name="pmid9663365">{{cite journal |author=Lettieri J, Dain B |title=Effects of beano on the tolerability and pharmacodynamics of acarbose |journal=Clin Ther |volume=20 |issue=3 |pages=497-504 |year= |id=PMID 9663365}}</ref>.


For severe diarrhea-predominant IBS, more potent [[opioids]] may be used, such as [[codeine]] or [[propoxyphene]] (Darvon®); [[Refractory period|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 [[psychological dependence]] ([[addiction]]).
For severe diarrhea-predominant IBS, more potent [[opioids]] may be used, such as [[codeine]] or [[propoxyphene]] (Darvon®); [[Refractory period|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 [[psychological dependence]] ([[addiction]]).

Revision as of 12:43, 14 February 2007

Irritable bowel syndrome
ICD-10 K58
ICD-9 564.1
MedlinePlus 000246

In gastroenterology, irritable bowel syndrome (IBS) or spastic colon is a functional bowel disorder characterized by abdominal pain and changes in bowel habits which are not associated with any abnormalities seen on routine clinical testing. It is fairly common and makes up 20–50% of visits to gastroenterologists. Lower abdominal pain, and bloating associated with alteration of bowel habits and abdominal discomfort relieved with defecation are the most frequent symptoms. The abdominal pain type is usually described in a patient as either diarrhea-predominant (IBS-D), constipation-predominant (IBS-C) or IBS with alternating stool pattern (IBS-A). In some individuals, IBS may have an acute onset and develop after an infectious illness characterised by two or more of the following; fever, vomiting, acute diarrhoea, positive stool culture. This post infective syndrome has consequently been termed "Post infectious IBS" (IBS-PI) and is acute onset Rome II criteria positive. This condition is more homogenous, being mostly IBS-D and is drawing much clinical investigation.

Because of the name, IBS can be confused with inflammatory bowel disease (IBD), a more serious condition.

Symptoms

The range of symptoms relating to IBS is relatively broad, but the main symptom is usually abdominal pain or discomfort associated with changes in bowel habits in the absence of any apparent structural abnormality. The pain is commonly relieved by defecating or modulated by other triggers of gut motility. Generally there is no pain when patients are asleep. Symptoms usually start in young adulthood.

Diagnosis

In the past it was thought that the diagnosis of Irritable Bowel Syndrome relied on a diagnosis of exclusion. That is, if one cannot find a cause then IBS is the diagnosis. Currently the diagnosis of Irritable Bowel Syndrome relies on meeting Rome II inclusion criteria (updated by Rome III criteria[1]) and excluding other illnesses based on history, physical exam, and laboratory testing. Although the Rome II and Rome III criteria were not designed to be a management guideline, it is currently a "gold standard" for the diagnosis of IBS. Unfortunately an IBS diagnosis in an adult patient is still only useful as a tool to rule out more serious problems unless further investigation is employed to discern an addressable condition.

Diagnostic criteria

Several sets of diagnostic criteria have been proposed[2].

Clinical History alone (Manning Criteria)

In 1978 Manning et al. found [3], from questionnaire data, that IBS sufferers reported four common symptoms. The Manning Criteria was established to distinguish organic causes for symptoms from those of IBS. The Manning criteria, for the detection of organic gastrointestinal disease, have a sensitivity of 75% and specificity of 60% [3][4]. The prevalence of organic gastrointestinal disease (other than polyps or diverticulosis) among patients suspected of having irritable bowel is about 20% in a primary care clinic [5] and about 50% among patients referred to a gastroenterologist [3][4][6][7]. Thus, patients with less than 3 Manning criteria have about a 10% chance of organic gastrointestinal disease in primary care and 40% chance of in referral care. In summary, the clinical history alone, as implemented by the Manning criteria, is not adequate to exclude underling organic illness.

Clinical history and physical examination (Rome Criteria)

In 1992 the Rome I Criteria were established by a multinational committee of specialists, which further refined the Manning Criteria. In 1998 the Rome Working Team proposed changes to the definition and diagnostic criteria for IBS to reflect new research data, and to improve clarity. These criteria have evolved, as the Rome Process has integrated fresh evidence and new conceptual approaches to the condition.

Physicians rely on a variety of procedures and laboratory tests to confirm a diagnosis. The cardinal requirement for the diagnosis of IBS is abdominal pain. The Rome II Criteria is used to diagnose IBS after a careful examination of a sufferer's medical history and physical abdominal examination which looks for any 'red flag' symptoms. More recently, the Rome III criteria, incorporating some changes over the previous set of criteria, have been issued. The Rome II and Rome III efforts have integrated pediatric contents to their set of criteria.

According to the Rome II committees and the Functional Brain Gut Research Group,[8] IBS can be diagnosed based on at least 12 weeks, which need not be consecutive, of the preceding 12 months, there was abdominal discomfort or pain that had two out of three of these features:[9]

  • Relieved with defecation; and/or
  • Onset associated with a change in frequency of stool; and/or
  • Onset associated with a change in form (appearance) of stool.

Symptoms that cumulatively support the diagnosis of IBS:

  • Abnormal stool frequency (for research purposes, “abnormal” may be defined as greater than 3 bowel movements per day and less than 3 bowel movements per week);
  • Abnormal stool form (lumpy/hard or loose/watery stool);
  • Abnormal stool passage (straining, urgency, or feeling of incomplete evacuation);
  • Passage of mucus;
  • Bloating or feeling of abdominal distention.

Supportive symptoms of IBS:

A) Fewer than three bowel movements a week
B) More than three bowel movements a day
C) Hard or lumpy stools
D) Loose (mushy) or watery stools
E) Straining during a bowel movement
F) Urgency (having to rush to have a bowel movement)
G) Feeling of incomplete bowel movement
H) Passing mucus (white material) during a bowel movement
I) Abdominal fullness, bloating, or swelling

Diarrhea-predominant: At least 1 of B, D, F and none of A, C, E; or at least 2 of B, D, F and one of A or E. Hard or lumpy stools do not qualify.
Constipation-predominant: At least 1 of A, C, E and none of B, D, F; or at least 2 of A, C, E and one of B, D or F.

Red flag symptoms which are NOT typical of IBS:

  • Pain that awakens/interferes with sleep
  • Diarrhea that awakens/interferes with sleep
  • Blood in the stool (visible or occult)
  • Weight loss
  • Fever
  • Abnormal physical examination

An update to these criteria was issued at the ROME III conference and published in May 2006. [1] The validity of subtypes is called into question:

The validity and stability of such subtypes over time is unknown and should be the subject of future research.

and

Because of the characteristic symptom instability, we prefer the terms IBS with constipation and IBS with diarrhea instead of constipation- and diarrhea-predominant IBS. In this categorical system, many people whose features place them close to a subtype boundary change pattern without a major change in pathophysiology. Moreover, the heterogeneity and variable natural history of IBS significantly limit clinical trials of motility-active drugs and drug therapy in practice.

The sensitivity of the Rome criteria is probably inadequate to exclude organic disease without laboratory testing. The reader must be savvy to whether the sensitivity in a report is for the diagnosis of IBS or for he diagnosis of organic disease. In one study, the Rome criteria was reported to have a sensitivity of 100% and specificity of 65% (when used along with the absence of red flags) for the diagnosis of underlying organic gastrointestinal illness [10]. In this study, diagnostic accuracy for IBS is over 95% when Rome II criteria are met, history and physical exam do not suggest any other cause, and initial laboratory testing is negative [10]. However, this is a single study in a referral population and 91% of the patients already had negative imaging of their colon before the study. In a second study, Rome criteria for organic disease was 71% with a specificity of 85% [11].

Clinical history, physical examination, and basic laboratory tests (Kruis Criteria)

The Kruis criteria include an ESR > 20 mm/2h, WBC > 10k and Hb < 12 g/dl (females) or <14 g/dl (males). In addition to meeting these positive criteria patients have initial laboratory testing with a complete blood count, basic chemistry panel, and an erythrocyte sedimentation rate [6]. Three studies of the Kruis criteria suggest the sensitivity is about 95% and specificity is 68% for diagnosing organic illness [6][7][5]. These values may be adequate to exclude organic disease in primary care, but cannot adequately exclude organic disease in referred patients.

Differential diagnosis

The diagnosis of a functional bowel disorder always presumes the absence of a structural or biochemical explanation for the symptoms. This can be excluded via:

Initial screening only requires a history and physical exam, as well as a full blood count, electrolytes, renal function, and an erythrocyte sedimentation rate. Additional testing is done when there is a poor response to treatment.

While these modalities may be employed to rule out other causes of abdominal symptoms, they are not necessary to make a diagnosis of IBS. Depending on local practice, many doctors avoid overdiagnosing if the history is clearly suggestive of a functional bowel disorder.

Although few doctors will run a complete set of testing, when it is performed the underlying cause of their symptoms can often be found and treated. Testing for bacterial abnormalities, food allergies (IgG type allergies), and parasites are particularly useful though often not covered by insurance and thus not performed.[13]

Diagnostic tests

Researchers have demonstrated abnormal sensitivity in IBS patients to intestinal and esophageal distention with balloons. However, this approach has not yet become available as a diagnostic test since the diagnostic accuracy is low and clinical utility is not yet high enough. The diagnosis of IBS is made by exclusion as there are no serological (blood) markers. A history of major life stress, anxiety, depression, abuse, or preceding infection may be suggestive, yet not diagnostic. Organs outside the gastrointestinal system may be sources of referred symptoms, and abnormalities should be ruled out. Red flags arguing against an IBS diagnosis include bleeding, weight loss, difficulty swallowing, nocturnal symptoms, incontinence, or onset of symptoms over the age of 50. Screening for ruling out colorectal cancer is still applicable.

Pathophysiology

IBS is highly prevalent in the Western world, but despite the advancement of many theories, no clear cause has yet been established. IBS may a conglomeration of disorders with similar symptoms but multiple different etiologies (root causes). In studies of twins, some [14][15] but not all studies [16], a genetic role is found. In the two positive studies, IBS concordance in monozygotic twins is 17% - 22% compared to dizygotic twins having IBS concordance of 8% to 9%. In one of the studies futher support for genetic inflences being a minority contributor, a dizygotic twin with IBS has 15.2% IBS in mothers, compared to 6.7% in their co-twin[14]. As with many other medical conditions, there is a lot of speculation about causes, including in the field of alternative medicine. Increasing prevalence in developing countries suggests some possible links to diet and cultural factors.[17]

Visceral hyperalgesia

Evidence of visceral hyperalgesia (increased sensitivity to noxious stimuli in the gut) includes perception of pain from distention of a rectal balloon at smaller volumes than in normal patients [18]. However somatic sensitivity testing, such as in controlled pressure on the nails of the hand show that IBS patients have greater pain tolerance than normal patients.

Post-infectious or post-antibiotic

Onset of IBS after an episodes of enteritis [19] or antibiotics [20] have been described. A meta-analysis found the prevalence of IBS to 9.8% after enteritis as compared to 1.2% in controls [19]. In these cases, a prolonged immune reaction may be the cause. Patients with IBS after a viral illness may have a self limited course of only 3 to 6 months duration..

Food allergies and sensitivities

Argument continues on the definition of cause as regards IBS and food allergies, but studies demonstrate that IBS symptoms are sometimes caused by immune response to foods and exclusion of those foods to which the immune system is responding results in reduction or elimination of IBS symptoms, a cause and effect link.[21]

Bacterial overgrowth

The intestine is colonised with bacteria (also termed the gut flora). Two studies from the same research group found that 78% to 84% of patients with IBS had bacterial overgrowth. In patients with evidence of bacterial overgrowth, those treated with neomycin had a >/= 35% reduction in clinical response (ie, improvement) compared with an 11% reduction in patients on placebo.[22][23] Subsequent studies have also identified significant bacterial overgrowth and demonstrated substantial reduction in symptoms following treatments, especially with antibiotics specific to the strains that are in excess. See section below on treatment with rifaximin.

Stress

Stress—feeling mentally or emotionally tense, troubled, angry, or overwhelmed—may trigger symptoms in people with IBS. One study found that women with IBS have are more likely to report prior physical or sexual abuse; almost half of the patients reported prior abuse [24].

There are various ways that stress may interact with IBS. First, the colon has a vast supply of nerves that connect it to the brain. These nerves control the normal rhythmic contractions of the colon and cause abdominal discomfort at stressful times. People often experience cramps or "butterflies" when they are nervous or upset. But with IBS, the colon can be overly responsive to even slight conflict or stress. Second, some evidence suggests that IBS is affected by the immune system, which fights infection in the body. The immune system is also affected by stress. Third, the link between stress and IBS may be due to socially stressful situations making the mind more tuned to the sensations that arise in the colon and makes the stressed person perceive these sensations as unpleasant.[25]

There appears to be an overlap of IBS with stress, chronic pelvic pain, fibromyalgia, chronic fatigue syndrome, the American folk medicine use of term hypoglycaemia, and various mental disorders (in a small minority). While no single explanation for this phenomenon exists, it does strengthen the view that there is a neurological and psychological component to IBS. Recent studies indicate that presynaptic neural effects secondary to the release of histamine (part of immune response) is likely related to these problems.[26]

It should be noted that the gut has its own nervous system - the enteric nervous system which has reciprocal connections to the main brain. The discovery of this system has lead to the development of the field of neurogastroenterology.

For all these reasons, stress management is an important part of treatment for IBS. Stress management comprises:

  • stress reduction (relaxation) training and relaxation therapies, such as meditation
  • counseling and support
  • regular exercise such as walking or yoga
  • changes to the stressful situations in your life
  • adequate sleep

Hormones

The role of hormones in IBS is not yet fully understood. Menstruation frequently triggers or exacerbates IBS symptoms,[27] while pregnancy and menopause can either worsen or improve symptoms. Hormone replacement therapy is associated with an increased risk of developing IBS.[28]

Treatment

One of the most important therapeutic measures is reassuring the patient that they have no fatal or otherwise threatening disease, as this is the major concern of patients seeking medical help. Dietary advice may be given and medication is an option in most forms.

A questionnaire in 2006 designed to identify patients’ perceptions about IBS, their preferences on the type of information they need, as well as educational media and expectations from health care providers, revealed misperceptions about IBS developing into other conditions, including colitis, malnutrition, and cancer.[29]

The survey found IBS patients were most interested in learning about foods to avoid (60%), causes of IBS (55%), medications (58%), coping strategies (56%), and psychological factors related to IBS (55%). The respondents indicated that they wanted their physician to be available via phone or e-mail following a visit (80%), have the ability to listen (80%), and provide hope (73%) and support (63%).


Diet

There are a number of dietary changes a person with IBS can make to prevent the overreaction of the gastrocolic reflex and lessen pain, discomfort, and bowel dysfunction. Having soluble fiber foods and supplements, substituting soy or rice products for dairy, being careful with fresh fruits and vegetables that are high in insoluble fiber, and eating regular small amounts, can all help to lessen the symptoms of IBS. Foods and beverages to be avoided or minimized include red meat, oily or fatty and fried products, dairy (even when there is no lactose intolerance), solid chocolate, coffee (regular and decaffeinated), alcohol, carbonated beverages (especially those also containing sorbitol), and artificial sweeteners. However, care should be taken to avoid adding foods to the diet to which the patient is allergic or intolerant.[30]

Definitive determination of dietary issues can be accomplished by testing for the physiological effects of specific foods. The ELISA food allergy panel can identify specific foods to which a patient has a reaction. Other testing can determine if there are nutritional deficiencies secondary to diet that may also play a role. Removal of foods causing IgG immune response as measured using the ELISA food panel has been shown to substantially decrease symptoms of IBS in several studies.[31]

There is no evidence that digestion of food or absorption of nutrients is problematic for those with IBS at rates different from those without IBS. However, the very act of eating or drinking can provoke an overreaction of the gastrocolic response in some patients with IBS due to their heightened visceral sensitivity, and this can lead to abdominal pain, diarrhea, and/or constipation.[32]

Several of the most common dietary triggers are well-established by clinical studies at this point; research has shown that IBS patients are hypersensitive to fats and fructose. [33] [34]

It also appears that some foods are more difficult for the gut as evidenced by elevated food-specific IgG4 antibodies being present,[35] [36] while others increase colonic contractions, which may be painful, due to increased visceral sensitivity in IBS sufferers. [37]

Fiber

In patients who do not have diarrhea predominant irritable bowel, soluble fiber at does of 20 grams per day can reduce overall symptoms but will not reduce pain. The research supporting dietary fiber contains conflicting, small studies that are complicated by the the heterogeneity of types of fiber and doses used [38]. The one meta-analysis that controlled for solubility found that only soluble fiber improved global symptoms of irritable bowel and neither type of fiber reduced pain [38]. Positive studies have used 20-30 grams per day of psyllium seed (also called ispaghula husk)[39] [40]. One study specifically examined the effect of dose and found that 20 grams of ispaghula husk was better than 10 grams and equivalent to 30 grams per day [41]An uncontrolled study noted increased symptoms with insoluble fibers. [42] It is unclear if these symptoms are truly increased compared to a control group. If the symptoms are increased, it is unclear if these patients were diarrhea predominant (which can be exacerbated by fiber [43][44]), or if the increase is temporary before benefit occurs.

Medication

Initial treatments

Medications may consist of stool softeners and laxatives in constipation-predominant IBS, and antidiarrheals (e.g., opioid or opioid analogs such as loperamide (Imodium®), or diphenoxylate (Lomotil®)) in diarrhea-predominant IBS for mild symptoms[45][46][47].

Anti-diarrheal agents

Randomized controlled trials have shown loperamide reduces diarrhea with an inconsistent effect on pain [48].

Laxatives

Regarding laxatives for patients who do not adequately respond to fiber, osmotic agents (polyethylene glycol, sorbitol, and lactulose) are good choices in order to avoid 'cathartic colon' which has been associated with stimulant laxatives [49]. Among the osmotic laxatives, a randomized controlled trial found greater improvement from 2 sachets (26 grams) of polyethylene glycol (PEG) versus or 2 sachets (20 grams) of lactulose [50]. Another randomized controlled trial found no difference between sorbitol and lactulose [51].

Antispasmodics

The use of antispasmodic drugs (e.g. anticholinergics such as hyoscine) 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)[45]. Antispasmodic drugs are also available in combination with tranquilizers or barbiturates, such as Librax® (chlordiazepoxide and clidinium) and Donnatal® (mixed salts of belladonna alkaloids and phenobarbital), respectively. However, the value of the combination therapies is not clear as the role of tranquilizers is not established.

Drugs affecting serotonin (5-HT)

Drugs affecting serotonin (5-HT) in the intestines can help reduce symptoms[52]. Serotonin stimulates the gut motility and so agonists can help constipation predominate irritable bowel while antagonists can help diarrhea predominant irritable bowel:

Agonists
  • 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. The USA FDA has issued two warnings about the serious consequences of Tegaserod. In 2005, Tegaserod was rejected as an IBS medication by the European Union; however, it is available in some other countries, including the United States. Tegaserod, marketed as Zelnorm in the United States, is 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) [53].
  • 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 [54] and randomized controlled trials [55] [56] [57] support this role.
Antagonists
  • 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 side-effects if taken mistakenly by IBS-A or IBS-C sufferers.
  • 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.

Other agents

Anti-depressents 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)[58]. A separate randomzied controlled trial found that TCAs are best for patients with diarrhea-predominant IBS [59]. SSRIs are discussed above under 'Drugs affecting serotonin'.

Recent studies have suggested that rifaximin, a non-absorbable antibiotic, can be used as an effective treatment for abdominal bloating and flatulence [60][61], giving more credibility to the potential role of bacterial overgrowth in some patients with IBS [62].

Enteric coated peppermint oil capsules has been advocated for IBS symptoms in adults and children [63]; however, results from trials have been inconsistent [64] [65]. Peppermint may exacerbate gastroesophageal reflux disease.

Two randomized controlled trials show reduction in gas by subjects taking oral alpha-galactosidase (Beano) [66] [67]; however, alpha-galactosidase may interfere with the diabetic medication acarbose [68].

For severe diarrhea-predominant IBS, more potent opioids may be used, such as codeine or propoxyphene (Darvon®); refractory cases may even be treated with paregoric, or, more rarely, 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 psychological dependence (addiction).

Cannabis has theoretical support for its role [69][70], but has not been subject of clinical studies. Although illegal in the United States, 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 sleep.

Psychotherapy and hypnotherapy

There is a strong brain-gut component to IBS, and cognitive therapy may improve symptoms in a proportion of patients in conjunction with antidepressants [71]. In a randomized controlled trial of referred patients, cognitive behavioral therapy helped even though patients in this study did not have any psychiatric diagnoses [72].

Gut-directed or gut-specific hypnotherapy or self-hypnosis is one of the most promising areas of IBS treatment. Current research shows that symptom reduction/elimination from IBS hypnotherapy can last at least five years [73].

Alternative treatments

Probiotics

Probiotics are generally accepted to be potentially beneficial strains of bacteria and yeast, often found in the human gut. One research study has shown a clear link between the ingestion of Lactobacillus plantarum LP299V and sufferers of IBS who reported resolution of their abdominal pain [74]. Another study showed the utility of B. infantis 35625, a strain of Bifidobacteria in normalizing bowel movement frequency in sufferers of IBS [75]. Some practitioners of Integrative Medicine, now recommend a strain of Lactobacillus known commonly as "LGG" after its discoverers Gorbach and Goldin. This strain in particular has shown an ability to endure the acidic environment of the stomach and survive until presentation to the intestinal tract [76].

Acupuncture

Many sufferers of IBS seek relief using Acupuncture, a component of Traditional Chinese Medicine and a discipline representing some of the oldest and most used medical procedures in the world. The meta-analysis by the Cochrane Collaboration concluded 'Most of the trials included in this review were of poor quality and were heterogeneous in terms of interventions, controls, and outcomes measured. With the exception of one outcome in common between two trials, data were not combined. Therefore, it is still inconclusive whether acupuncture is more effective than sham acupuncture or other interventions for treating IBS'[77]. Acupuncture continues to find increasingly widespread acceptance in the United States, and it is estimated that nearly 8.7 million Americans have sought its benefits [78]. One practitioner of Tradtional Chinese Medicine asserts that IBS has become a bit of a "garbage diagnosis" for some medical practitioners. Traditional Chinese Medicine does not recognize the Western diagnosis of IBS per se, as the named condition has no definitive single test for diagnosis, clear cause, or cure. Traditional Chinese Medicine approaches IBS on an individual symptom-by-symptom basis, rather than recognizing a standard "IBS" diagnosis, which then warrants a blanket "IBS" treatment [79]. The concept of Qi is important in Acupuncture, as obstructions to its proper flow throughout the body are considered a contributing factor to illness. Details of the specific mechanisms through which Qi function remain as yet unexplained by Western scientific methods. According to the National Institutes of Health, "Preclinical studies have documented acupuncture's effects, but they have not been able to fully explain how acupuncture works within the framework of the Western system of medicine that is commonly practiced in the United States." [80].

Epidemiology

Point prevalence is 10–20% of the general population of Western countries with a much higher lifetime prevalence. Prevalence is similar in India, Japan and China. IBS is less common in Thailand and rural South African areas. In Western countries, but not in India or Sri Lanka, females have a greater risk of developing IBS.

Of the persons who have symptoms of IBS, only a proportion seeks medical help. However, there is not yet a predictor known for who will seek medical help and who will not.

Prognosis

IBS is not fatal nor is it linked to the development of other serious bowel diseases. However, due to the chronic pain, discomfort, and other symptoms, work absenteeism, social phobias, and other negative quality-of-life effects can be common in more serious cases. Individuals who find a caring primary caregiver and/or sufficient self-help options should be able to develop a successful treatment program for their symptoms and lead normal lives.

References

  1. ↑ 1.0 1.1 Longstreth Cite error: Invalid <ref> tag; name "FBD2006-Rome" defined multiple times with different content
  2. ↑ Fass R, Longstreth G, Pimentel M, Fullerton S, Russak S, Chiou C, Reyes E, Crane P, Eisen G, McCarberg B, Ofman J (2001). "Evidence- and consensus-based practice guidelines for the diagnosis of irritable bowel syndrome.". Arch Intern Med 161 (17): 2081-8. PMID 11570936.
  3. ↑ 3.0 3.1 3.2 Manning AP, Thompson WG, Heaton KW, Morris AF. Towards positive diagnosis of the irritable bowel. BMJ 1978; 2: 653–4. PMID 698649 Cite error: Invalid <ref> tag; name "pmid698649" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid698649" defined multiple times with different content
  4. ↑ 4.0 4.1 Talley N, Phillips S, Melton L, Mulvihill C, Wiltgen C, Zinsmeister A (1990). "Diagnostic value of the Manning criteria in irritable bowel syndrome.". Gut 31 (1): 77-81. PMID 2318433. Cite error: Invalid <ref> tag; name "pmid2318433" defined multiple times with different content
  5. ↑ 5.0 5.1 Bellentani S, Baldoni P, Petrella S, Tata C, Armocida C, Marchegiano P, Saccoccio G, Manenti F (1990). "A simple score for the identification of patients at high risk of organic diseases of the colon in the family doctor consulting room. The Local IBS Study Group.". Fam Pract 7 (4): 307-12. PMID 2289644. Cite error: Invalid <ref> tag; name "pmid2289644" defined multiple times with different content
  6. ↑ 6.0 6.1 6.2 Kruis W, Thieme C, Weinzierl M, Schüssler P, Holl J, Paulus W (1984). "A diagnostic score for the irritable bowel syndrome. Its value in the exclusion of organic disease.". Gastroenterology 87 (1): 1-7. PMID 6724251. Cite error: Invalid <ref> tag; name "pmid6724251" defined multiple times with different content Cite error: Invalid <ref> tag; name "pmid6724251" defined multiple times with different content
  7. ↑ 7.0 7.1 Frigerio G, Beretta A, Orsenigo G, Tadeo G, Imperiali G, Minoli G (1992). "Irritable bowel syndrome. Still far from a positive diagnosis.". Dig Dis Sci 37 (2): 164-7. PMID 1735330. Cite error: Invalid <ref> tag; name "pmid1735330" defined multiple times with different content
  8. ↑ Thompson WG, Longstreth GL, Drossman DA et al. (2000). Functional Bowel Disorders. In: Drossman DA, Corazziari E, Talley NJ et al. (eds.), Rome II: The Functional Gastrointestinal Disorders. Diagnosis, Pathophysiology and Treatment. A Multinational Consensus. Lawrence, KS: Allen Press. ISBN 0965683729.
  9. ↑ Irritable Bowel Syndrome Self Help and Support Group, (2005). Diagnostic Criteria. Retrieved on December 4, 2005.
  10. ↑ 10.0 10.1 Vanner S, Depew W, Paterson W, DaCosta L, Groll A, Simon J, Djurfeldt M (1999). "Predictive value of the Rome criteria for diagnosing the irritable bowel syndrome.". Am J Gastroenterol 94 (10): 2912-7. DOI:10.1111/j.1572-0241.1999.01437.x. PMID 10520844. Research Blogging. Cite error: Invalid <ref> tag; name "pmid10520844" defined multiple times with different content
  11. ↑ Tibble J, Sigthorsson G, Foster R, Forgacs I, Bjarnason I (2002). "Use of surrogate markers of inflammation and Rome criteria to distinguish organic from nonorganic intestinal disease.". Gastroenterology 123 (2): 450-60. DOI:10.1053/gast.2002.34755. PMID 12145798. Research Blogging.
  12. ↑ Suarez F, Savaiano D, Levitt M (1995). "A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance.". N Engl J Med 333 (1): 1-4. PMID 7776987.
  13. ↑ Wangen, Stephen O. The Irritable Bowel Syndrome Solution. 2006. ISBN 0976853787. Excerpted with author's permission at The IBS Treatment Center
  14. ↑ 14.0 14.1 Levy R, Jones K, Whitehead W, Feld S, Talley N, Corey L (2001). "Irritable bowel syndrome in twins: heredity and social learning both contribute to etiology.". Gastroenterology 121 (4): 799-804. PMID 11606493. Cite error: Invalid <ref> tag; name "pmid11606493" defined multiple times with different content
  15. ↑ Bengtson MB, Ronning T, Vatn M, Harris J (2006). "IBS in twins: genes and environment.". Gut. PMID 17008364.
  16. ↑ Mohammed I, Cherkas L, Riley S, Spector T, Trudgill N (2005). "Genetic influences in irritable bowel syndrome: a twin study.". Am J Gastroenterol 100 (6): 1340-4. PMID 15929767.
  17. ↑ Gwee KA. Irritable bowel syndrome in developing countries—a disorder of civilization or colonization? Neurogastroenterol Motil. 2005 Jun;17(3):317–24. PMID 15916618
  18. ↑ Lawal A, Kern M, Sidhu H, Hofmann C, Shaker R (2006). "Novel evidence for hypersensitivity of visceral sensory neural circuitry in irritable bowel syndrome patients.". Gastroenterology 130 (1): 26-33. PMID 16401465.
  19. ↑ 19.0 19.1 Halvorson H, Schlett C, Riddle M (2006). "Postinfectious irritable bowel syndrome--a meta-analysis.". Am J Gastroenterol 101 (8): 1894-9; quiz 1942. PMID 16928253. Cite error: Invalid <ref> tag; name "pmid16928253" defined multiple times with different content
  20. ↑ Maxwell P, Rink E, Kumar D, Mendall M (2002). "Antibiotics increase functional abdominal symptoms.". Am J Gastroenterol 97 (1): 104-8. PMID 11808932.
  21. ↑ Zar S, Mincher L, Benson MJ, Kumar D (2005). "Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome.". Scandinavian Journal of Gastroenterlogy 40 (7): 800–7. PMID 16109655.
  22. ↑ Pimentel M, Chow EJ, Lin HC (2000). "Eradication of small intestinal bacterial overgrowth reduces symptoms of irritable bowel syndrome". Am J Gastroenterol 95 (12): 3503–6. PMID 11151884.
  23. ↑ Pimentel M, Chow EJ, Lin HC (2003). "Normalization of lactulose breath testing correlates with symptom improvement in irritable bowel syndrome. a double-blind, randomized, placebo-controlled study". Am J Gastroenterol 98 (2): 412–9. PMID 12591062.
  24. ↑ Drossman D, Leserman J, Nachman G, Li Z, Gluck H, Toomey T, Mitchell C (1990). "Sexual and physical abuse in women with functional or organic gastrointestinal disorders.". Ann Intern Med 113 (11): 828-33. PMID 2240898.
  25. ↑ National Institutes of Health, 2003. Irritable Bowel Syndrome. Publication No. 03–693, April 2003.
  26. ↑ Wood JD (2006). "Histamine, mast cells, and the enteric nervous system in the irritable bowel syndrome, enteritis, and food allergies". Gut 55: 445–447.
  27. ↑ Heitkemper MM, Cain KC, Jarrett ME, Burr RL, Hertig V, Bond EF (2003). "Symptoms across the menstrual cycle in women with irritable bowel syndrome". Am J Gastroenterol 98 (2): 420–30. PMID 12591063.
  28. ↑ Ruigomez A, Garcia Rodriguez LA, Johansson S, Wallander MA (2003). "Is hormone replacement therapy associated with an increased risk of irritable bowel syndrome?". Maturitas 44 (2): 133–40. PMID 12590009.
  29. ↑ Halpert AD, Thomas AC, Hu Y, Morris CB, Bangdiwala SI, Drossman DA (2006). "A survey on patient educational needs in irritable bowel syndrome and attitudes toward participation in clinical research". J Clin Gastroenterol 40 (1): 37–43. PMID 16340632.
  30. ↑ Van Vorous, Heather. Eating for IBS. 2000. ISBN 1569246009. Excerpted with author's permission at Help for Irritable Bowel Syndrome (see IBS Diet Section)
  31. ↑ Atkinson W, Sheldon TA, Shaath N, Whorwell PJ (2004). "Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial". Gut 53 (10): 1459–64. PMID 15361495 Full text.
  32. ↑ Sjölund K, Ekman R, Lindgren S, Rehfeld J (1996). "Disturbed motilin and cholecystokinin release in the irritable bowel syndrome.". Scand J Gastroenterol 31 (11): 1110-4. PMID 8938905.
  33. ↑ Caldarella MP, Milano A, Laterza F, Sacco F, Balatsinou C, Lapenna D, Pierdomenico SD, Cuccurullo F, Neri M (2005). "Visceral sensitivity and symptoms in patients with constipation- or diarrhea-predominant irritable bowel syndrome (IBS): effect of a low-fat intraduodenal infusion". Am J Gastroenterol 100 (2): 383–9. PMID 15667496.
  34. ↑ Choi, Y. Fats, Fructose May Contribute to IBS Symptoms. ACG 68th Annual Scientific Meeting: Abstract 21, presented October 13, 2003; Abstract 547, presented October 14, 2003.
  35. ↑ Zar S, Benson MJ, Kumar D (2005). "Food-specific serum IgG4 and IgE titers to common food antigens in irritable bowel syndrome". Am J Gastroenterol 100 (7): 1550–7. PMID 15984980.
  36. ↑ Zar S, Mincher L, Benson MJ, Kumar D (2005). "Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome". Scand J Gastroenterol 40 (7): 800–7. PMID 16109655.
  37. ↑ Mayer EA, Berman S, Suyenobu B, Labus J, Mandelkern MA, Naliboff BD, Chang L (2005). "Differences in brain responses to visceral pain between patients with irritable bowel syndrome and ulcerative colitis". Pain 115 (3): 398–409. PMID 15911167.
  38. ↑ 38.0 38.1 Bijkerk C, Muris J, Knottnerus J, Hoes A, de Wit N (2004). "Systematic review: the role of different types of fibre in the treatment of irritable bowel syndrome.". Aliment Pharmacol Ther 19 (3): 245-51. PMID 14984370. Cite error: Invalid <ref> tag; name "pmid14984370" defined multiple times with different content
  39. ↑ Prior A, Whorwell P (1987). "Double blind study of ispaghula in irritable bowel syndrome.". Gut 28 (11): 1510-3. PMID 3322956.
  40. ↑ Jalihal A, Kurian G. "Ispaghula therapy in irritable bowel syndrome: improvement in overall well-being is related to reduction in bowel dissatisfaction.". J Gastroenterol Hepatol 5 (5): 507-13. PMID 2129822.
  41. ↑ Kumar A, Kumar N, Vij J, Sarin S, Anand B (1987). "Optimum dosage of ispaghula husk in patients with irritable bowel syndrome: correlation of symptom relief with whole gut transit time and stool weight.". Gut 28 (2): 150-5. PMID 3030900.
  42. ↑ Francis CY, Whorwell PJ (1994). "Bran and irritable bowel syndrome: time for reappraisal". Lancet 344 (8914): 39–40. PMID 7912305.
  43. ↑ Cann P, Read N, Holdsworth C, Barends D (1984). "Role of loperamide and placebo in management of irritable bowel syndrome (IBS).". Dig Dis Sci 29 (3): 239-47. PMID 6365490.
  44. ↑ Cann P, Read N, Holdsworth C (1984). "What is the benefit of coarse wheat bran in patients with irritable bowel syndrome?". Gut 25 (2): 168-73. PMID 6319244.
  45. ↑ 45.0 45.1 Quartero A, Meineche-Schmidt V, Muris J, Rubin G, de Wit N. "Bulking agents, antispasmodic and antidepressant medication for the treatment of irritable bowel syndrome.". Cochrane Database Syst Rev: CD003460. PMID 15846668. Cite error: Invalid <ref> tag; name "pmid15846668" defined multiple times with different content
  46. ↑ Lesbros-Pantoflickova D, Michetti P, Fried M, Beglinger C, Blum A (2004). "Meta-analysis: The treatment of irritable bowel syndrome.". Aliment Pharmacol Ther 20 (11-12): 1253-69. PMID 15606387.
  47. ↑ Jailwala J, Imperiale T, Kroenke K (2000). "Pharmacologic treatment of the irritable bowel syndrome: a systematic review of randomized, controlled trials.". Ann Intern Med 133 (2): 136-47. PMID 10896640.
  48. ↑ Efskind P, Bernklev T, Vatn M (1996). "A double-blind placebo-controlled trial with loperamide in irritable bowel syndrome.". Scand J Gastroenterol 31 (5): 463-8. PMID 8734343.
  49. ↑ Joo J, Ehrenpreis E, Gonzalez L, Kaye M, Breno S, Wexner S, Zaitman D, Secrest K (1998). "Alterations in colonic anatomy induced by chronic stimulant laxatives: the cathartic colon revisited.". J Clin Gastroenterol 26 (4): 283-6. PMID 9649012.
  50. ↑ Attar A, Lémann M, Ferguson A, Halphen M, Boutron M, Flourié B, Alix E, Salmeron M, Guillemot F, Chaussade S, Ménard A, Moreau J, Naudin G, Barthet M (1999). "Comparison of a low dose polyethylene glycol electrolyte solution with lactulose for treatment of chronic constipation.". Gut 44 (2): 226-30. PMID 9895382.
  51. ↑ Lederle F, Busch D, Mattox K, West M, Aske D (1990). "Cost-effective treatment of constipation in the elderly: a randomized double-blind comparison of sorbitol and lactulose.". Am J Med 89 (5): 597-601. PMID 2122724.
  52. ↑ Talley N (2001). "Serotoninergic neuroenteric modulators.". Lancet 358 (9298): 2061-8. PMID 11755632.
  53. ↑ Evans B, Clark W, Moore D, Whorwell P. "Tegaserod for the treatment of irritable bowel syndrome.". Cochrane Database Syst Rev: CD003960. PMID 14974049.
  54. ↑ Tack J, Broekaert D, Fischler B, Oudenhove L, Gevers A, Janssens J (2006). "A controlled crossover study of the selective serotonin reuptake inhibitor citalopram in irritable bowel syndrome.". Gut 55 (8): 1095-103. PMID 16401691.
  55. ↑ Vahedi H, Merat S, Rashidioon A, Ghoddoosi A, Malekzadeh R (2005). "The effect of fluoxetine in patients with pain and constipation-predominant irritable bowel syndrome: a double-blind randomized-controlled study.". Aliment Pharmacol Ther 22 (5): 381-5. PMID 16128675.
  56. ↑ Creed F, Fernandes L, Guthrie E, Palmer S, Ratcliffe J, Read N, Rigby C, Thompson D, Tomenson B (2003). "The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome.". Gastroenterology 124 (2): 303-17. PMID 12557136.
  57. ↑ Tabas G, Beaves M, Wang J, Friday P, Mardini H, Arnold G (2004). "Paroxetine to treat irritable bowel syndrome not responding to high-fiber diet: a double-blind, placebo-controlled trial.". Am J Gastroenterol 99 (5): 914-20. PMID 15128360.
  58. ↑ Jackson J, O'Malley P, Tomkins G, Balden E, Santoro J, Kroenke K (2000). "Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis.". Am J Med 108 (1): 65-72. PMID 11059442.
  59. ↑ 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 (2003). "Cognitive-behavioral therapy versus education and desipramine versus placebo for moderate to severe functional bowel disorders.". Gastroenterology 125 (1): 19-31. PMID 12851867.
  60. ↑ Sharara AI, Aoun E, Abdul-Baki H, Mounzer R, Sidani S, Elhajj I (2006). "A randomized double-blind placebo-controlled trial of rifaximin in patients with abdominal bloating and flatulence". Am J Gastroenterol 101 (2): 326–33. PMID 16454838.
  61. ↑ Pimentel M, Park S, Mirocha J, Kane S, Kong Y (2006). "The effect of a nonabsorbed oral antibiotic (rifaximin) on the symptoms of the irritable bowel syndrome: a randomized trial.". Ann Intern Med 145 (8): 557-63. PMID 17043337.
  62. ↑ Quigley EM (2006). "Germs, gas and the gut; the evolving role of the enteric flora in IBS". Am J Gastroenterol 101 (2): 334–5. PMID 16454839.
  63. ↑ Hadley SK, Gaarder SM (2005). "Treatment of irritable bowel syndrome". Am Fam Physician 72 (12): 2501–6. PMID 16370407.
  64. ↑ Nash P, Gould S, Bernardo D (1986). "Peppermint oil does not relieve the pain of irritable bowel syndrome.". Br J Clin Pract 40 (7): 292-3. PMID 3527248.
  65. ↑ Liu J, Chen G, Yeh H, Huang C, Poon S (1997). "Enteric-coated peppermint-oil capsules in the treatment of irritable bowel syndrome: a prospective, randomized trial.". J Gastroenterol 32 (6): 765-8. PMID 9430014.
  66. ↑ Di Stefano M, Miceli E, Gotti S, Missanelli A, Mazzocchi S, Corazza G (2007). "The effect of oral alpha-galactosidase on intestinal gas production and gas-related symptoms". Dig Dis Sci 52 (1): 78-83. PMID 17151807.
  67. ↑ Ganiats T, Norcross W, Halverson A, Burford P, Palinkas L (1994). "Does Beano prevent gas? A double-blind crossover study of oral alpha-galactosidase to treat dietary oligosaccharide intolerance". J Fam Pract 39 (5): 441-5. PMID 7964541.
  68. ↑ Lettieri J, Dain B. "Effects of beano on the tolerability and pharmacodynamics of acarbose". Clin Ther 20 (3): 497-504. PMID 9663365.
  69. ↑ Massa F, Storr M, Lutz B (2005). "The endocannabinoid system in the physiology and pathophysiology of the gastrointestinal tract.". J Mol Med 83 (12): 944-54. PMID 16133420.
  70. ↑ Russo E. "Clinical endocannabinoid deficiency (CECD): can this concept explain therapeutic benefits of cannabis in migraine, fibromyalgia, irritable bowel syndrome and other treatment-resistant conditions?". Neuro Endocrinol Lett 25 (1-2): 31-9. PMID 15159679.
  71. ↑ Kennedy T, Jones R, Darnley S, Seed P, Wessely S, Chalder T (2005). "Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial". BMJ 331 (7514): 435. PMID 16093252 Full text.
  72. ↑ Heymann-Mönnikes I, Arnold R, Florin I, Herda C, Melfsen S, Mönnikes H (2000). "The combination of medical treatment plus multicomponent behavioral therapy is superior to medical treatment alone in the therapy of irritable bowel syndrome.". Am J Gastroenterol 95 (4): 981-94. PMID 10763948.
  73. ↑ Gonsalkorale WM, Miller V, Afzal A, Whorwell PJ (2003). "Long term benefits of hypnotherapy for irritable bowel syndrome". Gut 52 (11): 1623–9. PMID 14570733.
  74. ↑ Niedzielin K, Kordecki H, Birkenfeld B (2001). "A controlled, double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome". Eur J Gastroenterol Hepatol 13 (10): 1143–7. PMID 11711768.
  75. ↑ New Studies Examine the Evidence of Probiotics on IBS (Oct 2005). American College of Gastrointerologists. Retrieved on March 2, 2006
  76. ↑ Ease the pain of IBS, (2006). Andrew Weil. Retrieved on March 2, 2006
  77. ↑ Lim B, Manheimer E, Lao L, Ziea E, Wisniewski J, Liu J, Berman B. "Acupuncture for treatment of irritable bowel syndrome.". Cochrane Database Syst Rev: CD005111. PMID 17054239.
  78. ↑ Culliton BJ (1997). "NIH says "yes" to acupuncture". Nat Med 3 (12): 1307. PMID 9396586. from Culliton BJ (1997). “107. Acupuncture”, Health Services/Technology Assessment Text (HSTAT). National Information Center on Health Services Research and Health Care Technology. 
  79. ↑ Irritable Bowel Syndrome - A Traditional Chinese Medicine Perspective, (2006). Al Stone L.Ac. Retrieved on February 14, 2006.
  80. ↑ Get the Facts, Acupuncture, (2006). National Institute of Health. Retrieved on March 2, 2006.

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