Irritable Bowel Syndrome - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References

IRRITABLE BOWEL SYNDROME A M EDICAL D ICTIONARY , B IBLIOGRAPHY , AND A NNOTATED R ESEARCH G UIDE TO I NTERNET R EFERENC...

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IRRITABLE BOWEL SYNDROME A M EDICAL D ICTIONARY , B IBLIOGRAPHY , AND A NNOTATED R ESEARCH G UIDE TO I NTERNET R EFERENCES

J AMES N. P ARKER , M.D. AND P HILIP M. P ARKER , P H .D., E DITORS

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ICON Health Publications ICON Group International, Inc. 4370 La Jolla Village Drive, 4th Floor San Diego, CA 92122 USA Copyright ©2004 by ICON Group International, Inc. Copyright ©2004 by ICON Group International, Inc. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America. Last digit indicates print number: 10 9 8 7 6 4 5 3 2 1

Publisher, Health Care: Philip Parker, Ph.D. Editor(s): James Parker, M.D., Philip Parker, Ph.D. Publisher's note: The ideas, procedures, and suggestions contained in this book are not intended for the diagnosis or treatment of a health problem. As new medical or scientific information becomes available from academic and clinical research, recommended treatments and drug therapies may undergo changes. The authors, editors, and publisher have attempted to make the information in this book up to date and accurate in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of this book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised to always check product information (package inserts) for changes and new information regarding dosage and contraindications before prescribing any drug or pharmacological product. Caution is especially urged when using new or infrequently ordered drugs, herbal remedies, vitamins and supplements, alternative therapies, complementary therapies and medicines, and integrative medical treatments. Cataloging-in-Publication Data Parker, James N., 1961Parker, Philip M., 1960Irritable Bowel Syndrome: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References / James N. Parker and Philip M. Parker, editors p. cm. Includes bibliographical references, glossary, and index. ISBN: 0-597-83946-8 1. Irritable Bowel Syndrome-Popular works. I. Title.

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Disclaimer This publication is not intended to be used for the diagnosis or treatment of a health problem. It is sold with the understanding that the publisher, editors, and authors are not engaging in the rendering of medical, psychological, financial, legal, or other professional services. References to any entity, product, service, or source of information that may be contained in this publication should not be considered an endorsement, either direct or implied, by the publisher, editors, or authors. ICON Group International, Inc., the editors, and the authors are not responsible for the content of any Web pages or publications referenced in this publication.

Copyright Notice If a physician wishes to copy limited passages from this book for patient use, this right is automatically granted without written permission from ICON Group International, Inc. (ICON Group). However, all of ICON Group publications have copyrights. With exception to the above, copying our publications in whole or in part, for whatever reason, is a violation of copyright laws and can lead to penalties and fines. Should you want to copy tables, graphs, or other materials, please contact us to request permission (E-mail: [email protected]). ICON Group often grants permission for very limited reproduction of our publications for internal use, press releases, and academic research. Such reproduction requires confirmed permission from ICON Group International Inc. The disclaimer above must accompany all reproductions, in whole or in part, of this book.

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Acknowledgements The collective knowledge generated from academic and applied research summarized in various references has been critical in the creation of this book which is best viewed as a comprehensive compilation and collection of information prepared by various official agencies which produce publications on irritable bowel syndrome. Books in this series draw from various agencies and institutions associated with the United States Department of Health and Human Services, and in particular, the Office of the Secretary of Health and Human Services (OS), the Administration for Children and Families (ACF), the Administration on Aging (AOA), the Agency for Healthcare Research and Quality (AHRQ), the Agency for Toxic Substances and Disease Registry (ATSDR), the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the Healthcare Financing Administration (HCFA), the Health Resources and Services Administration (HRSA), the Indian Health Service (IHS), the institutions of the National Institutes of Health (NIH), the Program Support Center (PSC), and the Substance Abuse and Mental Health Services Administration (SAMHSA). In addition to these sources, information gathered from the National Library of Medicine, the United States Patent Office, the European Union, and their related organizations has been invaluable in the creation of this book. Some of the work represented was financially supported by the Research and Development Committee at INSEAD. This support is gratefully acknowledged. Finally, special thanks are owed to Tiffany Freeman for her excellent editorial support.

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About the Editors James N. Parker, M.D. Dr. James N. Parker received his Bachelor of Science degree in Psychobiology from the University of California, Riverside and his M.D. from the University of California, San Diego. In addition to authoring numerous research publications, he has lectured at various academic institutions. Dr. Parker is the medical editor for health books by ICON Health Publications. Philip M. Parker, Ph.D. Philip M. Parker is the Eli Lilly Chair Professor of Innovation, Business and Society at INSEAD (Fontainebleau, France and Singapore). Dr. Parker has also been Professor at the University of California, San Diego and has taught courses at Harvard University, the Hong Kong University of Science and Technology, the Massachusetts Institute of Technology, Stanford University, and UCLA. Dr. Parker is the associate editor for ICON Health Publications.

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About ICON Health Publications To discover more about ICON Health Publications, simply check with your preferred online booksellers, including Barnes&Noble.com and Amazon.com which currently carry all of our titles. Or, feel free to contact us directly for bulk purchases or institutional discounts: ICON Group International, Inc. 4370 La Jolla Village Drive, Fourth Floor San Diego, CA 92122 USA Fax: 858-546-4341 Web site: www.icongrouponline.com/health

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Table of Contents FORWARD .......................................................................................................................................... 1 CHAPTER 1. STUDIES ON IRRITABLE BOWEL SYNDROME ................................................................. 3 Overview........................................................................................................................................ 3 The Combined Health Information Database................................................................................. 3 Federally Funded Research on Irritable Bowel Syndrome ........................................................... 27 E-Journals: PubMed Central ....................................................................................................... 64 The National Library of Medicine: PubMed ................................................................................ 64 CHAPTER 2. NUTRITION AND IRRITABLE BOWEL SYNDROME ..................................................... 109 Overview.................................................................................................................................... 109 Finding Nutrition Studies on Irritable Bowel Syndrome .......................................................... 109 Federal Resources on Nutrition ................................................................................................. 117 Additional Web Resources ......................................................................................................... 117 CHAPTER 3. ALTERNATIVE MEDICINE AND IRRITABLE BOWEL SYNDROME ............................... 119 Overview.................................................................................................................................... 119 National Center for Complementary and Alternative Medicine................................................ 119 Additional Web Resources ......................................................................................................... 119 General References ..................................................................................................................... 126 CHAPTER 4. DISSERTATIONS ON IRRITABLE BOWEL SYNDROME ................................................. 127 Overview.................................................................................................................................... 127 Dissertations on Irritable Bowel Syndrome ............................................................................... 127 Keeping Current ........................................................................................................................ 128 CHAPTER 5. CLINICAL TRIALS AND IRRITABLE BOWEL SYNDROME ............................................ 129 Overview.................................................................................................................................... 129 Recent Trials on Irritable Bowel Syndrome ............................................................................... 129 Keeping Current on Clinical Trials ........................................................................................... 131 CHAPTER 6. PATENTS ON IRRITABLE BOWEL SYNDROME ............................................................ 133 Overview.................................................................................................................................... 133 Patents on Irritable Bowel Syndrome ........................................................................................ 133 Patent Applications on Irritable Bowel Syndrome..................................................................... 151 Keeping Current ........................................................................................................................ 182 CHAPTER 7. BOOKS ON IRRITABLE BOWEL SYNDROME ............................................................... 183 Overview.................................................................................................................................... 183 Book Summaries: Federal Agencies............................................................................................ 183 Book Summaries: Online Booksellers......................................................................................... 186 The National Library of Medicine Book Index ........................................................................... 191 Chapters on Irritable Bowel Syndrome ...................................................................................... 191 Directories.................................................................................................................................. 196 CHAPTER 8. MULTIMEDIA ON IRRITABLE BOWEL SYNDROME ..................................................... 199 Overview.................................................................................................................................... 199 Video Recordings ....................................................................................................................... 199 Bibliography: Multimedia on Irritable Bowel Syndrome ........................................................... 201 CHAPTER 9. PERIODICALS AND NEWS ON IRRITABLE BOWEL SYNDROME .................................. 203 Overview.................................................................................................................................... 203 News Services and Press Releases.............................................................................................. 203 Newsletters on Irritable Bowel Syndrome.................................................................................. 207 Newsletter Articles .................................................................................................................... 207 Academic Periodicals covering Irritable Bowel Syndrome......................................................... 210 CHAPTER 10. RESEARCHING MEDICATIONS................................................................................. 211 Overview.................................................................................................................................... 211 U.S. Pharmacopeia..................................................................................................................... 211 Commercial Databases ............................................................................................................... 212

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APPENDIX A. PHYSICIAN RESOURCES .......................................................................................... 217 Overview.................................................................................................................................... 217 NIH Guidelines.......................................................................................................................... 217 NIH Databases........................................................................................................................... 219 Other Commercial Databases..................................................................................................... 222 APPENDIX B. PATIENT RESOURCES ............................................................................................... 223 Overview.................................................................................................................................... 223 Patient Guideline Sources.......................................................................................................... 223 Finding Associations.................................................................................................................. 235 APPENDIX C. FINDING MEDICAL LIBRARIES ................................................................................ 237 Overview.................................................................................................................................... 237 Preparation................................................................................................................................. 237 Finding a Local Medical Library................................................................................................ 237 Medical Libraries in the U.S. and Canada ................................................................................. 237 ONLINE GLOSSARIES................................................................................................................ 243 Online Dictionary Directories ................................................................................................... 245 IRRITABLE BOWEL SYNDROME DICTIONARY ................................................................ 247 INDEX .............................................................................................................................................. 325

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FORWARD In March 2001, the National Institutes of Health issued the following warning: "The number of Web sites offering health-related resources grows every day. Many sites provide valuable information, while others may have information that is unreliable or misleading."1 Furthermore, because of the rapid increase in Internet-based information, many hours can be wasted searching, selecting, and printing. Since only the smallest fraction of information dealing with irritable bowel syndrome is indexed in search engines, such as www.google.com or others, a non-systematic approach to Internet research can be not only time consuming, but also incomplete. This book was created for medical professionals, students, and members of the general public who want to know as much as possible about irritable bowel syndrome, using the most advanced research tools available and spending the least amount of time doing so. In addition to offering a structured and comprehensive bibliography, the pages that follow will tell you where and how to find reliable information covering virtually all topics related to irritable bowel syndrome, from the essentials to the most advanced areas of research. Public, academic, government, and peer-reviewed research studies are emphasized. Various abstracts are reproduced to give you some of the latest official information available to date on irritable bowel syndrome. Abundant guidance is given on how to obtain free-of-charge primary research results via the Internet. While this book focuses on the field of medicine, when some sources provide access to non-medical information relating to irritable bowel syndrome, these are noted in the text. E-book and electronic versions of this book are fully interactive with each of the Internet sites mentioned (clicking on a hyperlink automatically opens your browser to the site indicated). If you are using the hard copy version of this book, you can access a cited Web site by typing the provided Web address directly into your Internet browser. You may find it useful to refer to synonyms or related terms when accessing these Internet databases. NOTE: At the time of publication, the Web addresses were functional. However, some links may fail due to URL address changes, which is a common occurrence on the Internet. For readers unfamiliar with the Internet, detailed instructions are offered on how to access electronic resources. For readers unfamiliar with medical terminology, a comprehensive glossary is provided. For readers without access to Internet resources, a directory of medical libraries, that have or can locate references cited here, is given. We hope these resources will prove useful to the widest possible audience seeking information on irritable bowel syndrome. The Editors

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From the NIH, National Cancer Institute (NCI): http://www.cancer.gov/cancerinfo/ten-things-to-know.

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CHAPTER 1. STUDIES ON IRRITABLE BOWEL SYNDROME Overview In this chapter, we will show you how to locate peer-reviewed references and studies on irritable bowel syndrome.

The Combined Health Information Database The Combined Health Information Database summarizes studies across numerous federal agencies. To limit your investigation to research studies and irritable bowel syndrome, you will need to use the advanced search options. First, go to http://chid.nih.gov/index.html. From there, select the “Detailed Search” option (or go directly to that page with the following hyperlink: http://chid.nih.gov/detail/detail.html). The trick in extracting studies is found in the drop boxes at the bottom of the search page where “You may refine your search by.” Select the dates and language you prefer, and the format option “Journal Article.” At the top of the search form, select the number of records you would like to see (we recommend 100) and check the box to display “whole records.” We recommend that you type “irritable bowel syndrome” (or synonyms) into the “For these words:” box. Consider using the option “anywhere in record” to make your search as broad as possible. If you want to limit the search to only a particular field, such as the title of the journal, then select this option in the “Search in these fields” drop box. The following is what you can expect from this type of search: •

Irritable Bowel Syndrome: Still Far from a Positive Diagnosis Source: Digestive Diseases and Sciences. 37(2): 164-167. February 1992. Summary: A scoring system has been proposed for the positive diagnosis of irritable bowel syndrome (IBS) where more than 44 points excluded organic digestive disease. This article reports on a study that attempted to determine the usefulness of this scoring system in a different setting. Patients (1257) consecutively referred to the authors' medical division were admitted to the study and 270 of these, complaining of abdominal symptoms, were scored on the Kruis system method. The positive predictive value and the sensitivity of the system did not appear to be adequate. The negative predictive value and the specificity gave higher results, but did not identify 11 cases of organic

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Irritable Bowel Syndrome

digestive diseases. The authors conclude that the scoring system may be useful only as a first step in a diagnostic flow chart. 4 tables. 5 references. (AA-M). •

Antibiotic Use, Childhood Affluence and Irritable Bowel Syndrome (IBS) Source: European Journal of Gastroenterology and Hepatology. 10(1): 59-62. January 1998. Contact: Available from Rapid Science Publishers. 400 Market Street, Suite 750, Philadelphia, PA 19106. (800) 552-5866. Summary: Antibiotics cause well-defined short-lived disturbances in bowel habits. There is evidence to suggest that antibiotics may play a role in the pathogenesis of irritable bowel syndrome (IBS). This article reports on a study that consisted of a survey examining the relationship between drug use and other epidemiological correlates of IBS. Subjects were 421 people (46 percent male, mean age 47 years) attending a general practice health screening clinic. Subjects were interviewed by a research nurse and completed a previously validated questionnaire. IBS symptoms were said to be present if abdominal pain with two or more Manning criteria symptoms occurred more than once a month over the previous 6 months. Results showed 48 subjects with symptoms of IBS. The following were strongly related to its presence: antibiotic use, female sex, childhood living density of less than 1 person per room, and a manual occupation for the father. The use of nonsteroidal anti-inflammatory drugs, H2 antagonists, or other types of medication was not greater in this group. The authors conclude that antibiotic use is associated with IBS and call for further research into this association. In addition, privileged childhood living conditions were also an important risk factor consistent with an allergic etiology for IBS. 2 tables. 12 references. (AA).

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Diarrhea-Constipation-Pain: When is It Irritable Bowel Syndrome? Source: Consultant. 41(8): 1089-1091, 1095-1096. July 2001. Contact: Available from Cliggott Publishing Company. 55 Holly Hill Lane, Box 4010, Greenwich, CT 06831-0010. Summary: Central to the diagnosis of irritable bowel syndrome (IBS) are the symptoms of abdominal pain and disordered defecation of at least 3 months' duration. This article helps physicians determine when the symptoms of diarrhea, or constipation, or pain are indeed due to IBS. Either diarrhea or constipation can predominate, although the defecation pattern may vary from day to day in some patients. In the absence of evidence of more serious disease, diagnosis is based largely on the results of a thorough history and examination. For most patients, general screening tests include a complete blood cell count, erythrocyte sedimentation rate, serum chemistry panel, stool guaiac test, and stool examination for ova (eggs) and parasites. For patients older than 50 years, flexible sigmoidoscopy, colonoscopy, or barium enema may be indicated. Management of IBS consists of patient education and reassurance; dietary modification, including increased fiber intake in patients with constipation; and in some cases, judicious use of medications or psychological interventions. 2 tables. 35 references.

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Impact of Irritable Bowel Syndrome on Health-Related Quality of Life Source: Gastroenterology. 119(3): 654-660. September 2000. Contact: Available from W.B. Saunders Company. 6277 Sea Harbor Drive, Orlando, FL 19106-3399. (800) 654-2452 or (407) 345-4000.

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Summary: Few data are available to evaluate health related quality of life (HRQOL) of people with irritable bowel syndrome (IBS). This article reports on a study that evaluated and compared the impact of IBS on HRQOL using previously reported HRQOL data for the United States general population and for people with selected chronic diseases. Using the SF 36 Health Survey, the authors compared the HRQOL of IBS patients (n = 877) with previously reported SF 36 data for the general U.S. population and for patients with gastroesophageal reflux disease (GERD), diabetes mellitus, depression, and dialysis-dependent end stage renal disease (ESRD). On all 8 SF 36 scales, IBS patients had significantly worse HRQOL than the U.S. general population. Compared with GERD patients, IBS patients scored significantly lower on all SF 36 scales except physical functioning. Similarly, IBS patients had significantly worse HRQOL on selected SF 36 scales than patients with diabetes mellitus and ESRD. IBS patients had significantly better mental health SF 36 scale scores than patients with depression. The authors conclude that IBS patients experience significant impairment in HRQOL. Decrements in HRQOL are most pronounced in energy and fatigue, role limitations caused by physical health problems, bodily pain, and general health perceptions. 3 figures. 4 tables. 44 references. •

Symptomatic Presentations of the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 235-247. June 1991. Summary: Functional gastrointestinal disorders have no reliable physiologic, biochemical, or structural markers, therefore, they must be defined by their symptoms. This article discusses the classification of functional bowel disorders and describes the symptoms, particularly those of irritable bowel syndrome (IBS). Possible mechanisms underlying the symptoms are also mentioned. Disorders discussed include psychological disorders, IBS, burbulence, functional constipation, functional diarrhea, and unspecified functional bowel disorder. 1 figure. 2 tables. 71 references.

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High-Fiber Diet Supplementation in Patients with Irritable Bowel Syndrome (IBS): A Multicenter, Randomized, Open Trial Comparison Between Wheat Bran Diet and Partially Hydrolyzed Guar Gum (PHGG) Source: Digestive Diseases and Sciences. 47(8): 1697-1704. August 2002. Contact: Available from Kluwer Academic Publishers. Customer Service Deparment, P.O. Box 358, Accord Station, Hingham, MA 02018-0358. (781) 871-6600. Fax (781) 6819045. E-mail: [email protected]. Website: www.wkap.nl. Distribution Centre, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. 31 78 6392392. Fax: 31 78 6546474. E-mail: [email protected]. Summary: High fiber diet supplementation is commonly used in irritable bowel syndrome (IBS), although it poses several management problems. Partially hydrolyzed guar gum (PHGG) has shown beneficial effects in animal and human studies, but its potential role in IBS symptom relief has not been evaluated. This article reports on a study that investigated PHGG in IBS patients and compared it to a wheat bran diet. Abdominal pain, bowel habits, and subjective overall rating were longitudinally evaluated in 188 adults IBS patients (138 women, 49 men) for 12 weeks. Patients were classified as having diarrhea predominant, constipation predominant, or changeable bowel habits and were randomly assigned to PHGG or wheat bran. After four weeks, patients were allowed to switch group, depending on their subject evaluation of their symptoms. Significantly more patients switched from fiber to PHGG (49.9 percent) than from PHGG to fiber (10.9 percent) at four weeks. Per protocol analysis showed that both

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fiber and PHGG were effective in improving pain and bowel habits, but no difference was found between the two groups. Intention-to-treat analysis showed a significantly greater success in the PHGG groups (60 percent) than in the fiber group (40 percent). In conclusion, improvements in core IBS symptoms (abdominal pain and bowel habits) were observed with both bran and PHGG, but the latter was better tolerated and preferred by patients, revealing a higher probability of success than bran and a lower probability of patients abandoning the prescribed regimen. 3 tables. 43 references. •

Psychophysiological Factors Associated with Irritable Bowel Syndrome Source: Gastroenterology Nursing. 17(2): 61-67. September-October 1994. Summary: In this article, the author reviews the psychophysiological factors associated with irritable bowel syndrome (IBS). The author addresses gastrointestinal neuroendocrinology; the effects of stress on gastrointestinal motility; and the nursing implications related to this syndrome. The mechanisms underlying the etiology of IBS remain to be elucidated. However, the author suggests that IBS is a stress-induced syndrome that involves the complex interactions between external or internal stressors, the central nervous system, and the enteric nervous system. 1 figure. 1 table. 44 references. (AA-M).

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Serotonin-Transporter Polymorphism Pharmacogenetics in Diarrhea-Predominant Irritable Bowel Syndrome Source: Gastroenterology. 123(2): 425-432. August 2002. Contact: Available from W.B. Saunders Company. 6277 Sea Harbor Drive, Orlando, FL 32887-4800. (800) 654-2452. Website: www.gastrojournal.org. Summary: Irritable bowel syndrome (IBS) affects approximately 15 percent of adults, causes abdominal pain, discomfort, and altered bowel habits, and predominantly affects women. This article reports on a study of the use of serotonin (5HT) receptor antagonists in women with diarrhea- predominant IBS (DIBS). 5HT undergoes reuptake by a transporter protein (SERT). In the study, 30 patients (15 men, 15 women) with DIBS received 1 milligram twice a day of alosetron for 6 weeks; colonic transit was measured by scintigraphy at baseline and at the end of treatment. Results showed that SERT polymorphisms tended to be associated with colonic transit response; there was a greater response in those with long homozygous than heterozygous polymorphisms. Age, gender, and duration of IBS were not significantly different in the three groups (long, short, heterozygous). The authors conclude that genetic polymorphisms at the SERT promoter influence response to a 5HT antagonist in DIBS and may influence benefit to risk ratio with this class of compounds. 3 figures. 1 table. 57 references.

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Compliance, Tone and Sensitivity of the Rectum in Different Subtypes of Irritable Bowel Syndrome Source: Neurogastroenterology and Motility. 14(3): 241-247. June 2002. Contact: Available from Blackwell Science, Ltd. Journal Subscriptions, P.O. Box 88, Oxford OX2 OEL, UK. +44 1865 206180 Fax +44 1865 206219. E-mail: [email protected]. Summary: Irritable bowel syndrome (IBS) consists of various subtypes; it is unknown whether these subtypes share a common pathophysiology. Evaluation of motor and sensory function of the rectum using a barostat may help to explore a common pathophysiological background or differences in pathophysiology in subtypes of BIS.

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This article reports on a study in which authors evaluated compliance, tone, and sensitivity of the rectum, in both fasting state and postprandially (after a meal), using a computerized barostat in 15 patients with diarrhea-predominant IBS (IBSD), 14 patients with constipation-predominant IBS (IBSC), and 12 healthy controls. Rectal compliance was decreased in both IBS groups compared with controls. The perception of urge was increased only in IBSD patients, whereas pain perception was significantly increased in both IBS groups. Spontaneous adaptive relaxation was decreased in IBSD patients. Postprandially, rectal volume decreased significantly in the controls and in IBSD patients, but not in IBSC patients. In conclusion, both rectal motor and sensory characteristics are different between IBSD and IBSC patients. Therefore, testing of rectal visceroperception, adaptive relaxation, and the rectal response to a meal may help distinguish groups of patients with different subtypes of IBS. 5 figures. 2 tables. 23 references. •

Advances in the Management of Irritable Bowel Syndrome Source: Journal of Gastroenterology and Hepatology. 17(4): 503-507. April 2002. Contact: Available from Blackwell Science. 54 University Street, Carlton South 3053, Victoria, Australia. +61393470300. Fax +61393475001. E-mail: [email protected]. Website: www.blackwell-science.com. Summary: Irritable bowel syndrome (IBS) is a chronic, relapsing disorder of brain-gut regulation that can have disabling symptoms that significantly affect daily life. Recent advances in different aspects of IBS have led to a need to reassess the overall management of this common, complex disorder. Important areas include: first, the heterogeneity of symptom patterns and the role of specific diagnostic symptom criteria for use in both clinical practice and in clinical research; second, the growing interest in the potential interaction between 'peripheral' and 'central' pathophysiological mechanisms; and third, the development of new and effective drugs designed to target specific receptor systems in the enteric nervous system. This review article covers each of these aspects and emphasizes an approach to the management of patients based on pathophysiological considerations. 1 figure. 2 tables. 15 references.

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Epidemiology of Irritable Bowel Syndrome in Chinese Source: Digestive Diseases and Sciences. 47(11): 2621-2624. November 2002. Contact: Available from Kluwer Academic Publishers. Customer Service Department, P.O. Box 358, Accord Station, Hingham, MA 02018-0358. (781) 871-6600. Fax (781) 6819045. E-mail: [email protected]. Website: www.wkap.nl. Distribution Centre, P.O. Box 322, 3300 AH Dordrecht, The Netherlands. 31 78 6392392. Fax: 31 78 6546474. E-mail: [email protected]. Summary: Irritable bowel syndrome (IBS) is common in Caucasians and Japanese persons, but its epidemiology has not been studied in urbanized Chinese populations. This study compares diagnostic criteria and explores the epidemiology of IBS in Hong Kong Chinese. In all, 964 subjects from public housing and 334 subjects from private housing were recruited for face-to-face interviews in Shatin, Hong Kong. A structured questionnaire was used to measure the prevalence of IBS. The prevalence of IBS, based on the Rome II criteria, was 3.6 percent in men and 3.8 percent in women. Men with IBS had significantly lower vitality scores on the SF-36 scale than the controls and women with IBS had significantly lower mental health scores than controls. The authors conclude that IBS is quite prevalent in Hong Kong Chinese and the quality of life of subjects with IBS is significantly affected. 3 tables. 35 references.

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Use of Antidepressants in Irritable Bowel Syndrome Source: Practical Gastroenterology. 26(3): 13-14, 19-20, 22-23, 27. March 2002. Contact: Available from Shugar Publishing. 12 Moniebogue Lane, Westhampton Beach, NY 11978. (516) 288-4404. Fax (516) 288-4435. Summary: Irritable bowel syndrome (IBS) is the most common bowel disorder seen in gastroenterology practice. IBS is characterized by a pattern of waxing and waning abdominal pain, bloating, and disturbance of bowel habits. This article describes the rationale for the use of antidepressants in IBS, the results of clinical trials, suggested treatment plan, and directions for future research. The authors note that IBS is a complex biopsychosocial disorder whose precise pathophysiology is unknown, although it is generally accepted that abnormal brain-gut interactions play a major role. At the time of clinical presentation, about 50 percent of IBS patients have a definable psychiatric disorder. Psychosocial stressors have been demonstrated to have an important modulatory role in IBS, affecting not only the illness experience but also health care seeking behavior and the clinical outcome. Antidepressants represent an attractive therapeutic approach for the treatment of IBS, not only for their psychotropic effects, but also for their neuromodulatory and analgesic properties. However, there is still a lack of well-designed, appropriately powered, randomized clinical trials examining the use of antidepressants in IBS. 1 figure. 4 tables. 51 references.

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Irritable Bowel Syndrome: Streamlining the Diagnosis Source: Postgraduate Medicine. 102(3): 197-198, 201-204, 207-208. September 1997. Contact: Available from McGraw-Hill, Inc. 1221 Avenue of the Americas, New York, NY 10020. (612) 832-7869. Summary: Irritable bowel syndrome (IBS), a common gastrointestinal disorder, is the condition for which patients are most often referred to gastroenterologists. Symptoms may be distressing enough to cause avoidance of work and social activities. Stress often exacerbates symptoms, and sensory abnormalities are common in patients with the disease. In this article, the authors describe how careful history taking and physical examination can avoid the overuse of diagnostic testing and point to the most effective treatment. Differential diagnosis for IBS includes consideration of many common gastrointestinal illnesses, including parasitic infections, salmonellosis, celiac sprue (gluten intolerance), chronic pancreatitis, Crohn's disease, ulcerative colitis, peptic ulcer disease, colon cancer, Campylobacter jejuni infection, and endometriosis. A strong physician-patient relationship at the time of IBS diagnosis improves the patient's ability to cope with the disease and reduces the number of subsequent office visits. The physician needs to involve the patient as a collaborative partner in the decision-making process and to avoid extensive invasive procedures if there is no firm indication for them. The patient's concerns and fears need to be addressed. Dietary changes, specifically elimination of troublesome foods, such as sorbitol, alcohol, caffeine, fats, legumes, sugar and, in lactose-intolerant patients, milk products, may benefit IBS patients. Relief of colonic spasm may be obtained with short-acting anticholinergics and other antispasmodic medications. Loperamide may also prove to be beneficial, especially in reducing post-meal diarrhea. Antidepressants are now being evaluated as potential therapeutic agents for IBS. One sidebar lists sources of information on IBS for physicians and patients, including organizations and Internet sites. 1 figure. 1 table. 21 references. (AA-M).

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Does a Physically Active Lifestyle Improve Symptoms in Women with Irritable Bowel Syndrome? Source: Gastroenterology Nursing. 24(3): 129-137. May-June 2001. Contact: Available from Williams and Wilkins. 351 West Camden Street, Baltimore, MD 21201-2436. (410) 528-8555. Summary: It has been proposed that physical activity moderates physiological or psychological responses to chronic conditions. This article reports on a study undertaken to determine if women with a chronic functional gastrointestinal (GI) disorder (irritable bowel syndrome, or IBS) had less active lifestyles than healthy controls. The study also tested whether active women with IBS had less severe recalled or daily reports of GI, psychological, and somatic symptoms than inactive women with irritable bowel syndrome. Questionnaires were used to measure GI and psychological distress and somatic symptoms in 89 women who participated in the study. A daily symptom and activity diary was kept for one menstrual cycle. Women with IBS were significantly less likely to be active (48 percent) than control women (71 percent). Within the IBS group, active women were less likely to report a feeling of incomplete evacuation following a bowel movement than inactive women, yet active women did not have less severe recalled psychological or somatic symptoms than inactive women. Active women with IBS reported less severe daily somatic symptoms, which were accounted for by a lower level of fatigue, but not daily GI or psychological symptoms. These results suggest that physical activity may produce select symptom improvement in women with IBS. 4 tables. 55 references.

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Naloxone Treatment for Irritable Bowel Syndrome: A Randomized Controlled Trial with an Oral Formulation Source: Alimentary Pharmacology and Therapeutics. 16(9): 1649-1654. September 2002. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: Opioids change gut motility and secretion, causing delayed intestinal transit and constipation. Endorphins play a role in the constipation troubling some patients with irritable bowel syndrome (IBS); hence naloxone, an opioid antagonist, may have a therapeutic role. This article reports on a study undertaken to assess the efficacy and safety of an oral formulation of naloxone in IBS patients with constipation. The randomized, double-blind, placebo-controlled trial included 25 patients with IBS (constipation-predominant and alternating types) who received 8 weeks of treatment with naloxone capsules, 10 milligrams twice daily, or identical placebo. Adequate symptomatic relief was recorded in six of 14 on naloxone and three of 11 on placebo. Whilst the differences were not significant, improvements in severity gradings and mean symptom scores for pain, bloating, straining and urgency to defecate were greater with naloxone than placebo for all parameters. In addition, quality of life assessments improved to a greater extent in patients taking naloxone. The authors conclude that preliminary results suggest that naloxone is well tolerated and beneficial in patients with irritable bowel syndrome and constipation. A larger clinical trial is needed to provide sufficient statistical power to assess efficacy. 4 figures. 2 tables. 29 references.

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Double-Blind Study of Nicardipine in Irritable Bowel Syndrome Source: European Journal of Gastrenterology and Hepatology. 3(2): 181-184. February 1991. Summary: Previous studies have suggested that calcium antagonists inhibit colonic motility and therefore may have therapeutic potential in irritable bowel syndrome (IBS). This article reports on a double-blind cross-over trial of the calcium antagonist nicardipine in 62 patients with IBS. Nicardipine significantly decreased whole gut transit time in constipated patients, but there was no effect on transit time in those with diarrhea, or on those with an alternating bowel habit. However, significant effects on general well-being, abdominal pain, abdominal distension or bowel habit were not observed. The authors conclude that this study suggests that nicardipine does not have a useful therapeutic effect in irritable bowel syndrome. 1 figure. 2 tables. 19 references. (AA-M).

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Irritable Bowel Syndrome and Psychiatric Illness Source: American Journal of Psychiatry. 147(5): 565-572. May 1990. Summary: Psychiatric illnesses such as mood, anxiety, and somatization disorders share many common features with irritable bowel syndrome. The authors of this article review recent developments in the definition of irritable bowel syndrome (IBS) and its relationship to psychiatric illness, discuss the diagnostic validity of IBS from several perspectives, and offer a pathophysiological model of IBS that integrates many of the biological and psychosocial findings of earlier studies. Psychiatric evaluation appears to be an important factor in the diagnosis and treatment of patients with IBS. 1 table. 96 references. (AA).

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Anxiety and the Irritable Bowel Syndrome: Psychiatric, Medical, or Both? Source: Journal of Clinical Psychiatry. 58(supplement 3): 51-61. 1997. Contact: Available from Physicians Postgraduate Press, Inc. P.O. Box 752870, Memphis, TN 38175-2870. Summary: The association between the irritable bowel syndrome (IBS) and psychiatric disorders is well-known to most clinicians, but the nature of the relationship is far from clear. There is an increased prevalence of psychiatric illness in IBS patients and an increase in IBS in psychiatric patients. Whether this association exists outside of treatment-seeking populations (i.e., in people with IBS who do not seek treatment) has not been well investigated. This article selectively reviews the existing literature regarding the association of IBS and psychiatric illness in both patient and nonpatient samples. The author presents a model of the brain-gut interaction, and offers a discussion of the practical implications of this model for treating individuals with IBS. The author considers patients with IBS and general anxiety disorder (GAD), panic disorder, posttraumatic stress disorder (PTSD), social phobia, and mood disorders. The treatment model suggests that, even in patients without psychiatric disorders, neuroactive medications may be a useful tool in improving functioning in individuals whose functional GI disorders have not responded to standard, conservative measures. Appended to the article is a discussion between three physicians on the concepts presented. 2 figures. 2 tables. 51 references. (AA-M).

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Irritable Bowel Syndrome: Managing the Patient With Abdominal Pain and Altered Bowel Habits Source: Medical Clinics of North America. 79(2): 373-390. March 1995. Contact: Available from W.B. Saunders Company, Periodicals Fulfillment, 6277 Sea Harbor Drive, Orlando, FL 32887. (800) 654-2452. Summary: The authors of this article outline the management of the patient with irritable bowel syndrome (IBS), particularly for abdominal pain and altered bowel habits. One goal of the article is to assist the practitioner in reaching a diagnosis of IBS efficiently by using a carefully obtained history, physical examination, and appropriate laboratory tests. The authors also hope to make the practitioner aware of advances in the understanding of pathophysiologic and psychosocial processes in IBS so that treatment may be tailored to an individual patient's needs. Specific topics include epidemiology, pathophysiology, diagnostic tests, and management, particularly the role of a supportive and empathetic physician-patient relationship. 5 tables. 107 references.

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Treatment of Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 16(8): 1395-1406. August 2002. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: The efforts of clinical researchers, lay organizations and pharmaceutical companies have increased the public profile of irritable bowel syndrome (IBS) and made it a respectable diagnosis. Diagnostic symptom criteria encourage a firm clinical diagnosis, which is the foundation of a logical management strategy. This article reviews the treatment of IBS, emphasizing that any plan of patient care begins with education. Reassurance that no structural disease threatens should be tempered with the reality that symptoms are likely to recur over many years. Patients expect diet and lifestyle advice, even if this is not specific to irritable bowel syndrome. Only a few of those with IBS see doctors, and even fewer see specialists. Therefore, the treating physician should ascertain the reason for the visit, the patient's fears and the presence of any comorbid illness, such as depression, that might require treatment in its own right. No drug treatment is useful for all of the symptoms of IBS, and many patients require no drug at all. If used, drugs should target the predominant symptom. Most patients with IBS need psychological support. Reassurance, discussion, and relaxation techniques can be provided by the family doctor. In all cases, successful treatment depends on a confident diagnosis and the strength of the doctor-patient relationship. 1 figure. 3 tables. 100 references.

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Health-Related Quality of Life and Health Care Costs in Severe, Refractory Irritable Bowel Syndrome Source: Annals of Internal Medicine. 134(9 Part 2): 860-868. May 1, 2001. Contact: Available from American College of Physicians. American Society of Internal Medicine. 190 North Independence Mall West, Philadelphia, PA 19106-1572. Website: www.acponline.org. Summary: The irritable bowel syndrome (IBS) may lead to considerable impairment of health related quality of life (HRQOL) and high health care costs. It is not clear whether these poor outcomes directly result from severe bowel symptoms or if they reflect a

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coexisting psychiatric disorder. This article reports on a study undertaken to determine whether bowel symptom severity and psychological symptoms directly influence HRQOL and health care costs. The cross sectional survey took place at secondary and tertiary gastroenterology clinics and included 257 patients with severe IBS who did not respond to usual treatments and who were recruited for a trial of psychological treatment. Predictors were abdominal pain, entries in a diary of 10 IBS symptoms, and measures of psychological symptoms. Outcomes were inability to work, HRQOL, and health care and productivity costs. Abdominal pain occurred on average 24 days per month and activities were restricted on 145 days of the previous 12 months. The mean Hamilton depression score was 11.3 plus or minus 6.1. The physical component summary score was low and the patients had incurred high health care costs over the previous year. Global severity and somatization scores on the Symptom Checklist, abdominal pain, and Hamilton depression scores independently contributed to the physical component score, but only psychological scores were associated with disability due to ill health. These variables did not accurately predict health care or other costs. History of sexual abuse was not an independent predictor of outcome. The authors conclude that both abdominal and psychological symptoms are independently associated with impaired health related quality of life in patients with severe IBS. Optimal treatment is likely to require a holistic approach. Since health care and loss of productivity costs are not clearly associated with these symptoms, alleviation of them will not necessarily lead to reduced costs. 2 figures. 3 tables. 28 references. •

Irritable Bowel Syndrome in Twins: Heredity and Social Learning Both Contribute to Etiology Source: Gastroenterology 121(4): 799-804. October 2001. Contact: Available from W.B. Saunders Company. 6277 Sea Harbor Drive, Orlando, FL 32887-4800. (800) 654-2452. Website: www.gastrojournal.org. Summary: The irritable bowel syndrome is a chronic functional gastrointestinal disorder characterized by abdominal discomfort or pain that beings with a change in the frequency or consistency of stool (diarrhea or constipation), that is relieved by defecation, and that is present in the absence of other diseases that could explain the symptoms. Heredity has been suggested to explain the finding that irritable bowel syndrome (IBS) tends to run in families. This article reports on a study undertaken to assess the relative contribution of genetic and environmental (social learning) influences on the development of IBS by comparing concordance rates in monozygotic (identical) and dizygotic (fraternal) twins to concordance between mothers and their children. Questionnaires soliciting information on the occurrence of more than 80 health problems, including IBS, in self and other family members were sent to both members of 11,986 twin pairs. The authors' analysis is based on 10,699 respondents representing 6,060 twin pairs. Concordance for IBS was significantly greater in monozygotic (17.2 percent) than in dizygotic (8.4 percent) twins, supporting a genetic contribution to IBS. However, the proportion of dizygotic twins with IBS who have mothers with IBS (15.2 percent) was greater than the proportion of dizygotic twins with IBS who have co-twins with IBS (6.7 percent). Logistic regression analysis showed that having a mother with IBS and having a father with IBS are independent predictors of irritable bowel status; both are stronger predictors than having a twin with IBS. Addition of information about the other twin accounted for little additional predictive power. The authors conclude that heredity contributes to development of IBS, but social learning (what an individual learns from those in his or her environment) has an equal or greater influence. 1 figure. 2 tables. 18 references.

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Review Article: An Integrated Approach to the Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 13(Supplement 2): 3-14. May 1999. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: The medical understanding of the pathophysiology of irritable bowel syndrome (IBS) has evolved from a motility disorder to a more integrated understanding of enhanced motility and visceral hypersensitivity associated with brain gut dysfunction. This article reviews recent work that supports an integrated approach to managing IBS. Psychosocial factors contribute to the predisposition, precipitation, and perpetuation of IBS symptoms and affect the clinical outcome. Newer brain imaging techniques (MRI, PET) may help physicians understand the relationship between altered emotional states with pain enhancement and other gastrointestinal symptoms. The author recommends diagnosis using symptom based (e.g., Rome) criteria and a conservative approach. A careful history will identify the need for diagnostic studies and treatments as determined by the nature and severity of the predominant symptoms. Treatment is based on an effective relationship between physician and patient and a combined pharmacologic and behavioral approach. For most patients with mild symptoms, dietary and lifestyle changes are usually sufficient for treatment. Newer medications acting at the 5-HT receptor may help reduce pain and bowel dysfunction. For more severe pain, antidepressants may be considered. 1 figure. 2 tables. 90 references.

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Long-term Safety of Tegaserod in Patients with Constipation-Predominant Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 16(10): 1701-1708. October 2002. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: The oral administration of the drug tegaserod causes gastrointestinal (GI) effects resulting in increased gastrointestinal motility (movement of contents through the GI tract) and attenuation of visceral sensation. This article reports on a study undertaken to determine the long term safety and tolerability of tegaserod in patients with irritable bowel syndrome (IBS) with constipation as the predominant symptom of altered bowel habits. The multicenter, open label study included 579 patients. Of these, 304 (53 percent) completed the trial. The most common adverse events, classified as related to tegaserod for any dose, were mild and transient diarrhea (10.1 percent), headache (8.3 percent), abdominal pain (7.4 percent), and flatulence (5.5 percent). Forty serious adverse events were reported in 25 patients (4.4 percent of patients) leading to discontinuation in 6 patients. There was one serious adverse event, acute abdominal pain, classified as possibly related to tegaserod. There were no consistent differences in adverse events between patients previously exposed to tegaserod and those treated for the first time in this study. The authors conclude that tegaserod appears to be well tolerated in the treatment of patients with constipation-predominant IBS. The adverse event profile, clinical laboratory evaluations, vital signs, and electrocardiogram recordings revealed no evidence of any unexpected adverse events, and suggest that treatment is safe over a 12 month period. 1 figure. 4 tables. 23 references.

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Diet and the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 313-324. June 1991. Summary: There is a prevailing patient perception that diet plays a key role in precipitating or perpetuating symptoms of irritable bowel syndrome (IBS). This article provides dietary information for the physician treating patients with IBS. The author focuses special attention on diagnostic and therapeutic suggestions directed toward reducing the intensity and frequency of symptoms. Topics covered include diagnostic considerations; lactose intolerance; fructose intolerance; sorbitol intolerance; and dietary considerations in functional gastrointestinal disorders including the esophagus, gastricduodenum, small bowel, colonic motor dysfunction and gas syndrome. 29 references.

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New Directions in the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 335-349. June 1991. Summary: This article about irritable bowel syndrome (IBS) focuses on possible subgroups of IBS and methods of diagnosis and treatment. The authors discuss treatments of IBS based on motility disturbances, psychologic problems, dietary intolerance, hormonal imbalance, and the effects of peptides such as cholecystokinin (CCK) and motilin. The authors note that future directions for psychologic treatment of IBS will likely depend on further investigation of the relative importance of psychologic factors in the etiology of and patient response to IBS. 349 references.

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Treatment of the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 325-333. June 1991. Summary: This article addresses treatment issues in the management of irritable bowel syndrome (IBS). The author stresses that although there is not a specific agent to treat IBS, once organic illness has been ruled out, a basis for therapy options can be formulated. Topics covered include psychologic factors, including stress, anxiety, depression, and the use of anti-anxiety agents; the use of antidepressant agents; anticholinergic medications; food-related factors, including gas-related agents; the treatment of functional constipation; treatment of diarrhea; and the role of the physician-patient relationship. The author concludes that careful, continued follow-up assessment of therapeutic endeavors, a sincere interest in the patient's concerns, and surveillance for intercurrent organic illness are the basics of complete ongoing care. 2 tables. 31 references.

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Irritable Bowel Syndrome: A Quick Review of a Common GI Problem Source: IM. Internal Medicine. 19(8): 24-25. August 1998. Contact: Available from Medical Economics. 5 Paragon Drive, Montvale, NJ 07645. (800) 432-4570. Summary: This article briefly brings readers up-to-date on the diagnosis and treatment strategies used for irritable bowel syndrome (IBS). IBS is a functional disorder of the gastrointestinal tract that occurs in 10 to 22 percent of adults. The most common symptoms are abdominal pain and altered bowel habits, including diarrhea or constipation or a combination of the two. The author discusses pathophysiology, the criteria for confirming a diagnosis of IBS, laboratory tests that may contribute to this diagnosis of exclusion, and treatment options. Criteria for confirming a diagnosis require that symptoms be present for at least 3 months. Management begins with the

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need for the physician to establish a therapeutic relationship. Because of their safety and frequent placebo effect, a trial of fiber supplements is reasonable in all patients with IBS. The author discusses the treatments for patients in whom diarrhea predominates; those in whom pain, gas, and bloating predominate; and those in whom constipation is the primary problem. The author notes that, in all cases of IBS, regardless of the predominating symptom, the use of antidepressants, anxiolytics, and psychotherapy may be indicated for patients with associated affective disorders. 1 figure. 4 references. •

Mental Medicine for Irritable Bowel Syndrome: Treatment Approaches for IBS Source: Mental Medicine Update. 1(1): 4-5. Spring-Summer 1992. Contact: Available from Center for Health Sciences, ISHK. P.O. Box 176, Los Altos, CA 94023. (415) 948-9428. Summary: This article brings readers up-to-date on irritable bowel syndrome (IBS). Topics include the symptoms of IBS; the role of stress and other psychosocial factors; and treatment modalities, including medical treatments, diet therapy, and psychological techniques for managing stress. Techniques covered in the latter section include the use of a symptom diary, relaxation techniques, psychotherapy, and hypnosis. The article concludes with a list of six references for readers who wish to obtain more information about IBS.

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Irritable Bowel Syndrome Defined by Factor Analysis: Gender and Race Comparisons Source: Digestive Diseases and Sciences. 40(12): 2647-2655. December 1995. Summary: This article describes a study to examine the applicability across subgroups of the Manning criteria commonly used to diagnose the irritable bowel syndrome (IBS). A 22-item symptom questionnaire was administered to male and female African-American and Caucasian adults (n=1344). Consistent with the findings of a previous factor analytic study, three of the six Manning symptoms (loose stools and more frequent bowel movements with onset of pain, pain relieved by defecation) formed a cluster corresponding to the IBS in all subgroups. The researches conclude that the three core Manning symptoms have equal applicability to both genders and to African-Americans as well as to Caucasians. They are useful symptoms criteria for the diagnosis of IBS when used in conjunction with medical evaluation. 1 figure. 2 tables. 18 references. (AAM).

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Diagnosis and Treatment of Irritable Bowel Syndrome Source: American Family Physician. 55(3): 875-880. February 15, 1997. Summary: This article discusses the diagnosis and treatment of irritable bowel syndrome (IBS), a common disorder characterized by symptoms of abdominal pain with diarrhea and or constipation. IBS is associated with significant disability and health care costs. The authors advocate a practical approach to diagnosis utilizing the symptombased Rome criteria. Management of patients has been helped by recent findings relating to the pathophysiology of the disorder. Dysregulation of intestinal motor functions, sensory functions and central nervous system functions is currently believed to be the basis for IBS symptoms. Symptoms are a result of both abnormal intestinal motility and enhanced visceral sensitivity. Psychosocial factors can affect the illness experience and the clinical outcome. The authors stress that an effective physicianpatient relationship is required for a successful outcome. Individualized treatment

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involves an integrated pharmacologic and behavioral approach determined by the predominant symptom type, the severity of the symptoms, and the degree of disability. 5 tables. 11 references. (AA). •

Diagnostic Evaluation of the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 269-278. June 1991. Summary: This article explores the diagnostic evaluation of Irritable Bowel Syndrome (IBS), one of the most common of all gastrointestinal disorders. Topics include a definition of IBS; diagnostic accuracy; historical features, including pain, altered bowel habits, distention, and extracolonic and extraintestinal symptoms; significant clinical features, physical findings, and laboratory features; and a philosophy of diagnosis as it applies to IBS. 4 tables. 35 references.

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Ileocecal Area and the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 297-311. June 1991. Summary: This article focuses on irritable bowel syndrome (IBS) and the ileocecal area, or the ileocolonic junction (ICJ). Topics covered include a summary of the normal physiology of the region; the symptoms of IBS; the role of altered functions of the distal small bowel-proximal colon in IBS; the role of ileal and colonic contractions; regulation of the motility of the ICJ; motility-transit relationships; and IBS as a grouping of symptoms that fulfill at least three of the Manning criteria. The author conclude that the ICJ, lying as it does at the gateway between the absorptive regions of the small intestine and the storage and excretory regions of the colon, may be important in the pathophysiology of pain, bloating, and altered bowel movements in patients with IBS. 8 figures. 52 references.

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Irritable Bowel Syndrome: A Cost-Effective Approach for Primary Care Physicians Source: Postgraduate Medicine. 101(3): 215-216, 219, 220, 223-226. March 1997. Summary: This article outlines for primary care physicians a cost-effective approach to patients with irritable bowel syndrome (IBS). IBS is a symptom complex of altered bowel habits, abdominal discomfort, and the absence of detectable organic disease. The author stresses that the key to cost-effective management is identification of the characteristic symptom pattern. Topics include pathophysiologic factors, clinical features, diagnosis, treatment options, medications commonly used to treat IBS, and medications currently being developed that may be of use in IBS. The author stresses that patient education and reassurance about the benign course of the disease are important aspects of effective treatment. 1 figure. 2 tables. 20 references. (AA-M).

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Interventions for Irritable Bowel Syndrome: A Nursing Model Source: Gastroenterology Nursing. 18(6): 224-230. November-December 1995. Contact: Available from Williams and Wilkins. 351 West Camden Street, Baltimore, MD 21201-2436. (800) 638-6423 or (410) 528-8555. Summary: This article presents a nursing model for interventions for irritable bowel syndrome (IBS). Using the Human Response Model, the authors review intervention studies for IBS. The model provides a context for integration of Person (vulnerability) and Environment (risk) factors that may modify the patient's response to a given therapeutic regimen. Human responses are categorized as Physiological,

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Pathophysiological, and Behavioral/Experiential. The authors discuss interdisciplinary therapeutic strategies including modility manipulations via pharmacological agents, dietary modifications, and self-care enhancement. Areas for nursing research are also described. 1 figure. 1 table. 34 references. (AA-M). •

Roundtable Conference on Irritable Bowel Syndrome, Part I Source: Practical Gastroenterology. 16(8): 12, 14-18, 21. September 1992. Summary: This article presents an edited transcript of a videotaped roundtable conference on irritable bowel syndrome (IBS) sponsored by Schwarz Pharma that took place in Chicago on June 13, 1992. Roundtable participants were Marshall Sparberg; Gerald Friedman; Norton Greenberger; Marvin Schuster; and William Snape. Topics include a definition of IBS; symptoms; etiology of IBS; the emotional components of IBS; extraintestinal manifestations of IBS; the interrelationship of IBS with menstruation and with diet; foods that may trigger, perpetuate, or accentuate IBS symptoms; the importance of a food diary in diagnosis and management of IBS; lactose sensitivity; dietary fiber; the use of psyllium products; bowel motility and dietary fat; motor dysfunctions in IBS; pain in IBS; and functional versus organic disease. 10 references.

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American Gastroenterological Association Medical Position Statement: Irritable Bowel Syndrome Source: Gastroenterology. 112(6): 2118-2119. June 1997. Summary: This article presents guidelines to help physicians in the diagnosis and management of patients with irritable bowel syndrome (IBS). These guidelines were developed from a comprehensive review of the medical literature pertaining to IBS. The IBS is a combination of chronic or recurrent gastrointestinal (GI) symptoms not explained by structural or biochemical abnormalities, which is attributed to the intestines and associated with symptoms of pain and disturbed defecation and or symptoms of bloating and distension. The authors note that psychological stress exacerbates GI symptoms in everyone, but to a greater degree in patients with IBS. IBS adversely affects health-related quality of life, including impairment of physical and psychosocial function, disability, work absenteeism, and physician visits. A physical examination and the following studies are recommended for routine evaluation: complete blood count; sedimentation rate; chemistries; stool for ova, parasites, and blood; and flexible sigmoidoscopy or colonoscopy or barium enema with sigmoidoscopy if older than 50 years. The treatment strategy is based on the nature and severity of the symptoms, the degree of physiological disturbance and functional impairment, and the presence of psychosocial difficulties affecting the course of the illness. Patients with mild symptoms usually respond to education and reassurance and simple treatments not requiring prescription medication. A smaller proportion of patients with moderate symptoms have more disability and require pharmacological treatments directed at altered gut physiology or psychological treatments. 1 table. 1 reference. (AA-M).

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Roundtable Conference on Irritable Bowel Syndrome, Part II Source: Practical Gastroenterology. 16(9): 30-39. October 1992. Summary: This article presents the second part of a videotaped conference on irritable bowel syndrome (IBS) that took place in Chicago in June 1992. Topics include the symptom of painless diarrhea; the role of fatty acids; the causes of constipation; hypersensitivity of the smooth muscle of the rectum and colon; colonic motility;

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problems with excessive gas, including classification, etiology, and treatment; dealing with aerophagic patients ('air swallowers'); the role of biofeedback and other behavioral therapies; handling patients who have excessive bloating; problems with excessive rectal gas, including excessively odorous rectal gas; the role of rice and rice products in the diet; medical history and physical examination; and diagnostic tests used after the determination of IBS. 3 figures. 7 references. •

Challenge of Irritable Bowel Syndrome Source: American Family Physician. 53(4): 1229-1236. March 1996. Summary: This article provides general practitioners with an overview of irritable bowel syndrome (IBS), a common disorder with symptom complexes that can include diarrhea, constipation, pain, and bloating. Topics include epidemiology, pathophysiology, diagnosis and diagnostic criteria, treatment options, and the course to follow when initial treatment fails. Treatments include the use of dietary fiber, addressing the psychological factors involved, a bowel-training regimen, diet therapy, antispasmodic drugs, and antidepressants. The authors stress the importance of a supportive professional-patient relationship in treating patients with IBS. 4 tables. 52 references.

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Health-Related Quality of Life Among Persons With Irritable Bowel Syndrome: A Systematic Review Source: Alimentary Pharmacology and Therapeutics. 16(6): 1171-1185. June 2002. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: This article reports on a literature review undertaken with three objectives: to compare the health related quality of life (HRQoL) of patients with irritable bowel syndrome (IBS) with that of health controls; to compare the HRQoL of irritable bowel syndrome patients to those with other diseases; and to examine therapy-associated changes in HRQoL of IBS patients. Searches of all English and non English articles from 1980 to 2001 were performed in MEDLINE and EMBASE and two investigators performed independent data abstraction. Seventeen articles met the selection criteria. Thirteen studies addressed objective number one; 11 of these studies showed a significant reduction in HRQoL among IBS patients. Of these, only one study was considered of high quality. Four studies addressed objective number two, none of which was considered to be high quality in addressing this objective. Four trials (three of high quality) addressed objective number three. One of these showed that symptomatic improvement with Leupron compared to placebo was accompanied by an improvement only in the comparative health domain of the HRQoL. The second study reported significant positive changes in HRQoL after 12 weeks of cognitive behavioral therapy. The third report of two placebo controlled studies indicated significant improvement with alosetron on most domains of IBS quality of life assessment instruments. The authors conclude that there is reasonable evidence for a decrease in HRQoL in patients with moderate to severe IBS. HRQoL in IBS patients is impaired to a degree comparable to other chronic disorders such as GERD and depression. A therapeutic response in IBS related pain has a corresponding improvement in HRQoL. 4 tables. 34 references.

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Office-Based Physician Visits: A Comparison of Irritable Bowel Syndrome with Other Gastrointestinal Disorders Using National Ambulatory Medical Care Survey Data Source: Practical Gastroenterology. 26(9): 58, 60-62, 65-66, 68. September 2002. Contact: Available from Shugar Publishing. 12 Moniebogue Lane, Westhampton Beach, NY 11978. (516) 288-4404. Fax (516) 288-4435. Summary: This article reports on a study in which National Ambulatory Medical Care Survey data were used to compare health care resource utilization and frequency of physician visits for irritable bowel syndrome (IBS) with other functional and organic gastrointestinal (GI) disorders. IBS accounted for more than four million ambulatory office visits between 1997 and 1999. A substantial proportion of these IBS visits were by female patients, and a high percentage of the visits were to a gastroenterologist. IBS visits frequently included diagnostic or screening tests and mentions of medications. This evidence suggests that patients with IBS require considerable medical attention, which incurs substantial costs. The emergence of effective medications, as well as education of both patients and providers, may reduce resource utilization associated with IBS and facilitate the delivery of quality health care to patients. 4 figures. 3 tables. 9 references.

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Sleep Disturbance Influences Gastrointestinal Symptoms in Women with Irritable Bowel Syndrome Source: Digestive Diseases and Sciences. 45(5): 952-959. May 2000. Contact: Available from Kluwer Academic/Plenum Publishers. 233 Spring Street, New York, NY 10013-1578. (212) 620-8000. Fax (212) 807-1047. Summary: This article reports on a study that evaluated the association between sleep disturbance and gastrointestinal symptoms in women with and without irritable bowel syndrome (IBS). The study also examined the role of psychological distress in this relationship. Women with IBS (n = 82) reported considerably higher levels of sleep disturbance compared with controls (n = 35), using both retrospective 7 day recall and daily diary recall for two menstrual cycles. The authors used daily diary data to estimate the association between sleep disturbance and gastrointestinal symptoms, both across women (i.e., whether women with high average sleep disturbance have higher average gastrointestinal symptoms) and within women (i.e., whether poorer than average sleep on one night is associated with higher than average gastrointestinal symptoms the following day). The regression coefficients for the across women effect are large and highly significant in both groups. The regression coefficients for the within woman effect are considerably smaller and statistically significant only in the IBS group. These regression coefficients showed little change when daily psychological distress or stress was controlled for, the one exception being the coefficient for the across women effect in the IBS group, which decreased substantially but still remained highly significant. Because it is possible that gastrointestinal symptoms could, in fact, cause poor sleep, the authors also fitted the temporally reversed model to evaluate the association between gastrointestinal symptoms on one day and sleep disturbance that night. The authors conclude that their results are consistent with the hypothesis that poor sleep leads to higher gastrointestinal symptoms on the following day among women with IBS. 1 figure. 2 tables. 41 references.

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Abdominal Pain and Irritable Bowel Syndrome in Adolescents: A Community-Based Study Source: Journal of Pediatrics. 129(2): 220-226. August 1996. Summary: This article reports on a study to determine the prevalence of gastrointestinal (GI) symptoms, including abdominal pain in a community-based population of adolescents; whether a subgroup of these subjects have symptoms resembling irritable bowel syndrome (IBS); and whether anxiety and depression are more commonly found in adolescents with IBS-type symptoms compared with unaffected adolescents. The study included 507 subjects; abdominal pain was noted by 75 percent of all students. The pain occurred weekly in 13 to 17 percent of the subjects and was severe enough to affect activities in approximately 21 percent. IBS-type symptoms were noted by 17 percent of high school students and 8 percent of middle school students who reported abdominal pain. Anxiety and depression scores were significantly higher for students with IBS-type symptoms compared with those without symptoms. Eight percent of all students had seen a physician for abdominal pain in the previous year. These visits were correlated with abdominal pain severity, frequency, duration, and disruption of normal activities but not with anxiety, depression, gender, family structure, or ethnicity. 3 tables. 23 references. (AA-M).

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Pharmacologic Treatment of the Irritable Bowel Syndrome: A Systematic Review of Randomized, Controlled Trials Source: Annals of Internal Medicine. 133(2): 136-147. July 18, 2000. Contact: Available from American College of Physicians. American Society of Internal Medicine. 190 North Independence Mall West, Philadelphia, PA 19106-1572. Website: www.acponline.org. Summary: This article reports on a study undertaken to evaluate the efficacy of pharmacologic agents (drugs) for irritable bowel syndrome (IBS). The study featured an electronic literature search (1966 to 1999) and a manual search of references from bibliographies of identified articles. Studies chosen for inclusion were randomized, double blind, placebo controlled, parallel or crossover trials of a pharmacologic intervention for adult patients; the studies had to report outcomes of improvement in global or IBS specific symptoms. Seventy studies met the inclusion criteria. The most common medication classes were smooth muscle relaxants (16 trials), bulking agents (13 trials), prokinetic agents (6 trials), psychotropic agents (7 trials), and loperamide (4 trials). The strongest evidence for efficacy was shown for smooth muscle relaxants in patients with abdominal pain as the predominant symptom. Loperamide seems to reduce diarrhea but does not relieve abdominal pain. Although psychotropic agents were shown to produce global improvement, the evidence is based on a small number of studies of suboptimal quality. Other treatment options, including psychotropic drugs, 5 hydroxytryptamine (5 HT) receptor antagonists, peppermint oil, and Chinese herbal medicine, require further study. 3 tables. 109 references.

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Management of Irritable Bowel Syndrome: A European, Primary and Secondary Care Collaboration Source: European Jounral of Gastroenterology and Hepatology. 13(8): 933- 939. August 2001. Contact: Available from Rapid Science Publishers. 400 Market Street, Suite 750, Philadelphia, PA 19106. (800) 552-5866 or (215) 574-2210.

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Summary: This article reports on the development of recommendations for the diagnosis and management of irritable bowel syndrome (IBS) for European doctors delivering primary medical care. These recommendations can be adapted by local medical groups according to their language, custom, and health care systems. The workshop, planned by a steering committee, was attended by 21 general practitioners and gastroenterologists from Europe. After a state of the art symposium, four working groups considered the following aspects of IBS management: what to tell the patient, diagnosis, non medical treatment, and psychosocial management. Current and future drug management was reviewed by the steering committee. The process permitted a unique dialog between general practitioners and gastroenterologists, in which it was necessary to reconcile the specialists' emphasis on thoroughness with the practical, epidemiological, and economic realities of primary care. The recommendations emphasize education of the patient, a positive symptom based diagnosis, dietary and lifestyle advice, psychological support, and a critical analysis of current specific psychological and pharmacological (drug) treatments. Patient education should be tailored to the patient's ideas, fears and expectations and should take into account their understanding of their IBS symptoms. The information can include the following elements: the symptoms are real, not imagined or merely psychological; IBS is chronic and fluctuates in severity and duration; factors that trigger symptoms are multiple and vary among patients and over time; the mind-gut link explains how stress, emotions, perceptions and thoughts can affect the symptoms; and the symptoms are not life threatening. The recommendations remind readers that some symptoms cannot be explained by IBS and should trigger further diagnosis; these include: fever, anemia, bleeding from the gut, significant weight loss, family history of cancer or inflammatory bowel disease, recent change in bowel habit, over 45 years of age, and physical findings (e.g., an abdominal mass). 2 tables. 48 references. •

Roundtable Conference on Irritable Bowel Syndrome, Part III Source: Practical Gastroenterology. 16(10): 20, 23-26, 28. November/December 1992. Summary: This article reprints part of an edited transcript of a videotape conference on irritable bowel syndrome (IBS) sponsored by Schwarz Pharma, that took place in Chicago in June 1992. Topics include dietary recommendations for patients with IBS; the role of dietary habits, including the aesthetics of mealtime; the role of stress; the link between anorexia nervosa and delayed gastric emptying; psychological factors that impact the motor function of the gastrointestinal tract; the use of anticholinergic medication; other medications used to treat IBS; timing of the dosing for IBS; sublingual administration of medications; the side effect of xerostomia; the importance of tailoring drug therapy for each individual with IBS; the emotional components of IBS; the role of sedatives or tranquilizers in IBS therapy; the effect of the menstrual cycle on symptoms of IBS; and the recent advances related to IBS. 5 references.

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Review Article: Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 11(1): 3-15. February 1997. Contact: Available from Mercury Airfreight International, Ltd. 2323 EF, Randolph Avenue, Avenel, NJ 07001. E-mail: [email protected]. Summary: This article reviews current knowledge on irritable bowel syndrome (IBS), the most common disease diagnosed by gastroenterologists and one that affects about 20 percent of all people at any one time. IBS can be diagnosed positively on the basis of an established series of criteria and limited exclusion of organic disease. Symptoms

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fluctuate, and the overall prevalence rate is relatively constant in Western communities. Ten percent of patients present to their physicians. The illness has a large economic impact on health care utilization and absenteeism. IBS is a biopsychosocial disorder in which three major mechanisms interact: psychosocial factors, altered motility, and or sensory function of the intestine. Management of patients is based on positive diagnosis of the symptom complex, limited exclusion of underlying organic disease, and institution of a therapeutic trial. If patient symptoms are intractable, further investigations are needed to exclude significant motility or other disorders. Symptomatic treatment includes fiber for constipation, loperamide for diarrhea, and low-dose antidepressants or infrequent use of antispasmodics for pain. The authors note that new pharmacological agents, psychotherapy, and hypnotherapy are being evaluated for their use in treating IBS. 5 figures. 6 tables. 109 references. (AA-M). •

Evolving Concepts in Irritable Bowel Syndrome Source: Current Opinion in Gastroenterology. 15(1): 16-21. January 1999. Contact: Available from Lippincott Williams and Wilkins Publishers. 12107 Insurance Way, Hagerstown, MD 21740. (800) 637-3030. Fax (301) 824-7390. Summary: This article reviews recent research in irritable bowel syndrome (IBS). The authors note that converging evidence from investigations of the peripheral and central aspects of bidirectional brain gut interactions is beginning to shape a pathophysiological model of IBS and related functional gastrointestinal (GI) disorders. This neurobiological model includes alterations in autonomic, neuroendocrine, and pain modulatory mechanisms. The frequent association of IBS and other functional GI disorders with comorbid affective disorders and the temporal association of symptom exacerbation with psychosocial or physical stressors are consistent with alterations in the neurobiological mechanisms underlying the central stress response. The author discusses work in the area of alterations in central nervous system responses of the brain, neuroendocrine responses, autonomic dysfunction, and altered viscerosomatic sensitivity; peripheral modulators of visceral sensitivity; symptom based diagnosis; and affective disorders and psychosocial stressors. Depression and anxiety are the most common comorbid affective disorders in IBS. Classification of functional disorders according to these evolving biological markers holds the promise of a rational treatment design for subgroups of patients in the future. Renewed interest in drug development for IBS treatment has resulted in the development of diagnostic instruments for assessing the impact of symptoms on quality of life and in the development of compounds (drugs) undergoing clinical evaluation. 53 references (16 annotated).

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Psychologic Considerations in the Irritable Bowel Syndrome Source: Gastroenterology Clinics of North America. 20(2): 249-267. June 1991. Summary: This article reviews recent studies regarding the psychological considerations in the irritable bowel syndrome (IBS). Topics covered include the self-selection hypothesis; diagnostic criteria; the psychologic symptoms and personality traits associated with IBS; learned illness behavior; the role of psychologic stress; psychologic treatment of IBS, including education and reassurance, managing fears and misconceptions, and scheduling return appointments; the use of antidepressant medications; and the role of psychotherapy, including behavior therapy and hypnosis. The authors conclude that psychologically-oriented treatments have a role in the management of IBS, even in patients who do not have a psychiatric disorder. 5 figures. 1 table. 51 references.

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Irritable Bowel Syndrome: A Continuing Dilemma Source: Gastroenterology Clinics of North America. 20(2): 363-367. June 1991. Summary: This article summarizes some of the dilemmas surrounding the diagnosis and treatment of the irritable bowel syndrome (IBS). The authors discuss the classification of IBS; the diagnostic challenge of demonstrating absence of organic disease; and therapeutic dilemmas including dietary adjustments, drug therapy, and limiting the diagnostic tests performed. The article serves as a concluding summary to a series of articles in this issue devoted to IBS. 34 references.

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OTC Therapy of the Irritable Bowel Syndrome Source: U.S. Pharmacist. 15(8): 43-48. August 1990. Summary: This article was written to help pharmacists understand irritable bowel syndrome (IBS). The author notes that although the exact cause of IBS is still unknown, the symptoms may be treated by psychotherapy, changes in diet, and drug therapy. Possible causes of IBS are discussed, including food, drugs, dysentery, and stress. The use of fiber, simethicone, and/or lactase replacement as methods of treatment are discussed. Two sidebars present patient information on the proper use of over-thecounter fiber supplements and relieving IBS. References are available on request. 1 table.

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Questions and Answers: Food Allergy and Irritable Bowel Syndrome; Elective Appendectomy During Abdominal Surgery Source: JAMA. Journal of American Medical Association. 265(13): 1736, 1738. April 3, 1991. Summary: This brief article, one of a regular series of questions and answers, addresses two issues of interest to digestive diseases professionals. The first exchange discusses the possible role of food allergy in triggering or exacerbating irritable bowel syndrome (IBS). The responding author discusses the difference between food allergy and IBS, mentions research support for this hypothesis, and concludes that food allergy as a contributing factor in the pathogenesis of IBS is valid. The second exchange involves elective appendectomy during abdominal surgery. The responding author notes that there is little, if any, morbidity and that there is apparent benefit gained from incidental appendectomies, provided certain contraindications are taken into account. 7 references.

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Consensus Report: Clinical Perspectives, Mechanisms, Diagnosis and Management of Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 16(8): 1407-1430. August 2002. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: This consensus document reviews the current status of the epidemiology, social impact, patient quality of life, pathophysiology, diagnosis, and treatment of irritable bowel syndrome (IBS). Current evidence suggests that two major mechanisms may interact in IBS: altered gastrointestinal motility and increased sensitivity of the intestine. However, other factors, such as psychosocial factors, intake of food, and prior infection, may contribute to its development. Management of patients is based on a positive diagnosis of the symptom complex, careful history and physical examination to exclude risk factors for organic disease, and, if indicated, investigations to exclude other

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disorders. Treatment choices include dietary fiber for constipation, opioid agents for diarrhea, and low-dose antidepressants or infrequent use of antispasmodics for pain, although the evidence basis for efficacy is limited or in some cases absent. Psychotherapy and hypnotherapy are the subject of ongoing study. Treatment should be tailored to patient needs and fears. Patient and physician education, early identification of psychosocial issues, and better therapies are important strategies to reduce the suffering and societal cost of IBS. 2 figures. 9 tables. 236 references. •

'It's Not All in Your Head': Irritable Bowel Syndrome Source: AJN. American Journal of Nursing. 101(1): 26-34. January 2001. Contact: Available from Lippincott Williams and Wilkins. AJN, P.O. Box 50480, Boulder, CO 80322-0480. (800) 627-0484 or (303) 604-1464. Summary: This continuing education article reviews the nursing care for patients with irritable bowel syndrome (IBS). The authors note that it is now believed that IBS has a basis in visceral hypersensitivity (of the bowel wall) and abnormal gut motor function, possibly caused by anomalies in the gut brain connection. The syndrome is neither life threatening nor associated with the development of gastrointestinal diseases such as cancer, but IBS accounts for a significant number of medical visits and prescribed medications, as well as lost work time and reduced productivity. The syndrome tends to manifest with either diarrhea or constipation or with an alternating pattern of the two. Other common symptoms include mucus in the stool, a sensation of incomplete evacuation, looser or more frequent stools with pain, and relief of abdominal pain after defecation. It has been postulated that there are differences related to sex in motility patterns, symptom and psychological profiles, pain sensitivity, and access to health care. No one factor appears to be responsible for the symptoms in all patients with IBS. Diet, stressful events, and psychological distress may also exacerbate symptoms in vulnerable patients. Diagnosis of IBS occurs by exclusion; there is no biologic marker. Therapy usually focuses on the patient's predominant symptoms and can include patient education and reassurance, nonpharmacologic interventions, and pharmacologic (drug) interventions. One sidebar explores the connection between emotional (sexual) abuse and IBS, notably assessing the effect of self blame and self silencing. A posttest for receiving continuing education credits is appended to the article. 3 figures. 1 table. 50 references.

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Treatment of Irritable Bowel Syndrome: New Approaches for a New Century Source: Practical Gastroenterology. 25(8): 13-14. August 2001. Contact: Available from Shugar Publishing. 12 Moniebogue Lane, Westhampton Beach, NY 11978. (516) 288-4404. Fax (516) 288-4435. Summary: This editorial serves as an introduction to a series of articles on irritable bowel syndrome (IBS). The authors note that major events have occurred in the last five years that demonstrate the role of heightened sensation to visceral pain in patients with IBS. This work has been followed by a rapidly enlarging body of knowledge using PET scanning and functional MRI imaging to detect alterations in brain activation in IBS patients. The authors emphasize that IBS does not occur in a biological vacuum, i.e., patients who seek treatment for IBS are more psychologically disturbed than patients with IBS who do not choose to seek medical care, and patients with functional GI disorders are more likely to have suffered physical or sexual abuse than patients with structurally originated GI conditions. It has become clear that gender, psychosocial trauma, concomitant psychiatric disorders, and a patient's health beliefs all can influence

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the acceptance of, adherence to, and improvement on a treatment regimen for IBS. The development of psychotherapeutic approaches, improvements in our understanding of the impact of gender and family history on treatment response, and the importance of screening for psychological disorders and psychosocial stress are all now recognized as key elements of optimal treatment. The series of articles (published in the same journal issue) reviews recent developments in the treatment of IBS using serotonergically active agents, antidepressants and antispasmodics, as well as the psychosocial dimensions that have an impact on optimal care of patients with IBS. 4 references. •

Irritable Bowel Syndrome: Simple Measures Often Relieve Symptoms Source: Mayo Clinic Health Letter. 10(12): 1-3. December 1992. Summary: This patient education article provides basic information about irritable bowel syndrome (IBS). Written in a question-and-answer format, the article covers topics including a definition of IBS; typical symptoms; and treatment options, including diet therapy and drug therapy. The author concludes that, with help from a physician and/or dietitian, patients can adopt diet and lifestyle changes that can help keep symptoms in check, usually without medication. 1 figure.

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Management of Irritable Bowel Syndrome Source: Journal of Gastroenterology and Hepatology. Volume 8: 287-293. 1993. Summary: This review article discusses recent advances in the understanding of irritable bowel syndrome (IBS) that may help the clinician design a more effective management plan. Topics include the symptom complexes that constitute IBS; the objective measurement of patient symptoms; specific intestinal motor abnormalities that may exist in patients with IBS; abnormalities in visceral perception in IBS; the role of behavioral factors in IBS; the initial patient approach and management of mild to moderate symptoms; the role of dietary manipulation, explanation and reassurance, medications, and behavioral therapy; managing patients in whom symptoms are severe and intractable; and priorities for future work in this area. 3 figures. 2 tables. 10 references.

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Review Article: Clinical Evidence to Support Current Therapies of Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 13(Supplement 2): 48-53. May 1999. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: This review article summarizes the clinical evidence to support current therapies in irritable bowel syndrome (IBS). In patients with constipation predominant IBS, fiber is indicated at a dose of at least 12 grams per day. Loperamide (and probably other opioid agonists) are of proven benefit in diarrhea predominant IBS; loperamide may also aid continence by enhancing resting anal tone. In general, smooth muscle relaxants are best used sparingly, on an as needed basis, since their overall efficacy is unclear. Psychotropic agents are important in relieving depression and are of proven benefit for pain and diarrhea in patients with depression associated with IBS. Further trials with selective serotonic reuptake inhibitors (SRRIs) are underway. Psychological treatments, including hypnotherapy are less widely available but may play an

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important role in pain relief. The author concludes that current therapies targeted on the predominant symptoms in IBS are moderately successful. However, therapies are needed to more effectively relieve this syndrome, not just symptoms. 1 figure. 3 tables. 60 references. •

Meta-Analysis of Smooth Muscle Relaxants in the Treatment of Irritable Bowel Syndrome Source: Alimentary Pharmacology and Therapeutics. 15(3): 355-361. March 2001. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: This review article updates previous overviews of placebo controlled double blind trials assessing the efficacy and tolerance of smooth muscle relaxants used to treat irritable bowel syndrome (IBS). A total of 23 randomized clinical trials were selected for meta analyses of their efficacy and tolerance. Six drugs were analyzed: cimetropium bromide (five trials), hyoscine butyl bromide (three trials), mebeverine (five trials), otilium bromide (four trials), pinaverium bromide (two trials), and trimebutine (four trials). The total number of patients included was 1,888, of which 945 received an active drug and 943 a placebo. The mean percentage of patients with global improvement was 38 percent in the placebo group (n = 925) and 56 percent in the myorelaxant group (n = 927). The percentage of patients with pain improvement was 41 percent in the placebo group (n = 568) and 53 percent in the myorelaxant group (n = 567). There was no significant difference for adverse events. The authors conclude that myorelaxants are superior to placebo in the management of IBS. These drugs showed significant efficacy on the global assessment despite a high placebo effect (38 percent global improvement), with a range of difference from 31 percent for cimetropium to 11 percent for hyoscin. The efficacy was also significant and in the same range for pain relief, as well as for abdominal distension relief, although lower. There was no significant difference for transit abnormalities, diarrhea, or constipation. 4 figures. 1 table. 37 references.

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Characteristics of Patients with Irritable Bowel Syndrome Recruited from Three Sources: Implications for Clinical Trials Source: Alimentary Pharmacology and Therapeutics. 15(7): 959-964. July 2001. Contact: Available from Alimentary Pharmacology and Therapeutics. Blackwell Science Ltd., Osney Mead, Oxford OX2 OEL, UK. +44(0)1865 206206. Fax +44(0)1865 721205. Email: [email protected]. Website: www.blackwell-science.com. Summary: Variation in the characteristics of irritable bowel syndrome (IBS) patients recruited for clinical trials from different sources could affect their response and the generalizability of trial results. This article reports on a study undertaken to describe and compare the characteristics of three different groups of IBS patients recruited into a 'mock clinical trial.' The authors enrolled 245 irritable bowel syndrome patients from three sources: 121 patients from British primary practitioners; 72 patients from California newspaper advertisements; and 52 from a California gastroenterologist's practice. The authors obtained demographic, clinical, and Hospital Anxiety and Depression (HAD) Scale data for each patient. Most patients were young to middle aged women; in all three groups, the majority reported symptoms for longer than 5 years. Subject characteristics varied among the groups. Typically, primary care patients were anxious, smokers, and daily alcohol drinkers who had sought care recently for IBS and had tried antispasmodic drugs. Their symptoms were intermediate in severity between

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those of the other two groups. Advertisement subjects were the oldest, most highly educated, most often depressed, and were least likely to have sought care recently for symptoms, which were almost uniformly only moderate in severity. Gastroenterologist patients tended to be anxious and had nearly all sought care recently for symptoms, which were the most severe and most likely to include all three pain related Rome I criteria. The authors conclude that recruitment methodology affects important characteristics of an IBS study group. Trial reports should describe as completely as possible the recruitment method and the relevant subject characteristics to aid clinicians in deciding how the results might apply to their patients. 1 table. 26 references. •

Irritable Bowel Syndrome in the Elderly Source: Gastroenterology Clinics of North America. 20(2): 369-390. June 1991. Summary: Very little has been written about irritable bowel syndrome (IBS) in the elderly, although epidemiologic studies suggest that it is a common problem in this age group. This article discusses the definition, clinical features, epidemiology, causes and pathogenesis, diagnosis and differential diagnosis, treatment, and prognosis of IBS in the elderly. The authors stress that more study is needed, particularly in the areas of pathophysiology of IBS in the aged, investigation of personality, psychiatric symptomatology, mental state, and functional status in the elderly with IBS, and in documenting the prevalence and incidence of this phenomenon. 6 tables. 125 references.

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Menstrual Cycle and Its Effect on Inflammatory Bowel Disease and Irritable Bowel Syndrome: A Prevalence Study Source: American Journal of Gastroenterology. 93(10): 1867-1872. October 1998. Contact: Available from Williams and Wilkins. 351 West Camden Street, Baltimore, MD 21201-2436. (800) 638-6423 or (410) 528-8555. Summary: Women with bowel disease commonly report that their symptoms worsen in relation to their menstrual cycle. This article reports on a study undertaken to determine the nature of gastrointestinal (GI) symptoms correlating with the menstrual cycle in women with inflammatory bowel disease and irritable bowel syndrome (IBS). This retrospective study involved 49 women with ulcerative colitis, 49 women with Crohn's disease (CD), 46 women with IBS, and 90 healthy community controls. Participants were interviewed using a questionnaire that included information on general health, medication history, pregnancy, and premenstrual and menstrual symptoms. Premenstrual symptoms were reported by 93 percent of all women but statistically more often by patients with CD. Patients with CD were also more likely to report increased GI symptoms during menstruation; diarrhea was the symptom reported most often. All disease groups had a cyclical pattern to their bowel habits significantly more than controls. Cyclical symptoms included diarrhea, abdominal pain, and constipation. The authors conclude that the prevalence of menstruation related symptoms is high and appears to affect bowel patterns. The physiological and clinical effects of the menstrual cycle should be taken into consideration when assessing disease activity. 3 figures. 2 tables. 13 references. (AA-M).

Federally Funded Research on Irritable Bowel Syndrome The U.S. Government supports a variety of research studies relating to irritable bowel syndrome. These studies are tracked by the Office of Extramural Research at the National

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Institutes of Health.2 CRISP (Computerized Retrieval of Information on Scientific Projects) is a searchable database of federally funded biomedical research projects conducted at universities, hospitals, and other institutions. Search the CRISP Web site at http://crisp.cit.nih.gov/crisp/crisp_query.generate_screen. You will have the option to perform targeted searches by various criteria, including geography, date, and topics related to irritable bowel syndrome. For most of the studies, the agencies reporting into CRISP provide summaries or abstracts. As opposed to clinical trial research using patients, many federally funded studies use animals or simulated models to explore irritable bowel syndrome. The following is typical of the type of information found when searching the CRISP database for irritable bowel syndrome: •

Project Title: A CASE CONTROL STUDY OF INTERSTITIAL CYSTITIS Principal Investigator & Institution: Warren, John W.; Professor; Medicine; University of Maryland Balt Prof School Baltimore, Md 21201 Timing: Fiscal Year 2003; Project Start 18-SEP-2003; Project End 31-AUG-2007 Summary: (provided by applicant): Interstitial cystitis (IC) is a chronic bladder disease manifested by severe bladder pain and urinary frequency and urgency. Using criteria established by the NIDDK, the diagnosis can be made by objective visible findings at cystoscopy. However, IC remains a disease of unknown etiology, inconvenient diagnosis, and unclear natural history. Women comprise 90% of IC cases for unknown reasons. Patients report less life satisfaction than those with end stage renal disease. Identification of risk factors is a proven method for providing clues to pathogenesis of a disease, yet a properly designed study of IC with incident cases, appropriate controls, and attention to disease onset date has never boon performed. Herein we propose such a study comprising national samples of incident IC cases and age and gender matched controls with rigorous attention to onset dates of symptoms. By telephone interview and medical record review, we will identify risk factors for IC and reveal non-bladder syndromes associated with IC. In this group of recent onset cases where a convenient diagnostic test would be most useful, we will test the utility of antiproliferative factor, a urinary factor discovered by Susan Keay of our group. We propose then to follow this well-investigated cohort of IC cases to initiate a natural history study of the disease. This project will allow us to test several hypotheses: 1. That certain features that precede onset of IC symptoms, e.g., bacterial cystitis, distinguish IC cases from controls matched for age and gender, and may be risk factors for the disease. 2) That patients with IC have higher prevalences of certain non-bladder syndromes, e.g., irritable bowel syndrome, than do matched controls. 3) That urine APF, HB-EGF, and/or EGF are sensitive and specific diagnostic markers for IC in patients with symptoms of

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