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9th May 2022
The use of a fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) diet has been shown in a randomised controlled trial to provide much better relief of irritable bowel syndrome (IBS) symptoms compared with using a musculotropic spasmolytic agent.
This was the main result from a study by researchers at the department of Gastroenterology and Hepatology, KU Leuven University Hospitals Leuven, Belgium.
Irritable bowel syndrome has been defined as a functional bowel disorder in which recurrent abdominal pain is associated with defecation or a change in bowel habits. It is a common condition and in one 2020 review, the pooled IBS prevalence among studies that used the Rome IV criteria was 3·8%.
Several treatment options are available for the management of IBS and a 2008 systemic review and meta-analysis concluded that fibre, anti-spasmodics (musculotropic spasmolytics) and peppermint oil were all more effective than placebo in the treatment of IBS.
One particular spasmolytic agent is otilonium bromide (OB) which acts as an L-type calcium channel antagonist in intestinal and colonic smooth muscle cells. OB has been found to be more effective than placebo in IBS with a significant therapeutic benefit after 10 weeks and which is maximal after 15 weeks.
In recent years however, the use of a FODMAP diet has been found to be effective at reducing functional gastrointestinal symptoms in patients with IBS.
Nevertheless, there is uncertainty over whether or not a FODMAP diet provides superior symptomatic relief for patients with IBS compared to the use OB.
For the current trial, the Belgium team randomised newly treated patients with IBS to either OB 40mg three-times daily or a FODMAP diet and which was made available via a smartphone app and for those without access to a suitable electronic device, the diet instructions were available as a booklet.
The diet itself was not a strict low FODMAP diet, but rather designed as a FODMAP-lowering diet. Consequently, small amount of FODMAPs were allowed, but the app did provide advice on which foods should be avoided or be reduced and offered suitable alternatives.
Patients self-completed several questionnaires, one of which was the IBS symptom Severity scale (IBS-SSS) and this used for the primary outcome, with a responder defined as a patient who improved by ≥50 points on the IBS-SSS compared with baseline after 8 weeks.
FODMAP and improvement in IBS symptom scores
A total of 459 patients were randomised to OB (232) or a FODMAP diet. The mean age of participants randomised to OB was 41.2 years (76% female) which was slightly higher than the mean age of those assigned to the diet (40.6 years). The mean baseline IBS-SSS score was the same (267) in both groups.
After 8 weeks, a significantly higher proportion of participants using the FODMAP diet arm achieved the primary outcome (71% vs 61%, diet vs OD, p = 0.03). In fact, this difference became significant after only 4 weeks (62% vs 51%, diet vs OB, p = 0.02). Numerically, FODMAP diet participants saw a change from baseline in their IBS-SSS score of -97.42 after 8 weeks whereas the OB experienced a smaller mean reduction of only -76.91.
The authors concluded that the FODMAP diet was superior to standard medical therapy and suggested that this simple dietary approach should be considered as a first-line therapy for patients with IBS.
Citation
Carbone F et al. Diet or medication in primary care patients with IBS: the DOMINO study – a randomised trial supported by the Belgian Health Care Knowledge Centre (KCE Trials Programme) and the Rome Foundation Research Institute Gut 2022
6th July 2021
The British Society of Gastroenterology (BSG) has revised its 2007 guidelines on the management of irritable bowel syndrome (IBS). The latest guidance covers all aspects of the condition ranging from initial assessment and management through to secondary care referral and any subsequent investigations that should be undertaken within that setting. The guideline makes reference to the revised diagnostic Rome IV criteria produced in 2016 and notes that while the criteria are an improvement on the earlier Rome III, the revision is perhaps more restrictive and calls into question whether these latest changes can be used to diagnose irritable bowel syndrome. The BSG therefore suggests that a more pragmatic definition of the condition is provided by NICE which states that the diagnosis should be considered only if the person has abdominal pain or discomfort that is either relieved by defecation or associated with altered bowel frequency or stool form. Furthermore, the BSG guidance recommends that all patients with IBS symptoms should have a full blood count, C-reactive protein or erythrocyte sedimentation rate, coeliac serology and that clinicians should discuss the underlying diagnosis, its causes and natural history to the patients. The guidance, while accepting a limited evidence-base, advises that all patients should take regular exercise and that soluble fibre is an effective treatment for global symptoms and abdominal pain. In contrast, it recommends against the use of insoluble fibre (e.g., wheat bran) as this might exacerbate symptoms.
Medical treatments endorsed for irritable bowel syndrome include loperamide, especially where IBS is associated with diarrhoea, antispasmodics and peppermint oil and polyethylene glycol for associated constipation. Where there is uncertainty over the diagnosis or if symptoms are refractory, a referral should be made to secondary care. Several second-line therapies including tricyclic antidepressants, selective serotonin re-uptake inhibitors, linaclotide, lubiprostone and plecanatide. There is also a discussion of new and emerging treatments together with a recognition of the value of cognitive behavioural therapy, gut-directed hypnotherapy and general psychological therapies.
Probiotics
One area new to the guideline is the acknowledgement of a potential pathological role of an altered microbiome and which has led to interest in the use of probiotics as a potential treatment for IBS. For the guideline, the authors updated a 2018 meta-analysis on the efficacy of probiotics and found that compared to placebo, a combination of probiotics, had a significant effect on global symptoms or abdominal pain (relative risk, RR = 0.79, 95% CI 0.70–0.89). This effect was also significant for individual species including lactobacillus, Bifidobacterium and Escherichia. Based on these data, the guidance recommended that patients wishing to use probiotics should take them for up to 3 months to assess the potential benefit.
The guideline concludes that irritable bowel syndrome is a multifactorial disorder that requires a positive diagnosis and the implementation of both non- and pharmacological therapy to improve symptoms and quality of life.
Citation
Vasant DH et al. British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. BMJ 2021
10th October 2019
Originally initiated by the Health Stomach Initiative, World Stomach Day aims to raise awareness of the global burden of gastric diseases and the need for further research in the field as well as improved prevention and treatment strategies.
Gastric diseases range in prevalence and severity, from common short-term occurrences of dyspepsia (indigestion), to more harmful and severe chronic disorders. These include a variety of widespread functional disorders such as irritable bowel syndrome (IBS), which can have a devastating and life-altering impact on the lives of sufferers. Gastric diseases also affect society as a whole, placing significant pressures on over-burdened healthcare systems. According to a United European Gastroenterology (UEG) report, IBS, which currently affects one in 10 people globally, is estimated to cost €3.2 billion per year in Germany alone.
As one of the most life-threatening forms of gastric disease, gastric cancer is estimated to be the fifth most frequently diagnosed cancer and third most common cause of cancer-related death in the world. In 2018, there were 80,000 new diagnoses of stomach cancer and nearly 60,000 attributable deaths in Europe. Due to the generalised nature of the symptoms, gastric cancer is often only detected at a later stage, leading to comparatively lower survival rates than many other cancers.
Despite the general decline in gastric cancer cases globally, recent studies have uncovered a concerning link between patients with chronic autoimmune gastritis (AIG) and the development of gastric cancer. In two studies carried in the USA and Sweden, results showed that individuals with AIG had a three-fold increased risk of developing stomach carcinoid tumours and adenocarcinomas. Like other autoimmune diseases, AIG predominately affects females (3:1 ratio), potentially providing a link between AIG and the increasing incidence of gastric adenocarcinoma among young white females in the USA. The recent detection of gastric cancer amongst younger sectors of the population may indicate that declining levels of gastric cancer could reverse in the future.
Identifying and treating gastric cancer at an early stage can dramatically increase survival rates and treatment options. The five-year survival rate for gastric cancer is currently 31% reflecting the often late-diagnosis of the condition. In comparison, the five-year survival rate for gastric cancer more than doubles (68%) if the cancer is detected before spreading outside the stomach. Earlier detection of gastric cancer can also lead to a reduced need for aggressive treatment options and invasive surgery. Although not a certainty, precancerous lesions can be an indicator of future cancer progression and should be followed carefully. Recognising precancerous lesions in patients and subsequently monitoring them is an essential measure in reducing the incidence of and mortality rates associated with gastric cancer. The recent publication ‘Management of epithelial precancerous conditions and lesions in the stomach (MAPSII)’ clearly characterises the various lesions and management methods, encouraging a standardisation of treatment strategies across Europe for precancerous conditions and lesions in the stomach.
Decreasing global mortality relies primarily on the early detection and accurate diagnosis of gastric cancer through endoscopy. Over the last few decades, there have been a number of critical technological advancements in endoscopic imaging, improving mucosal visualisation and diagnosis. High definition endoscopy with chromoendoscopy (CE) is currently one of the most effective diagnostic methods for identifying gastric adenocarcinoma, potentially allowing for the visualisation of gastric atrophy and intestinal metaplasia (IM). Despite these advances, continual improvements in endoscopic imaging are still necessary to significantly improve the prognosis of gastric cancer.
H. pylori is one of the greatest risk factors for gastric cancer. Often contracted during childhood, approximately two-thirds of the world’s population harbours H. pylori bacteria within the stomach. Although an important factor in the development of gastric cancer, evidence has shown that the successful eradication of H. pylori does not completely prevent the development of gastric cancer. A 2018 study suggested that H. pylori infection may only be an early event in the development of gastric cancer preparing the gastric mucosa for further changes. Further research on the gastric microbiome is required to identify the precise role of H. pylori in the development of gastric cancer, potentially opening up pathways to novel prevention and treatment strategies.
Important strides are continually being made in the treatment of H. pylori infection. Quadruple therapy is becoming increasingly common in areas with growing levels of resistance to standard triple therapy and impressive eradication rates and being achieved. More recently, vonoprazan, a potassium-competitive acid blocker has been explored as a novel treatment strategy. A large Japanese study comparing vonoprazan to proton-pump inhibitors (PPIs) demonstrated a higher eradication rate with vonoprazan. Noticeably, the eradication rates of vonoprazan combined with amoxicillin and clarithromycin in clarithromycin-resistant patients was over 80%. With a general rise in antibiotic resistance rates globally, evolving treatment options are necessary to combat H. pylori infections and associated gastric conditions.
Despite major advancements in the field, gastric diseases remain prominent across the globe. Concerning evidence has also suggested that a variety of gastric diseases may be increasing amongst the younger population. With the pathogenesis of many gastric conditions still being debated, further research is urgently required to improve patient outcomes and reduce the societal impact caused by these often burdensome and disruptive diseases.
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