Irritable Bowel Syndrome: Kumar D

Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P, Anonymous00175. · Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK. · Gut. · Pubmed #17488783 No free full text.

Abstract: BACKGROUND: IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance. AIM: To provide a guide for the assessment and management of adult patients with irritable bowel syndrome. METHODS: Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases. RESULTS: Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms. CONCLUSIONS: Better ways of identifying which patients will respond to specific treatments are urgently needed.

Jones J, Boorman J, Cann P, Forbes A, Gomborone J, Heaton K, Hungin P, Kumar D, Libby G, Spiller R, Read N, Silk D, Whorwell P. · Division of Gastroenterology, University Hospital, Nottingham, UK. · Gut. · Pubmed #11053260 links to  free full text

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Zar S, Kumar D, Kumar D. · OGEM Department, St. Georges Hospital Medical School, London, UK. · Minerva Med. · Pubmed #12410172 No free full text.

Abstract: A significant proportion of IBS patients attribute their symptoms to adverse food reactions. Dietary elimination and re-challenge studies support the role of diet in the pathogenesis of IBS. The aetiopathogenesis of IBS is thought to be multifactorial involving an interaction between diet, infection, antibiotics and psychosocial factors. Serum IgE and IgG4 antibodies are elevated in food hypersensitivity induced atopic conditions and a similar mechanism has been postulated in IBS. Increased number of mast cells is present in the ileocaecal region of IBS patients. Once sensitized, they are capable of inducing secretory and sensorimotor abnormalities of the gut. The management of IBS is usually aimed at controlling symptoms, however, evaluation of food hypersensitivity may provide a useful adjunct in those with severe symptoms or a clear history of adverse food reaction. There are no well-established tests available but skin prick tests and food specific serum IgG4 and IgE antibodies may help in identifying the offending foods. Other options, which may be explored in individual cases, include sequential dietary exclusion, use of hypoallergenic diets, disodium cromoglycate and novel techniques such as colonoscopic allergen provocation test. Pathophysiology of hypersensitivity induced IBS has been discussed in the light of current data and a management algorithm has been proposed for managing food hypersensitivity in IBS.

Zar S, Kumar D, Kumar D. · OGEM Department, St. Georges Hospital Medical School, London, UK. · Minerva Med. · Pubmed #12410172 No free full text.

Abstract: A significant proportion of IBS patients attribute their symptoms to adverse food reactions. Dietary elimination and re-challenge studies support the role of diet in the pathogenesis of IBS. The aetiopathogenesis of IBS is thought to be multifactorial involving an interaction between diet, infection, antibiotics and psychosocial factors. Serum IgE and IgG4 antibodies are elevated in food hypersensitivity induced atopic conditions and a similar mechanism has been postulated in IBS. Increased number of mast cells is present in the ileocaecal region of IBS patients. Once sensitized, they are capable of inducing secretory and sensorimotor abnormalities of the gut. The management of IBS is usually aimed at controlling symptoms, however, evaluation of food hypersensitivity may provide a useful adjunct in those with severe symptoms or a clear history of adverse food reaction. There are no well-established tests available but skin prick tests and food specific serum IgG4 and IgE antibodies may help in identifying the offending foods. Other options, which may be explored in individual cases, include sequential dietary exclusion, use of hypoallergenic diets, disodium cromoglycate and novel techniques such as colonoscopic allergen provocation test. Pathophysiology of hypersensitivity induced IBS has been discussed in the light of current data and a management algorithm has been proposed for managing food hypersensitivity in IBS.

Zar S, Kumar D, Benson MJ. · Department of General Surgery, St George's Hospital Medical School, London, UK. · Aliment Pharmacol Ther. · Pubmed #11284772 links to  free full text

Abstract: Irritable bowel syndrome is a common condition but its pathophysiology remains poorly understood. Many irritable bowel syndrome patients give a history of food intolerance, but data from dietary elimination and re-challenge studies are inconclusive. Multiple aetio-pathological mechanisms have been postulated. The gut has an extensive immune system but current understanding of processing of food antigens in health and disease is limited. There is no clinically useful marker available to test for food hypersensitivity in irritable bowel syndrome. Researchers have employed both skin tests and serum immunoglobulins (IgG and IgE) as markers of food hypersensitivity in various disorders including irritable bowel syndrome, but published data are equivocal. In this article, the evidence for the role of food hypersensitivity in irritable bowel syndrome is reviewed and, based on the available data, a possible pathophysiological hypothesis has been formulated.

Davis K, Philpott S, Kumar D, Mendall M. · St Georges Hospital Medical School, London, UK. · Int J Clin Pract. · Pubmed #16749917 No free full text.

Abstract: Aloe vera (AV) is suggested to be beneficial in treating irritable bowel syndrome (IBS) symptoms, but no scientific trials exist to confirm this. We aim to assess the efficacy of AV on IBS in refractory secondary care patients. Patients with IBS were randomised to receive AV or matching placebo for a month. Symptoms were assessed at baseline, 1 and 3 months. Fifty-eight patients randomised, 49 completed the protocol to 1 month and 41 to 3 months. Eleven of thirty-one (35%) AV patients, and 6 of 27 (22%) placebo patients responded at 1 month (p = 0.763). Diarrhoea predominant patients showed a trend towards a response to treatment at 1 month (10/23 V 2/14, p = 0.07). There was no evidence that AV benefits patients with IBS. However, we could not rule out the possibility that improvement occurred in patients with diarrhoea or alternating IBS whilst taking AV. Further investigations are warranted in patients with diarrhoea predominant IBS, in a less complex group of patients.

Zar S, Benson MJ, Kumar D. · St Helier Hospital, Carshalton, Surrey, UK. · Eur J Gastroenterol Hepatol. · Pubmed #16394796 No free full text.

Abstract: OBJECTIVES: To evaluate the differences in rectal compliance and sensory thresholds for the urge to defecate and discomfort between irritable bowel syndrome (IBS) subgroups and controls, and to correlate these parameters with rectal symptoms. METHODS: A total of 38 IBS patients [Rome II criteria; 19 diarrhoea-predominant IBS (D-IBS), 16 constipation-predominant IBS (C-IBS), three with alternating diarrhoea and constipation IBS (Alt-IBS)] and 10 controls were studied. A barostat was used to measure rectal compliance and sensory thresholds, in the 'unprepared' rectum. The thresholds for the urge to defecate and discomfort were determined using phasic rectal balloon distension in a double random staircase sequence. RESULTS: D-IBS had significantly lower rectal compliance and threshold for the urge to defecate compared with controls [4 ml/mmHg interquartile range (IQR) 3.99 versus 8.4 ml/mmHg IQR 5.69; P=0.001; 8 mmHg IQR 6 versus 20 mmHg IQR 4; P=0.003]. D-IBS also had significantly lower rectal compliance and threshold for the urge to defecate compared with the C-IBS group (5.8 ml/mmHg IQR 4.61; P=0.027; 16 mmHg IQR 12; P=0.003). The volume at the threshold for discomfort was significantly lower in D-IBS compared with controls (163 ml IQR 99.5 versus 212 ml IQR 147.25; P=0.016). The severity of abdominal pain and rectal symptoms showed a significantly negative correlation with rectal sensory thresholds. CONCLUSION: This study shows that the sensory threshold for the urge to defecate and rectal compliance is significantly lower in D-IBS compared with C-IBS and controls. The consequent inability to tolerate rectal faecal loading may account for the symptoms of the passage of frequent, small-volume stools in D-IBS patients.

Zar S, Mincher L, Benson MJ, Kumar D. · OGEM Department, St George's Hospital Medical School, London, UK. · Scand J Gastroenterol. · Pubmed #16109655 No free full text.

Abstract: OBJECTIVE: Dietary modification improves symptoms in irritable bowel syndrome (IBS). Identification of offending foods by dietary elimination/re-challenge is cumbersome. IgG4 antibodies to common food antigens are elevated in IBS. The aim of this article was to evaluate the effect of exclusion diet based on IgG4 titres on IBS symptoms and rectal sensitivity and compliance. MATERIALS AND METHODS: The study comprised 25 patients with IBS (3 M, 22 F, mean age 43 years, Rome II criteria). IgG4 titres to 16 foods (milk, eggs, cheese, wheat, rice, potatoes, chicken, beef, pork, lamb, soya bean, fish, shrimps, yeast, tomatoes and peanuts) were measured. Foods with titres >250 microg/l were excluded for 6 months. Symptom severity was assessed with a previously validated questionnaire at baseline, at 3 months and at 6 months. Rectal compliance and sensitivity were measured in 12 patients at baseline and at 6 months. RESULTS: IgG4 antibodies to milk, eggs, wheat, beef, pork and lamb were commonly elevated. Significant improvement was reported in pain severity (p < 0.001), pain frequency (p = 0.034), bloating severity (p = 0.001), satisfaction with bowel habits (p = 0.004) and effect of IBS on life in general (p = 0.008) at 3 months. Symptom improvement was maintained at 6 months. Rectal compliance was significantly increased (p = 0.011) at 6 months but the thresholds for urge to defecate/discomfort were unchanged. CONCLUSIONS: Food-specific IgG4 antibody-guided exclusion diet improves symptoms in IBS and is associated with an improvement in rectal compliance.

Zar S, Benson MJ, Kumar D. · OGEM Department, St Georges Hospital Medical School, Blackshaw Road, London, UK. · Am J Gastroenterol. · Pubmed #15984980 No free full text.

Abstract: INTRODUCTION: Food hypersensitivity is a common perception among irritable bowel syndrome (IBS) patients. Data from dietary elimination and food challenge studies support an etiopathological role of diet in IBS, but there are no well-established tests to identify food hypersensitivity. AIM: To compare IgG4 and IgE titers to common food antigens in IBS and controls. METHOD: One hundred and eight IBS [52 diarrhea-predominant (D-IBS); 32 constipation-predominant (C-IBS); 24 alternating (Alt-IBS)], and 43 controls were included in the study. IgG4 and IgE titers and skin prick testing (SPT) to 16 common foods including milk, eggs, cheese, wheat, rice, potatoes, chicken, beef, pork, lamb, fish, shrimps, soya bean, yeast, tomatoes, and peanuts were measured. RESULTS: IBS had significantly higher IgG4 titers (mug/L) to wheat (395 IQR +/- 1,011 vs 0 IQR +/- 285, p < 0.001), beef (1,079 IQR +/- 930 vs 617 IQR +/- 435, p < 0.001), pork (481 IQR +/- 379 vs 258 IQR +/- 496, p < 0.001), and lamb (241 IQR +/- 460 vs 167 IQR +/- 232, p= 0.009) compared to controls. These differences were maintained across all three subgroups. The antibody titers to potatoes, rice, fish, chicken, yeast, tomato, and shrimps were not significantly different. No significant difference in IgE titers was observed between IBS and controls. SPT was positive for only a single antigen in 5 of 56 patients tested with the same panel of foods. No correlation was seen between the pattern of elevated IgG4 antibody titers and patients' symptoms. CONCLUSION: Serum IgG4 antibodies to common foods like wheat, beef, pork, and lamb are elevated in IBS patients. In keeping with the observation in other atopic conditions, this finding suggests the possibility of a similar pathophysiological role for IgG4 antibodies in IBS.

Kumar D. · Department of General Surgery, St George's Hospital, Tooting, London, UK. · Eur J Gastroenterol Hepatol. · Pubmed #15618826 No free full text.

Abstract: Irritable bowel syndrome (IBS) is common. The symptom criteria for the diagnosis of IBS remain non specific. Similarly, pelvic inflammatory disease and endometriosis present with symptoms that may be similar to those of IBS. The site of pain, intermenstrual bleeding and exacerbation of symptoms by food may be able to help differentiate the two groups. However, there is still considerable overlap in the symptomatology of the two conditions and to this end both specialties should work together to investigate and manage these patients.

Maxwell PR, Rink E, Kumar D, Mendall MA. · Department of General Practice and Primary Care, St George's Hospital Medical School, London, United Kingdom. · Am J Gastroenterol. · Pubmed #11808932 No free full text.

Abstract: OBJECTIVES: Data suggest that subjects with irritable bowel syndrome are more likely to report a recent course of antibiotics. This study tests the hypothesis that a course of antibiotics is a risk factor for an increase in the number of functional bowel complaints over a 4-month period in a general population sample. METHODS: We initiated a prospective case-control study in three general practices in South London. Consecutive patients aged 16-49 attending their general practitioner with non-GI complaints and given a prescription for antibiotics were invited to participate. Comparison subjects who had not had antibiotics for 1 yr were identified from the practice records by age group, gender, and previous general practitioner visits. Fifty-eight antibiotic and 65 control patients agreed to participate. Questionnaires covering demographic, GI, and psychological data were sent at recruitment and at 4 months. Seventy-four percent of subjects completed the study. The number of symptoms at follow-up compared to that at recruitment. RESULTS: Twenty of 42 antibiotic subjects (48%) versus 11/49 control subjects (22%) demonstrated one or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 3.14 [1.27-7.75]) (chi2 = 6.4, p = 0.01). Ten of 42 antibiotic subjects (24%) versus 3/49 control subjects (6%) demonstrated two or more additional functional bowel symptoms at 4 months (unadjusted odds ratio = 4.79 [1.22-18.80]) (chi2 = 5.8, p = 0.02). CONCLUSIONS: Functional bowel symptoms come and go, but subjects who are given a course of antibiotics are more than three times as likely to report more bowel symptoms 4 months later than controls.