Irritable Bowel Syndrome: Rubin G

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.

Zijdenbos IL, de Wit NJ, van der Heijden GJ, Rubin G, Quartero AO. · Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Stratenum 6.131, P.O. Box 85500, Utrecht, Netherlands, 3508. · Cochrane Database Syst Rev. · Pubmed #19160286 No free full text.

Abstract: BACKGROUND: No consensus exists on the optimal treatment for irritable bowel syndrome (IBS). Psychological treatments are increasingly advocated but their effectiveness is unclear. OBJECTIVES: To evaluate the efficacy of psychological interventions for the treatment of irritable bowel syndrome. SEARCH STRATEGY: A computer assisted search of MEDLINE, EMBASE, PsychInfo, CINAHL, Web of Science, The Cochrane Library and Google Scholar was performed for the years 1966-2008. Local databases were searched in Europe. SELECTION CRITERIA: Randomised trials comparing single psychological interventions with either usual care or mock interventions in patients over 16 years of age. No language criterion was applied. DATA COLLECTION AND ANALYSIS: The search identified 25 studies that fulfilled the inclusion criteria. The relative risk (RR), risk difference (RD), number needed to treat (NNT) and standardized mean difference (SMD) along with 95% confidence intervals were calculated using a random effects model for each outcome. MAIN RESULTS: Psychological interventions as a group The SMD for symptom score improvement at 2 and 3 months was 0.97 (95% CI 0.29 to 1.65) and 0.62 (95% CI 0.45 to 0.79) respectively compared to usual care. Against placebo, the SMDs were 0.71 (95% CI 0.08 to 1.33) and -0.17 (95% CI -0.45 to 0.11) respectively. For improvement of abdominal pain, the SMDs at 2 and 3 months were 0.54 (95%CI 0.10 to 0.98) and 0.26 (95% CI 0.07 to 0.45) compared to usual care. The SMD from placebo at 3 months was 0.31 (95% CI -0.16 to 0.79). For improvement in quality of life, the SMD from usual care at 2 and 3 months was 0.47 (95%CI 0.11 to 0.84) and 0.31 (95%CI -0.16 to 0.77) respectively. Cognitive behavioural therapy The SMD for symptom score improvement at 2 and 3 months was 0.75 (95% CI -0.20 to 1.70) and 0.58 (95% CI 0.36 to 0.79) respectively compared to usual care. Against placebo, the SMDs were 0.68 (95% CI -0.01 to 1.36) and -0.17 (95% CI -0.45 to 0.11) respectively. For improvement of abdominal pain, the SMDs at 2 and 3 months were 0.45 (95% CI 0.00 to 0.91) and 0.22 (95% CI -0.04 to -0.49) compared to usual care. Against placebo the SMD at 3 months was 0.33 (95% CI -0.16 to 0.82). For improvement in quality of life, the SMDs at 2 and 3 months compared to usual care were 0.44 (95% CI 0.04 to 0.85) and 0.92 (95% CI 0.07 to 1.77) respectively.Interpersonal psychotherapy The RR for adequate relief of symptoms was 2.02 (95% CI 1.13 to 3.62), RD 0.30 (95% CI 0.13 to 0.46), NNT 4 for comparison with care as usual. The SMD for improvement of symptom score was 0.35 (95% CI -0.75 to 0.05) compared with usual care. Relaxation/Stress management The SMD in symptom score improvement at 2 months was 0.50 (95%CI 0.02 to 0.98) compared with usual care. The SMD in improvement of abdominal pain at 3 months was 0.02 (95%CI -0.56 to 0.61) compared with usual care. Long term results Very few long term follow-up results were available. There was no convincing evidence that treatment effects were sustained following completion of treatment for any treatment modality. AUTHORS' CONCLUSIONS: Psychological interventions may be slightly superior to usual care or waiting list control conditions at the end of treatment although the clinical significance of this is debatable. Except for a single study, these therapies are not superior to placebo and the sustainability of their effect is questionable. The meta-analysis was significantly limited by issues of validity, heterogeneity, small sample size and outcome definition. Future research should adhere to current recommendations for IBS treatment trials and should focus on the long-term effects of treatment.

de Wit N, Rubin G, Jones R. · Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg, Utrecht, The Netherlands. · Clin Evid. · Pubmed #16135274 No free full text.

This publication has no abstract.

Kennedy T, Rubin G, Jones R. · Department of General Practice, Guy's, King's, and St Thomas's Medical School, King's College, London, UK. · Clin Evid. · Pubmed #15865669 No free full text.

This publication has no abstract.

Quartero AO, Meineche-Schmidt V, Muris J, Rubin G, de Wit N. · Julius Center for General Practice and Patient Oriented Research, University Medical Center Utrecht, P.O. Box 85060, 3508 AB Utrecht, Netherlands. · Cochrane Database Syst Rev. · Pubmed #15846668 No free full text.

Abstract: BACKGROUND: Irritable bowel syndrome (IBS) is a common health problem, often presenting in primary care as well as in internal medicine and gastroenterology outpatient clinics. Therapeutic options are dominated by drug therapies but there is uncertainty about their effectiveness. OBJECTIVES: The primary objective of this review was to evaluate the efficacy of bulking agents, antispasmodic and antidepressant medication for the treatment of IBS. SEARCH STRATEGY: A computer assisted search of MEDLINE, EMBASE, PsychInfo and the Cochrane Library was performed for the years 1966-2001; local and national databases were searched in 10 European countries. SELECTION CRITERIA: Randomised trials comparing bulking agents, antispasmodic or antidepressant medications with a placebo, in IBS patients over 12 years of age. Only studies published as a full paper were included. No language criterion was applied. DATA COLLECTION AND ANALYSIS: The search identified 687 studies, 66 of which fulfilled all eligibility criteria. After removal of cross-over studies that did not report separately on the first phase, data from 40 studies remained for analysis. Relative risk (RR), risk difference (RD) and standardized mean difference (SMD) along with 95% confidence intervals were calculated for all subgroups. The number needed to treat (NNT) was also calculated where appropriate. MAIN RESULTS: Forty-one study reports from 40 studies, comprising 78 comparisons, were analysed. These included 11 reports on bulking agents, 6 on antidepressants, and 24 on spasmolytics.BULKING AGENTS: Three studies comprising 159 patients reported a dichotomous outcome for relief of abdominal pain. The pooled RR using a random effects model was 1.22 (95% CI 0.86 - 1.73). Three studies comprising 128 patients reported a continuous outcome for relief of abdominal pain. Using the random effects model, the SMD was 0.68 (95% CI -0.86 - 2.33). Nine studies comprising 482 patients reported a dichotomous outcome for global assessment of improvement. The pooled RR was 1.09 (95% CI 0.78 - 1.50). Five studies comprising 253 patients reported a dichotomous outcome for improvement of symptom score. The pooled RR using a random effects model was 0.93 (95% CI 0.56 - 1.54). Two studies comprising 70 patients reported a continuous outcome for improvement of symptom score; the SMD using a fixed effects model was -0.44 (95% CI -1.20 - 0.31). SPASMOLYTIC AGENTS: Eleven studies comprising 1260 patients reported a dichotomous outcome for relief of abdominal pain. The pooled RR using a random effects model was 1.34 (95% CI 1.13 - 1.59; RD=0.17, 95% CI 0.06 -0.28; NNT=6, 95% CI 4 - 15). Seven studies comprising 467 patients reported a continuous outcome for relief of abdominal pain. Using a fixed effects model the pooled SMD was -0.65 (95% CI -0.94 to -0.35). Sixteen studies comprising 1236 patients reported a dichotomous outcome for global assessment of improvement. The pooled RR using a random effects model was 1.42 (95% CI 1.17 - 1.72; RD=0.20, 95% CI 0.09 -0.30; NNT=5, 95% CI 3 - 11). One study comprising 34 patients reported a dichotomous variable for improvement of symptom score. The RR was 1.33 (95% CI 0.96 - 1.85). Three studies reported a continuous outcome for improvement of symptom score; two studies comprising 66 patients could be pooled. Using a fixed effects model, the SMD was -0.37 (95% CI -0.85 - 0.12). ANTIDEPRESSANTS: Two studies comprising 81 patients reported a dichotomous outcome for relief of abdominal pain. Using the random effects model, the pooled RR was 0.83 (95% CI 0.33 - 2.12). Two studies comprising 101 patients reported a continuous outcome for relief of abdominal pain. The SMD using a random effects model was -0.53 (95% CI -2.29 - 1.23). Four studies comprising 241 patients reported a dichotomous variable for global assessment of improvement. The pooled RR was 1.16 (95% CI 0.78 - 1.73). AUTHORS' CONCLUSIONS: The evidence for efficacy of drug therapies for IBS is weak. Although there is evidence of benefit for antispasmodic drugs for abdominal pain and global assessment of symptoms; it is unclear whether anti-spasmodic subgroups are individually effective. There is no clear evidence of benefit for antidepressants or bulking agents. The physician should be aware that global assessment is a construct containing various dimensions. For each individual, these will have a different weighting and treatment should be aimed at the most debilitating symptom. Stool problems are by definition part of the IBS symptom complex. Bulking agents may improve constipation and can be used empirically, but should be evaluated at an early stage for individual benefit. Future research should pay attention to study methodology and the use of valid outcome measures.

Kennedy T, Rubin G, Jones R. · Department of General Practice Guy's, King's, and St Thomas's Medical School King's College, London, UK. · Clin Evid. · Pubmed #15652025 No free full text.

This publication has no abstract.

Jones R, Rubin G. · Department of General Practice and Primary Care, King's College London School of Medicine, London SE11 6SP. · BMJ. · Pubmed #19528114 No free full text.

This publication has no abstract.

de Wit N, Rubin G, Jones RH. · Julius Center for Health Sciences and Primary Care, University Medical Center, Universiteitsweg, Utrecht, The Netherlands. · Clin Evid (Online). · Pubmed #19454062 No free full text.

Abstract: INTRODUCTION: The prevalence of irritable bowel syndrome (IBS) varies depending on the criteria used to diagnose it, but ranges from about 5% to over 15%. IBS is associated with abnormal gastrointestinal motor function and enhanced visceral perception, as well as psychosocial and genetic factors. People with IBS have an increased likelihood of having a cholecystectomy or hysterectomy compared with people without IBS. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments in people with IBS? We searched: Medline, Embase, The Cochrane Library and other important databases up to June 2006 (BMJ Clinical evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: 5HT(3) receptor antagonists other than alosetron, 5HT(4) receptor agonists (tegaserod), alosetron, antidepressants, antispasmodics, cognitive behaviour therapy, hypnotherapy, insoluble fibre supplementation, loperamide.

Seifert B, Rubin G, de Wit N, Lionis C, Hall N, Hungin P, Jones R, Palka M, Mendive J. · Department of General Practice, Charles University, Prague, First Faculty of Medicine, Prague, Czech Republic. · Dig Liver Dis. · Pubmed #18406672 No free full text.

Abstract: BACKGROUND: Gastrointestinal (GI) disorders account for 10% of all consultations in primary care. Little is known about the management of GI disorders by general practitioners (GP) across different European countries. AIM AND METHODS: We undertook a postal survey of randomly selected samples of GPs in six European countries (UK, Holland, Spain, Greece, Poland, Czech Republic) to determine patterns of diagnosis, management and service use in GI disorders. RESULTS: We received 939 responses, response rate 32%. Over 80% of GPs were aware of at least three national guidelines for gastrointestinal disease. The availability of open access endoscopy ranged from 28% (Poland) to over 80% (Holland, Czech and UK). For uninvestigated dyspepsia the preferred first line management was proton pump inhibitor therapy (33-82%), Helicobacter pylori test and treat (19-47%), early endoscopy (5-32%), specialist referral (2-21%). Regarding irritable bowel syndrome, 23% of respondents were familiar with one or more diagnostic criteria, but between 7% (Netherlands) and 32% (Poland) would ask for a specialist opinion before making the diagnosis. CONCLUSION: The wide variation between GPs both between and within countries partly reflects variations in health care systems but also differing levels of knowledge and awareness, factors which are relevant to educational and research policy.

Rubin G, De Wit N, Meineche-Schmidt V, Seifert B, Hall N, Hungin P. · Centre for Primary and Community Care, University of Sunderland, Sunderland, UK. · Fam Pract. · Pubmed #17062586 links to  free full text

Abstract: BACKGROUND: The criteria used to identify and diagnose irritable bowel syndrome (IBS) in primary care are unclear, even though most patients are managed entirely in this setting. OBJECTIVE: To use a validated method of consensus development [Nominal Group Technique (Rand version)] (NGT-R) in order to construct a diagnostic framework for IBS appropriate to primary care. METHODS: NGT-R is a formal method of consensus development, which uses structured interaction within a group combined with statistical derivation of group judgements. The group comprised 10 GPs with a special interest in gastroenterology and two gastroenterologists, from 10 European countries. Mailed questionnaires elicited judgements on 242 scenarios for the diagnosis of IBS, within four domains of symptoms, social and lifestyle features, psychological features and investigations. Feedback of group decisions was followed by structured face-to-face interaction and private rescoring of the questionnaire. Consensus was defined as 10/12 ratings within one of three bands, 1-3 (disagreement), 4-6 (equivocal) or 7-9 (agreement). RESULTS: The defining features of IBS in primary care are alteration in bowel habit, bloating and abdominal pain, or discomfort or annoyance (the last reflecting important cultural differences in symptom description). These symptoms need to be present for at least 4 weeks. Supportive characteristics include female sex, family history of IBS, frequent clinic attendances, a recent major life event and a history of somatization behaviours. Abdominal examination was considered necessary in all patients and rectal examination, haemoglobin estimation and colonoscopy in those aged > 55 years. The subtypes of IBS are recognized, but the diagnostic process differs only in minor ways. Final consensus was reached on 46% of statements. CONCLUSION: The basis of IBS diagnosis in primary care differs from, and is less exclusive than, existing criteria. Few features are deemed essential for diagnosis, while psychosocial features, patient characteristics and contextual factors are important in increasing diagnostic probability. There are important cultural differences in the description of key symptoms. These results provide information on the defining characteristics of IBS and the diagnostic process, as it occurs in primary care, and can guide clinical practice.

Jones R, Rubin G. · No affiliation provided · Int J Clin Pract. · Pubmed #16862637 No free full text.

This publication has no abstract.