Management of Abdominal Pain in Irritable Bowel Syndrome:

Introduction

 

This article is based around a research assignment I wrote as part of my postgraduate study in pain management. Academic articles don't make for the easiest read, so I've made some modifications and added explanations to make the article more straightforward to understand.

 

Though I hope this does show the importance of continual medical research for diseases - in this can irritable bowel syndrome.

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The complexity of Irritable Bowel Syndrome (IBS) is not only the symptomology (wide variety of symptoms), but also the changes in diagnostic criteria used over the years, that makes global prevalence difficult to assess. 

 

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 The Different subtypes of Irritable Bowel Syndrome

 

IBS has four subtypes labelled by the stool pattern, 

• IBS-D (diarrhea), 

• IBS-C (constipation), 

• IBS-M (mixed) and 

• IBS-U (unclassified). 

 

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Committee in Rome form diagnostic criteria becomes the ROME Foundation.

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The diagnostic criteria that allocate patients to these subtypes are are 

• Rome I (1994), 

• Rome II (1999), 

• Rome III (2006), 

• And the most recent update Rome IV in 2016. 

 

Oka et al. (2020) in their meta-analysis found there was a reduction of prevalence depending on criteria used; Rome IV produced IBS prevalence of 3.8%, but using Rome III IBS prevalence is 9.2% and this varied between countries. 

 

Global rates of irritable bowel syndrome range from 1 in 11 to 1 in 26 people. This annotated bibliography investigates the biopsychosocial (biological, psychological, and social aspects) treatments that are available to people with IBS. Kim & Kim (2018) found IBS is more common in women with the ratio 2-2.5:1. In some Asian countries more men are diagnosed although symptomology may be different (Camilleri, 2020).

 

Irritable Bowel Syndrome causes many visits to GP mainly for the abdominal pain or discomfort due to changing bowel movement (Aziz & Simren, 2021). The etiology (cause or reasons for) of IBS is unclear, suggestions of mucosal inflammation, dysregulated HPA axis and prevalence amongst those with early life trauma.

 

Whatever the cause IBS symptoms can cause a devastating impact on lifestyle (Ng, et al, 2018). 

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Vasant  (2021) recognises the gut-brain connection is integral to this illness. Due to the complexity of symptomology and defining the cause of IBS this annotated bibliography takes a biopsychosocial approach to treatment with five diverse research articles. 

 

These five articles include:

• A high quality network meta-analyses and meta-analyses, extensively covering research into all areas of treatment. Also included are 

• An RCT on peppermint oil,

• A three-way RCT of a new psychological approach Emotional Awareness and Expression Training (EAET), 

• A qualitative research on exercise  

• A single case study on Cognitive Behaviour Hypnotherapy.

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Peppermint Oil Treatment for IBS

 

Alammar, N., Wang, L., Saberi, B., Nanavati, J., Holtmann, G., Shinohara, R. T., & Mullin, G. E. (2019). The impact of peppermint oil on the irritable bowel syndrome: a meta-analysis of the pooled clinical data. BMC complementary and alternative medicine, 19(1), 1-10.

 

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Alammer et al conducted a meta-analysis of RCT’s for the period from 1979 to 2016 on enteric-coated peppermint oil in the treatment of IBS. They presented separate efficacy for abdominal pain enabling inclusion in this bibliography on pain. Duration of trials ranged from 2 to 12 weeks. 

 

The longer duration showed fewer negative effects of peppermint oil. One drawback of this meta-analysis the time period covered was decades, could confound results due to changes in research methodology and analysis. 

 

This research is published in a complimentary and alternative medicine journal so this may lack credibility in the medical community, although the RCT’s were gathered from highly reputable databases. Different diagnosis of IBS varied using Rome I, II, III, and IV between trials, with only the initial parts of the trials used omitting any crossovers, nevertheless this changing diagnosis criteria and four decades of research impacting on the findings. 

 

This meta-analysis showed that abdominal pain with IBS symptoms was moderated by peppermint oil. Although results for pain were only specified in six of the 12 trials they were of longer duration more efficacious for abdominal pain. Particular bias was eight trials were university based single center, rather than multicenter, although it's strength was multicultural and global

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Hypnosis Treatment for IBS - Case Study

 

Chandrasegaran, A., M.B.B.S. (2020). A Single Case Study: Utilising Cognitive Behavioural Therapy Techniques into Hypnosis for Irritable Bowel Syndrome. Australian Journal of Clinical Hypnotherapy and Hypnosis, 41(1), 27-37,48. 

 

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Chandrasegaran (2020), a consultant anesthesiologist documented a single case study to describe the non-pharmacological approach of cognitive behavioural hypnotherapy, focused on desentisation and self-care. 

 

A 54-year-old woman first diagnosed when she was 25 years old had seven consultations and an email follow-up two months after her last session. Using VAS (90-100) scale, results were 90% reduction in pain and other IBS symptoms and she regularly practiced learnt hypnotic skills.

 

A notable benefit from this psychosocial therapy was her improved management of personal relations and stressful events. 

 

The author’s aim was to create clinical validity for hypnotherapy as an adjunct to current therapeutic protocols. The descriptive nature of this case study is informative, enabling clinicians to understand a different methodology to their own, to reduce IBS abdominal pain, particularly important for possible patient referral. 

 

Chandrasegaran hopes this article will prompt further research in clinical hypnotherapy. His attached references although thorough and relevant, lack recent evidence for cognitive behavioural hypnotherapy. Dates range from 1980’s with only one article within the last 10 years. 

 

Although hypnotherapy was included in the research of Vasant (2021), they did draw attention to the fact of poor accessibility to hypnotherapy, particularly in rural areas.

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IBS Patients Share the Effects of Physical Activity on their Symptoms 

 

Johannesson, E., Jakobsson Ung, E., Sadik, R., & Ringström, G. (2018). Experiences of the effects of physical activity in persons with irritable bowel syndrome (IBS): a qualitative content analysis. Scandinavian Journal of Gastroenterology, 53(10-11), 1194-1200.

 

 

Johannesson’s qualitative research investigated the opinions of IBS patients taking part in physical activity as part of their treatment. The fifteen patients interviewed were aged from 31-78 years; 10 were women, diagnosed with irritable bowel syndrome, using Rome II, duration from 10 – 57 years.

 

Unstructured interviews of 30-80 minutes were conducted by the Johannesson using pre-set, open-ended questions with further deepening questions following responses. 

 

The aim was to better understand IBS patients’ perspectives to better inform clinicians who were providing support. 

 

Three aspects of IBS with activity were discussed: 

• Gastrointestinal symptoms, including abdominal pain; 

• Extra-intestinal symptoms, included flexibility, strength and pain modulation, 

• And quality of life. 

 

The results found many patients had reduced abdominal pain when physically active, whereas for others the pain either remained during exercise or worsened pain that patients identified as activity specific. 

 

Participants had a range of education levels and occupations including retired people together with the diverse age demographics provided for a wide range of opinions. Although, it could be questioned whether this diversity in such a small number of patients provided reliable evidence in such a complex condition as IBS. The opinions and results could inform further research as exercise stimulates bowel movements and is a fundamental part of holistic health.

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Emotional and Psychological Treatment of IBS

 

Thakur, E. R., Holmes, H. J., Lockhart, N. A., Carty, J. N., Ziadni, M. S., Doherty, H. K., ... & Lumley, M. A. (2017). Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial. Neurogastroenterology & Motility, 29(12), e13143.

 

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Thakur et al (2017) conducted a randomised three-armed study to compare 

• Emotional Awareness and Expression Training (EAET), 

• Relaxation training 

• And control of no treatment for IBS. 

 

The inclusion criterion was a Rome III diagnosis, and IBS symptoms at least two days per week. Treatment consisted of three, 50-minute weekly sessions plus home practice, involving 106 adults (85% female). Assessments used Irritable Bowel Syndrome Severity Score (IBSSS), Quality of Life (Qol) and Brief Symptom Inventory (BSI) conducted at two weeks, end of treatment and ten week follow-up.

 

Final assessment showed; 

• EAET reduced IBS symptom severity;

• EAET and relaxation training improved quality-of-life; 

• Relaxation training had some effective change in psychological symptoms but surprisingly EAET did not. 

 

EAET is a recent psychological treatment for chronic pain, developed by Howard Schubiner and Mark Lumley, between 2006 and 2011 (Lumley & Schubiner, 2019). EAET works to engage people with their emotions related to previous trauma and stresses in their life. 

 

The researchers were surprised by the failure to reduce psychological symptoms, suggesting that EAET should be tested alongside proven psychological therapies Cognitive Behavioural Therapy (CBT) and/or Acceptance and Commitment Therapy (ACT).

 

This result is disappointing for a new therapy, as stress and anxiety are known to impact negatively on IBS symptoms, though as EAET improved somatic symptoms further adds to the complexity of IBS itself.

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Treatment Guidelines for IBS - British Society of Gastroenterology

 

Vasant, D. H., Paine, P. A., Black, C. J., Houghton, L. A., Everitt, H. A., Corsetti, M., ... & Ford, A. C. (2021). British Society of Gastroenterology guidelines on the management of irritable bowel syndrome. Gut, 70(7), 1214-1240.

 

 

This article by Vasant et al. (2021) covers the recent research between January 2017 and September 2020 to augment the treatment guidelines for the British Society of Gastroenterology. Extensive information including any language, web based resources including Medline, Embase, Embase classic, Cochrane, and global conference proceedings. Included are RCT’s, systematic reviews and network meta-analyses. 

 

Sections covered in research included; 

• Fibre 

• Diet, 

• Probiotics, 

• Drugs, 

• Psychological therapies, 

• Plus drugs and procedures in development such as 5-HT and faecal transplant. 

 

At the end of each results section, are recommendations and comments.  Vasant (2021) also discussed barriers to further irritable bowel syndrome research, notwithstanding a global IBS prevalence and a dissatisfaction of patients about their medical care. There is a lack of funding together with poor design and operation of relevant research to develop new treatments. 

 

A supplementary section gave clearly, tabulated results with recommendations of strong or weak, and quality of evidence, very low, moderate or high were provided. Forrest plots within each treatment modality provided easy to compare results of RCT’s and meta-analyses.

 

In this review, the lack of recent research on accepted drugs used today, gives pause for thought concerning relevance and accuracy of research done twenty or thirty years ago? 

 

The thoroughness of this research makes it a clinical must have for reference for any clinician when treating IBS patients, to understand their medical treatment as it provides an effective visual display for clinicians to quickly evaluate and consider future avenues of therapy, or referrals.

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Comments on Research into IBS Treatments

 

 

This annotated bibliography illustrates the levels of rigor of research into IBS treatments taking a biopsychosocial perspective, when possible informing about patients’ abdominal pain. Vasant et al. (2021) coverage and references are exemplary, providing clarity and update with a full range of drugs and treatments globally as they included research published in all languages. 

 

However Faltinsen et al. (2018) advises careful awareness of methodology of network meta-analyses to direct clinical treatment (Greco et al., 2013; Gurevitch et al, 2018; Ter Schure & Grunwald, 2019). Though lower ranked as evidence Gabb & Ronson (2015) argue that clinical research in the form of observation and case studies inform in a practical way that meta-analyses cannot. 

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In past decades different classifications of IBS have been used.

 

Of clinical importance is the complexity of different classifications of IBS, due to symptomology, compounded by changes in Rome criteria, first developed by committee in 1988, for diagnosis over the past two decades that statistically changes the prevalence of global IBS (Oka et al, 2020). 

 

These changes of criteria illustrate a challenge for clinicians when diagnosis criteria change, as shown throughout the annotated bibliography. The clinical conclusion from this bibliography examines some of the diverse treatments for IBS, drugs, exercise and psychological approaches. As IBS can have such a major impact on lifestyle this creates a need for this diversity that may provide management of symptoms that patients’ desire. 

 

Vasant (2021) admits the failure to develop successful symptomology relief that consequently drives patients to seek help elsewhere. 

 

Research done in Turkey by Gemcioglu et al. (2022) found that 

• 41% patients used herbal treatment. 

• 57% took advice from acquaintances

• 34% from media, 

• only 9% that sought practitioner advice. 

 

Schaper & Stengel (2022) state that mental stress can acerbate IBS symptoms, the reason for including exercise, EAET and CBH as therapies to address psychological components of this functional gastrointestinal disorder. 

 

To compare research findings from the five articles, are like comparing apples with oranges. 

 

Although diversity of research provides information for clinicians working with patients on a daily basis, information from quantitative research to prescribe medication, to qualitative that gives the patients’ viewpoint and to regular case studies that inform on the practical methodology of treatment that RCT’s cannot.

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Further medical research information from American College of Gastroenterology, 2018.

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Thoughts from Natural Pain Solutions

 

Irritable bowel syndrome is complex and although there are many treatments and ideas above living with IBS can be a daily challenge.

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What I, Jean director of NPS, can offer-

• ​information as you can see above, as learning from reliable sources and being informed helps you understand what is happening within your body - helping you make decisions of how you live.

• Sometimes stories of what has happened to others can add to your store of information although remember we're all different, have different experiences and reactions.

• IBS and its associated chronic pain can have likenesses to other chronic pain conditions, we are body, mind and brain. Holistic lifestyle behaviour should be kept in mind - be healthy in all ways.

• There are many articles on this website (increasing each month). Enjoy browsing!

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Some useful resources on Natural Pain Solutions Website

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Self-Help Skills and Techniques for Chronic Pain Relief

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Sign Up for Regular Monthly Blogs

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References

 

Aziz, I., Simrén, M. (2021). The overlap between irritable bowel syndrome and organic gastrointestinal diseases. The Lancet Gastroenterology & Hepatology, 6(2), 139-148. 

Camilleri, M.  Sex as a biological variable in irritable bowel syndrome. Neurogastroenterol Motil.  2020; 32:e13802

 

Faltinsen, E. G., Ole Jakob Storebø, Jakobsen, J. C., Boesen, K., Lange, T., & Gluud, C. (2018). Network meta-analysis: the highest level of medical evidence? BMJ Evidence - Based Medicine, 23(2), 56. 

 

Gabb, G.M. & Ronson,S. (2016). Limitations of meta-analysis, drug safety remain uncertain. Internal medicine Journal, 46(5), 640-641

 

Gemcioglu, E., Cakmak, N. Y., Baser, S., Kocaoz, S., & Ersoy, O. (2022). Factors affecting the use of herbal products in patients with Irritable Bowel Syndrome and their results: case–control study. BMC Gastroenterology, 22, 1-8. 

 

Greco, T., Zangrillo, A., Biondi-Zoccai, G., & Landoni, G. (2013). Meta-analysis: pitfalls and hints. Heart, lung and vessels, 5(4), 219–225.

 

Gurevitch, J., Koricheva, J., Nakagawa, S. et al. Meta-analysis and the science of research synthesis. Nature 555, 175–182 (2018). 

 

Kim, Y. S., & Kim, N. (2018). Sex-Gender Differences in Irritable Bowel Syndrome. Journal of neurogastroenterology and motility, 24(4), 544–558. 

 

Lumley, M.A., Schubiner, H. Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Curr Rheumatol Rep 21, 30 (2019).

 

Ng, Q. X., Soh, A., Loke, W., Lim, D. Y., & Yeo, W. S. (2018). The role of inflammation in irritable bowel syndrome (IBS). Journal of inflammation research, 11, 345–349. 

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Oka, P, Parr, H, Barberio, B (2020) Global prevalence of irritable bowel syndrome according to Rome III or IV criteria: a systematic review and meta- analysis. The Lancet Gastroenterology & Hepatology. ISSN 2468-1253. 

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Schaper, S. J., Andreas Stengel, A. (2022). Emotional stress responsivity of patients with IBS - a systematic review. Journal of Psychosomatic Research, 153, 110694. ISSN 0022-3999. 

 

Ter Schure, J., & Grünwald, P. (2019). Accumulation Bias in meta-analysis: the need to consider time in error control. F1000Research, 8, 962. 

 

https://theromefoundation.org/about/

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