Patients With IBD Prone to Irritable Bowel Syndrome

Ingrid Hein

December 16, 2019

Irritable bowel syndrome can have multiple causes, including inflammatory bowel disease, said William Chey, MD, from Michigan Medicine in Ann Arbor.

Patients who only have irritable bowel symptoms almost never have inflammatory bowel disease, but "once in remission for IBD, 30% to 40% of patients show signs of IBS," he reported. "That's a lot of people."

"I used to say, jokingly, that the gut is the center of the universe," he added, "but as we go from 2019 to 2020, I increasingly believe that it's true."

Both conditions have similar symptoms — including abdominal pain and altered bowel habits — but once inflammatory bowel disease is under control, irritable bowel syndrome can be hot on its heels, Chey said during his keynote speech at Advances in Inflammatory Bowel Disease 2019 in Orlando, Florida.

Unlike inflammatory bowel disease — which is defined by histologic, endoscopic, and imaging findings of inflammation in the gastrointestinal tract — irritable bowel syndrome is a symptom-based diagnosis predicated on bowel pain, he explained.

"The inflammation leads to symptoms; they look the same but they are different. You cannot conflate the two," he told Medscape Medical News.

When calprotectin levels are normal for inflammatory bowel disease patients in remission, "then it's IBS," he said.

"Every Patient Is Different"

Treatment for irritable bowel syndrome needs to be holistic and integrative, said Chey, because "every patient is different."

"More than two-thirds of symptoms are associated with food," he pointed out, so it's important to use deductive reasoning that takes patient history into account.

The first line of action is to improve diet. It is still the most effective modifiable factor for relieving symptoms, but patients need to understand what is healthy.

"There's no mystery to the obvious egregious things" that are not healthy, Chey explained, but there is still confusion about what is healthy. "Beyond more fruits and vegetables, we are falling short on education about nutrition."

People are also not equipped with enough information to achieve a healthy lifestyle, he added. Despite logical explanations, on any given day, one in four individuals is eating fast food.

"That's an astronomical number," he pointed out.

Food affects a variety of physiologic factors — including motility, visceral sensation, brain–gut interactions, the microbiome, permeability, immune activation, and neuroendocrine function — all of which are relevant to the pathogenesis of irritable bowel syndrome, he writes in a review of food and irritable bowel syndrome.

Dietary changes to address irritable bowel syndrome have focused on gluten-free and low fermentable oligo-, di-, monosaccharides, and polyols (FODMAP) diets, but the elimination of certain foods "is the beginning, not the end," Chey explained, citing a systematic review and meta-analysis he was involved with.

Each patient's sensitivities need to be determined, and diet needs to be diversified to improve the microbiome. "Each patient's low-FODMAP diet needs to be personalized," he said.

Lifestyle Changes

The gut is also affected by what's going on in the brain, and lifestyle changes can go a long way, said Chey. Cognitive behavior therapy, relaxation training, dynamic psychotherapy, and hypnotherapy have all been shown to be beneficial for patients with irritable bowel syndrome, according to another systematic review and meta-analysis.

"We talk to our patients and find out where the stress is," he explained. For work-related stress, "we start with behavioral strategies and psychological therapies." The approach with the most evidence is hypnotherapy, as reported by Medscape Medical News.

"These are very helpful for some patients, but not everybody," he said. When these integrative treatments are not enough, pharmacologic options are available.

Treatment with a probiotic supplement — Bimuno, which contains beta-galactooligosaccharide — has also been shown to increase microbiota activity and decrease symptoms.

Glutamine, an alpha amino acid used in the biosynthesis of proteins, was shown to improve intestinal permeability, compared with placebo, in a recent study.

In addition, the "adequate relief" response rate was better with eluxadoline than with placebo in a phase 2 study that Chey was involved with, and rifaximin was effective, well tolerated, and seemed to reduce symptoms during recurrence of irritable bowel syndrome in the open-label TARGET3 study.

"Our patients, relieved to have healing of inflammation, become frustrated that they now have symptoms of IBS that need a different pathway of treatment," said Miguel Regueiro, MD, from the Cleveland Clinic.

And treatment for irritable bowel syndrome is far from straightforward. "About half do well with diet and lifestyle changes," such as improving sleep, adding exercise, reducing stress, and participating in cognitive behavioral therapy, he told Medscape Medical News.

For the other half, "we get into pharmacologic approaches," Regueiro said.

It can take time to find the right treatment for irritable bowel syndrome, said Chey. "We may not be able to completely get rid of all of your symptoms, but we can usually find a solution that helps you to take back control of your life."

Advances in Inflammatory Bowel Diseases (AIBD) 2019. Presented December 12, 2019.

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