Schmerztherapie beim Reizdarmsyndrom

Irritable bowel syndrome (IBS) is one of the most common gastrointestinal diseases. It is characterized by chronic abdominal pain, typically associated with altered bowel habits that cannot be explained by structural abnormalities in routine diagnostic workup. Based on the predominant symptom, IBS can be divided into different subtypes: IBS with predominant constipation, diarrhea, bloating, or pain. Knowledge about the complex and multifactorial IBS pathophysiology has increased tremendously in recent years, e.g., IBS may be related to alterations in gastrointestinal motility, visceral sensitivity, and the mucosal immune system. It is important, both for the patient and the physician, that IBS diagnosis is made quickly and thoroughly based on the typical symptom complex and exclusion of relevant differential diagnoses and to reassure the patient that IBS is a chronic, but benign disease. These components are the fundamental basis for a good patient–physician relationship and for a successful long-term management of this potentially very compromising disorder. IBS therapy is based on general measures as well as symptom-oriented medical therapy, where improvement of abdominal pain is one of the main goals in treating IBS patients. Several pain treatment options are available, which may be used long-term or on demand and which may be combined with other therapies. General medical approaches include antispasmodics, improvement of bowel function, phytotherapy, and probiotics. Especially in patients with psychological comorbidities, antidepressants may be used. Modern drug treatments include the GC-C agonist linaclotide in IBS with predominant constipation, the locally acting antibiotic rifaximin in IBS with bloating, and 5-HT3 antagonists in IBS with predominant diarrhea. Psychotherapy should be included in an interdisciplinary approach in refractory cases or in psychological comorbidity.     

Use of Rome III criteria for diagnosing irritable bowel syndrome

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders(FGIDs) characterized by chronic abdominal pain or discomfort, which is associated with changes in stool frequency and/or form. Rome II criteria for IBS was used widely in research and practice. Besides, Rome III criteria was recently published. Because IBS is a frequent disease, the spread of Rome III criteria will play an important role of pathophysiological study and new therapy in gastrointestinal medical care.     

Education to the patients of irritable bowel syndrome: diet and lifestyle advice

Irritable bowel syndrome (IBS) is a functional gastrointestinal illness. In spite of its benign nature, we should pay much attention to IBS because of its huge negative impacts on 'quality of life', not only for mental or physical pain and medical expenses but also for significant social and job-related consequences. The treatment of IBS is based on the guidelines of the Ministry of Health, Labour and Welfare in Japan, with a proper physician-patient rapport. At the first step in these guidelines, physicians should advise IBS patients about their diet and lifestyle according to their main symptoms. It is also essential for the physicians to educate the patients properly, which relieves the symptoms in many cases without any cost involvement and untoward side effects.     

Irritable bowel syndrome in children

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects children and adolescents. The recent development of the Rome diagnostic criteria and brain-gut pathways have greatly advanced the field. The child with IBS is best evaluated and treated in the context of a biopsychosocial model of care to relive symptoms and disability. Additional research is needed to develop drugs to modulate abnormalities in sensorimotor function of the enteric nervous system in IBS and relive specific symptoms and to assess the proper role of these drugs in the treatment of children and adolescents.     

The spectrum of irritable bowel syndrome: A clinical review

BACKGROUND: Irritable bowel syndrome (IBS) is associated with a substantial burden on individual patients, health care systems, and society as a whole. OBJECTIVES: This review article provides an overview of the disease state and discusses treatment options. METHODS: The MEDLINE database was searched for original research and review articles published in English (from 1966 to July 2005) using the medical subject heading irritable bowel syndrome and the following subheadings: diagnosis, economics, pathophysiology, and therapy. Preference was given to articles that focused on new insights regarding pathophysiology and to those that addressed global symptom improvement for IBS. RESULTS: Symptoms of IBS vary with each patient and disease episode. Although improvement in individual IBS symptoms is desirable, the overall goal in managing patients with IBS is to achieve global symptom improvement. Traditional IBS therapies (ie, psychotherapy/behavioral therapy, bulking agents, antidiarrheals, antispasmodics, and tricyclic antidepressants) have lacked demonstrable efficacy in randomized controlled trials. Recent improvements in the understanding of IBS pathophysiology, particularly regarding the role of neurotransmitters and hormones in gastrointestinal motility, secretion, and visceral perception, have resulted in the development of novel treatments for IBS. In clinical trials, IBS-specific treatments (ie, agents that affect serotonergic pathways) have been associated with significant improvements in global symptoms. However, the added cost of treatment with these agents and the potential risks of serious adverse events (eg, severe constipation, severe diarrhea, ischemic colitis) may preclude their widespread use. Initial cost-effectiveness analyses with the novel IBS-specific agents suggest the benefits may outweigh the added costs. From a managed care perspective, the costs incurred by IBS-specific therapies may be offset by subsequent reductions in health care resource utilization by patients with IBS. CONCLUSIONS: IBS-specific agents offer an opportunity for patients with IBS to achieve global symptom improvement. However, when weighing the costs and potential risks against the potential benefits, clinicians should consider the nature and severity of the patient's symptoms, the degree of functional impairment, and the presence of psychosocial comorbidities.     

Hypnosis for irritable bowel syndrome: the empirical evidence of therapeutic effects

Irritable bowel syndrome (IBS) is a complex and prevalent functional gastrointestinal disorder that is treated with limited effectiveness by standard medical care. Hypnosis treatment is, along with cognitive-behavioral therapy, the psychological therapy best researched as an intervention for IBS. Eleven studies, including 5 controlled studies, have assessed the therapeutic effects of hypnosis for IBS. Although this literature has significant limitations, such as small sample sizes and lack of parallel comparisons with other treatments, this body of research consistently shows hypnosis to have a substantial therapeutic impact on IBS, even for patients unresponsive to standard medical interventions. The median response rate to hypnosis treatment is 87%, bowel symptoms can generally be expected to improve by about half, psychological symptoms and life functioning improve after treatment, and therapeutic gains are well maintained for most patients for years after the end of treatment.     

Irritable bowel syndrome: Quality of life and nursing interventions

Irritable bowel syndrome (IBS) is a functional bowel disorder. It is one of the most common gastrointestinal diseases diagnosed in medical practice and can account for up to 50% of referrals to gastroenterology outpatient clinics. IBS remains a poorly understood and mysterious medical condition. Individuals can suffer from abdominal pain and abnormal bowel function for unexplained reasons and the impact of these symptoms can have a detrimental affect on health-related quality of life. In this article the incidence, causes, diagnosis and management of IBS are addressed. Specific attention is given to the nursing role in the management of this chronic condition.     

Endocannabinoids and pregnancy

Acylethanolamides such as anandamide (AEA), and monoacylglycerols like 2-arachidonoylglycerol are endocannabinoids that bind to cannabinoid, vanilloid and peroxisome proliferator-activated receptors. These compounds, their various receptors, the purported membrane transporter(s), and related enzymes that synthesize and degrade them are collectively referred to as the “endocannabinoid system (ECS)”. Poorly defined cellular and molecular mechanisms control the biological actions of the ECS. Over the last decade evidence has been emerging to suggest that the ECS plays a significant role in various aspects of human reproduction. In this review, we summarize our current understanding of this role especially the involvement of AEA and related ECS elements in regulating oogenesis, embryo oviductal transport, blastocyst implantation, placental development and pregnancy outcomes, and sperm survival, motility, capacitation and acrosome reaction. Additionally, the possibility that plasma and tissue AEA and other cannabinoids may represent reliable diagnostic markers of natural and assisted reproduction and pregnancy outcomes in women will be discussed.     

Cannabinoids: Medical implications

Herbal cannabis has been used for thousands of years for medical purposes. With elucidation of the chemical structures of tetrahydrocannabinol (THC) and cannabidiol (CBD) and with discovery of the human endocannabinoid system, the medical usefulness of cannabinoids has been more intensively explored. While more randomized clinical trials are needed for some medical conditions, other medical disorders, like chronic cancer and neuropathic pain and certain symptoms of multiple sclerosis, have substantial evidence supporting cannabinoid efficacy. While herbal cannabis has not met rigorous FDA standards for medical approval, specific well-characterized cannabinoids have met those standards. Where medical cannabis is legal, patients typically see a physician who “certifies” that a benefit may result. Physicians must consider important patient selection criteria such as failure of standard medical treatment for a debilitating medical disorder. Medical cannabis patients must be informed about potential adverse effects, such as acute impairment of memory, coordination and judgment, and possible chronic effects, such as cannabis use disorder, cognitive impairment, and chronic bronchitis. In addition, social dysfunction may result at work/school, and there is increased possibility of motor vehicle accidents. Novel ways to manipulate the endocannbinoid system are being explored to maximize benefits of cannabinoid therapy and lessen possible harmful effects.

• Key messages

• The medical disorders with the current best evidence that supports a benefit for cannabinoid use are the following: multiple sclerosis patient-reported symptoms of spasticity (nabiximols, nabilone, dronabinol, and oral cannabis extract), multiple sclerosis central pain or painful spasms (nabiximols, nabilone, dronabinol, and oral cannabis extract), multiple sclerosis bladder frequency (nabiximols), and chronic cancer pain/neuropathic pain (nabiximols and smoked THC).

• Herbal cannabis has not met rigorous US FDA standards for medical approval, while specific well-characterized cannabinoids have met those standards, and more are being studied. However, herbal cannabis is legal for medical use in certain US states/countries, and patients must usually see a physician who “certifies” that a benefit may result. Participating physicians should be knowledgeable about cannabinoids, closely look at the risk/benefit ratio, and consider certain important criteria in selecting a patient, such as: age, severity, and nature of the medical disorder, prior or current serious psychiatric or substance use disorder, failure of standard medical therapy as well as failure of an approved cannabinoid, serious underlying cardiac/pulmonary disease, agreement to follow-up visits, and acceptance of the detailed explanation of potential adverse risks.

• The limitations of use of medical cannabis include the following potential adverse effects that are discussed with potential patients: acute central nervous system effects such as deficits in memory, judgment, attention, coordination, and perception (such as time and color), anxiety, dysphoria, and psychosis; chronic central nervous system effects such as cannabis use disorder, cognitive and memory deficits, and increased risk of psychosis; pulmonary effects such as chronic bronchitis; social dysfunction, such as work/school; increased risk of accidents, such as motor vehicle accidents; and preliminary data suggest possible risk for acute cardiovascular event, especially with underlying heart disease.

• The normal human endocannabinoid system is important in the understanding of such issues as normal physiology, cannabis use disorder, and the development of medications that may act as agonists or antagonists to CB1 and CB2. By understanding the endocannabinoid system, it may be possible to enhance the beneficial effects of cannabinoid-related medication, while reducing the harmful effects.

     

Medical cannabis education among healthcare trainees: A scoping review

ObjectivesIt has been previously demonstrated that healthcare professionals would like additional education on medical cannabis. However, there has not yet been a review of the status of medical cannabis curriculum for medical and allied healthcare trainees worldwide, even though future healthcare workers will be placed on the forefront of patient care and must be prepared to counsel patients. This study was designed to address this gap in knowledge.DesignA search syntax was generated and databases PubMed, ERIC, CINAHL, and Web of Science were searched for relevant articles. A grey literature search of Google Scholar, MedEd, Medline, and the Proquest Dissertations and Theses section was also performed. All titles and abstracts were screened. Selected articles were subsequently screened using predetermined inclusion and exclusion criteria.ResultsAllied healthcare trainees lacked sufficient knowledge about medical cannabis and did not feel prepared to counsel patients on this subject. Additionally, they expressed a growing interest in medical cannabis and would like more standardized education on the topic. Finally, faculty and deans in various institutions agreed on the need to educate students on the subject, and aimed to implement courses on medical cannabis or expand their existing curricula.ConclusionsWhile the medical cannabis landscape is developing, medical and allied health students are not properly educated and knowledgeable on this emerging field of clinical care. The findings suggest that the implementation of competencies-based curricula on medical cannabis is essential for medical and allied healthcare trainees to have the appropriate level of knowledge to counsel and educate their patients.     

In vivo real-time endocytoscopic visualization of blood flow in rectal microvasculature

Endocytoscopy (ECS) is a new technology that enables endoscopists to visualize gastrointestinal mucosa at the cellular level. This reported case demonstrates the ability to visualize real-time blood flow utilizing ECS. Methylene blue dye was sprayed onto normal rectal mucosa during a routine screening colonoscopy of an asymptomatic patient. High-magnification views of colonic mucosa revealed normal mucosal cellular structure and microvasculature with normal flow of red blood cells. Individual red blood cells were seen circulating through the arterioles. Epithelial colonocytes appeared to be organized in a hexagonal pattern around crypts with borders demarcated by microvasculature. ECS can provide high-magnification views of the gastrointestinal mucosa including microvasculature in real time. This establishes possibilities for future in vivo research in areas such as cancer biology, angiogenesis, and inflammatory bowel disease.     

Probiotics,prebiotics, and low FODMAP diet for irritable bowel syndrome – What is the current evidence?

Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders worldwide. While the pathogenesis is not clearly understood, current research points to the role of the gut microbiome and alterations in the diversity of the microbiota. Probiotics, prebiotics, and low FODMAP diet are therapeutic means associated with modification of the gut microbiome for the alleviation of IBS symptoms.This narrative review assesses the current evidence on the efficacy of these treatment options based on findings from recent systematic reviews and meta-analyses published from October 2013 to October 2018.There is a general agreement in the 11 included systematic reviews and meta-analyses that probiotic therapy is safe and can be effective in improving overall IBS symptom scores and abdominal pain in the general IBS population. Nonetheless, conflicting findings remain and no recommendation on the specific species/strains or combination can be made.Short-term restriction of FODMAP in the diet can improve IBS symptoms as per the findings of 7 systematic reviews and meta-analyses, even though the quality of the evidence remains questionable. Inappropriate use of the low FODMAP diet can potentially impact health negatively. As such, a low FODMAP diet is only recommended as a second line treatment guided by qualified clinicians with specialized training.Despite preclinical studies of some prebiotics demonstrated the potential use in improving gut microbiome and intestinal inflammatory response, the beneficial effect of prebiotics for IBS remains theoretical. Two systematic reviews found no evidence to support the clinical use of prebiotics for IBS.     

Crohn’s disease diagnosis,treatment approach,and management paradigm: what the radiologist needs to know

Crohn’s disease is one of the major subtypes of idiopathic inflammatory bowel disease and is characterized by chronic transmural intestinal inflammation of the gastrointestinal tract anywhere from mouth to the anus, with a predilection for the small bowel. Cross-sectional imaging with computed tomography and magnetic resonance enterography plays a key role in confirming diagnosis, identifying and managing complications, assessing disease severity, and identifying response to medical therapy. This review will focus on the role of radiologists in the diagnosis and assessment of Crohn’s disease. Additionally, a review of current medical therapy approaches, available medications, and side effects will be discussed. The review will also highlight key complications of medical therapy and associated diseases that should be evaluated by the radiologist with cross-sectional imaging.

     

肠易激综合征的脑功能磁共振成像研究进展

肠易激综合征（IBS）是一种慢性功能性肠胃病,其发病率高、症状易反复,严重影响患者的生活和工作。fMRI研究发现IBS多个脑区活动存在异常,分析IBS各亚型活动异常脑区特征对完善其诊疗流程具有重要意义。本文对fMRI技术在IBS及其亚型中的应用进行综述。     

Probiotic agents in the treatment of irritable bowel syndrome

Irritable bowel syndrome (IBS) is characterized by abdominal pain and alterations in bowel habits. Several pathogenetic factors, such as altered intestinal motility, visceral hypersensitivity, serotonin system abnormalities and psychic disturbances have been identified. Recently, a pathogenetic role of intestinal microflora has been shown in IBS: viral or bacterial infection can trigger post-infectious IBS; some patients have small intestinal bacterial overgrowth; the composition of patients' enteric flora is altered; and minimal inflammatory changes, consistent with the pro-inflammatory role of bacteria, have been demonstrated. Probiotics may, therefore, offer a rational therapeutic approach to IBS. The data available on the use of probiotics in IBS are still limited and results of controlled clinical trials are contradictory because they have been performed using different species, dosages, treatment durations and end-points for results evaluation. A critical evaluation of the therapeutic role of the various probiotics in IBS is presented in this article.     

Impact of sex and gender on irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common functional bowel disorder characterized by abdominal pain and change in defecation pattern. This review addresses the topic of possible sex (genetic, biological) and gender (experiential, perceptual) differences in individuals with and without IBS. Several observations make the topic important. First, there is a predominance of women as compared to men who seek health care services for IBS in the United States and other industrialized societies. Second, menstrual cycle-linked differences are observed in IBS symptom reports. Third, women with IBS tend to report greater problems with constipation and nongastrointestinal complaints associated with IBS. Fourth, serotonin (5-HT3) receptor antagonist and 5-HT4 partial agonist drugs appear to more effectively diminish reports of bowel pattern disruption in women with IBS as compared to men. This review examines sex and gender modulation of gastrointestinal motility and transit, visceral pain sensitivity, autonomic nervous system function, serotonin biochemistry, and differences in health care-seeking behavior for IBS.     

Wirksamkeit,Verträglichkeit und Sicherheit von Cannabinoiden in der Gastroenterologie

Background

The medical use of cannabis is discussed in gastroenterology for inflammatory bowel diseases (IBD), irritable bowel syndrome (IBS), and chronic pancreatitis.

Materials and methods

A systematic literature search until March 2015 was performed in the databases Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, www.cannabis-med.org, and clinicaltrials.gov. Randomized controlled trials (RCT) investigating herbal cannabis and/or pharmaceutical cannabinoids in IBD, IBS, or chronic pancreatitis with a study duration of ≥?4 weeks and a sample size of at least n?=?10 per study arm were identified. Clinical outcomes comprised efficacy (pain, nausea, appetite/weight, diarrhea, health-related quality of life, and remission rates for IBD), tolerability (drop-out rate due to side effects), and safety (severe side effects). Methodology quality of RCTs was evaluated with the Cochrane Risk of Bias Tool.

Results

Only one RCT treating 21 patients with Crohn’s disease and herbal cannabis was identified. The study revealed no significant differences of remission rate because of low statistical power. However, there was a clear tendency for less abdominal pain and improved appetite with medical cannabis. The methodological risk of the study was high. Furthermore, results of two RCTs investigating synthetic cannabis in IBD and chronic pancreatitis, respectively, have not yet been released. No RCT for IBS was found. Several case reports described cannabis-induced acute pancreatitis.

Conclusions

Cannabis may be useful for symptom relief in Crohn’s disease such as pain, nausea, and loss of appetite. However, studies with high methodological quality, sufficient sample size, and study duration are mandatory to determine potential therapeutic effects and risks of cannabis in gastroenterology. Currently, use of tetrahydrocannabinol to alleviate symptoms such as pain and appetite loss in Crohn’s disease should only be considered in individual patients after failure of established medical therapies and only after careful risk–benefit assessment.

     

Psychobiologische Mechanismen bei der Pathophysiologie chronischer viszeraler Schmerzen

Although visceral pain is of high clinical relevance, it remains poorly understood especially when compared to somatic pain. Nevertheless, interdisciplinary research approaches bridging psychophysiology and neurogastroenterology have contributed to a more refined knowledge about the complex peripheral and central mechanisms of the bidirectional brain-gut axis in recent years. This review summarizes current knowledge regarding psychobiological mechanisms in the pathophysiology of chronic visceral pain in functional gastrointestinal disorders with a focus on irritable bowel syndrome (IBS). Special attention is paid to the role of affective disturbances and emotions, particularly psychological stress as well as to influences of cognition and learning on gastrointestinal motor and sensory functions in healthy individuals and patients with IBS. In this emerging field of research, new evidence from the fields of placebo research and pain-related fear conditioning provide new insights into the psychological and neurobiological mechanisms involved in the transition from acute to chronic pain and the maintenance of pain. This opens up new perspectives for innovative treatment approaches for IBS and other functional gastrointestinal disorders.     

The irritable bowel syndrome

Symptoms of IBS are very prevalent. One quarter of symptomatic individuals present for medical care because of symptom severity and psychologic factors. The pathogenesis of IBS is multifactorial, involving abnormalities in the gut, immune system, enteric sensory and motor nerves, and the CNS. IBS is diagnosed by symptomatology according to the Rome criteria and the absence of alarm findings suggestive of organic disease. Minimal testing is advocated to confirm the diagnosis in patients presenting with typical symptoms. Therapy is based on the dominant symptom (IBS subtype). Therapeutic options include dietary modifications, counseling, medications, and psychologic treatments. Novel therapies are being investigated to correct potentially pathogenetic peripheral and CNS abnormalities in IBS.