Professional Documents
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EDITORIAL
IRRITABLE BOWEL SYNDROME: RECENT PROGRESS IN
PATHOPHYSIOLOGY, DIAGNOSIS AND MANAGEMENT?
Eamonn M M Quigley, Aamir Ghafoor Khan*
Professor of Medicine and Human Physiology, Head of the Medical School, National University of Ireland, Cork; *Department of
Gastroenterology and Hepatology, Postgraduate Medical Institute, Khyber Medical University, Peshawar.
Irritable bowel syndrome (IBS) is one of the most more study is required on this issue. Very recent studies,
common of all medical disorders, whether surveyed in using molecular techniques, have, not only begun to reveal
the community, in a primary care practice or at a the true diversity of the intestinal microbiota, but have
specialist gastroenterology referral centre.1,2 Its begun to establish, on a firmer footing, differences
prevalence has long been appreciated in the West; what between IBS and control subjects.7 Even more
is new is a recent accumulation of evidence to indicate controversial has been the suggestion that a significant
that IBS is also highly prevalent in the East and even in proportion of the IBS population harbour bacterial
developing nations like Pakistan.3,4 These same studies overgrowth in their small intestines and that they can
have also revealed some interesting differences in expect a significant symptomatic response to course of
demographics and mode of presentation between East antibiotics.8 Critics of this hypothesis have drawn attention
and West. Thus, female predominance, a hallmark of IBS to the poor specificity of the test (the lactulose breath
in Europe and North America, is not as striking in the hydrogen test) used to diagnose bacterial overgrowth in
East and may not even exist in certain countries, where these studies, to the non-specificity of gastrointestinal
male IBS subjects may be in the majority. Furthermore, symptoms, in general, and to the far from spectacular
symptom patterns may vary, with lower abdominal pain response to antibiotic therapy.9,10 Furthermore, others have
and a preoccupation with bowel habit being the foremost failed to reproduce this finding. This is an important issue,
pattern in the West, whereas upper abdominal symptoms as the prospect of long-term, or even repeated, courses of
are common in the East where sufferers also seem less antibiotics to subjects with a disorder as chronic and
exercised about bowel dysfunction. The latter reminds us relapsing as IBS, is a cause for some considerable concern.
of the importance of overlap with another functional The inflammatory concept, in contrast, continues to gather
disorder, functional or non-ulcer dyspepsia (FD). Some, momentum. It began with the demonstration, in biopsy
indeed, would refer to evidence such as this to emphasise material from the rectum, colon and ileum, of evidence of
the degree of overlap between these conditions and increased numbers of a variety of cells (lymphocytes, mast
would question whether FD, a disorder which has proven cells) known to participate in an inflammatory response
difficult to define clinically, is really a distinct entity but and to produce cytokines and other biologically active
rather a part of the spectrum of IBS, a much more substances that could modulate enteric nerve and muscle
accepted clinical entity.5 function.11 Since then, others have gone on to demonstrate
While research continues, in a variety of areas, elevated levels of pro-inflammatory cytokines in the
on the pathophysiology of IBS, work on a possible peripheral blood of IBS patients and have even suggested
inflammatory component to IBS is currently attracting the that some IBS patients may be genetically predisposed to
greatest attention. Three principal strands of evidence have develop a low-grade, but sustained, inflammatory response
been explored: the role of enteric infection in initiating IBS to certain stimuli, including those that may originate in the
(post-infectious IBS, or PI-IBS), the possibility that lumen itself.12-14 In this way, a luminal stimulus could
alterations, be they quantitative or qualitative, in the enteric initiate a local inflammatory response in the colon or small
flora might be relevant to the genesis of symptoms in IBS intestine and, through the local or systemic release of
and, finally, the suggestion that low-grade inflammation cytokines, generate the motor (“spasm”), sensory (visceral
and immune activation may be a fundamental abnormality hypersensitivity and hyperalgesia) and mucosal responses
in IBS. With regard to the former, there is now an that typify IBS. It is also feasible, based on evidence from
overwhelming body of epidemiological and clinical data to animal models as well as from man, to reconcile these
support the concept of PI-IBS, an entity that clinicians “inflammatory” findings with more central {aberrant
have recognised for decades.6 Though the risk of cerebral activation and disturbances in the hypothalamic-
developing PI-IBS following an episode of bacterial pituitary-adrenal (HPA) axis} and even systemic
gastroenteritis is low, afflicted patients may endure disturbances (fatigue, fibromyalgia) associated with IBS.
prolonged and significant IBS-type symptoms and may Whether these linkages between inflammation and other
exhibit an associated persistent inflammatory response in physiological perturbations represent mere associations or,
the rectal mucosa. Over the years a number of studies have indeed, even epiphenomena, or are truly causal remains to
suggested that the colonic (or, more correctly, the faecal be determined. For now, these findings have raised the
flora) flora may demonstrate quantitative changes in IBS; possibility that a targeted anti-inflammatory approach may
studies on the faecal flora in IBS have, however, provided ameliorate symptoms or even cure IBS is tantalizing one;
variable results, one of the few consistent findings being an evidence with a probiotic (Bifdobacterium infantis infantis
apparent suppression of the population of bifidobacteraia. 35624) with potent anti-inflammatory properties suggests
Given the limitations of faecal sampling as a reflection of that journeys down this therapeutic avenue may prove
the colonic flora and of current culture techniques, per se, productive.12
http://www.ayubmed.edu.pk/JAMC/PAST/21-1/Editorial.pdf 1
J Ayub Med Coll Abbottabad 2009;21(1)
2 http://www.ayubmed.edu.pk/JAMC/PAST/21-1/Editorial.pdf