Summary Background The pathogenesis of irritable bowel syndrome (IBS) is founded on interactive mechanisms. Disentangling these processes is a prerequisite for the development of effective drug therapy. Aim To identify the interaction between the various factors implicated in IBS. Methods Articles pertaining to IBS pathogenesis focusing on psychoneuroimmunology were identified using following search terms: IBS, animal models, microbiota, probiotics, immunology, visceral hypersensitivity, imaging, psychology and visceral pain. Results Cerebral imaging using MRI and proton emission tomography scanning has revealed differential regional cerebral activation, whereas stimuli induced activation has been captured by both MRI and cortical evoked potentials. At the peripheral neurological level, the concept of visceral hypersensitivity has been challenged as perhaps representing psychological traits with symptom over‐reporting or hyper‐vigilance. Gut mucosal immunology is thought to be relevant with immunological changes reflected as peripheral blood cytokine level changes. Molecular technology advances suggest a role for microbiota by activating the gut immunological system. These interactions have been examined in IBS animal models. Conclusions Translation of animal model findings to humans is needed to link the various psychological, neurological and immunological changes noted in IBS. This analysis may identify patient sub‐groups, which will ultimately be critical for drug testing to be focused accordingly.
Percutaneous endoscopic colostomy (PEC) is a minimally invasive endoscopic procedure that offers an alternative treatment for high-risk patients with sigmoid volvulus or intestinal pseudo-obstruction who have tried conventional treatment options without success or those who are unfit for surgery. The procedure acts as an irrigation or decompressing channel and provides colonic ‘fixation’ to the anterior abdominal wall. The risk of complications highlights the importance of informed consent for patients and relatives.
The objective of this study was to determine whether cortical evoked potentials (CEPs) can define neurophysiological patterns in irritable bowel syndrome (IBS). In this prospective study of consecutive patients attending secondary and tertiary centers, patients with Rome II-defined IBS underwent rectal sensory and pain threshold (RST and RPT, respectively) testing with electrical stimulation on three separate visits. CEPs were collated for 75% pain thresholds, and anxiety [Spielberger State-Trait Anxiety Inventory (SSTAI)] questionnaires were completed. Subjects were 33 IBS patients (27 female, mean age 40.1 yr) and 21 healthy controls (14 female, mean age 31.4 yr). At visit 3, RPT was significantly lower [mean (95% CI)] in IBS patients than in control subjects: 58.2 mA (48.0-68.5) vs. 79.5 mA (69.3-89.6) (P < 0.01). No significant differences were observed in CEP latencies and amplitudes between visits 1, 2, and 3 within each group, except P2 latency for controls (P = 0.04) and N2 latency (P = 0.04) and N2 amplitude (P = 0.02) for IBS patients. Group comparisons showed significant differences in 3-day mean RPT, CEP amplitudes, and CEP latencies between IBS patients and controls. RPT <50 mA and P1 latency >106 ms were identified four IBS subgroups: 24% were hypersensitive, 12% were hypervigilant, 15% were hyposensitive, and 49% exhibited normal P1 latency and pain threshold. CEPs are reliable and reproducible measures of early sensory processing. Identification of four IBS neurophysiological patterns highlights its heterogeneous nature. These findings mark the first step toward personalized medicine in IBS, whereby therapy may be directed at the underlying physiological process.
IntroductionThe BSG guidelines1 recommend that every endoscopy unit in an acute hospital setting should provide a basic percutaneous endoscopic gastrostomy (PEG) service, which is a part of the nutritional support team. The service should provide a framework for patient selection, pre-assessment and post-procedural care as well as working closely with the community-based services. Our trust recently appointed an accredited therapeutic endoscopist and gastroenterology nurse practitioner to run this service.MethodsRetrospective analysis of all PEG insertions performed from Jan 2014 to Nov 2015 over a 23 month period. We looked at early-term (four weeks) and late term (eight weeks) mortality after PEG insertion.ResultsAll patients were referred via a revised pathway proforma and examined by the team before the procedure to assess suitability. Further help and advice is offered to the community team upon discharge. 71 patients were referred for PEG insertion during the period of study. 29 (41%) were male, with a mean age 68 (range 29–87 years), 42 (59%) were female, with a mean age 69 (range 18–93 years). Indications for referrals included: 37 (52%) stroke related dysphagia, 15 (21%) head and neck cancers, 6 (8.5%) Huntington’s disease, 4 (5.6%) traumatic head injury, 3 (4.2%) learning disability, 2 (2.8%) cerebral palsy, 2 (2.8%) multiple sclerosis, 1 (1.4%) supranuclear palsy, 1 (1.4%) mitochondrial myopathy, 1 (1.4%) syringomyelia, 1 (1.4%) parkinsonism, 1 (1.4%) Korsakoff’s psychosis, and 1 (1.4%) myoclonic epilepsy with ragged-red fibres (MERRF) syrdrome. Patients with a formal diagnosis of dementia were not selected to undergo PEG insertion during this period. No short-term complications were reported post-insertion.Early-term mortality was 12.7% and late-term rose to 22.5%. Previous departmental audit in 2014 revealed early-term mortality of 20% and late-term mortality of 28%.ConclusionMeta-analysis has reported a 19% 30 day mortality following PEG insertion. 3We have shown that in our centre, both early and late-term mortality has improved due to careful patient selection and a dedicated PEG service. Adherence to the BSG guidelines on PEG service has had a direct impact on improving mortality and clinical outcome.References1 Westaby D, Young A, O’Toole P, Smith G, Sanders DS. The provision of a percutaneously placed enteral tube feeding service. Gut. 2010;59:1592–1605. doi:10.1136/gut.2009.2049822 Johnston S, Tham T, Mason M. Death after PEG: results of the national confidential enquiry into patient outcome and death. Gastrointestinal Endoscopy 2008;68:223–7.3 Mitchell SL, Tetroe JM. Survival after percutaneous endoscopic gastrostomy placement in older persons. J Gerontol A Biol Sci Med Sci 2000;55:M735–9.Disclosure of InterestNone Declared
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