Functional gastrointestinal disorders in inflammatory bowel disease: Time for a paradigm shift?

Recent advances in biological therapies have revolutionalised and redefined treatment targets in inflammatory bowel disease(IBD).There is now a stronger emphasis on achieving the more stringent therapeutic goals of mucosal and histological healing,rather than clinical remission alone.Consequently,the treatment of refractory“functional”gastrointestinal symptoms,often attributed as the aftermath of previous inflammation,has recently become more prominent in quiescent disease.With further expected advances in anti-inflammatory treatments on the horizon,the burden of such symptoms in quiescent disease,which have been relatively neglected,is set to become an even bigger problem.In this article,we highlight the current state of research and understanding in this field,including recent developments and clinical practice guidelines on the diagnosis and management of functional gastrointestinal symptoms,such as irritable bowel syndrome and functional anorectal and pelvic floor disorders,in patients with quiescent IBD.These disorders are not only highly prevalent in these patients,they are often misdiagnosed,and are difficult to treat,with very few evidence-based therapies.Moreover,they are associated with substantial impairment in quality-of-life,considerable morbidity,and psychological distress.There is therefore an urgent need for a change in emphasis towards earlier recognition,positive diagnosis,and targeted treatment for patients with ongoing functional gastrointestinal symptoms in the absence of active IBD.This article also highlights the need for further research to develop much needed evidence-based therapies.

Non-alcoholic fatty liver disease in irritable bowel syndrome:More than a coincidence?

Irritable bowel syndrome(IBS)and non-alcoholic fatty liver disease(NAFLD)are amongst the most common gastrointestinal and liver conditions encountered in primary and secondary care.Recently,there has been interest in the apparent coincidence of NAFLD in patients with IBS mainly driven by improved understanding of their shared risk factors and pathophysiology.In this paper we summarize the shared risk factors which include;overlapping nutritional and dietary factors as well as shared putative mechanisms of pathophysiology.These include changes in the gut microbiome,gut permeability,immunity,small bowel bacterial overgrowth and bile acid metabolism.This paper describes how these shared risk factors and etiological factors may have practical clinical implications for these highly prevalent conditions.It also highlights some of the limitations of current epidemiological data relating to estimates of the overlapping prevalence of the two conditions which have resulted in inconsistent results and,therefore the need for further research.Early recognition and management of the overlap could potentially have impacts on treatment outcomes,compliance and morbidity of both conditions.Patients with known IBS who have abnormal liver function tests or significant risk factors for NAFLD should be investigated appropriately for this possibility.Similarly,IBS should be considered in patients with NAFLD and symptoms of abdominal pain associated with defecation,an altered bowel habit and bloating.