Probiotic effects on intestinal fermentation patterns in patients with irritable bowel syndrome

AIM: To determine whether Lactobacillus casei strain Shirota (Yakult ) can alter small intestinal bacterial overgrowth (SIBO), as tested by the lactulose breath test, and whether this is associated with changes in symptoms in irritable bowel syndrome (IBS). METHODS: 18 patients with IBS (Rome Ⅱ criteria), who showed an early rise in breath hydrogen with lactulose (ERBHAL), consumed 65 mL of Yakult daily for 6 wk. Lactulose breath test was repeated at the end of the treatment period. Symptoms were recorded daily using a 10 cm visual analogue scale. RESULTS: 14 patients completed the study, 9 (64%) had reversal of ERBHAL, with the median time of f irst rise in breath hydrogen increasing from 45 to 75 min (P = 0.03). There was no signifi cant improvement in the symptom score with probiotic therapy, except for wind (P=0.04). Patients commencing with at least moderate symptoms and who no longer had ERBHAL at the end of treatment, showed improvement in the overall symptoms scores [median fi nal score 5.3 (IQR3.9-5.9), 55% reduction; n=6] to a greater extent than those who had had persisting ERBHAL [final score 6.9 (5.0-7.0), 12% reduction; n = 5; P = 0.18]. CONCLUSION: Yakult is effective in altering fermentation patterns in the small bowel, consistent with reducing SIBO. The loss of ERBHAL was associated with reduced symptoms. The true interpretation of these fi ndings awaits a randomised, controlled trial.

Time to clinical response and remission for therapeutics in inflammatory bowel diseases: what should the clinician expect, what should patients be told?

An awareness of the expected time for therapies to induce symptomatic improvement and remission is necessary for determining the timing of follow-up, disease(re)assessment, and the duration to persist with therapies, yet this is seldom reported as an outcome in clinical trials. In this review, we explore the time to clinical response and remission of current therapies for inflammatory bowel disease(IBD) as well as medication, patient and disease related factors that may influence the time to clinical response. It appears that the time to therapeutic response varies depending on the indication for therapy(Crohn's disease or ulcerative colitis). Agents with the most rapid time to clinical response included corticosteroids, calcineurin inhibitors, exclusive enteral nutrition, aminosalicylates and anti-tumor necrosis factor therapy which will work in most patients within the first 2 mo. Vedolizumab,methotrexate and thiopurines had a longer time to clinical response and can take several months to achieve maximal efficacy. Factors affecting the time to clinical response of therapies included use of concomitant therapy, disease duration, smoking status, disease phenotype and advanced age. There appears to be marked variation in time to clinical response for therapies used in IBD which is further influenced by disease and patient related factors. Understanding the expected time to therapeutic response is integral to inform further decision making, maintain a patientcentered approach and ensure treatment is given an appropriate timeframe to achieve maximal benefit prior to cessation.

Food,fibre,bile acids and the pelvic floor: An integrated low risk low cost approach to managing irritable bowel syndrome

Patients presenting with abdominal pain and diarrhea are often labelled as suffering from irritable bowel syndrome,and medications may be used often without success. Advances in the understanding of the causes of the symptoms(including pelvic floor weakness and incontinence,bile salt malabsorption and food intolerance) mean that effective,safe and well tolerated treatments are now available.