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18 Pulse 30 July 2008
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underlying causes and investigate further for neuromuscular disorders of the gut. If delayed GI motility is identified I often useprokinetics, probiotics and sometimes specialist Professor antibiotics if bacterial overgrowth issuspected or confirmed on breath testing. • Consider screening for Qasim Aziz answers In really difficult cases where nothing works, a multidisciplinary approach with coeliac disease in those Dr Linden Ruckert's psychologists, dieticians and pain with persistent diarrhoea management experts can be helpful. questions on the role but also those with The new NICE guidelines recommend
functional dyspepsia and of stress, whether IBS 3 serological screening for coeliac disease in
patients with IBS. I have read prevalence levels
constipation with is a useful term and of one in 300 to one in 100 in the adult
bloating and flatulence population. Are symptoms a reliable guide to
the use of probiotics the possibility of coeliac disease? How far
• Food intolerance – rather should we pursue this as IgA-based screening
IBS is said to affect 20% of the population.
may give a false negative?
than a true allergy – is 1 Do you think it is a useful or meaningful
I agree with NICE that IBS patients should more likely in patients be screened for coeliac disease because this The term is useful insofar as it suggests that is easily treatable and a misdiagnosis can with functional GI disease there is no obvious and readily recognised lead to considerable morbidity. I routinely pathology for the symptoms. But I often perform serological tests for coeliac disease • Amitriptyline can be find physicians lose interest in patients in patients with diarrhoea-predominant useful in IBS patients, but once they are labelled as having IBS and symptoms. But because of the varying this is where mistakes are made because presentation of this condition I would SSRIs less so, unless there sometimes treatable causes for symptoms consider serological screening for patients is underlying depression are missed. The differential diagnosis of IBS with functional dyspepsia and even is very wide and many different conditions constipation associated with bloating and • Evidence now supports can produce symptoms identical to this flatulence. I request small bowel biopsies condition – like coeliac disease. Or IBS can for patients undergoing upper GI the use of probiotics in be a manifestation of hitherto undiagnosed endoscopy and would consider referral for patients with IBS conditions such as connective tissue and endoscopy and biopsy if the serological test neurological disorders or diabetes. So IBS was positive. There is a small chance of a • Some patients labelled often becomes a diagnosis of convenience false negative serological test for coeliac for doctors when an easy solution is not disease. But in cases with considerable as having IBS actually suspicion – especially those who respond have very treatable very well to a gluten-free diet – a small Foregut problems such as functional
bowel biopsy should be considered after a pathologies on further 2 dyspepsia are very difficult to manage.
gluten challenge if necessary. Do you have any tips?
It should be noted latent coeliac disease Milder cases of functional dyspepsia can is increasingly being recognised in patients • Slow transit constipation often be managed by PPIs and eradication with abnormal serology but normal biopsy, of Helicobacter pylori, but management can or even normal serology and biopsy but be very frustrating in more resistant cases.
with tissue transglutaminase antibodies Again, one has to explore underlying present in the small bowel mucosa1.
causes. In patients with a previous history Patients with latent coeliac disease often of gastroenteritis, psychological stress or respond well to a gluten-free diet. a strong history of atopy I look into the • A trial of cholestyramine dietary history carefully as there is evidence Many patients develop IBS and have it
for increased small bowel permeability in attributed to stress and yet they have
these conditions, which can potentially been stressed for ages. It doesn't answer the
suggestive symptoms can cause delayed hypersensitivity reactions ‘why now' question…
be offered in primary care (see question 5, opposite). I agree. More often than not, once the Food elimination in selected patients diagnosis of IBS or another functional to avoid complex testing who are well motivated can be very GI disorder (FGID) is made there is a rewarding. I also explore the possibility of misconception that symptoms must be searchmedica.co.uk The GP's search engine
30 July 2008 Pulse 19
Motoring expenses and what you can claim for access to a second car Business briefing, page 28 • IBS patients
related to stress. Although I don't disagree test to common food allergens. should be
that stress can exacerbate and perpetuate Instead I tend to try dietary therapy, in screened for
GI problems, there can still be an the form of eliminating the two most underlying pathology. common foods that cause intolerance in my (gut wall
pictured left

These patients have often been ill for experience – wheat and dairy products. with missing
a long time and suffer considerable I might consider a proper elimination diet morbidity. They may have lost their jobs for patients who are well motivated and at and/or partners and have an uncertain the severe end of the spectrum. future. It is understandable that they willbe stressed, anxious and depressed. How do you use amitriptyline or SSRIs in
It is increasingly recognised that IBS IBS and how do you ‘sell' them? Especially
symptoms should be considered within as there's the problem of constipation with
the framework of biological, psychological them too.
and social factors2. I work closely with I tend to use amitriptyline in IBS patients colleagues in psychiatry and psychology to manage their pain and visceral to manage these patients, but often find hypersensitivity – that is excessive underlying biological causes for symptoms sensitivity to experimental gut stimulation.
which are worsened by the psychological It's a useful strategy, particularly in patients co-morbidity. Once the biological factor with diarrhoea-predominant symptoms is treated it is very rewarding to see a as the drug has anticholinergic effects. remarkable improvement in psychological But I have often used it in patients with health. Nevertheless, there are some constipation as well, where pain is a major patients with considerable psychological feature. I often compensate for the use of issues who need to be dealt with very amitriptyline by using additional doses sensitively by colleagues experienced in of laxatives and more often than not managing such patients. constipation does not get worse in thesepatients. Patients are very keen on the idea of
Other drugs that I sometimes use in 5 testing for food ‘allergies' or intolerance.
patients with pain as a predominant How useful is this in practical terms? I note the
symptom are pregabalin or duloxetine. NICE guidance recommends avoidance of
I don't use SSRIs very much unless there is an underlying depressive disorder. I agree that a large number of FGID patients I ‘sell' these drugs by explaining the describe food-related symptoms. I don't importance of brain-gut communication regard this as a food allergy but rather as for normal gut function and why pain is intolerance. It is rare for a food allergy to caused by abnormal communication. develop in adults because these allergies I explain to them that the nerves in the are usually evident from childhood. There gut are too sensitive and they are sending is evidence for increased gut permeability exaggerated signals to the brain and that in patients with IBS and it is therefore low-dose amitriptyline reduces the conceivable that delayed hypersensitivity intensity of these signals and hence reduces reactions develop to food antigens getting pain. I also explain that the doses used to past the mucosal barrier. Indeed evidence treat depression are much higher and most of increased IgG-mediated food accept this explanation. hypersensitivity has been reported3. A delayed hypersensitivity reaction could What is the role of probiotics?
take up to 72 hours to manifest. Hence I am using probiotics increasingly it is not surprising that there is a poor frequently. The role of bacterial flora in correlation between dietary intake and normal gut function is in no doubt and symptoms in IBS patients. Of course, evidence suggests that abnormal flora can consuming too much junk food will also lead to abnormal gut immune responses in have more direct effect – for instance, from patients with IBD and IBS. Probiotics have the direct effect of fat on gut function – and been shown to normalise the ratio of needs to be explored in patients. plasma pro-inflammatory versus anti- When I suspect food intolerance I don't inflammatory cytokines in patients with organise allergy tests unless I suspect an IBS4. I tend to use VSL3, now available OTC immediate IgE-mediated hypersensitivity in most pharmacies. I recommend a SCIENCE PHOTO LIBRARY to food. In that case I will consider a RAST starting dose of one sachet a day, EL DISORDERS
searchmedica.co.uk The GP's search engine
20 Pulse 30 July 2008
1 Kaukinen K, Collin P and Mäki M.
3 Lea R, Whorwell PJ. The role of food
Latent coeliac disease or coeliac intolerance in irritable bowel syndrome.
disease beyond villous atrophy? Gastroenterol Clin North Am.2005;34:247-55 4 Quigley EM. Probiotics in irritable bowel
2 Levy RL, Olden KW, Naliboff BD et al.
syndrome: an immunomodulatory strategy? Psychosocial aspects of the functional J Am Coll Nutr 2007;26:684S-90S Review.
going up to two if necessary in patients and pains, which are then diagnosed as manometry and anorectal physiology WHAT I WILL DO NOW
with previous gastroenteritis, frequent fibromyalgia or even ME. studies are also helpful. The mainstay of antibiotic use and abnormal gut motility treatment is lifestyle advice and adequate Dr Linden Ruckert considers
where bacterial overgrowth is likely. Some people seem to have lifelong
laxatives. However, in cases where standard Professor Aziz's answers to
constipation. How do you explain
laxative therapy fails, more novel forms of I have had a number of patients with
‘slow-transit' problems? Is there an identifiable
treatment, such as sacral nerve stimulation 8 ‘low-grade inflammatory changes' on
abnormality and how should we manage it?
and antigrade continence enema (ACE) • The question of food intolerance rectal biopsy attributed to the bowel prep and
There is increasing evidence that procedures to irrigate the colon, can be comes up time and again so it is diarrhoea. Do you think some patients might
slow-transit constipation is related to tried. Surgery should normally be avoided interesting to know about delayed have a ‘low-grade' chronic inflammatory
neuromuscular dysfunction of the in these patients but in very intractable hypersensitivity and small bowel gastrointestinal tract. Increasingly cases there may be a role for it.
Yes. Numerous studies in patients with a abnormalities are being identified in the history of gastroenteritis who have gone on enteric nervous system in these patients.
Who might need cholestyramine? Is there
• It might be worth supporting a to develop IBS have shown persistence of Why this dysfunction occurs from an easy way to identify such patients in
supervised exclusion diet but resisting low-grade chronic inflammatory processes childhood in some patients is not clear, ‘allergy testing' in mucosal biopsies. It has been suggested although developmental defects of the Cholestyramine is used in patients with • I will continue screening for coeliac that IBS patients may have abnormal enteric nervous system in this condition bile salt malabsorption, which can occur in disease in IBS and the notion of latent anti-inflammatory cytokine production, have been reported.
terminal ileal disease such as Crohn's coeliac disease is helpful predisposing them to low-grade These patients can be investigated in a disease or in patients who have had surgical • The explanation of the use of number of ways. Their condition can be resection of the terminal ileum. However, a amitriptyline in IBS is a useful form of It is now known that stress can activate differentiated from other causes of number of cases of bile salt malabsorption the immune system by causing constipation such as obstructed defecation are idiopathic. One needs to consider this words to try with patients degranulation of mast cells within the gut caused by pelvic floor dyssynergia, using diagnosis when patients complain of • It is interesting to note that SSRIs are wall, leading to release of inflammatory transit studies with either radio-isotopes or diarrhoea that is suggestive of steatorrhoea mediators. Indeed, there is evidence that simple radiological markers. Whole-colon where all other causes have been excluded.
• The idea of a low-grade inflammatory patients who are stressed by significant life We can do a SeCHAT test to diagnose process in the whole GI tract is an events are more likely to develop post bile salt malabsorption. However, if this interesting one that might be infective IBS, compared with those subjects test is difficult to organise in primary acceptable to patients as part of a not exposed to such stressors. care then an empirical treatment with Extra online at
It is important to remember that brain- cholestyramine in a patient with suggestive gut communication can occur not only via pulsetoday.co.uk/clinical history may be considered.
Dr Linden Ruckert is a GP in north London
the nerves but also via the immune system.
Professor Qasim Aziz is professor of
Go online to read Professor Aziz's views on bowel
So it is not surprising that peripheral and neurogastroenterology at Barts and the London
disturbance and damage in childbirth. You can also
central factors combine to produce School of Medicine
post your own question in the comment box and
symptoms. Low-grade inflammation may Competing interests Professor Aziz is currently trialling a new IBS drug
Professor Aziz will answer the first two.
well lead to fatigue and generalised aches

Source: http://www.vsl3.ca/worddocs/PULSE%20article%20NTK%20(30%20July%2008).pdf

caag.org.gt

Que  mediante  la  Resolución  No.  85­2002  del  19  de  junio  de  2002,  el  Consejo  Arancelario  y Aduanero  Que conforme los artículos 38, 39 y 55 del Protocolo al Tratado General de Integración Económica Centroamericana  ­Protocolo  de  Guatemala­,  modificado  por  la  Enmienda  del  27  de  febrero  de 2002,  el  Consejo  de  Ministros  de  Integración  Económica  (COMIECO), tiene  bajo  su  competencia los asuntos de la Integración Económica Centroamericana y como tal, le corresponde aprobar los actos administrativos del Subsistema Económico; 

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