Irritable bowel syndrome - an enterometabolic disorder?

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Presentation transcript:

Irritable bowel syndrome - an enterometabolic disorder? Jørgen Valeur Institute of Medicine University of Bergen Norway

= Irritable bowel syndrome IBS = Irritable bowel syndrome Psychopathology? Stress? Altered brain-gut axis? Disturbed microflora? Hormonal dysfunction? Inflammation? Atopy? Enteric neuropathy?

– Why do we have colon? Ruminant (sheep) Monogastric herbivore (pony) Omnivore (human) Carnivore (dog) Valeur J, Berstad A. Tidsskr Nor Legeforen 2008; 128: 1298-300

– What is fermented in colon? Mainly carbohydrates Complex carbohydrates Dietary fiber Soluble (Insoluble) Resistant starch FODMAP* Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols ~ 60-80 g/day * term registered by Shepherd & Gibson

Simren M et al. Digestion 2001; 63: 108-15

Clinical gastroenterology and hepatology, 2009

In IBS Low digestible carbohydrates: Tolerability in health Grabitske & Slavin, 2009

Hypothesis: IBS is a fermentation disorder Lancet 1991; 338: 495-6

British journal of Nutrition, 2002 Madden JAJ, Hunter JO. British journal of Nutrition, 2002

Deutsches Arch f klin Med 1901; LXIX: 570-605

Quarterly Journal of Medicine, 1931

Lactulose Nonabsorbable, but fermentable synthetic disaccharide Lactulose challenge: Model for carbohydrate malabsorption 10 g lactulose causes abdominal symptoms (pain, gas, borborygmia, diarrhoea) in IBS patients, but not in healthy subjects Symptoms resemble habitual symptoms Morken MH et al. Eur J Gastroenterol Hepatol 2007; 19: 589-93 Morken MH et al. Scand J Gastroenterol 2008; 43: 141-5

Symptoms following lactulose ingestion negative expectations or hypersensitivity to fermentation ?

Study Randomized Double-blinded Placebo-controlled (10 g glucose)

Design

Rectal dialysis

Conclusions IBS patients seem to be hypersensitive to intestinal fermentation Lactulose replicates habitual symptoms, both qualitatively and quantitatively Neither gas production nor altered rectal fermentation could fully account for symptom generation

Hypersensitivity to fermentation Normal perception of abnormal fermentation or abnormal perception of normal fermentation ?

Modified from Simrén (2009) Speculations Modified from Simrén (2009)