Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

Diagnosis of mitochondrial dysfunction and role of muscle biopsy

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Brief overview of  mitochondrial disorders and dysfunction

• Multi-system disorders affecting in varying proportions the nervous system, heart, muscles, vision, hearing and kidneys etc.
• Symptoms may wax and wane.
• Manifest in a variety of ways and neurodevelopmental problems like mental or growth retardation and seizures occur only in some but not all cases. Likewise the severity of symptoms varies.
• Even family members with the same disorder can experience vastly different symptoms.
• Usually seen during childhood although they may in some cases manifest during adult life. 
• Patients partially fulfilling criteria for mitochondrial disorders are frequently termed as mitochondrial dysfunction.

Are mothers to blame for mitochondrial disorders/dysfunction

• Contrary to popular misconception mitochondrial diseases are inherited not just from the mother; rather they represent complex inheritance patterns including mutations, most of which are not in the mitochondrial DNA.
• Disorders occurring as a results of mutations in mitochondrial DNA are of course derived from mother only.
• Mitochondrial disorders may also occur as a result of environmental factors like infections and toxins that may “poison” the mitochondrial functional processes. 

Outcome and prognosis of mitochondrial disorders

• Not curable
• Therapy is aimed at control of symptoms and disabilities 

Therapeutic options/strategies

• Avoiding  trigger like stress etc.
• Medications
• Nutritional supplements tend to help in many cases. 

Diagnosis of mitochondrial disorders/dysfunctiom

According to Dr. Rodenburg  from the Nijmegen Center for Mitochondrial Disorders (NCMD),  Department of Pediatrics, Department of Laboratory Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands. as reported in the journal Journal of Inherit and Metabolic diseases, “The diagnostic examination of patients requires a multi-disciplinary clinical and laboratory evaluation in which the biochemical examination of the mitochondrial functional state often plays a central role. In most cases, a muscle biopsy provides the best opportunity to examine mitochondrial function". 

Diagnostic strategies for mitochondrial disorders/dysfunction

• One should not oversimplify the diagnosis of a mitochondrial disorder. Broadly, the diagnostic criteria may be classified into  Clinical, Biochemical and Genetic. Presence of more than two abnormal tests makes the diagnosis more likely.
• There is no single test to diagnose mitochondrial disease. There is dearth of less invasive, specific and sensitive diagnostic tools based on serum biomarkers.
• An experienced integrated approach is necessary for accurate diagnosis and relies on a combination of clinical observations, laboratory evaluation, brain imaging, and muscle biopsies
• Blood levels of lactate are frequently used as a screening tool. An abnormal test invariably calls for further investigation. , however, a normal test does not exclude the diagnosis.
• A battery of tests that can be performed include analysis of on blood, urine and spinal fluid to look for presence of mitochondrial dysfunction.
• For example, an abnormal genetic test on a blood sample may not be adequate for diagnosis of mitochondrial disorder and may require muscle biopsy for confirmation in many cases.
• A comprehensive portrait of mitochondrial energy-generating system can be obtained by tests performed on  of muscle biopsy including evaluation of  individual oxidative phosphorylation enzymes,  mitochondrial respiration, substrate oxidation and rate of ATP synthesis. 

Role of muscle biopsy for diagnosis

• Muscle tissue is subjected to comprehensive analysis including histology, genetic and  enzyme testing.
• Although a muscle biopsy is frequently touted as the "gold standard" for diagnosis of mitochondrial disorders, it is fraught with its own shortcomings.
• The enzyme testing on a tissue sample is especially difficult and has not been standardized making interpretations subject to interpretation.
• Muscle biopsy makes results of research studies on mitochondrial disorders more trustworthy. 

What is muscle biopsy

• Muscle biopsy is a simple, low risk surgical procedure involving skeletal muscle.  The analysis on the on other hand tends to be complex and varies with laboratories.
• Muscle biopsy is usually performed under local anesthetic.
• All muscle biopsy are not the same.
• May be Open versus Needle Biopsy. The open biopsy involves use of sharp scissors/scalples. An open biopsy, a  2-to-3-inch incision is made and  tissue is taken and sutures may be used to close the incision.  In a needle biopsy, tissue is collected with a large bore needle.
• Typically two to three pieces are taken. One is analyzed as fresh specimen, while other is analyzed as fixed tissue. Still another piece is used for analysis of enzyme and genetic testing. Analysis may be undertaken on fresh or frozen samples. 

Tests done on muscle biopsy

Tests performed on muscle biospy include but are not limited to:

• H&E stain for routine histology
• Nicotinamide adenine dinucleotide tetrazolium reductase (NADH) staining for assessment of NADH enzymes seen in mitochondria and endoplasmic reticulum.
• Staining for myofibers
• Modified Gomori trichrome stain
• Fat stains to assess for presence of fat in muscle
• Human leukocyte antigen class by immunohistochemistry
• The lab may also use electron microscopy to get very high magnification views of the cellular structure, which can confirm structural abnormalities.
• Enzyme testing may be undertaken on the ground up muscle tissue or from the mitochondria extracted from the muscle. Although controversial, analysis of fresh tissue sample may have advantages over frozen tissue analysis.
• Although mutations can be detected by blood sample, DNA analysis may be needed on a muscle sample to test for mitochondrial DNA mutations. 

Contraindications of muscle biopsy

• High risk of intractable bleeding or presence of infection at the biopsy site. 

Caution about muscle biopsy for mitochondrlal disorders/dysfunction

Undertaking a muscle biopsy and it’s comprehensive analysis  should not be undertaken lightly.

• A diagnosis of mitochondrial disorder/dysfunction has limited impact on long-term outcome. The benefits and its limitations of muscle biopsy  should also be weighed with the surgical risks although small.
• The cost associated with it which can easily be north of $10,000 should be a matter for serious consideration for most people.
• Because of limited impact on outcome, many physicians do not insist on muscle biopsy for a diagnosis.
• A muscle biopsy may not always be necessary in cases where diagnosis can be made based on identification of a genetic mutation associated with mitochondrial function along with clinical manifestations consistent with it. 

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FODMAP diet and foods: Implications in health and disease

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FODMAP DIET: ROLE IN IRRITABLE BOWEL, LEAKY GUT AND ALTERATION IN INTESTINAL BACTERIA

What is FODMAP and FODMAP Diet (Gibson and Shepherd 2010)

FODMAP is an acronym applied to group of short chain carbohydrates and sugar alcohols comprised of Fermentable Oligo- Di and Monosaccharides And Polyols

Disease associations: High FODMAP diet have been implicated in the rising tide of a variety of disorders.

• Crohn’s disease
• Celiac disease
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Autism

FODMAPs share thee physiological properties:

• Poor absorption in small intestine
• Osmotically active small molecules
• Rapid fermentation by gut flora: the smaller the length of carbohydrate, faster the fermentation

High luminal FODMAP foods undergo rapid fermentation and create metabolic products that predispose to enhanced intestinal permeability, altered intestinal flora, intestinal gases and predispose to small bowel bacterial overgrowth (SIBO).

Examples of high FODMAP foods/diet include:

• Fructose (fruits, honey, high fructose corn syrup)
• Lactose (diary products)
• Fructo-oligosaccharides or fructans (wheat, onions)
• Galacto-oligosaccharides or galactans ( raffinose and stachyose) contained in legumes, beans, cabbage, onions etc.
• Polyols (sorbitol, mannitol, xylitol, maltitol) contained in apples, pears, plums etc. and low calorie sweeteners. Polydextrose and isomalt are frequently used as artificial sweeteners, are poorly absorbed.

What happens when you ingest high FODMAP diet

• Excess intake and delivery of undigested carbohydrates to the colon renders them subject to bacterial fermentation.
• The metabolic fermentation products including increased organic acids (short chain fatty acids), increased surfactant activity, increased gases (hydrogen, carbon dioxide, methane and hydrogen sulfide) and gut distension injure intestinal barrier by in part causing apoptosis.
• Short chain fatty acids (SCAFAs) excess excess has been shown to increase intestinal permeability in animal models.
• The gas content of gut plays an important role in gastrointestinal symptoms.

Problems occur especially when high FODMAP diet is consumed fast:

The process if rapid, can be especially “explosive”. This occurs when large amounts of undigested carbohydrates are exposed to disproportionately high and potentially pathogenic bacteria in gut e.g. small bowel bacterial overgrowth.

Type of food versus speed

• Oligosaccharides (smaller chain length carbs) and sugars are metabolized at a much faster rate than the longer chain length molecules like dietary soluble fiber.
• The speed of bacterial fermentation and generation of metabolic products varies according to substrate (lactulose >inulin> resistant starch)
• FODMAP elimination diet plan requires global and not individual product restriction.

FOMAP drawbacks

• Low FODMAP diet diminishes access to benefits of prebiotics like fiber
• Effects of high fiber/prebiotics

1. Increased bowel fluid by osmotic effects

2. Increased motility

3. Increased generation of short chain fatty acids that serve as food for colonocytes

4. Increase in beneficial strains of bacteria like bifidobacteria.

FODMAP diet and vegetarians

• Legumes and milk products are a major source of nutrition for vegetarians.
• Since the goal of FODMAP strategy is overall reduction, greater cuts need to be made in other categories in order to accomplish the desired goals.  
• Eat good carbs!

Turning harmful effects of FODMAPs into benefits

• A lower proportion of rapidly fermentable carbohydrates along with greater amount of slowly fermentable carbohydrates have potential for ameliorating harmful effects of FODMAPs and shifting the balance towards benefits.
• For example, ingestion of raw potato starch, guar gum and arabinoxylan causes intestinal injury especially involving enzymatic activities. The deleterious effects of these foods do not occur if they are consumed along with slowly fermentable wheat bran.
• Considering the demonstrated potential health benefits of prebiotics, the harm versus benefits may be individual specific based on diet consumed, gastrointestinal flora, rapidity and amount of bacterial fermentation, and presence of comorbid conditions in the context of genetic susceptibility.

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Aquatic water therapy for chronic pain: Myth or reality?

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AQUATIC THERAPY FOR PAIN: Fact or fiction Author: Anil Minocha of Shreveport, LA

Aquatic therapy also known as Water aerobic therapy or pool therapy refers to the physical therapy and rehabilitation performed in water without the need for weights.

• Scientific data and expert opinions indicate that it provides therapeutic benefit in fibromyalgia. 
• Aquatic therapy has potential for benefit in patients with other types of chronic pain disorders and cancer and neuro-rehabilitation.
• Human trials suggest that aquatic therapy also provides short-term benefit in patients with osteoarthritis.

A variety of hydrofitness devices are available and can be individualized.

Principles of aquatic or water therapy

Water provides resistance and is believed to be healthier than the use of weights. The hydrostatic pressure produces forces perpendicular to the bodys surface Water buoyancy helps support the weight of the patient.

The combination of water resistance and  buoyancy reduces weight bearing and stress placed on the joints allowing low impact exercises with reduced joint stress as compared to exercises on land.

A decrease in stress on joints makes it easier for patients to get benefits of exercise with lesser pain/stress.

Types of aquatic therapy

Water enthusiasts have many options regarding not only depth of water, i.e.shallow versus deep water therapy but also the format of exercises that they may enjoy and find easy to perform consistent with their health. Various types of aquatic therapy are available:

Ai Chi: Developed by Jun Konno of Japan, it combined deep breathing associated with slow movements of limbs and torso. 

Ai Chi Ne: This is a partner requiring 2-person exercise program involving breathing and stretch exercises.

BackHab: This may be undertaken as an individual or a group. It is specially tailored for patients with physical impairments including back problems. It includes walking in water and a variety of limb movements tailored to the patient’s health problems.

Bad Ragaz: Initially developed in Germany, it is described as  the Bad Ragaz Ring Method targeting  muscle re-education via utilizing particular ways of resistance, endurance, and  range of motion.

The Burdenko Method: The Burdenko Method combines land and water exercise therapy for athletic training as well as physically challenged subjects.

Feldenkrais: Created by nuclear physicist Moshe Feldenkrais, it is based on principle that our movements etc depend upon the way we think and feel. Thus exercises of combining breathing and flexibility of movement are undertaken in context of awareness of old patterns and concerted effort to modify them to improve the overall other aspects of life. Touch and tissue manipulation by the therapist may be involved.

Halliwick: It is a 10-point program of motor learning and mental adjutments that specializes in teaching patients with a variety of physical or mental disabilities to get involved with water activities exercises with the goal of getting them to move about and swim in water independently in water, and to swim.

Wassertanzen: Wassertanzen means water dance. This type of aquatic therapy is a dynamic movement therapy that involves exercises below the water surface utilizing nose clips. This form of therapy is unique in the sense that it involves the patient surrendering control of his/her breath to go under water.

Water Yoga: Yoga exercises are performed with subject in waist- to chest-depth water. 

Watsu: Created by Harold Dull, watsu as the name suggests is a combination of water and shiatsu wherein the subject is held in warm water by the therapist and moved around using water resistance as the source of massage. Watsu aims to integrate massage, muscle stretching and dance. It has been described as especially suited for elderly and pregnant.

Yogalates: It uses a combination of yoga, Pilates, and Ai Chi. 

Miscellaneous aquatic therapies: Other modifications/styles include Lyu Ki Dou and Water Pilates

Contraindications to aquatic/water therapy

• Significant cardiac or respiratory disease
• Fever and active  infections
• Urinary or stool incontinence
• Consult your physician prior to any exercise program 

Significance in of aquatic therapy in health and sickness

• While there is lack of data on the role of aquatic therapy in digestive health, data on its beneficial effect in chronic pain disorders like fibromyalgia indicates that it may have potential for therapeutic benefit in chronic functional bowel disorders. 
• Randomized controlled trials indicate that an exercise program thrice a week in a warm pool improves symptoms of fibromyalgia.
• Thomas and Blotman conclude that aerobic-only exercise provides improves physical function and may be therapeutic for tender points and pain in fibromyalgia.

Bottomline: Aquatic therapy is well suited for healing as well as health maintenance for diverse patient populations. Besides wide margin of therapeutic safety, the therapist can easily develop a specifically targeted therapeutic program for diverse clinical conditions.

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Food triggers and natural supplements, treatments for migraine headache

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Identify foods triggers and supplements beneficial for migraine headaches

Authored by Anil Minocha MD of Shreveport, La

Many patients do not obtain the expected relief from migraine headaches by using the myriad medications alone. Complementary and alternative medicine is playing increasing role in the patient's preferences. Lifestyle modifications and use of supplements has frequently been recommended.

Drs. Sun-Edelstein and Mauskop from the The New York Headache Center, New York reviewed the role of the role of food triggers and supplements for treatment and revention of migraine headaches. The findings were published in the Clinical Journal of Pain.

They studied the English language literature on preclinical and clinical studies pertaining to food triggers and supplements and migraines. They concluded as follows:

1. A thorough food/nutritional history using food diaries can help identify food triggers.

2. A subset of patients may be sensitive to foods that trigger headaches and these include the following:

• Phenylethylamine
• Tyramine
• Aspartame
• Monosodium glutamate
• Nitrates and nitrites
• Alcohol
• Caffeine

3. There is evidence to support the use of certain vitamins and supplements for preventing migraine headaches and many have been endorsed by the American Headache Society and American Academy of Neurology 2012:

• Magnesium
• Petasites hybridus aka butterber
• Mig-99 or Feverfew
• Coenzyme Q10
• Riboflavin
• Alpha lipoic acid

Read about Dr. Minocha's book Natural Stomach Care

Do you or someone you know has migraine headaches? Please share your thoughts.

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Riboflavin prevents migraine headache

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Riboflavin or Vitamin B2 for migraine prophylaxis

 

Complementary and alternative medicine is being used for numerous chronic disorders including pain. A disorder of mitochondrial energy metabolism has been implicated in pathogenesis of migraine headaches. Riboflavin may help correct that. Riboflavin deficiency is rare. Studies indicate that high dose of B2 have prophylactic effects against migraine headaches. 

 

Study

Schoenen et al. from the Department of Neurology, University of Liège, CHR Citadelle, Belgium conducted a randomized, double-blind, placebo-controlled examined the role of riboflavin (400 mg/d) in patients (n=55) suffering from 2 to 8 attacks of migraine headaches per month. 

 

Results

Greater than 50% improvement was seen in 54% of treatment group as compared to 19% in placebo. Riboflavin reduced the headache days from 57% as compared to 19% in placebo group. This was associated with a significant improvement in migraine index score of 39 in treatment group as compared to 8% in placebo. The number-needed-to-treat for effective response was 2.3.

 

 

Migraine in children and adolescents

 

Study

Condo and colleagues from the Department of Neurological Sciences, University of Bologna, Bologna, Italy, conducted a retrospective study to examine the role of riboflavin for preventing migraine heaaches in pediatric and adolescent patients (n=41). The findings about beneficial effect of riboflavin were published in the Journal of Headache and Pain.

Methods

Subjects with migraine headaches receieved 200 or 400 mg/day oral dose of riboflavin for 3, 4 or 6 months.

Results

The riboflavin supplementation resulted in a significant reduction in migraine episode frequency and intensity (p<0.05). 

Follow up these subjects revealed that 68 percent of the subjects demonstrated a 50% or greater reduction in frequency of attacks. Adverse events included vomiting and increased appetite which the authors felt were unrelated to the riboflavin administration.

It should however be noted that other studies in children have however provided opposing results.

Do you take riboflavin or anyother vitamin or supplement to prevent migraines? Please share.

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 Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Cognitive behavioral therapy in irritable bowel syndrome

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Cognitive behavioral therapy or CBT appears to have a direct effect on global manifestations of irritable bowel syndrome(IBS) or spastic colon. This may not correlate with resolution of psychological distress. Improvement in IBS symptoms is associated with improvements in the quality of life and the improvement in psychological distress may be a reason for, effect of or part of it.

Scientific basis

Cognitive therapy for irritable bowel syndrome results in decrease in limbic activity and improves digestive symtoms and anxiety. Thus CBT induced symptomatic improvement in IBS may be a biologically oriented change mediated by changes in neural activity of CNS foci that relate to hypervigilance and emotions.

• Drossman (2003) conducted a randomized, comparator-controlled, multicenter trial in 431 adults to examine the clinical efficacy and safety of cognitive-behavioral therapy versus education and tricyclic antideppressant (desipramine) versus t placebo in female patients with moderate to severe functional bowel disorders including IBS. Significantly higher number of patients responded in CBT group as compared to education (70% vs 37%). Desipramine was similar to placebo in intent to treat analysis.
• Kennedy conducted randomized controlled trial of the addition of nurse administered CBT to standard general practice management of IBS (antispasmodic agent mebeverine) in in primary care. The addition of CBT was significantly superior to mebeverine-only group at 3 months. Authors concluded that specially trained practice nurses can provide effective CBT to primary care patients with a clinical diagnosis of IBS, which although effective does not reduce service or social costs although the beneficial effects of the addition of CBT to antispasmodic therapy persist for up to 6 months.
• A randomized controlled trial (Ljotsson 2010) has documented that cognitive behavior therapy based on exposure and mindfulness exercises and conducted over the internet delivered via the Internet alleviating the total burden of symptoms and increasing IBS-related quality of life in patients with IBS. The treatment group reported a 42% decrease in primary IBS-symptoms as compared to 12% in controls.
• Another randomized controlled trial (Moss-Morris 2010) found that cognitive behavioral therapy based self-management in the form of a structured manual without much contact with the therapist contact is a effective for treatment of patients with IBS in primary care.
• In contrast to studies on CBT and IBS above, Boyce (2003) reported that cognitive behavior and relaxation therapy seem not to be superior to standard care alone in IBS.             

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Irritable bowel syndrome? Peppermint oil works!

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Use of peppermint oil  for irritable bowel syndrome treatment: Irritable bowel syndrome or IBS also known as spastic colon is a type of functional bowel disorder.

IBS affects 10-20 percent of the population. IBS is more common in females. Treatment options for this chronic disorder are limited. Of note, irritable bowel syndrome is not the same thing as diverticulitis.

Study to examine effect of peppermint oil in IBS: Merat et al. from Shariati Hospital, T. University of Medical Sciences performed a  randomized double-blind placebo-controlled trial to examine the efficacy of peppermint oil in  90 patients with IBS.

Methods of irritable bowel syndrome study: Patients received one capsule of enteric-coated peppermint oil (Colpermin) or placebo three times daily for 8 weeks. Clinical symptoms and quality of life were assessed at follow up visits.

Results of IBS and perppermint: The number of patients free of abdominal pain at 8 weeks increased from 0 to 14 in the peppermint oil treatment group as compared to 0 to 6 in the placebo group (p<0.001).

There was significantly  greater reduction in the severity of abdominal pain associated with significantly better quality of life in the peppermint oil  group. No significant adverse reactions were noted due to peppermint oil.

American College of Gastroenterology in its evidence based guidelines includes use of peppermint oil as one of treatment options for treatment of irritable bowel syndrome.

Do you or someone you know has irritable bowel syndrome or IBS? What treatments have you used and have they worked for you. Please sure your thoughts.

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Yogurt gaining popularity

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Health conscious Americans are increasingly using fermented foods ranging from yogurt to kimchee because of the potential health benefits in a variety of chronic ailments. This was reported by Chicago Tribune/Tribune Media Services (4/28/2010)

Helicobacter pylori and migraine headache

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Helicobacter pylori infection has been implicated in numerous disorders including vasomotor dysfunction in patients with Raynaud's and cardiovascular disease and may be an uncommon or uusual cause of migraine.

Studies by Hong and colleagues demonstrated that eradication of Helicobacter pylori reduces intensity, duration, and frequency of episodes migraine in patients with Hepatitis B related liver cirrhosis. The authors speculated that H. pylori antigens cause intermittent vasospasm of arterioles thus leading to migraine-type attack and the reduction of these vasoactive substances upon eradication provides protection against migraine attacks.

Gasbarrini and colleagues showed that H. pylori is found in 40% of patients with migraine which is similar to controls. However, among infected subjects, a significantly higher prevalence of the more virulent CagA-positive strains was seen among those complaining of migraine with aura as compared to those suffering from migraine without aura (41% vs. 19%, P<0.01) and with controls (41% vs. 17%, P<0.01).

 Yiannopoulou and colleagues argue that H. pylori infection is a probable independent environmental risk factor for migraine without aura, especially in patients that are not genetically or hormonally susceptible to migraine.

Of note, H. pylori has been implicated in numerous non-gastrointestinal disorders. However, the causal relationship has been difficult to establish in most cases.

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Does botox works at both ends: check anal fissures

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You have heard about botox or botulinum toxin for skin wrinkles. Even botox parties are celebrated. Seems funny considering its use in anal fissure? By the way, botox or botulinum toxin has other uses too, like in achalasia, gastroparesis due to pyloric spasm etc.

Anal fissure

Anal fissure (different from hemorrhoids) can really be a pain the rear (no pun intended). Although acute anal fissures can be managed by conservative measures alone, the optimal medical treatment for chronic anal fissure is still lacking.

Surgery is effective for treatment of chronic anal fissure but has significant morbidity.

Botox or botulinum toxin for anal fissures 

Recently, Brisinda and colleagues (Br J Surg 94:162-7) from Italy compared the efficacy of local nitroglycerin ointment versus botulinum toxin (botox).

Results

Botox group had superior healing rates at both 4 and 8 weeks. Adverse events were more likely to be due to nitroglycerin.

Bottomline

This finding of a comparison between two medical treatments must be interpreted in the context of data on comparison with placebo where nitroglycerin has only been marginally superior. In contrast, the efficacy of botox was similar to placebo.

Until long term studies can show superiority of botox over placebo, its use for routine treatment of chronic anal fissure may not be prudent.

Have you used botox for any reason? Do you or someone you know has chronic anal fissures? Please share the remedies that have or have not worked for you.

Here is info on botox or nitroglycerine for anal fissures

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IRRITABLE BOWEL SYNDROME

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IBS and how to manage it medically or by complimentary and alternative medicine

Irritable bowel syndrome (IBS) or spastic colon affects 5-20 percent population. It is likely that you or someone you know has irritable bowel syndrome. But what is this irritable bowel syndrome or spastic colon or IBS?

Irritable bowel syndrome

IBS is a symptom based diagnosis of unclear etiology. It should not be confused with diverticulosis or diverticultis. Irritable bowel syndrome is probably is not a single disease. More likely, IBS is comprised of multiple diseases, all lumped into one at the present time for lack of understanding its pathogenesis. Infantile colic is considered by many to be a variant of IBS in infants and kids.

Features of irritable bowel syndrome and Rome criteria

Irritable bowel syndrome is a functional disorder characterized by chronic (at least three months in the preceding one year) abdominal pain and a disturbance of bowel habit. The disturbed bowel habit of IBS may manifest as diarrhea, constipation or alternating diarrhea with constipation. Pain frequently improves with defecation.

A waxing and waning pattern of symptoms is seen in most patients. The precise conglomeration of symptom complex is defined under ROME III criteria.

What causes irritable bowel syndrome?

• The pathogenesis of irritable bowel syndrome remains an enigma and no single etiology fits all cases. IBS is predominantly seen in young females but can be seen in adults of any age and either sex. It is more prevalent among Caucasian Americans than African Americans.
• Motility disorder has been frequently implicated; however no consistent motility pattern can be demonstrated.
•  Visceral hypersensitivity (pain with a stimulus not severe enough to cause pain in healthy subjects) is seen in many patients.
• Autonomic dysregulation has also been implicated. A dysfunction of 5-HT system is supected in many cases. Stress does not cause it but does tend to exacerbate symptoms. Food allergy or intolerance may be present in some cases.
• Many patients attribute the onset of disease to a bout of flu-like illness e.g. viral gastroenteritis, travelers diarrhea.
• Low grade inflammation in the gut can be documented in many cases.
•  Several authors claim small intestinal bacterial overgrowth to be the cause in most cases of IBS although these observations have not been confirmed by others.

My opinion: IBS occurs when there is a perfect storm of combination of increased intestinal permeability (Leaky gut) and low grade inetestinal inflammation,  altered gut bacteria and some harmful factor in gut lumen in a patient with genetic predisposition. The role of diet in at least affecting the IBS manifestations can not be emphasized enough.

Note: The leaky gut, inflammation and altered bacteria can affect not only the gut but also systems far away including the brain.

IBS medical consensus

Overall, in the absence of clear cut cause, a bio-psychosocial model for pathogenesis for irritable bowel syndrome has been proposed. This model emphasizes the role of mind-body interactions with the environment.

In this context, it should be noted that there is an increased prevelance of certain chronic pain disorders in IBS patients, e.g. functional dyspepsia, fibromyalgia, chronic fatigue syndrome, interstitial cystitis, chronic back pain etc.

Diagnostic strategy for irritable bowel syndrome

While the diagnosis of irritable bowel syndrome should be positive, physicians frequently perform studies to exclude any treatable cause. The work up for IBS should be individualized and may include complete blood count (CBC), routine chemistries and stool studies. Flexible sigmoidoscopy or colonoscopy may be performed depending upon age and risk for colon cancer and suspicion for alternative diagnosis like inflammatory bowel disease (Crohn's disease and ulcerative colitis).

Celiac sprue should be excluded by antibody testing for anti-tissue transglutaminase antibody. The use of anti-gliadin antibody has recently seen a resurgence with the identification that many IBS patients get relief from gluten free diet.

Lactose hydrogen breath test may be done to exclude lactose intolerance. Small bowel bacterial overgrowth can be excluded by hydrogen breath test or cultures of small bowel aspirate.

Treatment of irritable bowel syndrome

The management of IBS patients follows a step-wise fashion and is largely symptom based. Realistic goals need to be established. Reassurance with a lot of hand-holding goes a long way in helping patient cope with the symptoms of IBS.

Placebo response rate in irritable bowel syndrome may be as high as fifty percent. 

Role of Diet: An often an forgotten factor in management

• High fiber diet and fluid are frequently prescribed as first line of treatment for IBS of all types. Much of positive data about fiber in IBS pertains to Isubghulla type.
• Patients with diarrhea may be helped by lactose-avoidance.
• Patients can frequently identify provoking factors and need to abstain
• Gluten-free diet helps many patients.
• Other exclusion diets are also helpful including the  FODMAP diet.

Role of GI medications

Over the counter laxatives or  prescription medication Zelnorm are used in cases with constipation predominant IBS. Of note, Zelnorm was withdrawn from US market on March 30, 2007 because of unacceptable side-effects. Lubiprostone is available.

Constipating agents like Imodium and Lomotil may be needed in patients with diarrhea predominant IBS. Lotronex is useful for diarrhea-predominant IBS but has high risk for ischemic colitis. Its availability is limited and its use in IBS has largely been abandoned by most physicians in the US.  Its is not to be used for irritable bowel syndrome of constipation type.

Antispasmodic agents e.g. Bentyl are frequently prescribed for abdominal pain associated with irritable bowel syndrome but provide only limited benefit at best.

Peppermint oil, A time proven remedy:

Peppermint oil is effective based on literataure as stated in guidelines by the American College of Gastroenterology.

Probiotics: Multiple studies have now documented beneficial effects of probiotics in IBS. Note, that all probiotics are not created equal and results depend on the species/strain used.

Treat SIBO if present: Small bowel bacterial overgrowth is treated with antibiotics. Rifaximin, a gut selective antibiotic is frequently used. Probiotics have also been shown to heal small bowel bacterial overgrowth and may have less adverse effects overall as compared to antibiotics.

Role of antidepressents in irritable bowel syndrome

Low dose tricyclic antidepressants (e.g. imipramine, desipramine) raise the pain threshold and are frequently prescribed to IBS patients not responding to above strategies; however their side-effects can be problematic.  Although frequently prescribed, there is less data about the use of newer antidepressant agents like SSRIs for management of IBS.

CAM therapies

Several trials have documented positive impact of probiotics in IBS patients. Cognitive behavioral therapy, hypnosis, IBS classes, yoga, Chinese herbal medicine etc have  also been used successfully in irritable bowel syndrome. Limited data points to efficacy of melatonin (over-the-counter sleep-aid) in IBS. A Mayo Clinic (Rochester) study showed that St John's wort does not have beneficial effect.

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Bacteria for your infant's colic?

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Infantile colic is a difficult problem, vexing both to parents and physicians. The cause is thought to be excess intestinal gas. On the lines of irritable bowel syndrome or IBS, new research indicates that probiotic bacteria help in kids with colic.

Probiotics or "good bacteria" that tend to maintain a healthy balance of good versus bad bacteria in the gut. They are being increasingly have been found to be useful for treatment of various illnesses, both gut and non-gut related.

Dr. Savino and colleagues from the University of Turin in Italy conducted a randomized placebo controlled trial to study the effect of Lactobacillus reuteri. Their findings were published in the journal Pediatrics (January 2007).

The study cohort consisted of 90 breast fed babies who were administered either the probiotic or the common over the counter anti-gas medication known as simethicone for 28 days. Mothers refrained from ingesting cow's milk in their diet. Baby crying times were assessed.

The daily median crying time at day 28 was 145 minutes/day in placebo group as compared to only 51 minutes/day in the probiotic group. 95% babies were termed as responders among the probiotic group in contrast to only 7% in the placebo group.

The mechanism of action of the probiotic in such conditions remains to be established. Possible mechanisms include immune-modulation and enhanced peristalsis thus affecting the balance of the gut flora and reduced triggers for abdominal pain.

Do you or someone close to have kids? Do any of them have colicky problems? What remedies have you tried for such episodes?

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Is melatonin useful in irritable bowel syndrome?

Melatonin in IBS or spastic colon

Irritable bowel syndrome continues to baffle the medical establishment because of lack of effective treatments. Now comes study suggesting that the naturally acting substance (melatonin) helps in ameliorating this vexing problem.

What is melatonin? It is a naturally occurring hormone in all living beings. It is synthesized in the brain (pineal gland), gastrointestinal system and retina from an amino acid tryptophan. In addition to its role in wake-sleep cycle, it is a powerful antioxidant, stimulator of immune system. It is sold over the counter as a natural sleep remedy.

Dr. Saha and colleagues from PGIMER in Chandigarh, India studied the role of melatonin in IBS patients. They published their findings in Journal of Clinical Gastroenterology (January 2007).

These investigators conducted a randomized controlled trial of the use of melatonin or placebo in 18 patients with IBS. They found that use of melatonin for 8 weeks significantly improved overall IBS score. The extracolonic IBS score was also significantly improved as compared with placebo. In addition, use of melatonin resulted in improvement in quality of life score to 43.63% as compared to 14.64% in placebo group.

Do you or someone you know has IBS? Do you find the currently available treatments effective? Have you ever used any natural remedies for anything including IBS?

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger.

Gas, boating and distention in IBS

Pooling of gas within the digestive tract and difficulty moving it downstream to get rid of it has been implicated in production of bloating and abdominal discomfort including infantile colic. However, the part of bowel involved in intestinal gas retention has not been well defined.

Salvioli and colleagues from the University of Barcelona recently performed a study of small bowel reaction to infusion of fat into the intestine and published their findings in the American Journal of Gastroenterology (August 2006). These investigators studied six patients with irritable bowel syndrome and compared them to healthy controls.

The authors found that in patients with IBS, there is gas retention associated with abdominal distention and distress. They concluded that fat infusion into the bowel inhibits propulsion of gas in the small intestine via reflex inhibition of small bowel transit. This is not accompanied by any significant effects on the colon.

Based on these results and those of some other recent studies, it may be concluded that the origin of bloating and distention symptoms lies in the small intestine.

Do you or someone you know has gas problems? If so, what measures have you taken to feel better?

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Irritable bowel syndrome due to water contamination

Irritable bowel syndrome (IBS) is a poorly understood disorder and multiple theories have been postulated to explain this syndrome. Recent studies suggest that a significant number of people develop IBS after a bout of gastrointestinal infection. Dr. Marshall and colleagues from Intestinal Diseases Research Program at the McMaster University in Canada sought to quantify the risk and characterize he risk factors for developing IBS associated with such an infection. They published their findings in the journal Gastroenterology (August 2006).

These investigators studied the development of IBS in subjects 2 years after they had been exposed to contaminated of municipal water supply system. The contaminants in this system included Escherichia coli 0157:H7 and Campylobacter jejuni. They excluded patients with prior history of IBS and inflammatory bowel disease.

The subjects filled out a standardized health questionaire. The subjects were then divided into groups depending upon whether they had developed gastroenteritis or not. Irritable bowel syndrome was diagnosed based on the ROME I criteria.

2069 subjects participated in the study of whom 904 had developed self-reported gastroenteritis while 464 had clinically suspected gastroenteritis. 701 subjects had not developed any gastrointestinal illness as a result of water contamination and were classified as control.

The authors found that IBS had developed in 28% of self-reported gastroenteritis and 36% of clinically suspected gastroenteritis patients. In contrast, IBS was seen in only 10% of subjects who had not developed gastroenteritis as a result of the water contamination. They also found that the IBS as a result of gastrointestinal infection was more likely to be of the diarrhea predominant type and was more likely to occur in younger women.

Disclaimer: Everything on this site including the blog and the ads are for your information only. I am not your doctor or pharmacist. Please do your own due diligence and consult your health care professional advisor. Dr. Minocha does not offer any opinion as to the ads on this site. The ads have potential to generate income for the blogger