Dissertations / Theses on the topic 'Irritable bowel syndrome - Homeopathic treatment'

Doctor of Philosophy<br>Nineteenth century philosophy and anatomy regarded the nervous system as the only pathway of communication between the brain and body but now, research in the field of psychoneuroimmunology (PNI) has provided evidence to prove the age-old belief that there is a connection between the mind (or mental/emotional states) and the body. Researchers in PNI have now shown that the communication between the nervous and immune systems is bi-directional – i.e. there is a psychological reaction to physical disease and a somatic presentation of psychological disorders - and that the immune system, the autonomic nervous system, the endocrine system and the neuropeptide systems all communicate with each other by means of chemicals called messenger molecules or ligands. This paper outlines research into the treatment of Irritable Bowel Syndrome (IBS) with hypnotherapy, taking into account the mind-body connection and treating both the patient’s physiological and emotional/psychological symptoms rather than treating the physiological symptoms only. In other words, using a more holistic approach to the treatment of IBS. IBS is probably the most common functional gastrointestinal disorder encountered by both gastroenterologists and physicians in primary care. It is estimated that from 10% to 25% of the general population suffer from this condition and that it comprises about 30-50% of the gastroenterologists’ workload, yet the aetiology of IBS is unknown and, so far, there is no cure. Researchers are beginning to view IBS as a multi-faceted disorder in which there appears to be a disturbance in the interaction between the intestines, brain, and autonomic nervous system, resulting in an alteration in the regulation of bowel motility and/or sensory function. Most researchers agree that a subset of IBS sufferers have a visceral hypersensitivity of the gut or, more specifically, an increased perception of sensations in the gut. To date, studies of IBS have proposed previous gastroenteritis, small intestine bacterial overgrowth, psychosocial factors, a genetic contribution, and an imbalance of neurotransmitters as either possible causes or playing a part in the development of IBS. It is generally agreed that a patient’s emotional response to stress can exacerbate the condition. In section 1 of the thesis, the introduction, a detailed description and background appropriate to the study undertaken are provided, including aspects of epidemiology, diagnostic symptom criteria and clinical relevance of the Irritable Bowel Syndrome. Previous studies of various forms of treatment for IBS are discussed with the main emphasis being on treatment with hypnotherapy. All these therapies have concentrated on either mind or body treatments whereas this study demonstrates how hypnotherapy, and the use of imagery, addresses both mind and body. Finally, the rationale for the current study and the specific aims of the thesis are outlined. In section 2, the methodology and assessment instruments used in the clinical trial are discussed, as well as recruitment processes, research plan and timetable, and treatment schedule. Statistical analyses are provided and the main outcomes measures of the clinical trial, its limitations and scientific implications are addressed.

Bloating and distension remain important and intrusive manifestations of Irritable Bowel Syndrome. Although much of previous literature has used the the terms bloating and distension interchangeably, epidemiological data suggest that (i) distension is seen more commonly in IBS with constipation (IBS-C) compared with IBS with diarrhoea (JBS-D) patients (ii) bloating and distension seem to "correlate predominantly but not exclusively in IBS-C.

Background The importance of interactions between the host and gut microbiota in the pathogenesis of irritable bowel syndrome (IBS) is becoming increasingly apparent. Probiotics offer a potential new therapy for the treatment of IBS, but current results with these products are conflicting, largely as a result of poorly designed trials and non-standardisation of outcome measures. Aims The objective of this study was to assess the efficacy and safety of a liquid, multi-strain probiotic in the treatment of IBS. Methods A single-centre, randomised, double-blind, placebo-controlled trial of adult patients with symptomatic IBS. Patients received 12 weeks of treatment with the probiotic or placebo (1ml/kg/day). The primary efficacy measure was a change in the IBS symptom severity score (IBS-SSS) from baseline to week 12. A secondary outcome measure was a change in the IBS quality of life (IBS-QOL) score. Results A total of 186 patients were randomised and 152 patients completed the study. The mean difference in change in IBS symptom severity scores between the two groups was statistically significant (-35.0 (95% CI; -62.03, -7.87); p=0.01). Adverse events were mild and transient and no serious adverse events were reported. Conclusion The multi-strain probiotic is associated with an improvement in overall symptom severity in patients with IBS, is well tolerated and has a good safety profile.

Background and aims Irritable bowel syndrome (IBS) is a common gastrointestinal disorder characterized by abdominal pain and altered bowel habits. The societal costs of the disorder are significant, as are its negative effects on quality of life. Medical treatment options are limited, but psychological treatments such as hypnotherapy have proven to be effective. Important pathophysiological mechanisms include disturbances in brain processing of visceral sensation and expectation of visceral sensation. Increased sensation of stimuli (hypersensitivity) is present in a subset of IBS patients to distensions in the lower part of the gastrointestinal tract, indicating a probable important pathophysiological mechanism in IBS. The overall aim of the thesis was to further study the central pathophysiological mechanisms involved in IBS. Specifically, we aimed to identify differences in brain response to standardized repeated rectal distensions and expectation of these stimuli between IBS patients (with or without perceptual rectal hypersensitivity), and healthy controls. Furthermore, we aimed to investigate IBS patients´ brain responses to standardized rectal distensions and expectation of these stimuli after either a successful course hypnotherapy or educational intervention. Methods Functional magnetic resonance imaging (fMRI) data were acquired and analyzed from 15 IBS patients with visceral hypersensitivity, and 18 IBS patients with normal visceral sensitivity (papers I and II). In paper III, fMRI data were analyzed from IBS patients who reported significant symptom reduction after either a course of hypnotherapy, or an educational intervention. FMRI data from IBS patients and healthy controls were also compared. Results The findings reported in papers I and II suggest, that the differences in brain response between IBS patients with and without rectal hypersensitivity, can be explained by changes in brain response during the course of the experiment. Even though the brain responses were similar between groups during the early phase of the experiment, they became substantially different during the late phase. The IBS patients with rectal hypersensitivity demonstrated increased brain response in several brain regions and networks involved in visceral sensation and processing. In contrast, IBS patients with normal rectal sensitivity exhibited reduced brain response during the late phase of the experiment. As reported in paper III, similar symptom reduction was achieved for both treatments. The symptomatic improvement was associated with a reduction of response in the anterior insula, indicating an attenuated awareness of the stimuli. The hypnotherapy group had a reduction of response in the posterior insula, indicating less input to the brain, possibly due to changed activity in endogenous pain modulatory systems. In patients who reported significant symptom reduction following treatment, the brain response to rectal distension got more similar to that observed in healthy controls. Conclusions The results from papers I and II indicate that a subpopulation of IBS patients lacks the ability to habituate to repeated rectal distensions and expectation of these stimuli. Results from paper III indicate that the abnormal processing of visceral stimuli in IBS can be altered, and that the treatments probably had a normalizing effect on the central processing abnormality of visceral signals in IBS.

Irritable bowel syndrome (IBS) is characterized by chronic abdominal pain/discomfort along with altered bowel habits, which accounts for a large proportion of gastrointestinal (GI) disorders worldwide. While psychiatric distress like depression is one of the most frequent comorbidities in IBS patients, which not only influences the quality of life, it also leads to a substantial economic burden and inefficient treatment in IBS patients. Inflammation, altered activities of the HPA axis, aberrant central neuroplasticity and neurotransmission have been highly regarded as pathogenic factors of the depression. Whereas, in recent years, dysfunctions in the gut microbial community has been increasingly discovered to provoke depression disorder. Considering that gut dysbiosis plays causal role in IBS progression, dysfunction of the gut microbiota has been speculated for contributing to the depressive symptoms in IBS (IBS-DP) patients. However, whether and how gut dysbiosis affecting IBS-DP patients remain unclear. We hypothesized that gut microbiota changes contribute to the development of IBS-DP and the change of gut microbiota-driven metabolites induces the structural and/or functional changes of the central nervous system (CNS), thus resulting in the development of IBS-DP. In this thesis, IBS patients with and without depression and animal models of IBS have been systematically studied, to investigate whether gut dysbiosis mediates depressive disorder in IBS. Firstly, we conducted a cross-sectional study involving the distribution of depressive disorder in the IBS population of Hong Kong. According to this survey, we found that there is 36.6% (135/369) of IBS patients showed symptoms of depression. The severity of depressive symptoms was positively associated with the harshness of visceral pain and bloating signatures in IBS patients. Secondly, in comparison to the non-depression of IBS (IBS-ND) group, faecal metagenomic results unveiled the disrupted gut microbiota in IBS-DP patients, mainly with the deficiency of several beneficial bacterial groups, including Akkermansia, Bifidobacterium and Eubacterium, whereas the gut microbiota profile between IBS-ND patients and healthy controls (HCs) showed no significant changes. Compared with HCs, enzyme-linked immunosorbent Assay (ELISA) results showed higher levels of serum IL-1β, IL-6, and TNF-a in IBS-DP patients, indicating a low-grade peripheral inflammation in IBS-DP patients. Moreover, the abundance of Akkermansia muciniphila (A. muciniphila), was negatively correlated with Hamilton Rating Scale for Depression (HAMD) score and Zung Self-Rating Depression Scale (SDS) score, IL-1β, TGF-β, and TNF-a in IBS-DP patients. These findings indicate that gut dysbiosis, especially deficiency in A. muciniphila, is related to the depressive symptoms and inflammation in IBS-DP patients. Thirdly, in a neonatal maternal separation (NMS) rat model, behavioural tests such as colorectal distention (CRD) test, open field test (OFT), forced swimming test (FST), and sucrose preference test (SPT) results showed visceral hypersensitivity and depression symptoms in rats. These results indicate that the model can successfully mimic the visceral hyperalgeisa and the depression-like behaviour of IBS-DP. Immunohistochemical analysis showed an altered morphology and decreased the quantity of astrocytes in the hippocampus of NMS rats when compared with that of controls. More importantly, the mRNA expressions of genes related to Astroglial glutamate transmission including glutamate transporters (GLTs), glutamate receptors, and also glutamate-related exchangers, as well as astrocyte biomarker glial fibrillary acidic protein (GFAP), which are mediated with chronic inflammation and/or stress, were decreased in NMS rats when compared with the control group. These results indicate that impaired astroglial glutamate neurotransmission in NMS rats. Furthermore, pseudo-GF rats with faecal microbiota transplantation (FMT) of NMS microbiota were also conducted, and results showed that the association of A. muciniphila deficiency, depressive-like behaviours and impaired astroglial glutamate neurotransmission were repeated in the rat recipients. These results indicate a causal relationship between NMS microbiota and depressive phenotype, involving dysfunction of the astrocyte- glutamate pathway. Fourthly, to further verify the role of A. muciniphila in NMS microbiota-induced depressive phenotype and impaired astrocytic glutamate pathway, we orally administered live and heat-killed A. muciniphila bacteria in NMS adult rats. A. muciniphila (108 CFU in 1mL PBS) was administered once-daily for four consecutive weeks. Besides, rifaximin and fluoxetine were also separately treated in NMS rats as control groups. Rifaximin is a broad-spectrum GI-specific antibiotic that is commonly used for IBS treatment, and fluoxetine, a selective serotonin re-uptake inhibitor, is one of the most frequently prescribed anti-depressants. The results showed that A. muciniphila efficiently improved depressive-like behaviours, attenuated the impaired astrocytic glutamate neurotransmission, as well as restored the normal morphology and number of astrocytes in the hippocampus of NMS rats. While rifaximin-treated rats only exhibited amelioration of visceral pain, and fluoxetine group mainly performed antidepressant effect, without any significant change in astrocytic glutamate neurotransmission impairment. These results demonstrate that A. muciniphila improves depressive symptoms in IBS phenotype and ameliorate astroglial-glutamatergic pathway dysfunction. Whether and how A. muciniphila modulates astroglial glutamate transmission, therefore leading to the improvement of depressive symptom in IBS, remains to be further investigated. Taken together, the works of this thesis, combining both clinical and animal studies reveal that gut dysbiosis, particularly deficiency of A. muciniphila, contributes to the development of IBS-DP via regulating the astroglial glutamatergic pathway. This study gives a different direction to microbial-guided therapy for the IBS-DP patients in the future

Irritable bowel syndrome (IBS) is a condition where abdominal pain, diarrhoea, constipation, gas distension and/or variability in the bowel habit are experienced. It has been suggested that the gut microflora may be involved in this condition and that an 'abnormal' colonic fermentation may provoke the symptoms ofIBS. In this study, the faecal flora of 11. IBS patients was compared with that of 11 healthy individuals quantitatively using fluorescence in situ hylJridisation (FISH) and· traditional plating techniques, as well as qualitatively using denaturating gradient gel electrophoresis (DGGE). It was found that IBS patients had lower total . . ./ bacterial counts, bifidobacteria, lactobacilli, bacteroides and clostridia than seen in healthy individuals. DGGE also showed differences between illS and healthy samples, especially in relation to stability ofthe microflora over time. A synbiotic version ofLactobacillus plantarum NCIMB 41114 with seven different prebiotics was tested in batch culture fermenters using faecal samples from IBS donors. From all the combinations GOS-synbiotic was chosen sirc~ it enhanced the . . growth of the probiotic and was found to be more effective in 'normalising' the . .~ faecal flora in IBS. This synbiotic combination was used in gut model· systems using faecal samples from donors belonging to different IDS subgroups. The results showed that administration of the synbiotic impacted the specific IBS subgroups .. differently, but modulated the rnicroflora towards selective stimulation of bifidobacteria and lactobacilli. In the last part of the study the amount of gas produced from IBS faecal flora during fermentation was compared to that ofhealthy faecal flora. The IDS flora produced more cumulative gas and had greater rates of production than the healthy flora. Administration of the synbiotic reduced gas production in all systems (IBS and healthy). Taken together, these observations help to define dietary management strategies, based on the gut flora and its activities, aimed towards improving IBS symptomology.

Background: IBS is the most common functional gastrointestinal disorders and affects approximately 10-20 % of the general population and is widespread in all societies and socio-economic groups. Although the disorder does not have a life-threatening course, it still seriously affects the patients in their everyday life. Aim: The general aims of this thesis were to estimate the occurrence of irritable bowel syndrome in the general population and to achieve a better understanding of present treatment of this disorder and impact on every-day life in those suffering from IBS. Material and methods: The LIPS study comprises two parts. Part I was a retrospective register study where the data collection was based on computerised medical records at three selected Primary Health Care centres in a defined region. Part II was a population based case-control study. The identified IBS cases from part I constitute the cases, while their control groups were randomly selected from the population census register in the same area as the cases. Data in part II were collected by means of a postal questionnaire to cases and controls. The study was conducted in Linköping, a city located in the south-east of Sweden with 135 000 inhabitants. Results: The female IBS patients reported lower influence on planning their work and working hours as well as fewer opportunities to learn new things at their work compared to their controls, even after adjustments in multiple logistic regressions for potential confounders like; mood, sleeping problems and perceived health. The female IBS patients had considerably lower HRQOL in all dimensions compared to their controls, even when compared to male patients. Younger female IBS cases (18-44 years) reported lower mental health on the SF-36 scale than the older IBS female cases (p=0.015). In the multivariate analysis these variables, lack of influence on planning the work, family history of IBS, anxiety and sleeping disturbance displayed an association with being diagnosed with IBS in women. In men, lack of influence on working pace, family history of IBS was associated with an IBS diagnosis.The consultation incidence of IBS in part I was 3.4 (95% CI 3.20-3.70) per 1000 person-years for all IBS cases, among females; the incidence rate was 4.6 per 1000 person-years (95% CI 4.16-4.97) and males; 2.3 per 1000 person-years (95% CI 2.01-2.59). The dominating pharmacological treatment prescribed for abdominal complaints were fibre and bulking laxatives agents as well as acid suppressive drugs. These variables had an independent impact on the probability of a follow-up consultation; diagnosed co-morbidity besides the IBS diagnosis, rectoscopy ordered and laboratory tests ordered. Conclusions: IBS patients identified in primary care are significantly affected in their working-life compared to individuals in the general population. Especially female IBS-patients report lower decision latitude at work and they also appear to have a particularly impaired psychosocial functioning in their every day life and impaired HRQOL. Factors associated with IBS diagnosis among females are anxiety as well as family history of IBS and lack of co-determination at work. The incidence rate of IBS was 3.4 per 1000 person-years which increased with age and with an overrepresentation of females. IBS patients did not appear to be heavy utilisers of primary care and those who attended were treated by their GP without further consultation. The strongest predictors for having a follow-up consultation were diagnosed co-morbidity, rectoscopy and laboratory tests ordered<br>Figure on page 8 reprinted from Lancet 360(9332), Nicholas, J Talley and Robin Spiller, "Irritable bowel syndrome: a little understood organic bowel disease?", pp. 555-564, Copyright 2006 with permission from Elsevier. On the day of the public defence of the doctoral thesis, the status of articles III and IV was Submitted.

Irritable bowel syndrome (IBS), majorly characterized by irregular bowel movements and abdominal pain, is one of the most prevalent functional gastrointestinal disorders (FGIDs) in the world. Disturbance of gut microbiota, closely linking with gut dysfunction, has been regarded as one of important pathogenetic factors for IBS. However, gut microbiota-driven mechanism underlying IBS remains unclear, which leads to inefficient and non-specific effects of current microbiota-oriented therapy. In this thesis, function-based microbiota investigation with combination of metagenomic and metabolomic analyses was separately performed in IBS cohort and model to precisely link pathogenic species with disordered GI motor function. A series of microbiota manipulation studies in rodents were conducted to explore bacteria-driven molecular mechanism. Firstly, a pilot study with 'omics' analyses revealed fecal microbial structure significantly varied in IBS patients with disorder GI motility relative to healthy controls (HC). Such changed IBS enterotype was functionally characterized by disturbed metabolism of bile acids (BAs) that are previously proved to regulate GI motor function. It indicates microbiota-driven GI dysmotility relevant to disturbance of BA metabolism in IBS. Secondly, a systematic review with meta-analysis was performed to comprehensively understand existing findings related to BA metabolism and its linkage with IBS. Results showed that abnormal BA excretion, previously reported in at least one IBS subtype, is associated with dysregulation of BA synthesis, marked with abnormalities of circulating indices 7α-hydroxy-4-cholesten-3-one (C4) and fibroblast growth factor 19 (FGF19). However, what's the role of gut microbiota in abnormal BA excretion is undetermined. Thirdly, to explore possible role of gut microbiota in abnormal BA excretion in IBS, BA metabolites and BA-related microbiome were simultaneously analyzed in stools of recruited subjects. Results found that total BA and microbiota-derived BAs were remarkably elevated in a quarter of IBS-D patients (BA+IBS-D) who exhibited more frequent defecation, higher level of serum C4 but lower level of serum FGF19 than those with normal BA excretion (BA-IBS-D). In line with metabolic results, abundances of BA-metabolizing bacteria, particularly Clostridium scindens (C. scindens) simultaneously expressed hdhA and bais that are responsible for BA 7α oxidation and dehydroxylation, were highly enriched in fecal metagenomes of such particular IBS-D population. These findings suggest the increased BA-metabolizing microbiome is associated with the dysregulated host BA synthesis in the subgroup of BA+IBS-D patients. Fourthly, by analyzing metabolites and bacteria related to BA metabolism, a neonatal maternal separation (NMS)-induced IBS-D rat model characterized by accelerated GI motility and excessive BA excretion were found to largely mimic gut microbial BA metabolism in BA+IBS-D patients. Specifically, intraluminal total and secondary BAs were significantly elevated in the large intestinal lumens (cecum, proximal colon and feces) of NMS rats, together with increased abundances of hdhA- and bais-expressing Clostridium species, including C. scindens. Moreover, quantitative polymerase chain reaction (PCR) analysis showed upregulated mRNA expression of cholesterol 7 α-hydroxylase (CYP7A1) whereas downregulated mRNA expression of small heterodimer partner (SHP) in the liver of NMS rats, indicating enhanced hepatic BA synthetic level. These observations based on such IBS-D model suggest the association of excessive BA-metabolizing microbiome and increased hepatic BA synthesis. Fifthly, to further clarify whether excessive BA-metabolizing bacteria contribute to enhanced hepatic BA synthesis and to explore the underlying molecular mechanism, we performed bacterial intervention in pseudo germ-free (GF) or/and specific pathogen free (SPF) mice by transplantation of human fecal microbiota and the signal strain C. scindens. Compared with GF mouse recipients of HC and BA-IBS-D fecal microbiota, BA+IBS-D fecal microbial recipients displayed shorter GI transit and increased subsistence of C. scindens in the cecal contents. In line with higher level of serum C4, taurine-conjugated BA contents and mRNA expressions of BA synthetase CYP7A1 and sterol 12α-hydroxylase (CYP8B1) were significantly elevated in the liver of BA+IBS-D recipients. These findings showed bioactive effects of BA+IBS-D fecal microbiota with enrichment of C. scindens on hepatic BA synthesis. Next, to further confirm the effects of the species C. scindens on host BA synthesis, we individually colonized C. scindens strains (ATCC 37504) to pseudo GF and SPF mice. Results showed both mice models with single strain colonization exhibited accelerated GI transit and higher contents of hepatic total and taurine-conjugated BAs compared with individual vehicles treated with PBS. Combining metabolic changes, the upregulated expressions of hepatic CYP7A1 mRNA in colonized mice indicate that C. scindens substantially promote hepatic BA synthesis in colonized mice. Furthermore, contents of taurine-conjugated BAs, served as natural antagonists of farnesoid X receptor (FXR) that negatively control of new BA synthesis, were elevated in ileal lumens of colonized mice. Expressions of FXR-targeted genes SHP and fibroblast growth factor 15 (FGF15) were consistently reduced in the liver and ileum tissues of colonized mice, respectively. Results suggest that suppression of FXR-mediated feedback signaling is involved in Clostridium-driven hepatic BA oversynthesis, which deserve the further investigation. Collectively, the works of this thesis integrating clinical and animal studies indicate that BA-metabolizing bacteria, particularly C. scindens, enhance hepatic BA synthesis and consequently leads to BA overexcretion. It provides novel bacteria-driven mechanism for enhanced GI motility, and supply a direction in precise microbiota-related pathogenesis and medication for IBS-D population in future.

Thesis (PhD)--Stellenbosch University, 2014.<br>ENGLISH ABSTRACT: Background: Irritable bowel syndrome (IBS) is a common gastrointestinal (GI) disorder. GI symptoms and impaired quality of life affect between 10-20% of all adults, corresponding to about 25-50% of all patients who visit a gastroenterologist’s clinic. In recent years, several novel mechanisms of IBS that likely relate to previously established theories have been identified. Inflammation, postinfectious low-grade inflammation, immunological and genetic predisposition along with altered microbiota are critical in IBS development, while several dietary factors may also play a role in this syndrome. However, none of these factors accounts for the full repertoire of IBS symptoms, and the pathophysiology of this condition is not fully understood. The overarching aim of this study was to investigate the nutrient intakes, GI microbiota and the effect of Lactobacillus plantarum (L.plantarum) 299v in IBS patients. Sub-aims: 1) Update healthcare professionals on current probiotic information and provide an overview of probiotic treatment approaches, with special emphasis on IBS, 2) conduct a well designed randomised, double blind, placebo-controlled trial (RCT) with L. plantarum 299v as part of an intervention and establish whether a course of probiotics may alleviate undesirable symptoms of IBS and improve quality of life, 3) assess nutrient intake in patients with irritable bowel syndrome (IBS) compared to dietary recommendations, 4) validate and assess the reproducibility of food records and 5) identify possible nutrient risk components for establishing GI microbiota involved in IBS and as part of an intervention, determine whether a course of probiotics may alter stool microbiota. Results: 1) A review article published by the author provides an overview of current probiotic treatment options to health care professionals and indicates certain probiotics are a promising therapeutic treatment option for management of IBS symtpoms, 2) the effects of the single strain probiotic, L. plantarum 299v, supplementation was evaluated in a RCT. Compared to placebo, the probiotic supplementation showed no significant reduction in GI symptom severity scores, particularly abdominal pain relief. Quality of life was also not improved in the treatment versus control group. Both the treatment and placebo groups improved significantly over the trial period, indicating a large placebo effect, 3) nutrient intakes of the IBS patients compared to current dietary reference recommendations indicates that this group of patients are at risk for nutrient inadequacies in key macro and micronutrients, 4) the validity and reliability of the dietary data showed good reliability but poor validity as measured by plasma fatty acids and 5) the GI microbiota composition in the phenotypically different diarrhoea-predominant IBS (D-IBS) vs. constipation-predominant IBS (C-IBS) showed that D-IBS patients had significantly lower counts of Lactobacillus plantarum compared to C-IBS patients. The probiotic had no significant effects on the GI microbiota as measured by quantitative polymerase chain reaction (qPCR). It was found that nutrient intakes had a significant impact on the microbiota. Lower fibre intakes were associated with higher Bacteroides spp., lower Bifidobacteria bifidum and Lactobacillus plantarum counts in both IBS groups. Conclusion: Taken together, L.plantarum 299v did not alleviate the GI symptoms of IBS, nor was it associated with significant changes in the GI microbiota. IBS patients may be at risk of key nutrient inadequacies. The influence of nutrient intakes on the GI microbiota provides an attractive explanation as a potential pathophysiological factor for IBS.<br>AFRIKAANSE OPSOMMING: Agtergrond: Prikkelbare derm-sindroom (PDS) is ‘n algemene gastro-intestinale (GI) stoornis. GI simptome affekteer die lewenskwaliteit van 10-20% van alle volwassenes. Dit stem ooreen met ongeveer 25-50% van alle pasiënte wat ‘n gastroënteroloog konsulteer. Verskeie oorspronklike meganismes vir die ontwikkeling van PDS is onlangs identifiseer. Inflammasie, post-infektiewe lae-graadse inflammasie, immunologiese en genetiese vatbaarheid tesame met veranderde mikrobiota is krities vir die ontwikkeling van PDS. Sekere dieetfaktore mag ook bydraend wees tot hierdie sindroom. Geen van hierdie faktore is egter verantwoordelik vir die volle spektrum van PDS simptome nie en die patofisiologie van die toestand word ook nog nie ten volle verstaan nie. Die oorkoepelende doel van hierdie studie is om nutriëntinname, GI mikrobiota en die uitwerking van L.plantarum 299v in PDS pasiënte bepaal. Sub-doelwitte: 1) Om gesondheidswerkers in te lig aangaande die nuutste inligting oor probiotika en om ‘n oorsig van probiotika behandelingsopsies te verskaf, met spesiale klem op PDS, 2) om ‘n goed beplande ewekansige, dubbel-blinde, plasebo-beheerde kliniese studie met L.plantarum 299v as deel van die intervensie uit te voer om sodoende te bepaal of ‘n kursus probiotika ongewensde simptome van PDS kan verbeter en lewenskwaliteit sodoende verhoog, 3) om nutriëntinname in pasiënte met PDS te bepaal vergeleke met dieet aanbevelings, 4) om die geldigheid en herhaalbaarheid van voedselrekords te bepaal en 5) om moontlike nutriënt risikokomponente vir die ontwikkeling van GI mikrobiota betrokke in PDS te identifiseer en om as deel van ‘n intervensie te bepaal of ‘n kursus probiotika stoelgang mikrobiota patrone verander. Resultate: 1) ‘n Oorsigartikel gepubliseer deur die kandidaat dui probiotika aan as ‘n belowende terapeutiese opsie in die behandeling van PDS simptome, 2) die effek van ‘n enkelstam probiotikum, L.plantarum 299v, is evalueer deur ‘n ewekansige, dubbel-blinde, plasebo-beheerde kliniese studie. Vergeleke met die plasebo, het probiotiese aanvulling geen betekenisvolle vermindering in die GI simptome in PDS pasiënte tot gevolg gehad nie. Lewenskwaliteit het ook nie verbeter in die behandelde versus die kontrole groep nie. Beide die behandelde en plasebo groepe het aansienlik verbeter oor die studietydperk, wat ‘n groot plasebo effek aandui, 3) nutriëntinname van die PDS groep vergeleke met huidige dieetaanbevelings, dui daarop dat hierdie groep pasiënte ‘n risiko het vir die ontwikkeling van kern nutriënttekorte (makro- en mikronutriënte), 4) die geldigheid en betroubaarheid van die dieetdata dui op goeie betroubaarheid, maar swak geldigheid soos bepaal deur plasma vetsure en 5) die dermkanaal mikrobiotiese samestelling in die verskillende fenotipes, diarree-oorheersende PDS (D-PDS) vs. konstipasie-oorheersende PDS (K-PDS) dui daarop dat D-PDS pasiënte aansienlike minder Lactobacillus plantarum gehad het vergeleke met K-PDS pasiënte. Die probiotikum het geen beduidende uitwerking op die oorheersende mikrobiota gehad nie, soos gemeet deur kwantitatiewe polimerase kettingreaksie (kPKR). Daar is gevind dat dieet ‘n beduidende impak op die mikrobiota gehad het. Daar is ‘n verband tussen laer vesel inname en hoёr Bacteroides spp. en laer Bifidobacteria bididum en Lactobacillus plantarum tellings gevind in beide PDS groepe. Gevolgtrekking: Die L.plantarum 299v enkelstam probiotikum het nie die gastrointestinale simptome van PDS pasiënte verlig nie en daar is ook geen beduidende veranderinge in die mikrobiota gevind nie. PDS pasiënte mag ‘n verhoogde risiko toon vir kern nutriënttekorte. Die invloed van nutriëntinname op GI mikrobiota verskaf ‘n belowende verduideliking as ‘n potensiële patofisiologiese faktor in PDS.

Background: Irritable bowel syndrome is a medically unexplained phenomena relating to the lower gastrointestinal tract with symptoms such as altered bowel habit and abdominal pain. Patients experience poor quality of life and consume significant healthcare resources. Mechanisms for the delivery of evidence based psychological interventions for irritable bowel syndrome within the National Health Service are lacking and the feasibility of these interventions is poorly understood. Methods: A novel, low-intensity, nurse-led psychological intervention has been developed and trialled within a mixed methods feasibility study. Twenty participants were randomly allocated across four treatment conditions consisting of; a treatment as usual control (n = 5), self-help (n = 5), low-intensity (n = 5) and high-intensity (n = 5) cognitive behavioural therapy interventions. A total of ten participants took part in post-intervention interviews analysed using a group thematic analysis. Results: Recruitment to this feasibility study was a significant challenge with 22 participants recruited of which, 20 were randomised to the feasibility interventions. Of the 104 patients approached within secondary care gastrointestinal clinics, 27.7% of patients volunteered to enrol into the study. Reasons provided relate to difficulties with committing to taking part and personal circumstances. Themes derived from post-intervention interviews suggest participant’s valued face-to-face therapist interaction and described their perceived treatment utility along with a variety of barriers and facilitators to engagement in CBT interventions. Conclusion: Low-intensity and self-help cognitive behavioural therapy may be feasible mechanisms for the delivery of evidence based psychological interventions for patients with IBS, although significant concerns regarding recruitment of participants to future trials will need to be addressed. Further development of these lower-intensity interventions in collaboration with service users is required in order to improve the acceptability and relevance of the interventions.

Irritable bowel syndrome (IBS) remains a heterogeneous condition and is a common condition. The causes of IBS remain poorly understood and there is a lack in biomarkers to distinguish this condition. Recently, there have been reports on the release of immune mediators leading to symptoms of irritable bowel syndrome. Mast cells, which can be activated by allergy or stress, are thought to be important cause of symptoms in some IBS patients because they can release chemicals, which cause pain and diarrhoea. Currently, there are few effective treatments available to alleviate these symptoms. Recent small studies have shown that Mesalazine, an ‘anti-inflammatory’ drug, may be able to modify and reverse the symptoms of IBS with diarrhoea. One small study suggested Mesalazine reduced mast cell numbers. This current study is one of the largest studies looking at the use of Mesalazine as a form of treatment for IBS with diarrhoea. Unfortunately, this study did not show any beneficial effect of Mesalazine treatment in unselected patients with IBS and diarrhoea. Potentially, there is a subgroup of IBS patients who developed their symptoms following a bout of gastroenteritis who appeared to benefit from Mesalazine treatment but a larger study is needed to confirm this. In this study, the mast cell mediators released from mucosal biopsies was not a useful marker of disease since it failed to correlate with any symptoms. Magnetic resonance imaging (MRI) is a potentially useful tool to assess the physiology of the gastrointestinal tract in patients with functional gut disorders as it does not involve radiation and is not invasive. So far, there is a lack of biomarkers to assist in diagnosis and treatment of irritable bowel syndrome. The MRI marker pill used in the multiple studies in Chapter 3 to assess whole gut transit time is very promising as it is now applied, in the research setting, to patients with chronic constipation such as slow transit constipation and irritable bowel syndrome with constipation. Further use of the MRI and adding a stimulus such as laxative in patients with chronic constipation is helpful to distinguish between functional constipation and irritable bowel syndrome with constipation; thus helping with its medical management. The use of MRI as a biomarker for diagnosis of irritable bowel syndrome remains promising although it was not demonstrated in this thesis.

Irritable Bowel Syndrome (IBS) is a chronic functional disorder of the gastrointestinal system with prevalence in adults of 10-20%. IBS is characterised by a number of troublesome symptoms including abdominal bloating, pain and excess gas, and has substantial impact on quality of life in addition to wider economic implications. Conventional medical treatment can be problematic however, due to the lack of established aetiology and the number of symptoms reported. Concurrently, use of complementary and alternative medicine (CAM) to relieve IBS symptoms is reported to be as high as 50%, although the benefits and impact of such treatments are not fully substantiated by primary research data. However, evidence has shown that people affected may benefit from psychological interventions in terms of reduced use of health care services and reported symptoms. This thesis has examined psychological factors that influence the use of CAM and quality of life in individuals affected by IBS. These factors were explored within the theoretical framework of an extended common-sense model of illness representations (CSM), which incorporated treatment beliefs. The main aim of the thesis was twofold: to examine the illness perceptions and treatment beliefs that influence CAM use and to explore pathways from illness and treatment representation to quality of life in CAM-users and those not using CAM (non-users). A web-based cross-sectional study and minimum six month time-period follow-up study were conducted. Participants were primarily recruited from an IBS self-help network in the UK and other online message boards. The cross-sectional study (n=63) considered illness perceptions and treatment beliefs associated with CAM use and how these factors differed in influencing coping strategies and quality of life in CAM-users and non-users. The follow-up study (n=197) focused on exploration of the influence of illness perceptions and treatment beliefs at study time one, on coping strategies and quality of life at study time two. The findings demonstrated that components of illness perceptions influenced CAM use, coping strategies and quality of life. Treatment beliefs were more strongly implicated in influencing the use of CAM. At the cross-sectional stage, stronger perceptions of illness consequences and emotional representations were major influences on reduced reported quality of life measures and poorer emotional outcomes in both survey groups, where similar strength effects were observed. There were many observed instances of of partial mediation of maladaptive and dysfunctional coping strategies such as self-blame and behavioural disengagement. In addition, follow up data demonstrated a reduction of the influence of illness perceptions (time one) on quality of life (time two)compared to the cross-sectional data. Moreover, evidence of mediation effects was only detected in CAM-users in the follow-up study. These results highlight the importance of psychological factors, in particular illness perceptions, and to an extent, treatment beliefs in influencing coping strategies, quality of life and emotional outcome in those affected by IBS. Practical and theoretical implications of the findings are considered and future applications discussed. This thesis concludes with the proposal of a novel conceptual model to utilise a mulitconvergent approach to enhance the quality of life and emotional outcomes in those affected bt IBS.

Background: The past forty years have seen an increase in the number of people with chronic illness and a struggle for biomedicine to provide effective treatments. The lack of effective biomedical treatments for conditions such as IBS creates opportunities for Chinese medicine; however, in its growing popularity, Chinese medicine has had to adapt to biomedicine’s dominant influence on research and practice. Purpose: The purpose of this thesis is to explore Chinese medicine’s adaptations to biomedicine regarding diagnosis differentiation and treatment individualisation through a study that places Chinese medicine in the context of IBS. Methods: Methods were selected based on a pragmatic mixed methodological underpinning that allowed for the research questions to dictate appropriateness. As such, a mixture of qualitative and quantitative methods were used to assess acupuncturists’ contextualisation and treatment of IBS; patient’ experiences with acupuncture and perceptions of outcome; and patients’, GPs’, and acupuncturists’ understanding of how acupuncture works and the impact of that understanding on outcome and acceptance of acupuncture. Findings: Acupuncturists contextualise IBS according to symptoms they perceive to be relevant, and do not perceive IBS to be a useful diagnosis. Acupuncture treatment of IBS incorporated three over-lapping approaches including: disease-specific, pragmatic, and individualised. The proportional influences of the approaches were different for different treatment aspects. Regarding how acupuncture works, patients, acupuncturists, and GPs used a variety of traditional, scientific, and physical explanations. Patients and acupuncturists perceived that the explanation may affect treatment outcome. Conclusions: Collective interpretation of the findings suggest that TCM diagnosis differentiation is fundamental to TCM treatment and plays a role similar to biomedical diagnoses in that it may validate patients’ symptoms and identify conditions that are treated effectively. Additionally, the use of combined treatment approaches notes an over-emphasis on individualisation that may be a by-product of TCM’s adaptation to biomedicine.

Chronic pelvic pain (CPP) is defined as constant or intermittent lower, cyclical or non-cyclical abdominal pain of at least six months’ duration. In the United Kingdom, over 1 million women suffer from CPP, with an estimated annual healthcare cost above £150 million. The aetiology of CPP is unknown in up to 50% of women, and in the remainder, the symptoms of CPP is associated with endometriosis, pelvic adhesions, irritable bowel syndrome or painful bladder syndrome. CPP is often accompanied by painful periods, pain during sexual intercourse and defaecation. Fatigue, sleep disturbances and depression are also common among this group of women. CPP asserts a heavy emotional, social and economic burden. Standard treatments such as hormonal and analgesic regimens are often associated with unacceptable side effects, even if helpful for the pain, underlining an urgent need for a satisfactory treatment. The meridian balanced method (BM) electro-acupuncture (EA) treatment (acupuncture needling + traditional Chinese medicine health consultation [TCM HC]) may be effective in managing CPP symptoms. Thus, I have completed a pilot study comprising of a three-armed randomised controlled trial (RCT), using a mixed methods research (MMR) approach, to assess the feasibility of a future large-scale RCT to determine the effectiveness of the meridian BMEA treatment on CPP in women. My hypothesis is that it is feasible to conduct such a large-scale RCT for CPP in women. The primary objectives were to determine recruitment and retention rates. The secondary objectives were to evaluate the, acceptability of the methods of recruitment, randomisation, interventions and assessment tools and any signals of effectiveness of the interventions. Thirty (30) women with CPP were randomised into three groups: BMEA treatment, TCM HC, or National Health Service standard care (NHS SC) group. The effects of my interventions were assessed by validated pain, physical and emotional functioning questionnaires, completed at weeks 0, 4, 8 and 12 of the study. Semi-structured telephone interviews and focus group discussions to explore participants’ experience of the study were conducted. Of the 59 women who were referred to the study, 30 women (51%) were randomised. There was a statistically significant difference in retention rates between the three groups. The retention rates were 80% (95% CI 74-96), in the BMEA treatment group, 53 % (95% CI 36- 70) in the TCM HC group and 87% (95% CI 63-90) in the NHS SC group. (Chi-square test, p=0.08) The attendance rates of the BMEA treatment group were 90% compared to 56% in the TCM HC group. There was a statistically significant difference (Mann-Whitney test, p=0.023) in attendance between the two intervention groups. Telephone interviews regarding the acceptability of the methods of recruitment, randomisation, assessment tools and interventions were positive. No adverse effects that were directly related to BMEA treatments were reported or observed. A higher proportion of the BMEA treatment group achieved clinical significance in the VAS-pain, BPI-pain severity, interference, and sleep scores, when compared to the other two groups. Due to small sample sizes, there was insufficient power to show statistically significant difference. (Fishers Exact Test, p=1.0) Analyses of the questionnaire data per group showed statistically significant differences in the following: the BMEA treatment group experienced less in pain at weeks 4 (p=0.01) and 8 (p=0.005); less helplessness (p=0.03) and their anxiety and depression scores declined at week 4 (p=0.04). The NHS SC group also reported less pain at week 4 (p=0.04). However, this group scored higher in anxiety and depression at weeks 8 and 12 (p=0.04). No statistically significant differences were achieved between the three groups at baseline, weeks 4, 8 and 12 in all scores. The therapeutic benefits gained by the TCM HC group were less compared to those of the BMEA treatment group, but better when compared to the NHS SC group. The BMEA treatment and TCM HC groups showed lower scores in anxiety and depression while the NHS SC group showed higher scores in anxiety and depression. The NHS SC group also tended to ruminate and magnify their problems as well as feeling more helpless than the other two groups. The three key themes that emerged from thematic analysis of focus group discussions were the “whole person effects” where participants reported an improvement in pain, sleep and a general sense of wellbeing in the two intervention groups; the “experience of standard care” and “impact of living with CPP”. In conclusion, the results of my pilot study are supportive of the feasibility of a future large-scale study. There were signals of effectiveness of interventions but the sample size was too small to make a definitive conclusion.

Made available in DSpace on 2015-05-14T13:00:02Z (GMT). No. of bitstreams: 1 arquivototal.pdf: 1170808 bytes, checksum: 7b299ea2ca71a584be9ecd4dbd10364c (MD5) Previous issue date: 2014-02-14<br>Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES<br>The irritable bowel syndrome (IBS) is defined as the presence of continuing or recurrent abdominal pain or discomfort and it is associated with altered bowel habit. Its pathophysiology involves the following aspects: genetic variables, changes in gut motility and visceral sensitivity, psychosocial factors, in addition to inflammatory and infectious processes. The treatment is based on dietary guidance and change in lifestyle. The use of drugs is indicated in symptomatic stages of IBS. The growing interest of patients for complementary and alternative medicine has been observed in recent years. Panax ginseng C.A. Meyer has been used for centuries in oriental medicine. Experimental studies have demonstrated the antinociceptive action of this herbal medicine on calcium and sodium channels, as well as on primary sensory neurons. The study aimed to: conduct phase II clinical trial with Panax ginseng CA Meyer in patients with IBS; contribute to the study of the pharmacological effects of Panax ginseng C.A. Meyer; evaluate the therapeutic efficacy of Panax ginseng C.A. Meyer in abdominal pain control in patients with IBS; and observe the adverse effects. Twenty-six patients were selected by means of the inclusion criteria for the study and they were divided into two groups. A clinical double-blind, randomized, prospective and experimental trial was conducted for eight weeks, comparing the action of dry extract of Panax ginseng (300 mg / day) with trimebutine (600 mg / day). Abdominal pain was assessed using the Likert scale. Patients were assessed at four visits and the results were analyzed using the Mann-Whitney and Friedman tests, with a significance level of p < 0.05. Twenty- four patients completed the study, being 87.50% female and mean age of 47.41 years. There was a relative homogeneity among patients with regard to sex, age and duration of symptoms. All patients, before beginning treatment with Panax ginseng and trimebutine, had negative scores for the Likert scale values. There was improvement in abdominal pain, through this scale, in patients who used Panax ginseng. This group started from a median basal of -5 to 2.5, 3 and 5 in the 1st, 4th and 8th weeks of treatment, respectively, with a statistically significant difference. Similar results were achieved in the group that used the trimebutine. The only adverse effect observed was the occurrence of headache in two patients (16.66%) in the group that used the herbal. Panax ginseng C.A. Meyer was effective in the control of abdominal pain in IBS patients, analogous to trimebutine, and may be used in future studies, with the prospect of a phase III clinical trial.<br>A síndrome do intestino irritável (SII) é definida pela presença de dor ou desconforto abdominal contínuo ou recorrente, estando associada com alterações do hábito intestinal. Sua fisiopatologia envolve os seguintes aspectos: variáveis genéticas, alterações da motilidade intestinal e da sensibilidade visceral, fatores psicossociais, além de processos inflamatórios e infecciosos. O tratamento é baseado em orientação dietética e na mudança do estilo de vida. O uso de fármacos é indicado nas fases sintomáticas da SII. Tem sido observado o crescente interesse dos pacientes pela medicina alternativa e complementar, nos últimos anos. O Panax ginseng C.A. Meyer é utilizado há séculos pela medicina oriental. Estudos experimentais demonstraram a ação antinociceptiva desse fitoterápico sobre os canais de cálcio e de sódio, assim como sobre os neurônios sensoriais primários. O estudo teve como objetivos: realizar ensaio clínico de fase II com o Panax ginseng C.A. Meyer em pacientes com SII; contribuir para o estudo dos efeitos farmacológicos do Panax ginseng C.A. Meyer; avaliar a eficácia terapêutica do Panax ginseng C.A. Meyer no controle da dor abdominal em pacientes com SII; observar os efeitos adversos. Foram selecionados vinte e seis pacientes, através de critérios de inclusão para a pesquisa, sendo divididos em dois grupos. Foi realizado um estudo clínico, duplo cego, randômico, prospectivo e experimental por oito semanas, comparando a ação do extrato seco do Panax ginseng (300 mg/dia) com a trimebutina (600 mg/dia). A dor abdominal foi avaliada através da escala de Likert. Os pacientes foram avaliados em quatro consultas e os resultados foram analisados através dos testes de Mann-Whitney e Friedman, com nível de significância quando p<0,05. Vinte e quatro pacientes concluíram o estudo, sendo 87,50% do sexo feminino e média de idade de 47,41 anos. Ocorreu uma relativa homogeneidade nos grupos de estudo no que se refere ao sexo, idade e duração dos sintomas. Todos os pacientes, antes do início dos tratamentos com Panax ginseng e trimebutina, apresentavam os valores negativos para os escores na escala de Likert. Houve melhora da dor abdominal, nos pacientes que utilizaram o Panax ginseng. Esse grupo partiu de uma mediana basal de -5 para 2,5, 3 e 5, na 1ª., 4ª. e 8ª. semanas de tratamento, respectivamente, com diferença estatisticamente significativa. O efeito adverso observado foi a ocorrência de cefaleia em dois pacientes (16,66%), no grupo que usou o fitoterápico. O Panax ginseng C.A. Meyer foi eficaz no controle da dor abdominal em pacientes com SII, de modo análogo à trimebutina, podendo ser utilizado em novos estudos, com a perspectiva de um ensaio clínico de fase III.

M.Tech.<br>Irritable bowel syndrome (IBS) is a multifactoral disorder of the gastrointestinal tract causing disturbances in gastric motility, resulting in abdominal pain, bloating and abnormal bowel movements. It is defined as a 'disorder of gut function in the absence of structural pathology' (Palmer et a!, 2002). It is the most commonly encountered functional gastrointestinal disorder in the primary and secondary health care system with a prevalence in the general population of five to twenty percent (Bellini et a!, 2005). No definite aetiological factor has been isolated, but factors such as psychological stress, anxiety and depression, certain dietary intolerances, increase in abnormal sensitivity to visceral distension, and hormonal changes in women have been implicated in compounding the symptoms of IBS (Ohman & Simren, 2007). Current treatment regimes include dietary changes and symptomatic relief using allopathic medications, which come with the risk of side-effects and may lead to dependency (University of Maryland Medical Center, 2007). Homoeopathic studies which have addressed the physical symptoms as well as the psychological contributing factors associated with IBS, have recorded favourable results when treating this syndrome (Mathie & Robinson, 2006).The aim of this research was to determine the efficacy of Homoeopathic Similimum treatment in IBS. In order to recruit volunteers, this study was advertised in local newspapers, pharmacies and at the University of Johannesburg's Doornfontein Campus. Volunteers completed the Rome III Criteria evaluation to determine their suitability for this study, with the likelihood of any other bowel pathology having been excluded. Ten suitable female volunteers, ranging in age from twenty to thirty five, were selected having met the inclusion criteria. Over a period of three months, each participant partook in four homoeopathic consultations. The initial consultation involved the completion of the information and consent form, an explanation of the research procedures, general well-being and general symptom rating questionnaires were completed, a full homoeopathic case history was taken, and a physical examination was performed. A baseline of four weeks without treatment followed. Participants were requested to complete daily symptom rating scales and keep a daily food diary in the four weeks between consultations. This was continued throughout the study period. The subsequent follow-ups, of which there were three, consisted of a follow-up on the initial consultation, completion of general well-being and symptom rating questionnaire, and a physical examination. A homoeopathic similimum remedy was chosen based on each participant's unique symptoms. Using physical, mental, and emotional symptoms in accordance with classical homoeopathic principles, a single remedy that most suited the individual was chosen and prescribed. It was predicted that the study would provide an alternative and safe treatment option to relieve the symptoms ofiBS. The results of the study showed that the homoeopathic similimum remedy does not provide a statistically significant improvement in the symptoms of IBS. Clinically, however, most participants experienced a general trend of improvement in physical symptoms and general well-being .

M.Tech. (Homoeopathy)<br>The aim of this study was to determine the effectiveness of Argentum nitricum 6CH and Lycopodium clavatum 6CH in the individualised treatment of patients suffering from Irritable bowel syndrome. These two homoeopathic remedies are well known for their effect on the gastrointestinal system, especially when the gastrointestinal symptoms are associated with emotional stress. 60 subjects participated in this single blind, placebo controlled study. Each subject underwent an initial evaluation in order to ascertain their symptoms prior to treatment. They were then given their appropriate remedy to be administered three times daily for one month. The subject's symptoms were monitored through questionnaires completed at two week intervals. The homoeopathic medication appeared to reduce the Irritable bowel syndrome symptoms, with the Lycopodium clavatum group achieving slightly better results than the Argentum nitricum group. It is, however, recommended that further similar studies using a larger sample group for a longer duration be conducted in order to verify these findings.

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Homoeopathy, Technikon Natal, 1997.<br>The aim of the study was to determine the effectiveness of Homoeopathic Simillimum treatment in Irritable Bowel Syndrome sufferers i.nterms of patient response to treatment. It was hypothesized that the homoeopathic simillimum treatment would result in a substantial improvement in all the clinical aspects of Irritable Bowel Syndrome sufferers, and that it could be used as an alternative to 'conventional' treatment in many cases. The study was a clinical trial, in which a placebo control group was compared with an experimental group. Convenience sampling was used to draw patients into the trial. Volunteers responded to advertisements that had been placed in various advertising media. A minimum of 30 participants was assessed and if they complied vvith the diagnostic- and Manning criteria they were accepted into the study. The participants were randomly divided into a double - blind study that lasted 3 months. During this period half of the patients received placebo treatment while the other half received homoeopathic simillimum treatment. Neither the researcher nor the participants knew what type of treatment they received until the end of the research. The participants that fell into the placebo group was given the opportunity after the study was over to be treated with homoeopathic simillimum treatment. All the data obtained hy the researcher through the questionnaires was interpreted by.<br>M

Background. Although irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder with an absence of demonstrable pathology, it is associated with significant impairment of quality of life and causes a heavy burden on the health care system. As conventional IBS treatments are far from satisfactory, people turn to Complementary and Alternative Medicine (CAM). One of the most acceptable CAM treatments is acupuncture, which has been considered to be effective in alleviating abdominal bloating, increasing rectal pain threshold, and improving the general well being of IBS patients. However, the underlying mechanisms of these therapeutic effects remain unknown. This study is an investigation of the therapeutic mechanisms of acupuncture treatment of IBS.<br>Conclusion. Acupuncture attenuates visceral hyperalgesia by inhibiting 5-HT and c-Fos activity in the brain-gut axis. This observation may shed light on possible mechanisms by which acupuncture alleviates symptoms of IBS.<br>Study 1. A Neonatal Maternal Separation Stress Model (NMSS) was tested. Our results showed that this model was a reliable and stable model for IBS animal study and that visceral hyperalgesia was associated with increased serotonin (5-HT) and c-Fos activity of the brain-gut axis.<br>Study 2. Two methods were used to test visceral hyperalgesia in response to colorectal distension (CRD), namely Abdominal Withdrawal Response (AWR) and Electromyogram (EMG). There methods were compared for their effectiveness in measuring visceromotor response (VMR) in a NMSS rat model. Our results showed that EMG is the more reliable tool for evaluating VMR to CRD in NMSS rats.<br>Study 3. There were three parts to this study. First, we reviewed the TCM literature on the use of acupuncture in IBS and concluded that the two most commonly used acupoints for this condition are ST-36 and CV-12 and that, of the two, ST-36 may be the more appropriate acupoint for treatment. Second, we tested invasive and non-invasive sham acupuncture (placebo) and found that neither produces any therapeutic effect when compared to real electroacupuncture. Third, we used the NMSS rat as the animal model, ST-36 as the treatment acupoint, non-invasive sham acupuncture as the placebo, and EMG as the tool to evaluate VMR in response to CRD alter acupuncture intervention. Our results showed that acupuncture not only attenuated 5-HT and c-Fos activity but also reduced visceral hyperalgesia in the NMSS rat.<br>Ziea, Tat Chi.<br>Source: Dissertation Abstracts International, Volume: 70-06, Section: B, page: 3423.<br>Thesis (Ph.D.)--Chinese University of Hong Kong, 2008.<br>Includes bibliographical references (leaves 122-141).<br>Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web.<br>Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.<br>Abstracts in English and Chinese.<br>School code: 1307.

M.A.<br>The purpose of this study is to investigate the effects of an individualized holistic psychotherapy and synergistic stress management programme for the treatment of Irritable Bowel Syndrome (IBS) and stress, both of which are common disorders in this present day and age. IBS is a functional bowel disorder of the gastrointestinal tract that leads to change in bowel habits with the additional features of abdominal pain and distension (Drossman, 1994b). This functional disorder has been associated with stress since time immemorial and it is only recently that research has begun to examine how and by what mechanisms IBS and stress are related. A review of the literature suggests a resurgent interest in IBS and stress. Tantalizing questions like ‘IBS – irritable bowel, irritable body, irritable brain or irritable mind?’ gives one an idea of the genesis from which the disorder has come, the complications in which it has been mired and the directions in which it is aspiring to go (Farthing, 1995). Using both the historical context and the present level of understanding in the research literature, one becomes aware of the shifting paradigm from the dualistic Cartesian-Newtonian biomedical perspective, to the biopsychosocial and integrative mind-body approaches which reflect the move to a holistic and non-linear quantum scientific worldview. The ecosystemic paradigm on which the present study is based, represents this shift whereby systemic changes in cyclical rhythmic patterns within the psychophysiology of clients reflect new ways of conceptualizing psychosomatic (mind-body) ill-health (Weiner, 1992). Within the behavioural and medical health fields, both psychologists and physicians as well as a number of other disciplines are moving towards more integrative solutions which include the mind-body-spirit dimensions of the individual. Drossman, Whitehead and Camilleri (1997) have begun to consider the individualized expression of the illness in the patient and to situate him among his wider systems, as well as incorporating a referral team approach to the treatment of IBS. Salt (1997) extends the use of the biopsychosocial model to include the spiritual dimension in his treatment of IBS patients. Broom (1997) weaves the various internal systems of the person into the story of the client’s illness that integrates the mind and body. The psychologically based holistic intervention of this study was developed in response to the calls for more integrative approaches to treatment which incorporate whole-person care. The specific aim of this study is to compare a group of IBS participants who receive the holistic individualized psychotherapy and synergistic stress management intervention with a group of IBS participants who do not receive the treatment. The sample consisted of two groups, an experimental (N = 20) group and a control (N = 20) group. The IBS Client Questionnaire also known as the Functional Bowel Disorder Severity Index (FBDSI) (Drossman, Zhiming, Toner, Diamant, Creed, Thompson, Read, Babbs, Barreiro, Bank, Whitehead, Schuster & Guthrie 1995) was used to verify a diagnosis of IBS as well as a measure of the severity of symptoms. This index is based on the current international diagnostic criteria for IBS. The Occupational Stress Inventory was used as a measure of vocational stress and was developed to provide an integrated theoretical model linking sources of stress in the work environment, psychological strains experienced by individuals as a result of work stressors and the coping resources available to counterbalance the effect of stressors and alleviate strain. It consists of three scales, namely Occupational Roles, Personal Strain and Personal Resources scales respectively. Wilks’ Lambda was used for the between-groups comparisons between the intervention and non-intervention groups and Paired Samples t-test was used for the within-groups analysis. The comparisons were made in terms of improvement in symptoms, determined by the Functional Bowel Disorder Severity Index (FBDSI) and lowering of occupational stress, determined by two of the scales of the Occupational Stress Inventory, namely the Occupational Roles and Personal Strain scales and an increase in coping responses determined by the Personal Resources scale. Both of these were administered as pre- and post-test measures before and three months after the intervention was completed. The results of the study indicate that the experimental group of IBS participants who received the intervention improved in symptom severity, their occupational stress was lowered and they began utilizing more coping resources than the group of IBS participants who did not receive the intervention. Thus it is concluded that an individualized holistic approach for the treatment of IBS is indicated and that individuals with refractory IBS can be helped to manage their illness and their lives. In particular, this psychologically based study confirms a very definite and specific place for psychologists in the treatment of clients with IBS and stress. An invitation was extended to the control group to use the facilities for therapeutic intervention offered by the RAU Psychogastroenterology project once the post-tests had been completed, thus addressing any ethical questions that could have arisen. This was an initial investigation using an ecologically based meta-theoretical framework as well as specific stress techniques for the holistic treatment of clients. A number of recommendations arose from this particular intervention and are included for future studies.

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) disorder seen by healthcare professionals, yet, effective treatment is lacking. The aim of this study was to explore the effects of osteopathic treatment on IBS. Two IBS patients were recruited and received osteopathic treatment over four consecutive weeks at Victoria University Osteopathic Medicine Clinic. The patients were assessed by the Bowel Symptom Scale (BSS) at the pre, mid and post treatment points. Subjects showed varied results throughout the study, however by the end of the study both patients showed a decrease in their overall severity of symptoms. Improvements did occur in the patients' individual presenting symptoms, where abdominal pain, bloating and diarrhoea were all reduced. The preliminary data of two patients indicates that osteopathic treatment may help. However, the results are inconclusive due to an insufficient patient population and inadequate study design. This highlights the need for further research of a larger scale, longer-term , randomised, controlled study. This minor thesis was written by a post-graduate student as part of the requirements of the Master of Health Science (Osteopathy) program.

Irritable bowel syndrome (IBS) is the most common chronic functional gastrointestinal disorder that affects approximately 11% of the global population with a higher prevalence in women and those under the age of 50. IBS is characterized and diagnosed by the presence of a group of symptoms including abdominal pain, bloating or distension accompanied by altered bowel movements. A positive diagnosis of IBS can be made in the presence of well-defined, validated diagnostic criteria and in addition to the exclusion of organic disease with minimal testing. The lack of specific therapeutic targets makes treatment of IBS very difficult and its management is focused on symptom relief. IBS has a well-established high comorbidity with anxiety, depression, and psychosomatic disorders which contributes significantly to a substantial burden of illness. IBS patients exhibit a markedly decreased quality of life, decreased work productivity and increased absenteeism from work, and increased direct healthcare utilization (such as office visits, medical tests, and specialty referrals), resulting in a large economic burden for society. Despite this, effective pharmacologic and non-pharmacologic treatment options are limited and many patients with IBS do not achieve complete symptom relief long term and continue to suffer from IBS symptoms. Early pioneering in the study of this disease has called for a biopsychosocial model, a model in which psychological and social factors are also considered in IBS treatment. Through consideration of this model, it has been discovered that the disease has strong ties with early life environment, daily stress, and coping skills. Research in the past decades has established IBS as a disease of neurogastroenterology and involves disturbances in the brain-gut axis, the connection between the central nervous system and enteric nervous system. The brain-gut axis is organized in hierarchies with the first control level consisting of the enteric nervous system (ENS) sensory, muscular, and interneurons, all of which form reflex circuitry to control gastrointestinal (GI) motility and sensation among other functions. The central nervous system (CNS) synapses onto these circuits via vagal and spinal afferents. Information from the luminal GI tract is processed in the higher cortical structures of the brain, particularly in the hypothalamus, amygdala, anterior cingulage cortex (ACC) and prefrontal cortex (PFC). These structures are also important for homeostasis and regulation of attention, emotion, and behavior. Disturbances of these pathways result in peripheral and eventually central sensitization, the subject of this thesis. Sensitization in IBS includes visceral hypersensitivity, increased pain perception, and increased GI motility. Due to the cortical regions where this information is processed, these physical symptoms often have a complex interplay with psychological symptoms including anxiety, fear, and stress. The connection between the physical symptoms and psychological symptoms lies in the pain matrix and emotional motor system. This has been confirmed by many brain imaging studies comparing normal individuals with IBS patients testing visceral, somatic and cutaneous pain as well as anxiety and depression levels. IBS patients, unlike control subjects, have been found to have increased pain perception localizing to all these regions and they also rate the pain as more unpleasant, a psychological factor, than normal patients. In addition to increased cortical activation, IBS patients have increased corticotropin releasing factor in the amygdala promoting anxiety and increasing stress levels and GI symptoms. Of note is the fact that stress is both a cause and effect of IBS symptoms and often compounds symptoms due to the cyclical nature of stress and chronic pain. Because stress ties in with both the physical and psychological symptoms faced by IBS patients, implementation of psychological treatment in IBS management is of great importance and have demonstrated improved outcomes in IBS patients. Psychological treatments with empirical evidence are discussed in this thesis and include cognitive behavioral therapy, psychodynamic psychotherapy, hypnotherapy, and mindfulness/relaxation exercises. Whether these all treatments tie into the alterations in cortical processing in brain-gut function is a topic that is yet to be explored.

M.A.<br>Irritable Bowel Syndrome (IBS) can be described as a bodily idiom - a nonverbal language which may have its roots in unspeakable dilemmas (Griffiths & Griffiths, 1994). The splitting of languages and silencing of the body may be the soil in which such symptoms grow. Unutterable conflicts lead to the symptoms being trapped within the body until the body itself begins to "speak" (Griffiths & Griffiths, 1994). In essence, this study seeks to evaluate the effects of attaching language, feelings and awareness to these symptoms and communicating this with other IBS subjects within the group context. Psychiatric illness is often found in IBS health care seekers (Drossman & Thompson, 1992). The specific aim of this study was to ascertain the effects of a holistic short-term group intervention in the treatment of IBS with comorbid depression and anxiety. The sample consisted of 24 South African women who had been positively diagnosed with severe IBS by either a gastroenterologist or a general practitioner. Furthermore, each subject had to have associated moderate to severe depression and anxiety. Four questionnaires were utilised, namely the Biographical Questionnaire, the Irritable Bowel Syndrome Client Questionnaire, the Personality Assessment Inventory (PAI) and the Functional Bowel Disorder Severity Index (FBDSI). The Biographical Questionnaire mainly requested personal details and sought a family history of psychological disorders. The Irritable Bowel Syndrome Client Questionnaire, based on the standardised Rome Criteria (Drossman, 1994; Drossman, Zhiming, Toner, Creed, Thompson, Read et al., 1995; Talley, Phillips, Melton, Mulvihill, Wiltgen & Zinsmeister, 1989), verified a positive IBS diagnosis, while the Functional Bowel Disorder Severity Index rated the severity of the subject’s IBS. Lastly, the depression score was rated on the depression scale of the Personality Assessment Inventory (PAI) and the anxiety score was rated on the anxiety scale of the PAI. The subjects were divided into two groups of twelve members each - Group 1 was the experimental group and Group 2 was the control group. The group design was a pre-test, post-test control group design where subjects in Group 1 (the experimental group) received group intervention and subjects in Group 2 (the control group) were placed on a waiting list and received no intervention. The subjects in the control group were offered individual therapy once the post-tests were completed. All the subjects completed the IBS Severity Index Questionnaire and the Depression and Anxiety subscales of the Personality Assessment Inventory before commencement of group therapy for Group 1 and again one month after completion of this intervention. The effect of the intervention was determined utilising comparative statistics with reference to the pre-test versus post-test scores. The t-test for the equality of means for between group variance was utilised for two analyses. Firstly, it was used to determine the variance regarding the pre-test scores between Group 1 (the experimental group – who received intervention) versus Group 2 (the control group – who received no intervention) (Hypothesis 1). Secondly, it was utilised to determine the between group variance in terms of the post-test scores for Group 1 (the experimental group) versus Group 2 (the control group) (Hypothesis 2). The paired samples t-test was also used for two analyses. Firstly, it was used to determine the within group variance regarding the pre-intervention test scores versus the post-intervention test scores for Group 1 (the experimental group)(Hypothesis 3). Secondly, the paired samples t-test was also utilised to determine if there were statistically significant differences in terms of the pre-test scores versus the post-test scores of Group 2 (the control group) who did not receive the intervention (Hypothesis 4). A short-term holistic group therapy model was applied based on the work of Broom (1997), Crafford (1985), Pretorius (1996) and Yalom (1970). The results of the study showed that there was a statistically significant improvement in the anxiety scores of Group 1 (the experimental group) after completion of the intervention when compared with Group 2 (the control group) who received no intervention. The within group depression and anxiety scores in the experimental group also revealed a statistically significant improvement after the intervention. However, the IBS symptom severity remained unchanged. Thus, it is concluded that holistic short-term group therapy is indicated in the treatment of severe IBS with comorbid depression and anxiety even if the IBS symptoms are unaltered. It is recommended that further research be conducted to ascertain whether holistic group therapy of a moderate duration (approximately eight to ten weeks) has a greater impact on the IBS symptom severity.