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ABSTRACT: BACKGROUND: Evidence supporting appropriate medical therapy to prevent recurrence of colonic diverticulitis is limited. Our goal was to evaluate the potential of rifaximin given periodically in addition to fibre for the prophylaxis of recurrences. METHODS: We conducted a multicentre, randomized, open controlled study in patients with a recent episode of colonic diverticulitis, currently in remission. Patients received 3.5g of high-fibre supplementation b.d. with or without one week per month of the non-absorbable antibiotic rifaximin (400mg b.d.) for 12months. Primary endpoint was recurrence of diverticulitis, encompassing acute symptomatic flare with or without complications, analyzed by multivariable logistic regression analysis and by Cox proportional hazard method. RESULTS: After randomizing 165 patients, the study was interrupted since the recruitment rate was largely below the minimum anticipated, and the trial was switched from evidence-gathering to proof-of-concept. Recurrences occurred in 10.4% of patients given rifaximin plus fibres vs. 19.3% of patients receiving fibres alone. The logistic analysis adjusted for sex, age, illness duration, time from last episode, disease localization and centre recruitment rate, yielded a significant treatment effect (odds ratio 3.20; 95% confidence interval: 1.16-8.82; P=0.025). Patients with diverticulitis diagnosed since ≥1year receiving rifaximin also had a lower incidence of recurrences (10%; 95% confidence interval: 2-47% vs. 67%; 95% confidence interval: 37-100%). Both treatments were safe. CONCLUSIONS: This study represents a proof-of concept of the efficacy of cyclic rifaximin treatment, added to fibre supplements, to reduce the risk of recurrences of diverticulitis in patients in remission.
Digestive and Liver Disease 10/2012; · 3.05 Impact Factor
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ABSTRACT: We studied the frequency of supraesophageal and dyspeptic symptoms and their impact on the quality of life (QoL) and treatment response in patients with gastroesophageal reflux disease (GERD).
Multicenter, prospective, observational study of patients who consulted a gastroenterologist because of typical GERD symptoms. Upper digestive symptoms were assessed using direct interviews. The Short Form-12 and the Quality of Life in Reflux and Dyspepsia questionnaires were used to measure QoL. Patients were treated with proton pump inhibitors (PPIs).
A total of 301 patients (58% men; mean age, 45 years) were included. Baseline symptoms were heartburn (99% of cases; nocturnal heartburn 78%), regurgitation (86%), both heartburn and regurgitation (85%), dyspeptic symptoms (91%; epigastric pain syndrome 20%, postprandial distress syndrome 4%, both 75%), and supraesophageal symptoms (58%). In 56% of cases of heartburn, 35% of regurgitation, and 34% of nocturnal heartburn, symptoms were severe or very severe. One in six patients had dysphagia. Supraesophageal and/or dyspeptic symptoms were associated with worse scores on the Short Form-12 and Quality of Life in Reflux and Dyspepsia instruments. After treatment, heartburn and regurgitation disappeared in 93 and 87% of the patients, respectively. The percentage of patients responding to PPI treatment was significantly higher (P<0.05) in those with heartburn than those without heartburn (96 vs. 86%) and in those with regurgitation than without regurgitation (95 vs. 83%), whereas no differences were observed in those with and without supraesophageal or dyspeptic symptoms.
Patients with typical GERD symptoms (heartburn and/or regurgitation) very frequently have dyspeptic and supraesophageal manifestations, which are related to a worse QoL but unrelated to PPI response.
European journal of gastroenterology & hepatology 02/2012; 24(6):665-74. · 1.66 Impact Factor
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ABSTRACT: As in previous years, a huge number of studies were presented at the Congress of the American Gastroenterology Association (Digestive Diseases Week [DDW]), some of which were better than others. The present article attempts to extract and summarize the most interesting findings reported. In general terms, certain technological advances have been consolidated, with full incorporation into clinical practice, such as impedancemetry and high-resolution manometry. New physiopathological data are coming to light that increasingly indicate the inextricable link between organic and psychological factors (the biopsychosocial model) in functional gastrointestinal disorders (FGID). Despite the high hopes that the Rome III criteria would improve the diagnosis of FGID and especially that of functional dyspepsia, their practical application has been fairly discouraging. Moreover, at least two studies have demonstrated that these criteria cannot be used to differentiate subtypes of functional dyspepsia and that there is wide overlap with gastroesophageal reflux disease. New data were presented on the role of genetic, microinflammatory and psychological factors in the etiopathogenesis of the two main FGID: functional dyspepsia and irritable bowel syndrome (IBS). The results on the safety and efficacy of acotiamide in functional dyspepsia and of linaclotide and prucalopride in idiopathic and IBS-associated constipation were also presented. Several studies, and even meta-analyses, have demonstrated the utility of biofeedback in the treatment of constipation. Even so, the efficacy of this therapy has been questioned due to certain methodological deficiencies in some studies. In DDW 2011, studies confirming the utility of biofeedback, whether hospital- or home-based were presented, in dyssynergy constipation. The present article also mentions certain features of special interest in the diagnosis and treatment of rumination syndrome, thoracic pain of possible esophageal origin and cannabinoid-induced hyperemesis syndrome.
Gastroenterología y Hepatología 10/2011; 34 Suppl 2:3-14. · 0.73 Impact Factor
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Fermín Mearin,
Agustín Balboa,
Antoni Castells,
J Enrique Domínguez,
Maria Esteve,
Jose A García-Erce,
Javier P Gisbert,
Javier Pérez Gisbert,
Fernando Gomollón,
Julián Panés,
Julio Ponce
Gastroenterología y Hepatología 10/2010; 33(8):605-13. · 0.73 Impact Factor
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ABSTRACT: 1. To analyze the symptom profile of gastroesophageal reflux disease (GERD) with typical clinical manifestations (heartburn and/or regurgitation); 2. to compare untreated patients with those with persistent symptoms despite treatment; 3. to evaluate severity according to physicians' and patients' opinions; and 4. to determine the diagnostic and therapeutic approaches used.
We performed a prospective, observational, cross-sectional study under conditions of standard clinical practice.
A total of 2356 patients were included. Dyspeptic symptoms were highly frequent (close to 90% in both groups) and supraesophageal symptoms were also common (50-60%). Patients with persistent symptoms despite treatment were older, and had more supraesophageal symptoms; in addition, the typical supraesophageal and dyspeptic symptoms of GERD were more severe in these patients. Severity evaluations by patients and doctors were concordant but patients considered severity to be greater. Older age was a risk factor for supraesophageal symptoms, female gender for dyspeptic symptoms and body mass index for greater severity of GERD symptoms. Endoscopy was requested in about 60% of the patients. Diet counseling was advised in most patients and postural recommendations were made in more than half. Proton pump inhibitors were prescribed in almost all patients, and were associated with prokinetics and/or antacids in many patients.
Dyspeptic symptoms should not be considered as independent of GERD, and typical and atypical symptoms are associated in 50% of patients. Gastroenterologists follow clinical practice guidelines fairly closely but diagnostic procedures seem to be overindicated.
Gastroenterología y Hepatología 04/2010; 33(4):271-9. · 0.73 Impact Factor
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ABSTRACT: Recently, a new lansoprazole formulation consisting of orally disintegrating tablets has become available, which could improve acceptability and compliance with this type of medication. The aim of the present study was to evaluate preferences in patients with gastroesophageal reflux disease concerning lansoprazole orally disintegrating tablets compared with lansoprazole capsules.
A phase IV, multicenter, crossed, open and randomized clinical trial was performed in patients with symptoms of gastroesophageal reflux disease and associated dysphagia. The patients were treated with 30mg lansoprazole capsules for 3 days and with 30mg lansoprazole orally disintegrating tablets for another 3 days. The order of treatment (first capsules followed by orally disintegrating tablets or vice versa) was determined by centralized block randomization. The main measure was the visual analog scale (VAS) score in which patients was asked to rate their degree of preference for the orally disintegrating tablets or the capsules.
Of the 145 patients included, 126 could be evaluated by the protocol. A total of 47% (59/126) of the patients preferred the orally disintegrating tablets, 33% (42/126) preferred the capsules and the remainder (25/126) had no preference. The mean preference value in the VAS was 5.31 (4.72 +/- 5.90) in favor of the orally disintegrating tablets, although this difference was not statistically significant. In general, differences in favor of the orally disintegrating tables were more marked in older patients. The percentage of patients free of pyrosis at the end of both treatment sequences was approximately 75% with no differences according to which treatment was administered first. Finally, preference evaluation through willingness to pay techniques showed similar results, again in favor of the orally disintegrating tablets (4.18 euro +/- 6.86 euro vs 3.47 euro +/- 5.78 euro).
The acceptability of pharmaceutical formulations of lansoprazole in capsules and orally disintegrating tables is similar among patients with gastroesophageal reflux disease and associated dysphagia. However, a clear, but nonsignificant, trend was observed in favor of orally disintegrating tablets among older patients.
Gastroenterología y Hepatología 08/2009; 32(8):542-8. · 0.73 Impact Factor
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ABSTRACT: Irritable bowel syndrome (IBS) is one of the most common functional gastrointestinal disorders and is that with the greatest socioeconomic impact worldwide. Diagnosis of IBS is based on clinical criteria that have been modified over time, the Rome II criteria being those that are currently followed. Some of the symptoms of IBS are similar to those in patients with inflammatory bowel disease (IBD), which can hamper or delay diagnosis. The use of inflammatory markers in stools (such as calprotectin) may help to distinguish between these two entities. A possible connection between IBS and IBD could be based on five points: (i) both disorders have similar symptoms; (ii) symptoms often overlap in the same patients; (iii) IBS and IBD have a common familial aggregation; (iv) some predisposing factors, such as a history of acute gastroenteritis, play a role in both disorders, and (v) importantly, signs of microinflammation are found in the bowels of patients with IBS. With regard to this latter point, an increase in inflammatory cells has been found in the intestinal mucosa of patients with IBS and, more specifically, mastocytes have been found to be increased in the jejunum and colon while CD3 and CD25 intraepithelial lymphocytes have be observed to be increased in the colon. Moreover, activated mastocytes are increased near to nerve endings in patients with IBS and this finding has been correlated with the intensity of both intestinal symptoms (abdominal pain) and psychological symptoms (depression and fatigue). A good model of microinflammation is post-infectious IBS, since the timing of the onset of the infectious process is known. In patients with post-infectious IBS, an increase in intraepithelial lymphocytes and enterochromaffin cells is initially found, which is reduced over time; consequently, although the symptoms of IBS persist, after 3 years no differences are detected in the number of inflammatory cells between IBS patients and controls. Among the various factors that can favor the development of IBS in these patients, two host-dependent mechanisms are most closely implicated in the physiopathology of IBS: polymorphism of the genes codifying pro- or anti-inflammatory cytokines and psychological factors such as anxiety, depression, somatization and neuroticism at the time of the acute infection. In view of all of the above, the similarities between IBS and IBD are probably more than mere coincidence and may reflect distinct manifestations of a broad spectrum of inflammation in the colon.
Gastroenterología y Hepatología 06/2009; 32(5):364-72. · 0.73 Impact Factor
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ABSTRACT: Functional gastrointestinal (GI) and motility disorders generate a large volume of consultations in gastroenterology and primary care offices. The present article summarizes the most interesting studies presented in the annual meeting of the American Gastroenterological Association 2008. For all functional GI disorders, studies were presented that evaluated the applicability of diagnostic criteria in clinical practice and new data were presented on physiopathology (for example, mediation by neuromodulators such as serotonin, microinflammation, alterations in intestinal microbiota, and psychological factors). More specifically, the therapeutic results of new prokinetic agents in functional dyspepsia, such as acotiamide, were presented. This agent has been demonstrated to have good efficacy in symptom control, especially in patients with postprandial distress syndrome. In irritable bowel syndrome, data were presented on several drugs that act through diverse mechanisms of action and have been shown to be more effective than placebo in symptom control. These drugs include antiinflammatory agents such as mesalazine, antibiotics such as rifaximin, probiotics with distinct bacterial strains, and prokinetic agents such as lubiprostone. Highly promising results have been obtained in the treatment of constipation with prokinetics such as prucalopride and with novel laxatives such as linaclotide, as well as with techniques that continue to be shown to be effective such as anorectal biofeedback, which is also highly useful in patients with fecal incontinence. Another disorder that is less frequent but highly difficult to treat is gastroparesis. For several years, treatment in the most severe cases has consisted of implantation of a gastric pacemaker. Although the results are far from perfect, new data were presented that allow better patient selection to achieve greater symptom control. The list of new advances, both in knowledge of the physiopathology of these disorders and on their treatments, is extensive. Consequently, 2008 has been a good year in terms of the useful information gathered for physicians interested in functional GI and motor disorders.
Gastroenterología y Hepatología 11/2008; 31 Suppl 4:3-17. · 0.73 Impact Factor
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Mónica Perona, Fermín Mearin,
Magda Guilera,
Miguel Mínguez,
Vicente Ortiz,
Miguel Montoro,
Jordi Serra,
Carlos Casanova,
Enrique Rey,
Onofre Alarcón,
Luis Bujanda,
Antonio Lima,
Montse Andreu,
Manuel Castro,
Antonio López,
Ricardo Carrillo,
Laura Sempere,
Xavier Badia
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ABSTRACT: Although constipation affects quality of life, questionnaires hardly exist for its evaluation. We aimed to develop and validate a questionnaire able to measure the quality of life in patients with constipation.
A Spanish multicenter study was performed in 2 stages: a) questionnaire development (open interview to patients with constipation, pilot questionnaire, quantitative and factorial analysis, Rasch analysis, and specific questionnaire design), and b) questionnaire validation in 136 patients. These patients were divided in 2 groups: a) reliability group (n = 55; no need to begin or change treatment; re-tested after 15 days), and b) sensibility to change group (n = 81; need to begin or change treatment; re-tested after 3 months). We collected clinical and socio-demographic data and we evaluated the quality of life through the general questionnaire EuroQoL-5D (EQ-5D) and the specific one, design in the previous stage (25 items). After that, we analysed feasibility, reliability and validity (of content, convergent and longitudinal).
The trial questionnaire was obtained during the development stage and the results were 51 items that were later reduced to 25 in the validation stage. A total of 126 patients (93% women; mean age [standard deviation]: 43.4 [1] years) completed the study properly. The answer average time was 12 min. The content validity process reduced the questionnaire to 20 items (CVE-20) within 4 domains: emotional, general physical, rectal physical and social. The reliability was good in relation to the general punctuation (Cronbach alpha coefficient = 0.87), being in the different domains of 0.79, 0.73, 0.75 and 0.60, respectively. The construct validity showed a good correlation between the CVE-20 results and constipation severity. The CVE-20 score positively correlated with EQ -5D changes. The test and re-test reliability were good: interclass correlation coefficient = 0.89 (ranging from 0.80 to 0.88 in the different domains). The clinically relevant and minimal difference was 17 points (95% confidence interval, 11-23). The content validity showed a strong correlation between CVE-20 and constipation severity.
The CVE-20 is the first specific questionnaire in Spanish language for constipated patients; it is valid, reliable, sensitive to changes and it meets the psychometric requirements to be applied in daily practice and clinical trials.
Medicina Clínica 10/2008; 131(10):371-7. · 1.38 Impact Factor
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Fermín Mearin
Gastroenterología y Hepatología 07/2008; 31(6):392-3. · 0.73 Impact Factor
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Fermín Mearin
Acta gastroenterologica Latinoamericana 10/2007; 37(3):178-82.
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Fermín Mearin
Medicina Clínica 04/2007; 128(9):335-43. · 1.38 Impact Factor
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Fermín Mearin
Gastroenterología y Hepatología 04/2007; 30(3):130-7. · 0.73 Impact Factor
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Agustín Balboa, Fermín Mearin,
Xavier Badía,
Jaume Benavent,
Antonio María Caballero,
José Enrique Domínguez-Muñoz,
Vicente Garrigues,
José María Piqué,
Montse Roset,
Mercedes Cucala,
Montse Figueras
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ABSTRACT: Functional digestive disorders constitute a sizable proportion of gastroenterology and primary healthcare consultations, and have a negative impact on health-related quality of life. Dyspepsia and heartburn are often associated with irritable bowel syndrome (IBS); however, the incidence of these symptoms and their effect on IBS patients have not been evaluated.
To investigate the clinical, psychological and health-related quality of life impact of upper digestive symptoms on IBS patients.
A prospective, observational, multicentered study was conducted in Spain: 517 IBS patients (Rome II criteria), grouped according to predominant symptoms of constipation (IBS-C), diarrhea (IBS-D) or alternating bowel habit (IBS-A) and 84 controls without IBS were recruited. Upper digestive symptoms were recorded in a 30-day diary. Health-related quality of life was evaluated by Irritable Bowel Syndrome Quality of Life and Euro-Quality of Life Five-Dimension Questionnaires; psychological well-being was evaluated by the Psychological General Well-Being Index.
IBS patients had greater frequencies of upper digestive symptoms (72.3 vs. 6.0%), dyspepsia (21.1 vs. 4.8%) and heartburn (40.0 vs. 13.1%) (all P < 0.05) than controls. Prevalence of upper digestive symptoms was lower in patients with IBS-D than in those with IBS-C or IBS-A (P < 0.05). Health-related quality of life and psychological status were significantly worse in IBS patients with upper digestive symptoms than in those without.
Upper digestive symptoms, frequently present in IBS patients, impair health-related quality of life and psychological status. This effect is greater in patients with IBS-C and IBS-A than in those with IBS-D. These data emphasize the importance of evaluating the presence of upper digestive symptoms in IBS patients.
European Journal of Gastroenterology & Hepatology 01/2007; 18(12):1271-7. · 1.76 Impact Factor
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ABSTRACT: Whatever our specialty, whether gastroenterology or primary care, physicians must manage patients with motility and functional gastrointestinal disorders. Therefore, it is not surprising that interest and research in these disorders have shown an exponential increase in the last few years. At the last congress of the American Gastroenterological Association (Digestive Diseases Week, 2006), 443 communications were presented on these topics: 72 oral communications and 371 posters. Spain made a significant contribution: four oral presentations and nine posters. The aim of this chapter is to summarize as easily and practically as possible the most important studies presented at the congress.
Gastroenterología y Hepatología 12/2006; 29 Suppl 3:31-44. · 0.73 Impact Factor
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Sera Tort,
Agustín Balboa,
Mercè Marzo,
Ricard Carrillo,
Miguel Mínguez,
Javier Valdepérez,
Pablo Alonso-Coello,
Juan José Mascort,
Juan Ferrándiz,
Xavier Bonfill,
Josep M Piqué, Fermín Mearin
Gastroenterología y Hepatología 11/2006; 29(8):467-521. · 0.73 Impact Factor
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ABSTRACT: Our group previously reported the absence of nitric oxide synthase (NOS) in the gastroesophageal junction of patients with achalasia. NOS exists in three distinct isoforms: neuronal NOS (nNOS), endothelial NOS (eNOS), and inducible isoform (iNOS). Some studies have shown that NO production is regulated by NOS polymorphisms.
To assess whether some functional polymorphisms in the nNOS, iNOS, or eNOS genes are involved in susceptibility to suffer from achalasia.
Genomic DNA from 80 unrelated Spanish Caucasian patients with sporadic achalasia and 144 healthy subjects matched for age (+/-5 yr) and gender was typed by PCR and RFLP methods for the 27-bp variable number of tandem repeat (VNTR) polymorphism in intron 4 of the eNOS gene, a CA microsatellite repeat and a Nla III (C-->T) restriction fragment length polymorphism (RFLP) in exon 29 of the nNOS gene, and two nucleotide substitutions located in exon 16 (C-->T) and exon 22 (G-->A) of the iNOS gene.
No significant differences in carriage, genotype, and allele frequencies of the nNOS, iNOS, or eNOS gene polymorphisms were found between patients with achalasia and controls. Individuals homozygous for genotype iNOS22*A/A tended to be more frequent in achalasia (20%vs 11%, odds ratio [OR] 1.79, 95% confidence interval [CI] 0.89-3.59, p= 0.09) as were those homozygous for the rare eNOS*4a allele (6.2%vs 1.4%, OR 4.5, 95% CI 0.89-22.67, p= 0.1) although the difference did not reach statistical significance. No differences in genotype and allele distribution were found with respect to epidemiological and clinical characteristics of patients with achalasia.
Our data suggest that NOS gene polymorphisms are not involved in the susceptibility to and nature of the clinical course of sporadic achalasia. However, studies in a greater number of patients are required to analyze the tendency toward a higher prevalence of genotypes iNOS22*A/A and eNOS*4a4a.
The American Journal of Gastroenterology 09/2006; 101(9):1979-84. · 7.28 Impact Factor
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Fermín Mearin
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ABSTRACT: Functional digestive disorders constitute one of the main causes of consultation in gastroenterology and primary health care. Is still unclear whether therapy has to be aimed to the gut, to the neural pathways controlling bowel motility and perception, or to the processing mechanisms of symptoms and disease behaviour. It is conceivable that in the next future better understanding of functional bowel disorders pathophysiology will help us to tailor treatment for different patients. At the moment, subclassification of the diverse patterns of symptomatology allows to adjust new treatments for irritable bowel syndrome (IBS) according to the clinical predominance for each patient. The knowledge of motor and sensorial response to different stimuli in IBS patients and the pathways to the central nervous system is an important source of information for the development of new molecules. Fiber-enriched diet is frequently given for constipation-predominant IBS. Loperamide, antispasmodic drugs and tricyclic antidepressants are nowadays the basis for pharmacological treatment of diarrhea- predominant IBS. The scientific evidence supporting this therapeutical approach is however limited. Visceral analgesics and serotonin agonists and antagonists may play an important therapeutical role in the near future. However, it is not likely that one single treatment will help every functional bowel disorder patient and many of them will need a more complex approach with a multidisciplinary therapy (diet, psychotherapy, medications).
Digestion 02/2006; 73 Suppl 1:28-37. · 2.05 Impact Factor
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ABSTRACT: It has been reported that some patients develop functional digestive disorders, particularly irritable bowel syndrome (IBS), after acute gastroenteritis (AGE). However, the presence of dyspepsia has not been specifically addressed. We prospectively evaluated development of dyspepsia and IBS during a 1-year follow-up in a cohort of adult patients affected by a Salmonella enteritidis AGE outbreak.
Questionnaires were sent to 1878 potential participants at baseline and 3, 6, and 12 months; 677 had experienced a Salmonella enteritidis AGE on June 23, 2002, and 1201 had not (randomly selected controls, matched for village of residence, age, and sex). At 12 months, 271 patients and 335 controls returned the questionnaires. Data permitted the establishment of dyspepsia and IBS diagnosis by Rome II criteria.
Before the AGE outbreak, the prevalence of dyspepsia was similar in cases and controls (2.5% vs 3.8%); the prevalence of IBS was also similar (2.9% vs 2.3%). At 3, 6, and 12 months, the prevalence of both dyspepsia and IBS had increased significantly in exposed compared with unexposed subjects. Overlap between dyspepsia and IBS was frequent. At 1 year, the relative risk for development of dyspepsia was 5.2 (95% confidence interval, 2.7-9.8) and for IBS was 7.8 (95% confidence interval, 3.1-19.7). Prolonged abdominal pain and vomiting during AGE were positive predictors of dyspepsia. No predictive factors for IBS were found.
Salmonella gastroenteritis is a significant risk factor not only for IBS but also for dyspepsia; at 1 year of follow-up, 1 in 7 and 1 in 10 subjects developed dyspepsia or IBS, respectively.
Gastroenterology 08/2005; 129(1):98-104. · 11.68 Impact Factor
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ABSTRACT: Irritable bowel syndrome (IBS) is a heterogeneous condition characterized by the presence of abdominal discomfort or pain and bowel habit alterations: constipation (C-IBS), diarrhea (D-IBS), or alternating C and D (A-IBS). Its clinical course is poorly known.
(i) To compare bowel habit subtypes distribution in IBS according to sample origin and diagnosis criteria; (ii) To evaluate IBS temporal patterns based on follow-up studies.
A literature search (1966-2003) was conducted in the MEDLINE and EMBASE databases. A total of 72 studies were found and 22 were finally selected.
Population-based studies from the United States (Manning) found similar distribution among C-IBS, D-IBS, and A-IBS, while European studies (Rome I, Rome II, or self-reporting) showed either C-IBS or A-IBS as the most prevalent subtypes. Primary care office-based studies (Rome I or Rome II) showed A-IBS as the most prevalent group. Gastroenterology specialized office-based studies found either C-IBS or D-IBS as the most frequently reported subtype. Prospective follow-up investigations showed that the most frequent IBS temporal pattern profile consists of mild to moderate symptoms appearing in cluster in an intermittent way, about once a week, and lasting 2-5 days on average.
IBS clinical subtypes distribution differs depending on the population evaluated, the geographical location, and the criteria employed to define IBS and bowel habit subtypes. In most cases, clinical course is characterized by the presence of mild-to-moderate symptoms appearing sequentially. Prospective studies, using clear and stable diagnostic criteria and subtype definitions, and based on daily data collection should further characterize IBS clinical course.
The American Journal of Gastroenterology 06/2005; 100(5):1174-84. · 7.28 Impact Factor
