Review | Published:

The Utility of Probiotics in the Treatment of Irritable Bowel Syndrome: A Systematic Review

The American Journal of Gastroenterology volume 104, pages 10331049 (2009) | Download Citation

Subjects

Abstract

OBJECTIVES:

Irritable bowel syndrome (IBS) is a common disorder and available therapies have limited efficacy. Mucosal inflammation and alterations in gut microflora may contribute to the development of IBS symptoms, and researchers have hypothesized that probiotics might improve these symptoms. The aim of this study was to perform a systematic review of randomized controlled trials (RCTs) evaluating the efficacy, safety, and tolerability of probiotics in the treatment of IBS.

METHODS:

Comprehensive literature searches of multiple databases were performed. Study selection criteria were as follows: (i) RCTs, (ii) adults with IBS defined by Manning or Rome II criteria, (iii) single or combination probiotic vs. placebo, and (iv) improvement in IBS symptoms and/or decrease in frequency of adverse events reported. Data about study design and results were extracted in duplicate using standardized data extraction forms. Owing to variability in outcome measures, quantitative pooling of data was not feasible.

RESULTS:

A total of 16 RCTs met selection criteria. Of those, 11 studies showed suboptimal study design with inadequate blinding, inadequate trial length, inadequate sample size, and/or lack of intention-to-treat analysis. None of the studies provided quantifiable data about both tolerability and adverse events. Bifidobacterium infantis 35624 showed significant improvement in the composite score for abdominal pain/discomfort, bloating/distention, and/or bowel movement difficulty compared with placebo (P<0.05) in two appropriately designed studies. No other probiotic showed significant improvement in IBS symptoms in an appropriately designed study.

CONCLUSIONS:

B. infantis 35624 has shown efficacy for improvement of IBS symptoms. Most RCTs about the utility of probiotics in IBS have not used an appropriate study design and do not adequately report adverse events. Therefore, there is inadequate data to comment on the efficacy of other probiotics. Future probiotic studies should follow Rome II recommendations for appropriate design of an RCT.

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References

  1. 1.

    , , et al. Irritable bowel Syndrome in the United States: Prevalence, symptoms patterns and impact. Aliment Pharmacol Ther 2005;21:1365–1375.

  2. 2.

    , , et al. AGA technical review on irritable bowel syndrome. Gastroenterol 2002;123:2108–2131.

  3. 3.

    , , . Symptom relief with Amitriptyline in the irritable bowel syndrome. J Gastroenterol Hepatol 1998;13:738–741.

  4. 4.

    , , et al. Tegaserod, a 5HT(4) receptor partial agonist, relieves symptoms in irritable bowel syndrome patients with abdominal pain, bloating and constipation. Aliment Pharmacol Ther 2001;15:1655–1666.

  5. 5.

    , , et al. Efficacy and safety of Alosetron in women with irritable bowel syndrome: A randomized, placebo-controlled trial. Lancet 2000;355:1035–1040.

  6. 6.

    , , . Normalization of Lactulose breath testing correlates with symptom improvement in irritable bowel syndrome: A double-blind, randomized, placebo-controlled study. Am J Gastroenterol 2003;98:412–419.

  7. 7.

    , , et al. The effect of a non-absorbed oral antibiotic (Rifaximin) on the symptoms of the irritable bowel syndrome. Ann Intern Med 2006;145:557–563.

  8. 8.

    , . The irritable bowel syndrome. N Engl J Med 2001;344:1846–1850.

  9. 9.

    . Crohn's disease and Escherichia coli. A new approach in therapy to maintain remission of colonic Crohn's disease? J Clin Gastroenterol 1997;25:653.

  10. 10.

    , , et al. Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis. Gut 2004;53:108.

  11. 11.

    , , et al. Prophylaxis of pouchitis onset with probiotic therapy: A double-blind placebo controlled trial. Gastroenterol 2003;124:1202.

  12. 12.

    , , et al. Treatment of recurrent Clostridium difficile colitis with Vancomycin and Saccharomyces boulardii. Am J Gastroenterol 1989;84:1285–1287.

  13. 13.

    , , et al. Administration of different Lactobacillus strains in fermented oatmeal soup: in vivo colonization of human intestinal mucosa and effect on the indigenous flora. Appl Environ Microbiol 1993;59:15–20.

  14. 14.

    , , et al. Recovery of Lactobacillus rhamnosus GG from human colonic biopsies. Lett Appl Microbiol 1997;24:361–364.

  15. 15.

    , , et al. Antimicrobial substance from a human Lactobacillus strain. Antimicrob Agents Chemother 1987;31:131–1233.

  16. 16.

    , , et al. Lactobacillus plantarum 299: Beneficial in vitro immunomodulation in cells extracted from inflamed human colon. J Gastroenterol Hepatol 2004;19:166–173.

  17. 17.

    , , et al. Effects of non-pathogenic bacteria on cytokine secretion by human intestinal mucosa. Am J Gastroenterol 2003;98:865–870.

  18. 18.

    , , et al. Lactic acid bacteria secrete metabolites retaining anti-inflammatory properties after intestinal transport. Gut 2004;53:821–828.

  19. 19.

    , , et al. Lactobacillus and Bifidobacterium in irritable bowel syndrome: Symptom responses and relationship to cytokine profiles. Gastroenterol 2005;128:41–551.

  20. 20.

    . Use of diet and probiotic therapy in the irritable bowel syndrome. J Clin Gastroenterol 2005;39:S243–S246.

  21. 21.

    , , et al. Towards positive diagnosis of the irritable bowel. BMJ 1979;2:653–654.

  22. 22.

    , , et al. Functional bowel disorders and functional abdominal pain. Gut 1999;45:II43–II47.

  23. 23.

    , , et al. Design of treatment trails for functional gastrointestinal disorders. Gut 1999;45 (suppl II): II69–II77.

  24. 24.

    The Cochrane Collaboration Meta-analysis of continuous data: Measuring the effect of treatment; 2002.

  25. 25.

    , , et al. A randomized controlled trial of a probiotic, VSL#3, on gut transit and symptoms in diarrhea-predominant irritable bowel syndrome. Aliment Pharmacol Ther 2003;17:895–904.

  26. 26.

    , , et al. A randomized controlled trial of a probiotic combination VSL#3 and placebo in irritable bowel syndrome with bloating. Neurogastroenterol Motil 2005;17:687–696.

  27. 27.

    , , . Prescript-Assist probiotic-prebiotic treatment for irritable bowel syndrome: A methodologically oriented, 2-week randomized placebo-controlled, double-blind clinical study. Clin Ther 2005;27:755–761.

  28. 28.

    , , et al. Single blind follow-up study on the effectiveness of a symbiotic preparation in irritable bowel syndrome. Chin J Dig Dis 2004;5:169–174.

  29. 29.

    . Probiotics in the treatment of irritable bowel syndrome. J Clin Gastroenterol 2004;38:S104–S106.

  30. 30.

    , , et al. A probiotic mixture alleviates symptoms in irritable bowel syndrome patients: A controlled 6-month intervention. Aliment Pharmacol Ther 2005;22:387–394.

  31. 31.

    , , et al. Clinical trial: multispecies probiotic supplementation alleviates the symptoms of irritable bowel syndrome and stabilizes intestinal microbiota. Aliment Pharmacol Ther 2008;27:48–57.

  32. 32.

    , , et al. The efficacy of Lactobacillus reuteri ATCC 55730 in the treatment of patients with irritable bowel syndrome—A double blind placebo-controlled, randomized study. Clin Nutr 2005;24:925–931.

  33. 33.

    , . Bacterial supplementation in the irritable bowel syndrome. A randomized placebo-controlled crossover study. Digest Liv Dis 2000;32:284–301.

  34. 34.

    , , et al. Treatment of irritable bowel syndrome with Lacteol-Fort: A randomized, double-blind, cross-over trial. Am J Gastroenterol 1996;91:1579–1585.

  35. 35.

    , , et al. Alteration of intestinal microflora is associated with reduction in abdominal bloating and pain in patients with irritable bowel syndrome. Am J Gastroenterol 2000;95:1231–1238.

  36. 36.

    , , . A controlled double-blind, randomized study on the efficacy of Lactobacillus plantarum 299V in patients with irritable bowel syndrome. Eur J Gastroenterol Hepatol 2001;13:1143–1147.

  37. 37.

    , , et al. Effect of Lactobacillus plantarum 299v on colonic fermentation and symptoms of irritable bowel syndrome. Dig Dis Sci 2002;47:2615–2620.

  38. 38.

    , , et al. Efficacy of an encapsulated probiotic Bifidobacterium infantis 35624 in women with irritable bowel syndrome. Am J Gastroenterol 2006;101:1581–1590.

  39. 39.

    , , et al. Safety and tolerability of the probiotic organism Bifidobacterium infantis 35624: Clinical experience and molecular basis. Gastroenterol 2006;130 (Suppl 2) (A-493).

  40. 40.

    , , et al. Effect of a fermented milk containing Bifidobacterium animalis DN-173 010 on the health-related quality of life and symptoms in irritable bowel syndrome in adults in primary care: A multicentre, randomized, double-blind, controlled trial. Aliment Pharmacol Ther 2007;26:475–486.

  41. 41.

    , , et al. Increased rectal mucosal expression of interleukin 1b in recently acquired post-infectious irritable bowel syndrome. Gut 2003;52:523–526.

  42. 42.

    , , et al. Full-thickness biopsy of the jejunum reveals inflammation and enteric neuropathy in irritable bowel syndrome. Gastroenterol 2002;123:1972–1979.

  43. 43.

    , , et al. Increased mast cells in the irritable bowel syndrome. Neurogastroenterol Mot 2000;12:449–457.

  44. 44.

    , , et al. Activated mast cells in proximity to colonic nerves correlate with abdominal pain in irritable bowel syndrome. Gastroenterol 2004;126:693–702.

  45. 45.

    , , et al. Double blind, placebo controlled trial of two probiotic strains in interleukin 10 knockout mice and mechanistic link with cytokine balance. Gut 2003;52:975–980.

  46. 46.

    , , et al. Design of treatment trials for functional gastrointestinal disorders. Gastroenterol 2006;130:1538–1551.

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Author information

Affiliations

  1. Division of Gastroenterology, Department of Internal Medicine, Northwestern University Feinberg School of Medicine, Ann Arbor, Michigan, USA

    • Darren M Brenner
  2. Department of Internal Medicine, Ann Arbor, Michigan, USA

    • Matthew J Moeller
  3. Division of Gastroenterology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA

    • William D Chey
    •  & Philip S Schoenfeld
  4. Veterans Affairs Center for Excellence in Health Services Research, Ann Arbor, Michigan, USA

    • Philip S Schoenfeld

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Correspondence to Darren M Brenner.

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DOI

https://doi.org/10.1038/ajg.2009.25

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